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

  1. 7

    Moral distress and its cousin, occupational post-traumatic stress disorder, are a growing concern for nurses in all specialities. We've defined it, examined its effects on the patient, nurse and workplace and utilized a case study to identify some situations that contribute to it in the PICU. But what do we do about it? How do we cope with it? Can it be survived? Here in Part IV we'll talk about that.

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

    Each of us brings our own particular personalities, opinions and experiences to the workplace and we all deal with issues in our own ways. Coping mechanisms are as individual as fingerprints. Some nurses have left their units and others have left the profession in an effort to escape the unrelieved stress of facing moral conflict on a day-to-day basis. There is, however, hope for those who don't want to take this path to rise above their own responses. Let's take a look at some suggestions for doing just that.

    The American Association of Critical-Care Nurses has examined moral distress and has developed a recipe for healthy coping. Their model is called the Four A's. For further information, please see - here are the basics:

    ASK: Is this moral distress I'm feeling, or is it something else?

    How is it affecting me? Is it affecting anyone else around me?


    Is it affecting the way we do our work?

    Not everyone will see things from the same perspective so things that bother me might not bother anyone else. But when there is a sense of widespread distress, it should not be ignored.

    AFFIRM: "Yes, this IS moral distress, and I'm not the only one rowing in this boat. I'm in good company. We should work together to make things better."

    There's safety in numbers so many people are more likely to become involved in efforts to improve a situation if they feel supported and their own exposure is limited. As well, it's a lot harder to deny an issue exists if more than one person is saying it does.

    ASSESS: What is the source of our distress?

    Is it a specific situation or is it a conglomerate of many?

    After all, one sad situation is usually something we can get through in one piece; a series of them with similar aspects and outcomes maybe not. As well, the other parties in the situation must be identified. How severe is the distress?

    There are many degrees of moral distress, ranging from mild ("The poor kid, he's so sick and nothing we're doing is making any difference") to extreme ("When are we going to stop doing all these things and let this child go in peace?").

    PICU nurses have described some of the interventions they perform as "torture", "sinful", "barbaric", "useless" and "experimenting", as well as many other similar adjectives. What words would you use to describe what you're doing and how you feel about it?

    And lastly, how ready are you to do something about it?

    Willingness to actually take action is probably the hardest part of the whole process.

    ACT: Decide what needs to be done. Develop tactics to address the sources of stress. If your unit administration and your physicians are sources of resistance to efforts to make positive changes, you will need to have several plans to implement the changes you have discerned to be the solution. You may have to convince them that your feelings and opinions are valid and deserve to be heard. (Of course they are, but it may be a hard sell.)

    Find a way to work with them and it will be much easier. Realize that there will be setbacks; things may change initially and the staff may feel that their input is valued, but over time this may erode and old patterns may resurface. Adjust your plan of action as needed to ensure that things continue on the correct road. And remember that this is a process, not an event. It's a continuous loop that may look a little different each time it makes its way around the spindles; the underlying issues will still be there.

    Having said all that, we all know how difficult it is to maintain group momentum... if we've even managed to get a group moving in the first place. Sometimes it's just easier to work on ourselves and let the others find their own way. Each of us brings our own personalities and experiences with us, no matter the situation. Our methods of coping have been developed and ingrained for our lifetimes. But that doesn't mean we can't find a way out of the maze and actually succeed in rising above our distress. Here are some suggestions...

    Call a spade a spade! Don't discount your feelings. So you're the only one who has a problem with a specific situation. That doesn't mean that you're wrong, or that it isn't morally difficult. If it meets the definition for YOU, then it is what it is.

    Know yourself. Understand how you react to circumstances that challenge your sense of yourself and your world. Recognize these reactions when they happen so that you can diffuse (defuse?) them as they arise. Act before you lose sight of yourself. You HAVE to look out for Number One... no one else will do it for you. There's a motivational poster out there that says, "I cannot change the direction of the wind, but I can adjust my sails". Charles R Swindoll said, "Life is 10% what happens to you and 90% how you react to it". To paraphrase, you may not be able to fix what's broken, but you CAN fix how you cope with it.

    Develop a network of support of trusted colleagues in your workplace. Talking things through with someone who truly understands what you're talking about is priceless. You just never know, the person you choose to speak to may be feeling the same way and needing to vent; it becomes a mutual aid society of two. Validate your feelings and help them validate their own.

    Identify other supports available to you, both within your workplace and outside of it. Your unit social worker is an obvious choice. They have knowledge of the issues and an understanding of the dynamics at play. They're great for unburdening to and great at identifying our strengths and weaknesses without making us feel bad about any of it. They also know what resources we can call upon to help us with our stress. Many organizations have employee assistance programs (EAP) available to all employees at no cost. These resources are provided confidentially and at no cost to the employee. Your employer will never know you've accessed their services and many people have found them to be very helpful. But not everyone will be comfortable with this option and there's no shame in that. If you're a religious person, your spiritual leader is another great source of support and comfort. They have an obligation not to share any disclosures made to them and are held to a similar degree of respect for confidentiality so they're safe people to vent to, especially when those crises of faith arise. Another method of releasing the tension is to journal about it. Once you've written down every single little thing that is bothering you, take the paper and put it in a box. Take the box out to the garage, or to the attic or some other remote place and hide in on a high shelf, in a deep hole or behind a pile of boxes. Symbolically let it all go. Sounds hokey but it works.

    Share the burden. We're all in this together. Speak up when you have questions or concerns about how things are being handled. Don't keep it all inside.

    Insist on being included in family conferences. Use your knowledge of the parents' coping mechanisms, their understanding of events and existing issues and their previous behaviour. Reframe and rephrase information for them so that they are on the same page as everyone else in the room. When a doctor says, "She's looking a little better today. Her labs have improved," make sure that they know this doesn't necessarily mean a whole lot when compared to the big picture. When a physician recommends a specific last-ditch treatment option, have the hard discussion about the pros and cons... and the likelihood that it will succeed where everything else has failed. Don't close the door on hope, just give them the facts and let them choose. Then accept their choice.

    Advocate for yourself and your coworkers by requesting a break from a distressing situation if you feel yourself slipping. Or, offer to take a coworker's assignment for a couple of days to allow them to have a break. If you encounter resistance, explain how this course of action will benefit everyone in the long run. Avoid being defensive. "Just the facts, Ma'am."

    Put it where it belongs. Don't take it home with you!! Your spouse, your children, your friends, your pets - they don't know or understand what's bothering you and they don't deserve to be on the receiving end of your frustration. Refer to points 2, 3 and 4 above. You wouldn't like it if the tables were turned so remember these are the people who love you and let them be your soft place to land.

    IF you choose to leave your job, do your research first. Make sure that the new job isn't going to be more of the same... or worse. Living through it once was bad enough, you really don't want history to repeat itself. Red flags include many positions vacant or reposted, high turnover, grapevine reputation of the unit and so on. The demeanor of the person interviewing you can also be a tip-off: if they seem very anxious to have you accept the job on the spot, if they seem overly cheerful and gushing about their unit, if they make a lot of promises that sound to good to be true, if they don't offer you a tour of the unit before you accept - RUN!

    Be good to yourself: have a pedicure or manicure (or both!), go for a massage, join a club, take up a hobby, learn a second language, love a pet, volunteer for a charity, eat healthy foods, take a trip to somewhere you've always wanted to go, take a hike - channel your thoughts in a direction away from that which is upsetting you. I've found several outlets for my own frustrations; I have a little dog that loves the heck out of me, I have several crafty hobbies that occupy my mind and my hands and I see God whenever I spend time in my garden. Being busy is a great salve to a troubled mind.

    Be the best YOU you can be.
    Last edit by Joe V on Jan 13, '15
    Do you like this Article? Click Like?

  2. Visit NotReady4PrimeTime profile page

    About NotReady4PrimeTime, RN Senior Moderator

    Since 1983 I've parented a medically-complex child who is both an NICU and PICU survivor. I graduated from nursing school in 1994 and since 1997 I've been a PICU nurse. I've cared for some very challenging patients and seen most of them recover to live wonderful lives. But I've also seen some of them suffer and die under distressing circumstances. It's these children to whose memory this series is dedicated.

    Joined: Jun '01; Posts: 10,014; Likes: 8,373

    Read My Articles


  3. by   cherryames1949
    All of the above suggestions are good advice and in the course of a career a nurse is likely to employ at least one of them. Mostly though, we just move on. I worked in a BMT unit for exactly six months to the day. What I saw was torture, barbaric,experimental, and mostly useless. I voiced my opinion to the head nurse and the social worker. They listened and were sympathetic but this was the reality on this unit. I choose to leave to maintain my sanity. What really got to me were the kids. I have never done children before or since in my career. Nursing is a challenge and to go the distance you have to know your limits and reach out for help when necessary. Thank you janfrn for laying it out for us.
  4. by   wooh
    Thanks for this. It's absolutely spot on...