Critical care nurses in the ICU face challenging ethical dilemmas, which put them at higher risk for moral distress than nurses in other specialties

As an ICU nurse, you know the excessive stress of caring for critically ill patients. But did you know the litany of ethical dilemmas you face day in, day out put you at higher risk for moral distress than nurses in other specialties? It's true. And if you're not careful, your chance of experiencing burnout syndrome also increases.

Ethical Dilemmas in Nursing

Ethical dilemmas litter ICUs. A 95-year-old with full code status and an erratic heart rhythm is admitted from a dementia ward. Families refuse to palliate an unresponsive 76-year-old ventilated patient because they live on his pension. A ventilated cancer patient shrivels into a yellowed mummy while his family fights over end-of-life care.

Despite medications for sedation and analgesia, patients still suffer in the ICU. Patients, heavily sedated and medicated for pain during the acute phase, must wake up for nurses to assess their breathing status. After their condition improves, ventilated patients receive minimal sedation to prepare for extubation.

Painful care includes endotracheal tube suctioning, central and arterial line insertion, patient lifts, Bipap machines, tracheostomy care, and regular turning and cleaning for urine and fecal incontinence. 

Patients often hit the nurses during care procedures or mouth the word “no,” but family decisions dictate care.

Moral Distress in Nursing

While ethical debates in clinical settings can produce productive and positive outcomes, they can also become destructive if not appropriately addressed—enter moral distress and its impact on your psychological and emotional well-being.

In 1984, Andrew Jameton defined moral distress as a phenomenon in which one knows the right action to take but is constrained from taking it. In other words, nurses often experience moral distress when they're required to provide patient care that goes against their personal and professional ethics.

Sources of moral distress among nurses include:

  • Continued life support or care with no chance of recovery.

  • Inadequate communication about end-of-life care.

  • Insufficient pain relief options for patients.

  • Staff not trained to provide the required care.

  • False hope given to patients and families.

By and large, a key element in moral distress comes from a sense of powerlessness and the inability to carry out an action that you perceive as ethically appropriate.

If you feel distressed after giving painful, futile care to a patient with a poor projected outcome, you could be experiencing moral distress. You may also feel conflicted between patient/family rights and your nursing ethics to advocate and protect your patient.

Nurses often experience moral distress when they're required to provide patient care that goes against their personal and professional ethics.

Burnout Syndrome in Nursing

Critical care nurses suffering from burnout syndrome are more apt to leave the ICU and sometimes the nursing profession altogether. But what is burnout syndrome exactly? It’s a work-related condition characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment.

Burnout syndrome manifests when your self-worth and expectations do not match those of your employer, causing symptoms such as:

  • Physical Exhaustion

  • Emotional Distress

  • Depression

  • Judgment Errors

  • Increased Sick Days

5 Prevention Strategies for Moral Distress and Burnout

In critical care nursing, preventing moral distress and burnout begins with caring for yourself. You need to advocate for your mental, emotional, and physical health. Standing up as a group of critical care nurses will empower nurses everywhere to speak out for their health and welfare.

If you suspect you might be experiencing moral distress, you must identify, assess, and address it immediately. Here are five prevention strategies for you to consider:

1. Be Proactive: Share your knowledge about moral distress and burnout with your colleagues. Moral distress is often not openly discussed. Many nurses suffer in silence, not knowing or understanding the underlying cause of their angst.

2. Engage in Self-Care Practices: To cope with the added stress of working in an ICU, you must take care of yourself. Eat healthy meals and get regular exercise and rest. Take time for daily meditation and practice mindfulness. Try journaling your feelings. Make emotional resilience a priority and a goal. 

3. Seek Support: Nurses who grapple with moral distress and burnout often isolate themselves, too embarrassed to reveal a flaw or weakness. If this is you, do you know what support networks are available? Some hospitals have an employee assistance program (EAP). You might also consider speaking with a counselor, nurse mentor or participating in peer conversations with your colleagues. 

4. Ethical Reflection: Do you know your nursing ethical principles and boundaries? Have you considered keeping a journal of ethical dilemmas you encounter? Writing will often help you process your feelings and allow for self-reflection. Ask for professional counsel from an in-house ethics physician for especially troubling situations.

5. Education and Communication: Ask your manager to provide ongoing education about end-of-life care ethics and how to deal with difficult family situations. Encourage open communication with family members about their loved one's medical status.

Moral distress varies in intensity and looks different from nurse to nurse. Check out this Moral Distress Quick Reference Guide from the American Association of Critical Care Nurses.

Moral Distress at the Systemic Level

Moral distress isn't something you should have to face alone. Management and administrative figures within a healthcare organization are responsible for finding ways to prevent moral distress and burnout in nursing.

Managerial Responsibility

Managers can decrease moral distress and burnout in their units by offering debriefing sessions and providing education on ethical dilemmas. They can also limit overtime for nurses struggling with burnout, provide a different rotation with better nurse mentors, ensure adequate staffing, and keep an open door to their office. 

Administrative Responsibility

Business models for healthcare are complicated. Most need to be updated and capable of achieving current healthcare goals. Traditional models address sickness, whereas the current models focus on improving patient health.

Administrators need to understand the implications of their business models on moral distress and burnout and provide institutional support to critical care nurses who face these dilemmas.

Real change begins with recognizing the problem, supporting ethical committees to address the issues, and encouraging interdisciplinary collaboration to find solutions. 

In Summary

Nurses working in ICUs face ethical dilemmas when their care causes pain and suffering to patients without hope of recovery. Ethical dilemmas may lead to moral distress and burnout. However, critical care nurses can acquire emotional resilience through self-care practices and seeking help through support networks.

In addition, education and institutional support empower nurses to discuss end-of-life issues with patients and families during family discussions. Don't let moral distress and burnout take hold in your lives. Instead, use our five strategies to embrace emotional resilience for you and your colleagues.

Alice Blackmore, MN, RN, Content Writer

Alice is a registered nurse and healthcare writer. She has more than 20 years of nursing experience, which ranges from labor and delivery to long-term care, with pediatrics, community nursing, and critical care sandwiched in the middle.

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