Ethical Dilemma in Critical Care Nursing

The intensive care unit (ICU) is a stressful setting where medically unstable and potentially vulnerable patients are admitted and treated. Managing patients with high mortality and morbidity and those who are unable to respond to treatment and interventions is a traumatic experience for critical care nurses. Critical care nurses, dealing with work-related stresses, emerging from end-of-life discussions and prolongation of life, are confronted with the ethical dilemma of moral distress that has significant clinical implications on the efficiency of healthcare delivery. The paper assumes a specific nursing position on the ethical predicament of moral distress in critical care nursing by explicating the impact of moral distress on patients and on nursing research and education; and also recommends the utilization of information technology to relieve of the moral distress in critical care nursing practice.

Dimensions of Moral Distress: Impact of Ethical Dilemma on Nurse Practitioners, Quality of Care, Patient and Role of Nursing Knowledge

Moral distress in critical care setting occurs when nursing professional faces organizational barriers in implementing the right course of action. She feels obliged to take a morally responsible decision on the basis of appropriate strategies. However, she is obstructed y internal and external institutional constraints to do perform morally sensible actions (Rushton, Caldwell & Kurtz, 2016). Moral distress is entrenched in critical care nursing so that nurses are more likely to be victims of moral distress than physicians partly due to the former’s seeming powerlessness to make decisions and their feeling of being silenced at times of morally complex communications (Rushton et al., 2016; Moss et al., 2016). Moral distress is an ethical problem that has severe repercussions for nursing profession and healthcare deliver.

Effects of Ethical Dilemma on Nurses, Patients, and Quality of Care

Research has shown that continued exposure to ethical dilemma contributes to nurses’ increased feelings of powerless and subsequent isolation from morally complicated scenarios. Oh and Gastmans (2015) indicated that long-term moral distress can aggravate withdrawal, emotional exhaustion, depersonalization toward patients, and other symptoms of burnout syndrome. Moral distress demoralizes critical nurses’ ability to provide patient care, hampers their capability to perform expected job responsibilities, and diminish the amount of time spent with patients and families (Mealer & Moss, 2016). What is more, critical care nurses are likely to leave the profession on account of moral distress (Rushton et al., 20156). Dyo et al. (2016) noted that the high turnover rates of critical care nurses can augment healthcare costs, decrease productivity, worsen staff morale, and reduce the overall quality of care due to dislocation of experienced nurses from the ICU. Dodek et al. (2016) examined the demographic characteristics related to moral distress in ICUs. They found that nurses were affected more by moral distress compared to physicians and that moral distress score being directly related to the tendency to leave the ICU job. Also, age was found to be inversely related to moral distress. Hence, moral distress in ICU varies with profession, age, and years of service.

Moral distress research program. A theoretical framework to understand moral distress is the sociological perspective that urges advocacy of moral spaces and interventions to mitigate the scope of moral distress. Pavlish et al. (2018) proposed a moral distress research agenda based on investigation of strong moral communities, individual and team-based risk reduction and treatment strategies, and knowing the moral distress of patients, families, and surrogates in providing secure and quality health care and retaining nurses. Moral empowerment programs by hospital administrators in critical care units can sufficiently decrease the mean score of moral distress (Abbasi et al., 2018).

Factors and Consequences of Moral Distress

Moral distress may originate from the perception of delivery of inadequate care. Mealer et al. (2016) defined inadequate and inappropriate care in terms of futile treatment, inadequate pain relief, and false hope to patients or their families; hastening the dying process; disregarding patients’ wishes; working with other caregivers who may not be competent to perform their job responsibilities. Internal constraints include lack of nursing skills. External constraints are specific policies, lack of a collegiality, the perceived hierarchical structure of healthcare institutions, and inadequate communication aspects of the ICU work environment (McCarthy et al., 2015; Bruce et al., 2015). Conflicts between hospital and unit policies and critical care nurses’ belief systems and values commonly give rise to the ethical challenge of moral distress.

Moral distress cause many complications such as job dissatisfaction, loss of capacity for caring, and turnover for nurses and poor quality of care for patients as well as health system (Abbasi et al., 2018). Moral distress also results in burnout among critical care providers. Fumis et al. (2017) studied the relation between moral distress and burnout. They concluded that moral distress emerging from therapeutic stubbornness and the requisite of futile care is a concern for critical care professionals leading to severe burnout. Henrich et al. (2017) conducted a qualitative study to investigate the consequences of moral distress in critical care unit. They found that as a result of moral distress healthcare providers experience negative emotional effects, patient care is undermined, and nurse workers are prone to leave intensive care unit job.

Mitigating Moral Distress via Information Technology

Moral distress can be alleviated to certain extent in critical care nursing related to admission and discharge of ICU patients with the help of information technologies. The data regarding the opinions of nurses collected by using this process can be used to improve decision-making about resource allocation in intensive care (Oerlemans et al., 2015). Ethical dilemmas associated with futile care, long duration of treatment, and intensive treatment are widespread in critical care unit. Medical technology can rightly fit into the ICU environment to overcome these treatment decisions.

Conclusion

Critical care setting is a highly stressful environmental culture and is also the breeding ground of moral distress for nurses who suffer from severe burnout, negative emotional consequences. The ethical dilemma adversely affects healthcare delivery due to turnover of critical care healthcare providers and poor patient outcomes. Moral empowerment intervention and organizational policies are required to handle the problem.

References

Abbasi, S., Ghafari, S., Shahriari, M., & Shahgholian, N. (2018). Effect of moral empowerment program on moral distress in intensive care unit nurses. Nursing ethics, 0969733018766576.

Bruce, C. R., Miller, S. M., & Zimmerman, J. L. (2015). A qualitative study exploring moral distress in the ICU team: the importance of unit functionality and intrateam dynamics. Critical care medicine, 43(4), 823-831.

Dodek, P. M., Wong, H., Norena, M., Ayas, N., Reynolds, S. C., Keenan, S. P., ... & Alden, L. (2016). Moral distress in intensive care unit professionals is associated with profession, age, and years of experience. Journal of critical care, 31(1), 178-182.

Dyo, M., Kalowes, P., & Devries, J. (2016). Moral distress and intention to leave: a comparison of adult and paediatric nurses by hospital setting. Intensive and Critical Care Nursing, 36, 42-48.

Fumis, R. R. L., Amarante, G. A. J., de Fátima Nascimento, A., & Junior, J. M. V. (2017). Moral distress and its contribution to the development of burnout syndrome among critical care providers. Annals of intensive care, 7(1), 71.

Henrich, N. J., Dodek, P. M., Gladstone, E., Alden, L., Keenan, S. P., Reynolds, S., & Rodney, P. (2017). Consequences of moral distress in the intensive care unit: a qualitative study. American journal of critical care, 26(4), e48-e57.

McCarthy, J., & Gastmans, C. (2015). Moral distress: a review of the argument-based nursing ethics literature. Nursing ethics, 22(1), 131-152.

Mealer, M., & Moss, M. (2016). Moral distress in ICU nurses. Intensive care medicine, 42(10), 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), 368-376.

Oerlemans, A. J., van Sluisveld, N., van Leeuwen, E. S., Wollersheim, H., Dekkers, W. J., & Zegers, M. (2015). Ethical problems in intensive care unit admission and discharge decisions: a qualitative study among physicians and nurses in the Netherlands. BMC medical ethics, 16(1), 9.

Oh, Y., & Gastmans, C. (2015). Moral distress experienced by nurses: a quantitative literature review. Nursing Ethics, 22(1), 15-31.

Pavlish, C. L., Robinson, E. M., Brown-Saltzman, K., & Henriksen, J. (2018). Moral Distress Research Agenda. In Moral Distress in the Health Professions (pp. 103-125). Springer, Cham.

Rushton, C. H., Caldwell, M., & Kurtz, M. (2016). CE: Moral Distress A Catalyst in Building Moral Resilience. AJN The American Journal of Nursing, 116(7), 40-49.

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