Four Proactive Interventions to Alleviate Moral Distress in the ICU

This article examines the definition, cause, and symptoms of moral distress in critical care nurses. It also provides four tangible and proactive ways for the critical nurse to alleviate moral distress. Specialties Critical Knowledge

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Four Proactive Interventions to Alleviate Moral Distress in the ICU

Four Proactive Interventions to Alleviate Moral Distress in the ICU

My inner gut wrenched when the double doors to the Intensive Care Unit (ICU) slid open to admit a thin, white-haired lady lying on a gurney, gasping for breath beneath a 100% non-rebreather mask. The emergency room phone report had been short. Eighty-seven-year-old female. End-stage Alzheimers. Respiratory failure. Family wants everything done. Did this patient or her family understand the physical and emotional trauma she would experience as we attempted to save her life? Why could we not just keep her comfortable and let her die with dignity, surrounded by her family?

I did not know what I do now. I was experiencing moral distress.

The ICU can be a violent and torturous place, where patients may spend days or weeks in the struggle to save their lives. The list of sufferings is long, and intravenous analgesics and sedatives do not completely alleviate the agony and distress caused by painful procedures and essential nursing care. Critical care nurses are highly trained nurses who provide care for unstable patients in an often excruciating fight for the future goal of health and wellness. However, what if the patient is emaciated and frail and elderly, or has end-stage pancreatic cancer or Amyotrophic Lateral Sclerosis (ALS), and there will be no win? The nigglings of moral distress set in; and one patient at a time, it takes hold of the nurse's soul, until one day it is too much.

Moral Distress

Nurses experience moral distress when they feel forced to participate in futile medical procedures that cause pain and suffering in patients for whom there is no hope of survival or a positive outcome. Moral distress often leads to burnout and the exit of nurses from the intensive care unit, and sometimes from the nursing profession altogether. Critical care nurses experience a higher level of moral distress than nurses working in other areas, with at least 30% displaying severe symptoms and more than 80% suffering from symptoms of burnout.

Symptoms

After caring for many such patients, I attended an ethics meeting, and then a second, hoping that my nursing concerns would be heard. After all, I was trained to speak for the welfare of my patients. After the third meeting, I, too, stopped going, like many of my nursing colleagues. I did not know that feeling powerless and voiceless were symptoms of moral distress.

Next to feeling helpless, nurses suffering from moral distress will often withdraw emotionally from their patients and colleagues, call in sick frequently, make more medication errors, and have an increased risk of depression.

Be Proactive to Alleviate Moral Distress

I worked many years in the ICU before I heard the term "moral distress,” but when I did, it all began to make sense. I spoke with my fellow nurses and found that they, too, were experiencing the same emotions but didn't have the language to describe it and were feeling stuck. We had been taught how to read cardiac rhythms, zero arterial lines, mix and hang epinephrine and nitroglycerin drips, but no one had addressed moral distress and subsequent burnout.

What I do know now is that critical care nurses can be proactive in alleviating moral distress before they reach a state of burnout. Here are four tangible interventions from one critical care nurse to another:

1. Acknowledge Your Moral Distress and Ask For Help

If you are experiencing the gut-busting feelings of moral distress, you can be assured that others are feeling it as well. It takes courage to communicate your feelings, and it is not a sign of being a "weak" nurse.

  • Explain to a colleague or the resource nurse what you are feeling
  • Ask for a different patient assignment
  • Don't isolate yourself from your colleagues or your feelings

Communicating your moral distress will make you feel less alone and allow others to share the load. These patients are often in the ICU for weeks, if not months, so you may have to take your turn again. However, even a few shifts away from the bedside of this patient will give your mind time to recover.

2. Attend Patient-Family Meetings With the Physician

Attending a family meeting provides insight and understanding into family dynamics. When you understand who they are and the reasons for their choices, it may decrease the level of moral distress you are feeling. Families often struggle with their decisions and appreciate the quiet and calm professional expertise you have to offer.

  • After the physician leaves the meeting, stay seated and ask the family if they have any questions
  • Be honest in your answers about your patient's condition and what they may experience in the ICU
  • Accept that their choices are not yours to make

Having a family member in the ICU is a shocking experience for most families, and the majority lack the medical knowledge needed to make informed decisions. As a trained professional, you can provide information on issues such as frailty, low probability of returning to baseline functioning, and prognosis.

3. Speak to Your Nurse Manager

Your nurse manager may not know that you are suffering from moral distress and burnout. However, they are in the unique position to offer guidance and support. Different rotations within the same critical care unit often experience varying levels of burnout, indicating that some staff are more supportive than others. Your nurse manager will have access to which rotations are more robust and may allow you to trade your shifts or scheduled line.

  • Ask your nurse manager if you can transfer to a different rotation or to buddy with a supportive colleague
  • Ask your nurse manager to set up a debriefing session
  • Speak with your manager about taking some time off or taking a temporary posting on a different unit, such as a post-anesthesia recovery room

Having regular multidisciplinary debriefing sessions provides a safe place for staff members to discuss their feelings. This also gives staff an opportunity to brainstorm about coping strategies, and to receive and offer support. Sometimes leaving the ICU for a temporary post in a related critical care area offers the emotional distance that you need. You will be able to return in a few weeks or months with fresh energy and emotional balance.

4. Take Care of Yourself

Only you can truly advocate for you. Work-life balance is key to longevity in our challenging jobs.

  • Limit or don't take overtime shifts
  • Sleep and exercise on your days off
  • Start a new hobby or hang out with friends

Don't let guilt drive you into taking extra shifts when you are exhausted. Schedulers are good at their jobs, and if you are unable to say no, don't answer your phone. Instead, wait to listen to the phone message or use text. Use your time off to re-energize your inner self. Get outside, ride your bike, go for a walk, and connect with friends.

These four proactive and tangible interventions to counter moral distress will help you thrive in the challenging ICU environment as a critical care nurse.

References

Čartolovni, A., Stolt, M., Scott, P. A., & Suhonen, R. (2021). Moral Injury in Healthcare Professionals: A Scoping Review and Discussion. Nursing Ethics, 28(5), 590–602.

Casella, C., Graziano, V., Di Lorenzo, P., Capasso, E., & Niola, M. (2018). Unreasonable Obstinacy: Ethical, Deontological and Forensic Medical Problems. Journal of Public Health Research, 7(3). 

Flaatten, H., Lange, D. W., Artigas, A., Bin, D., Moreno, R., Christensen, S., Joynt, G. M., Bagshaw, S. M., Sprung, C. L., & Benoit, D. (2017). The Status of Intensive Care Medicine Research and a Future Agenda for Very Old Patients in the ICU. Intensive Care Medicine, 9, 1319. 

Fumis, R. R., Amarante, G.A., Nascimento, A., & Vieira, J. M. (jr). (2017). Moral Distress and Its Contribution to the Development of Burnout Syndrome Among Critical Care Providers. Annals of Intensive Care, 7(1), 1–8.

Kerlin, M. P., McPeake, J., & Mikkelsen, M. E. (2020). Burnout and Joy in the Profession of Critical Care Medicine. Critical care (London, England), 24(1), 98.

Kleinknecht-Dolf, M., Spichiger, E., Müller, M., Bartholomeyczik, S., & Spirig, R. (2017).  Advancement of the German Version of the Moral Distress Scale for Acute Care Nurses- A Mixed Methods Study. Nursing Open, 4(4), 251–266

Mealer, M., & Moss, M. (2016). Moral Distress in ICU Nurses. Intensive Care Med 42, 1615–1617. 

Moss, M., Good, V. S., Gozal, D., Kleinpell, R., & Sessler, C. N. (2016). An Official Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Health Care Professionals: A Call for Action. American Journal of Critical Care, 25(4), 368.

Schwarzkopf, D., Rüddel, H., Thomas-Rüddel, D. O., Felfe, J., Poidinger, B., Matthäus-Krämer, C. T., Hartog, C. S., & Bloos, F. (2017). Perceived Non-beneficial Treatment of Patients, Burnout, and Intention to Leave the Job Among ICU Nurses and Junior and Senior Physicians. Critical Care Medicine, 45(3), e265–e273.

Whitehead, P. B., Herbertson, R. K., Hamric, A. B., Epstein, E. G., & Fisher, J. M. (2015). Moral Distress Among Healthcare Professionals: Report of an Institution-Wide Survey. Journal of Nursing Scholarship, 47(2), 117. 

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Alice Blackmore

About Alice Blackmore, MSN, RN

I am a registered nurse who has experience in labor and delivery, maternal health, paediatrics, critical care, and long-term care. My greatest passion lies in critical care where I spent fourteen years as a bedside nurse, resource nurse, and educator, teaching Paediatric Advanced Life Support.

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Specializes in Critical Care.

Great article. As nurses - especially in critical care environments - we fail to take care of ourselves and do the things we need to do to prevent burnout. 

If I may share another strategy that has been helpful: feed the mind. It's easy after a series of difficult shifts (during more uncertain times) to get caught up in negative thinking or "staying in your head"... Rumination, excessive worrying, asking yourself unhelpful questions like "did I do everything? did I miss something?" and therefore, bringing down one's mental well being, and bringing work home or into other areas of life (like a "spill over" affect). 

When I leave the hospital, I leave work behind. On my drives to/from work, or on a drive to/from anywhere, I can easily tune into and listen to something that feeds my head with things that are helpful, positive, motivational, interesting, or enjoyable. Podcasts. Audio books. Music. Anything.

Practicing this regularly is another tool that can be helpful in preventing wear and tear on a person's mental health by shifting the focus from work to other things, and mentally "check out" once exciting those doors. 

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Specializes in Intensive Care, Paediatrics, Long-term care.

This is an awesome suggestion. Maintaining a healthy mind is essential to longevity in critical care nursing. I actually did a variation of what you suggested. What I most enjoy is learning so I pursued a master of nursing. I researched and wrote my final paper on a variation of this topic. It gave me a greater depth of understanding of some of the contributing pieces to moral distress. Thank you so much for your comments.

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Studies have shown that unrestricted presence of a family member/support person in the ICU is beneficial for both patient and their family member and does not show any harmful elements for the patient or their family member, and professional organizations support this practice, but I am not personally aware of this happening in practice, and, as far as I know, this practice is not widespread, even allowing for the difficulties and visitor restrictions that Covid caused.  I conclude that at least some of the reason for lack of support of this practice is staff/administrator convenience/preference.

Moral distress for nurses is real, but I think part of the difficulty is that particularly in units such as the ICU which use a lot of high tech equipment and require knowledge to operate this equipment, along with other specialized training, there is a tendency for some staff (in my experience) to believe and behave as though they are the expert who knows what is best for the patient and their family, to the point of sometimes disregarding the input of the person who knows the patient the best and who may be their full time caregiver.  I see this resulting in barriers between staff and patient/family that can result in a lack of trust that can become polarized by both patients and family members/decision makers towards staff, and I think this can contribute to the moral distress some nurses experience.

I believe there are a number of contributors to the moral distress nurses experience.  I don't believe it is as simple as just that the families and/or patients want everything done for the end stage patient or want the end stage patient to continue to receive curative care and the nurses understand what the treatment involves and that it will cause further suffering for the patient and thus the nurse will suffer personally by providing the care.

In my view, there is room for more analysis and action in regard to the above situation.  

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Specializes in Intensive Care, Paediatrics, Long-term care.

Thank you for your comments. Moral distress is a topic that should be discussed openly amongst critical care nurses, if only to gain further understanding and provide support for colleagues.

I personally advocate for the presence of families if at all possible. In the ICU where I worked, the open environment and very small rooms often made it difficult or almost impossible for families/friends to be at the bedside during some care procedures. However, they were welcomed whenever possible, and cots provided in rooms that had adequate space. Older ICU's were not built to accomodate the larger, high tech beds and equipment we now use. Newer ICU's are built with added capacity to accomodate this very real and compassionate need. 

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I am not a nurse, but a close friend is an ICU nurse.  This article helps me know how to support her better and give her space to decompress.  I know that her job is overwhelming at times; sometimes she needs to talk and other times she just needs a frozen meal and a hug.  I believe that North American society truly needs to take a long hard look at death and dying.  We invest time to develop intricate birth plans, 5-year plans, dream boards, strategic plans ... few want to openly and honestly discuss or explore our choices in dying well.  We are not living longer anymore; it's just taking us a lot longer to die and at a high cost to our quality of life.  This only serves to enhance the moral distress of many health care workers.

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Specializes in Intensive Care, Paediatrics, Long-term care.

Thank you for supporting your ICU nurse friend. I agree that our society needs to open up some hard discussions about death and dying. This difficult and emotional topic is fraught with many pitfalls, one of them being political. However, until we are willing and allowed to speak with honesty and transparency, nothing will change.

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Specializes in Primary Care, Long Term Care, Writing, Editing.
Alice Blackmore said:

Communicating your moral distress will make you feel less alone and allow others to share the load.

Great article! Indeed, as healthcare providers, we must not consider voicing our moral distress as a sign of weakness. This has been known to cause some nurses to leave the profession. As a brand new RN, I did in-patient oncology and was made to feel like voicing moral distress meant I was not "strong enough." While it did not drive me away from nursing, it made me turn my back on oncology. 

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Specializes in Intensive Care, Paediatrics, Long-term care.

So insightful. Is it because "nursing" symbolizes strength and empathy that we feel we are letting our profession down by admitting to our humanity? Our own hurts, pains, and weaknesses? Yet that is what makes us who we are.

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