Moral Distress among nurses (and others).

This publication appeared on-line a couple of months ago, and still isn’t in print. Prentice T, et al. Moral distress within neonatal and paediatric intensive care units: a systematic review. Arch Dis Child. 2016. It is a systematic review from Melbourne, with the help of Annie Janvier, of the literature surrounding moral distress in health care workers in the NICU and the PICU. All of the studies included nurses, and some of them also studied other health care workers.

Moral Distress refers to subjective feelings of distress in response to the ethical challenges of health care work. It is a term which first appeared in the nursing literature, and, although other terms have been suggested, I think it fits. Moral residue is another term these authors refer to, which is the lingering feelings which persist after the “morally distressing” case has ended. As we deal with children and babies who are fragile, dependent, and may have life-long complications, the NICU and PICU are places where moral distress is likely to be frequent. How frequent it is, and what causes the situations most likely to lead to distress, where the questions that lay behind this systematic review.

They found 13 articles, of varying size and quality, (including one of ours); from the results of the systematic review article:

Common themes represented included disproportionate care, ‘aggressive’ use of technology, powerlessness, and communication around life and death issues. Interestingly, moral distress is generally reported as occurring because a provider feels she/he is ‘doing too much’….. The converse is rarely reported as causing moral distress, for example, deciding for palliative care in the face of uncertainty. Concepts of moral distress are expressed differently within nursing and medical literature.

One of their findings is the different ways in which moral distress is discussed in the articles, publications in the nursing literature frequently emphasize the subjective experience of the nurses, and the fact that they lack power and are having to provide interventions that they do not always agree with; they are sometimes portrayed as the victims of the aggressive care being perpetrated by the physicians. Whereas in the medical literature moral distress is described in terms of the objective situations that create confrontations or dilemmas. The reality is though, that physicians also experience moral distress (with about the same frequency as nurses), they also find themselves sometimes performing tasks and providing care which is against their own conception of what the best interest is for their patients.

What has been shown previously is that moral distress may lead to burnout, and decrease retention of staff. It is also probably unavoidable in intensive care, but we should, and could, work harder to minimize it, and minimize its impact.


About Keith Barrington

I am a neonatologist and clinical researcher at Sainte Justine University Health Center in Montréal
This entry was posted in Neonatal Research and tagged . Bookmark the permalink.

1 Response to Moral Distress among nurses (and others).

  1. Meredith McSwain, RNC-NIC says:

    Thank you for posting. After a particularly hard day in the NICU today, I feel the effect of moral distress and, after a number of years in this profession, I feel the moral residue that lingers. It is even harder living in a world where few know what we do and understand how one day of work can be uplifting, devastating and exhausting. Communication between physicians and nurses is crucial- prior to, during, and after events that lead to moral distress. We tend to mask our feelings and deal with things separately instead of working collectively to understand the feelings that naturally occur with loss. It is vital that debriefings occur after an event and that a collaborative environment exist to ensure all members of the healthcare team are heard. So often, good nurses leave the NICU, or the profession entirely, due to the gradual build-up of moral residue. I hope that with increasing publications on this topic, we can come up with better ways to retain members of our team.

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