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.