Grow Brave Through Reflection: Moral Distress in PICU (Part II)

by janfrn Asst. Admin

5,375 Views | 13 Comments

Now that we all know what moral distress is and why it's a bit different in PICU, let's look at what effects it has and whom it affects.

  1. 22

    Grow Brave Through Reflection: Moral Distress in PICU (Part II)

    We all know nurses who exhibit signs of burnout. Everyone will have different reasons for their behaviour, and moral distress is often on the list. What does burnout look like? It has many faces, and no two individuals will have the same signs and symptoms. Often the most obvious is apathy, the loss of that attitude of caring about what goes on around them. They take shortcuts in providing care; they omit some of the basic nursing care activities we take for granted: mouth care, skin care, turns, dressing changes and the like. They ignore alarms at any other bedside and pretend to be busy when others around them could use a hand. They withdraw from the social activity on the unit, no longer chatting easily in the break room. They do their work and go home without interacting on any but the most superficial level with their peers. This withdrawal will eventually extend to their patients and if the underlying issues remain unresolved, to their families and friends as well.

    Apathy typically has its roots in frustration. When a nurse does the best s/he can to provide professional, competent, ethical care but finds those efforts continually unappreciated or thwarted by circumstances outside the nurse's control, there is a tendency toward irritation, dissatisfaction and unfulfillment. Repetitive feelings of having failed in some sense leads to attempts to change the environment, which if unsuccessful, adds frustration. Outward expressions of frustration may include short-temperedness, sarcasm, refusal to help others, refusal to engage in expected activities and insubordination.

    Another offspring of frustration is cynicism. Patterns of behaviour and predictable outcomes discerned on a unit create a sense of distrust and bitterness that evolves into pessimism. The expectation of failure in effecting the desired outcome may cause some people to simply go through the motions. It may not be spoken aloud but the nurse may be thinking, "Why are we doing this? It's not going to work and the kid is going to die anyway. When was the last time someone in this condition actually got better? What's the point?" This emotional disconnect cannot fail to affect care and the nurse's interaction with the patient, their family and coworkers. Couple this with an unsympathetic administration and the problem is magnified. Being told, "This is your job. This is what you signed up for. It's not your place to make decisions here, you're expected to carry out orders. Now get on with it," isn't helpful. (What does the nurse hear? "Suck it up, Buttercup!") It suggests that the individual is the only one on the unit with these feelings. Other frustration-related burnout behaviours may include control issues - inflexibility, rigid thinking, having to be "right" all the time... and bullying.

    Some facets of burnout that might not be recognised as such are depersonalisation and negative self-image. Depersonalisation has been described as feeling as though one is watching oneself from a distance, having no control over a situation. There are sensations of unreality, being in a dream state, divorced from one's emotions. Moral distress can lead to this state becoming a defense mechanism. Negative self-image may be an off-shoot of depersonalisation, when the individual is disturbed or disappointed by their own behaviour in situations they once felt in control of. Over time these emotional reactions may become self-perpetuating.

    A major component of burnout is compassion fatigue: a gradual emotional and physical exhaustion people in helping professions develop over time. It may be exacerbated by heavy work loads, absense of proper referral resources, witnessing pain and suffering in others daily without being able to help and other factors. It mimics depression, causing sufferers to feel hopeless, loss of experiencing pleasure in everyday life, stress, anxiety and negative attitude. Confusion, guilt, fear and grief are all associated emotions. Crying at inappropriate times can be most distressing to the individual, who may not even know why they're crying. At its worst, compassion fatigue can lead to abuse of the very people in need of help. This is obviously not where we expected to end up when we chose nursing as a career.

    Interestingly, critical care nurses are much more likely to have advanced directives in place than the average person. Participation in resuscitating people for prolonged periods with poor outcomes isn't exactly an attractive proposition when you're the one being resuscitated. They are also far LESS likely to be willing to donate blood or organs. The reason behind these statistics is that critical care nurses see what happens to these altruistic gifts.... blood banks being depleted for a trauma victim who never stood a chance of survival, organs being placed into patients whose comorbidities will result in failure of the transplant or failure of other organs with death ensuing in the short-to-intermediate term. Moral distress influences their thinking, their belief that their donation would ultimately be wasted.

    Sleep disorders are yet another side-effect of moral distress. They may walk hand-in-hand with depersonalisation; as the sufferer is lying in bed awaiting sleep, they relive their last shift at work and analyse their performance. They may obsess over some small detail or place inaccurate perceptions on interactions with others. They may fall asleep easily, only to awake several times and re-experience the filmstrip of their shift over and over, a sort of PICU Ground Hog Day. They may sleep for part of their time in bed but awaken much earlier than desired, worrying over what may happen during their impending shift. They may have dreams about work or nightmares about situations they've experienced at work. Alternatively, they may sleep excessively (although I don't know anyone with this complaint). Sleep deprivation only makes it all so much more difficult to manage.

    Physical effects may also manifest, although often not associated temporally with morally-distressing situations but cumulatively. Migraines, gastrointestinal disorders, weight gain or loss, musculoskeletal injuries, increased susceptibility to illness, memory loss and exhaustion are just a few symptoms. You might wonder how musculoskeletal injuries are associated with moral distress. When the combined effects of apathy, frustration, depersonalisation and cynicism collide with short-staffing, lack of equipment and other workplace circumstances, the sufferer will be less likely to be thinking about protecting their back and more likely to just want to get the job done. So lifts, turns, transfers and other physically taxing activities may be undertaken without due consideration for accessing adequate assistance and proper body mechanics. And so another layer is added to the burden experienced by the indvidual.

    Addictive behaviours may arise. Besides addictions to alcohol and mind-altering substances, food, sex, shopping, gambling or the Internet could become problematic. None is any less serious than the others; they all have the potential to damage a person's life and those of their loved ones. Interpersonal relationships are the usual casualties of addictions. Becoming further isolated from the "normal" world makes the sufferer of moral distress who follows this road even less likely to overcome it.

    The issue of boundary violations is typically downplayed in most cases. However, for nurses this represents a serious breach of their professional responsibilities. Nurses are expected to maintain a professional distance from their patients and patients' families. It is inappropriate to invite a patient's mother into one's home for a meal, to arrange for a spa day or to take a father to a baseball game. It's also not okay to buy birthday gifts for siblings, to buy toys or clothing for a patient or to lend them money. Professional compassion does not extend that far. Neither is it permissible for a nurse to accept personal gifts from families, borrow money, seek employment from or become romantically or physically involved with either patients or their family members. But when strong emotions are involved in combination with day-to-day proximity, it's not hard to lose sight of these boundaries.

    Yet another manifestation of moral distress is the crisis of faith. Most of us partake of some form of spiritual belief, whether formally or informally. No matter what we call our higher power - our God, none of us can conceive of a world where our God would allow suffering and loss of the magnitude we observe everyday. Our patients and their families pray for miracles that our experience tells us will be long in coming, if they come at all. Then we begin questioning our own faith... losing our religion. Once this stage is reached, bouncing back is more difficult than ever.

    All of these effects lead to one destination: moral residue. Even if a nurse is able to move from one distressing situation to the next seemingly unscathed, underneath the surface moral residue is growing. Webster and Baylis (2004) from the University of Victoria defined it thus: "that which we carry with us from those times in our lives when in the face of moral distress we have seriously compromised ourselves or allowed ourselves to be compromised." Moral residue isn't an obvious, in-your-face thing; its' insidious creeping tendrils influence our behaviour and interactions often without us even realising it. It becomes a giant positive feedback loop. The more a person sublimates their distress, the more distress they will experience until eventually they implode under the weight of it.

    The effects of moral distress reach far beyond the individual. A 2007 study at the University of Pennsylvania revealed that 25% of nurses surveyed said that moral distress made them want to leave their jobs. These results were expanded upon by a study reported in the Journal of Advanced Nursing (2008) in which 15% of subjects HAD left their jobs as a result of moral distress. High turnover is very disruptive to quality care and the price goes far beyond the financial. Replacing an ICU nurse is reported to cost $145,000 in direct and indirect costs. Staff satisfaction and the impact on patient care are far harder to quantify.

    In 2006-7, Wendy Austin, RN, MScN, PhD from the Faculty of Nursing, University of Alberta collaborated with Franco Carnevale, RN, MScN, PhD Faculty of Nursing, McGill University, Arthur Frank, MA, PhD, Department of Sociology, University of Calgary and Daniel Garros, MD, FRCCP, PICU, Stollery Children's Hospital to study moral distress in pediatric intensive care. The study was a qualitative, narrative-based inquiry with participants from three teaching hospitals in two Canadian provinces, from which a number of themes were distilled.


    • I'm unable to make the story one I can live with: "We did this to him." (RN) "I am uncomfortable with the idea of playing God." (Intensivist)
    • This is a contest of plights: "The case was discussed in ethics rounds. I did attend but did not bring up the feeding issue because it seemed like a small issue compared to the kind of 'whether we should withdraw or not' issue. (Dietician)
    • What do you mean, "STOP"??: "Faced with the question, "Could we stop it today?" their answer was "Not on my shift." (RN)
    • We're not of one mind: "I don't mesh with the team usually on quality of life, or death, issues. It's discouraging to the point where sometimes I wonder if I can continue to work with a team that has such a disparate view."(Intensivist)
    • PICU is a NO ANGER zone: "I don't get to express how I'm feeling as much as I would like. I save that for home, or when I'm with other social workers." (Social worker)

    The unrelenting pressures created by moral distress in this environment creates ripples that extend far beyond the PICU doors. How good are you at picking out those factors from a situation that may expose the PICU staff to moral distress? In Part III we'll find out.
    Last edit by Joe V on Jun 20, '11
    trixie333, BreeLPN2RN, Altra, and 19 others like this.
  2. Read more articles from janfrn

  3. Get our hottest nursing topics delivered to your inbox.

  4. About janfrn

    With more than 16 years of pediatric critical care experience and a lifetime of caring for a PICU survivor, moral distress is a topic I am intimately familiar with. In seeking healthy methods of coping with my own issues in this regard, this article was born.

    janfrn joined Jun '01 - from 'the Great White North'. janfrn has '19' year(s) of experience and specializes in 'NICU, PICU and peds oncology'. Posts: 8,979 Likes: 6,415; Learn more about janfrn by visiting their allnursesPage Website


    Find Similar Topics

    13 Comments so far...

  5. 0
    looking forward to the rest
  6. 7
    Thank you as a NICU nurse I think I have written a post about moral distress before, with not much feedback and explaining that feeling like we torture some of our kids, and lack of MD's painting the real picture. You did a wonderful job! And I recently was talking to fellow coworkers about alarm fatigue, in NICU especially and not in private rooms, you miss that occassional brady because the others in the pod do it so often. Desats to the teens, ya they will come up (not this RN) I was once stuck bagging in one isolette, and had 3 other vents sats in the 30's. Just two of us in the area. We laughed, who do we save first? It was that bad. ( sets of 24 wk twins in same pod ) good planning huh? So anyway, sorry but I see myself in a few paragraphs, the migraines, GI problems, the mood changes, the worrying prior and after a shift, the stress we are under and the pressure we are under to do everything possible. All of this I DID NOT have until I went to NICU. Recently I had coworkers asking if I was okay.... makes me think of what I might be showing to those that know me best. When you speak of the ethics committee, without too many details, a couple of a different culture wanted their 23.5 wk baby to pass peacefully, not in the NICU. They held the baby until they said goodbye. Baby was still alive, and cold. We were called twice, took over, babes temp was really low (good since we cool kids) and had a decent sat. Parents were specific that their OB told them and they knew what they wanted for their child. Ethics committee took over custody, babe was intubated, perf'd, and was in our unit 9 months. Babe ended up in another hospital later on, still hasn't come home. Parents may have not wanted to take on the responsiblity of a child with that prognosis and we chose for them. That was one of the saddest days.
  7. 12
    What an excellent series of articles! Bravo. I too, am a RN, but first and foremost, mom to twins who were born at 25ish weeks. One of my daughters sustained a grade IV bilateral brain bleed. We wanted life support to be removed, neonatologist refused. She is now 25 years old and extremely mentally and physically disabled and medically fragile. We made the right decision back then, and we were dismissed.

    Part of the problem of moral distress, I feel, is 1) the passage of the Reagan Baby Doe Laws way back in 1984 that essentially removes the decision making from the parents - ironically though, it is the parents who then are left with providing life-long care to this child.

    Another component to all of this, is the extremely successful hospital relations departments - miracle baby and miracle child stories. . the public comes to the hospital with unrealistic expectations because the only thing parents are exposed to for the most part, are stories in the newspaper and on TV about these so-called miracle survivors. Never does the general public really see the other part of this - the infants and kids left severely brain-damaged and attached to artificial support of one kind or another. Really, why *wouldn't* a parent want everything done?

    Moral distress and/or post traumatic stress are seen in both parents of survivors as well as nurses. Thank you so much for your excellent article. I look forward to seeing more.
  8. 8
    nicu4me, it sounds like you are on the path to burnout. You're in good company. I hope you're finding some outlet for your emotions and that you're able to rise above. It's not easy.

    Your vignette about the baby apprehended so that s/he could be "saved" resonates. I've seen families talked out of stopping, only to be left with the sad results once the window of opportunity has closed. As tralalaRN relates, and alluded to in Part I, parents don't have a crystal ball or the experience that would tell them the outcome is going to be something other than what they expect/hope for. When the child survives and they're left to deal with the consequences, they're not prepared. I agree that the "miracle baby", "miracle doc" and "amazing recovery" stories hospitals use to boost their images are very harmful to children and families. What do you say to a parent who asks why we can't just do a brain transplant? Or run dialysis on a child with barely perceptible BPs being supported with ultra-high continuous infusions of inotropes? Or positive that Janey is going to wake up after a 3 week coma and walk out of the hospital in a couple of days? "But I saw it on TV!" Unfortunately there's not much we as nurses can do about that, but we can do something about how we deal with it. We have to.
    Isitpossible, ebear, Zookeeper3, and 5 others like this.
  9. 0
    Not in PICU, but work the floor where the chronic no real hope for a quality life kids end up for most of their admissions. And you've just described me to a T.
    Thankfully in just over a month I'm starting school and changing shifts, which I think will give me the fresh outlook I need. And before then I'm getting a much needed vacation.
    But oh my goodness, thank you for this article. I've always been good at leaving it at the door. And I've known I'm quickly approaching burn out. But it's like, "Why am I having so much trouble with this lately? What's wrong with me?" That "moral residue" is totally me. And the lack of control, the "Suck it up, buttercup." It's me. So me.

    Thank you for the article. I look forward to the next.
  10. 4
    At least part of the answer if to work on reversing the Reagan Era law mentioned above.

    Another is to get Hollywood to start showing the other side of the coin - the non-miracles.

    We also need to have medical schools begin teaching doctors that it is often kinder and wiser to let a patient go and not subject him or her to all the treatments that Medicine currently has to offer. Med students and residents, attendings, parents, everyone - all need to see the outcomes of their heroics/torture (older kids who are profoundly damaged and who will never know life other than as dependent upon God only knows what kind of caregivers - good people or perverts?

    A precious, darling newborn or infant is not so great-looking and appealing come the time he or she reaches 5 or 15 or 35.

    I think nurses in other areas are also prone to this kind of burnout. Long-term care of any age patients, who never really get better, is an area that comes to mind.
    not.done.yet, trixie333, tralalaRN, and 1 other like this.
  11. 1
    Quote from tralalaRN
    What an excellent series of articles! Bravo. I too, am a RN, but first and foremost, mom to twins who were born at 25ish weeks. One of my daughters sustained a grade IV bilateral brain bleed. We wanted life support to be removed, neonatologist refused. She is now 25 years old and extremely mentally and physically disabled and medically fragile. We made the right decision back then, and we were dismissed.

    Part of the problem of moral distress, I feel, is 1) the passage of the Reagan Baby Doe Laws way back in 1984 that essentially removes the decision making from the parents - ironically though, it is the parents who then are left with providing life-long care to this child.

    Another component to all of this, is the extremely successful hospital relations departments - miracle baby and miracle child stories. . the public comes to the hospital with unrealistic expectations because the only thing parents are exposed to for the most part, are stories in the newspaper and on TV about these so-called miracle survivors. Never does the general public really see the other part of this - the infants and kids left severely brain-damaged and attached to artificial support of one kind or another. Really, why *wouldn't* a parent want everything done?

    Moral distress and/or post traumatic stress are seen in both parents of survivors as well as nurses. Thank you so much for your excellent article. I look forward to seeing more.
    I hope you have let the doctor know that she made a decision that sentenced you and your dtr to the life you've had. Not to say there probably haven't been some happy times, but that, for the most part, these are overshadowed by the sadness, by the fears for her future, not to mention the expense. Please forgive me if I have misperceived or overstated.
    tralalaRN likes this.
  12. 4
    OP, although I never faced the million dollar babies that you did, 15 years I spent "wasting" valuable resources in an adult ICU. I could have written your words myself. I wish I had the wisdom to balance QUALITY of life, with life in these difficult families, or doctors that steer many wrong or simply lack the ability to steer in the right place.

    I resemble the burn out, cardiac, GI, HTN, stress, lack of sleep, alcohol abuse to cope... I had to leave my love of ICU nursing to save myself. While I may be whole now in a procedure lab, I always worry about how much I could be contributing; talking to family, teaching new staff, serving as a role model and providing care. I have so MUCH to offer, but at way too high of an expense for my own health, and that of my family.

    My problem was that I needed to leave, because I didn't provide excellent care anymore to those that were "going to die, or should be allowed to die" and THEN it was time to leave. No one can give a half effort to the critically ill, as we all know ... but some remain for years and years and I refused to be one of those.

    Until I have an answer to your elequant post, I'll just urge those with burn out to leave as I did, as our patients need more than we can give, and we CAN make a difference elsewhere. I'm renewed, invigorated and making a difference and I sleep well, and all my health issues are just about gone.

    Sometimes, it is time to move on in a facility that doesn't fix issues detremental to nursing care, and to it's employees.

    OP, thank you for your excellent post.
    not.done.yet, trixie333, Altra, and 1 other like this.
  13. 1
    Even with a great employer, management and co-workers, and healthy coping skills, is it ever enough? I seem to feel that my time in critical care is limited, because how can ANYONE stand these difficult situations for a long amount of time? Or is it just me, that I'm not "strong enough" to continue being a critical care nurse?

    Very interesting article.
    wooh likes this.


Top