The Power of One: Moral Distress Is
Common in Critical Care Nursing
By Kimberly Brown, RN, MSN, FNP, CS, CEN
Ethics Work Group
Moral distress is an all too common and frustrating aspect of
critical care nursing. Just consider the following case scenarios.
Because of staffing constraints, Connie must again be assigned
three patients. The one familiar face is Mr. C., a 60-year-old patient with
acute pancreatitis and dehydration. What initially was believed to be a
pancreatic ampula stone, has turned out to be adenocarcinoma. Mr. C. and his
wife are being advised of his diagnosis as Connie begins her shift.
Patient #2 is a one-day postoperative CABG who is still intubated
secondary to a lengthy smoking history. Patient #3 is a 33-year-old motor
vehicle collision patient, postsplenectomy, right pneumohemothorax with
continued bleeding. Nurses on the previous shift have spent the past two hours
pushing blood and crystalloids to maintain blood pressure.
Although Mr. C. is Connie's most physiologically stable patient,
it is clear by the way he grips her hand and looks desperately into her eyes
that he needs her psychosocial support.
Eleven hours later, patient #3 has returned to OR; patient #2 has
failed weaning and requires frequent sedation and analgesia; and Mr. C. is being
transferred to the floor. Connie catches a last glimpse of him as he is wheeled
out of the unit. Although she knew what he needed, she didn't provide it. She
feels as if she has failed him.
Emily is a 48-year-old woman with stage IV breast cancer with
metastases to the spine and now the brain. Since her admission with status
epilepticus two days ago, she has had a CT, MRI, multiple LPs, an EEG and
numerous blood tests. She is mechanically ventilated and, despite weaning off
lorazepam, her GCS is <5. John, the RN, is listening to the physician tell
Emily's husband and two teenage daughters that she is much better today, that
her seizure activity has decreased and the prognosis is good. He assures them
that she will be home by Christmas, but will need frequent invasive tests to
monitor her progress.
John knows that Emily will probably not survive this
hospitalization and approaches the physician to discuss the information given to
the family. The doctor simply rolls his eyes and mutters as he walks away. Once
again, John finds himself knowing that futile care is being given with the
potential for prolonged suffering and false hopes for the patient and family.
And, once again, he is encouraged by his supervisor to keep quiet.
Conflict in Action
The hallmark of ethical dilemmas, which occur daily in the
critical care unit, is the conflict between rights, duties, values and
principles. In the scenarios presented, the nurses clearly know the correct
For Mr. C., the nurse needed to be able to spend uninterrupted
time with him and his wife as they begin to process his catastrophic diagnosis.
The nursing relationship she had developed with the family would enhance
communication and caring on all levels. However, staffing constraints and
patient acuity prevented her from acting on what she knew was the right thing to
In Emily's case, John recognized the lack of veracity and false
hope being communicated to the vulnerable family. He also recognized the
potential discomfort continued invasive procedures would bring. Nevertheless, he
was expected by the culture within his institution to act as silent partner to
these occurrences, which he obviously believed to be morally wrong.
Knowing What's Right
What Connie and John experienced was moral distress. In studying
nursing ethics, Andrew Jameton acknowledged that many nursing narratives deemed
to be "moral dilemmas" did not meet the criteria. In contrast to dilemmas or
uncertainty, moral distress involved knowing the right thing to do but, for a
multitude of reasons, being unable to act on it. Since this introduction into
the literature, many sources are beginning to recognize that moral distress is
one of the leading causes of burnout and loss of nurses' moral integrity.
Alvita Nathaniel describes moral distress as the pain or anguish
affecting the mind, body or relationships in response to a situation in which
the nurse is aware of a moral problem, acknowledges moral responsibility and
makes a moral judgment about the correct action, yet, as a result of real or
perceived constraints, participates in a perceived moral wrongdoing.
Given the complex and demanding atmosphere of the critical care
unit, nurses are at an even higher risk of experiencing moral distress. Factors
contributing to this risk include the significant shortage of critical care
nurses, unhealthy healthcare systems, high acuity patient populations, the
multitude of technological advances in care of the critically ill, and novice
nurses with inadequate training forced into care of multiple critically ill
patients. Finding their "bold voices" will assist critical care nurses in the
identification and resolution of these challenging issues. How do we begin?
The AACN Synergy Model for Patient Care, developed by AACN
Certification Corporation, recognizes that the needs or characteristics of
patients and families influence and drive the characteristics or competencies of
the nurse. Nurse characteristics in this model are clinical judgment,
advocacy/moral agency, caring practices, collaboration, systems thinking,
response to diversity, clinical inquiry and facilitator of learning.
Synergy results when the patients' needs and characteristics are
matched with the nurses'competencies. For synergy to exist and for moral
distress to be minimized, support must be given by the profession and individual
institution to allow each nurse to achieve the desirable competencies.
For example, providing ample training to novice critical care
nurses and continued education to experienced clinicians supports the
development of clinical judgment. Classroom training is not sufficient. Instead,
bedside experience must provide mentored practice to allow for safe and
modulated growth in new patient care situations. Ethical decision making and
understanding of system support and how it interfaces with nursing will assist
each nurse in finding her personal way to navigate patient care dilemmas and
avoid moral distress.
Speaking up about the truth with "bold voices" will help critical
care nurses to provide optimal care.
1. Nathaniel A. Moral distress among nurses. American Nurses
Association Ethics and Human Rights Issues Update. Spring 2002;4.
2. Jameton A. Dilemmas of moral distress: moral responsibility
and nursing practice. AWHONNS Clin Issues Perinat Womens Health Nurs.
Across the Continuum of Care: Inclusive Leadership Supports
Progressive Care Nurses
By Melissa A. Fitzpatrick, RN, MSN, FAAN
Cochair, Progressive Care Task Force
Since their inception, progressive care units have represented
the "step down" from critical care and the "step up" from the general
medical-surgical floor. Patients on progressive care units are typically not
sick enough to be in an ICU but too sick for medical-surgical, nurse-to-patient
ratios. As a result, progressive care nurses often feel as though they reside in
"no-man's land"�neither a part of the critical care service nor a part of the
Traditional organizational charts place progressive care units in
the medical-surgical arena, though the two care environments are very different.
Today, again despite differences, progressive care units are often grouped with
critical care. What can a progressive care nurse do? Where do they go for
resources and support? How can they get past the "us versus them" scenario that
is all too common between the staffs at various points along the continuum of
One answer is a reporting mechanism that has staff at various
points along the continuum of care accountable to the same leadership team. With
the advent of service lines, grouping like patients and providers into a
division or service has helped to ameliorate the divisiveness and isolation that
has plagued progressive care unit staff.
For example, having one director over the coronary care unit,
cardiothoracic and the cardiac progressive care unit can bring the environments
of care and the care providers together. Instead of being distracted by the
geography in which the care is delivered, one leadership team responsible for
care delivery throughout the acute phases of cardiac care can take a more
patient-focused approach to problem solving. When one director or manager is
responsible for these three cardiac units, he or she can see the issues more
globally and remove the "us/them" language from conversations. In effect, such
an organizational structure helps to put the "we and us" back into the dialogue.
This type of shared leadership structure can best support a
philosophy of shared decision making, open dialogue and mutuality. Instead of
saying, "That's how we do it in the CCU," the conversation becomes more driven
by what the cardiac patient and family need as they move through the continuum.
The "dumping syndrome" is no longer acceptable when all nurses within the
service are accountable to the same standards of practice and communication
expectations, and to seeing the patient's needs through to discharge. When
nurses are all part of the same larger team, all reporting to the same
leadership team, it can break down many of the barriers and obstacles that have
fragmented patient care for too long.
A Success Story
I have seen such an inclusive leadership concept work wonders in
a cardiac setting in New England, after the director responsible for the CCU and
CT ICU resigned. The CPCU director, who had been in his role for many years, had
dealt with many of the "stepchild" symptoms related to managing a progressive
care area. I decided that appointing him to also lead the two critical care
areas might help to bridge the gaps that existed among these areas.
The assistant directors in the critical care areas joined the
assistant director of the CPCU and two clinical nurse specialists in rounding
out the leadership team. They spent considerable time initially getting to know
the director, who had to convince the critical care nurses that he could support
them and advocate for their needs. At weekly team meetings, issues about patient
flow, giving report, visiting hours and floating quickly surfaced.
At first, the dialogue centered around "turf," with each leader
advocating for what was best for his or her own staff. However, as greater
understanding developed, the dialogue became focused on the patient's
experience, and what could be done to best meet the patient's wishes and to
achieve the best outcome for the patient. Gradually, the walls, both physical
and imaginary, started to crumble.
The CPCU staff was teamed with critical care nurses to learn new
assessment skills, while enhancing continuity of care. When the critical care
nurses reluctantly accepted an assignment on the CPCU, they learned that the
CPCU nurses had admirable expertise, time management and delegation skills.
Issues, concerns and praise were shared openly at joint staff meetings, which
were scheduled monthly. Social events encompassed all three areas, and an
all-inclusive cardiac esprits de corps evolved.
Embracing such an inclusive leadership model was certainly a
stretch for all involved. By focusing on how the areas were alike instead of how
they were different, the staff involved was able to rise to the challenges. The
outcomes were positive for the patients, for staff retention and comradery, and
for leadership development. An unexpected outcome was that the physicians also
started to communicate better.
Although not a panacea, this model moved the organization closer
to a patient- and family-centered environment in which cardiac nurses, including
CPCU nurses, made their optimal contribution.
NTI Session Targets Conflict: Learn How to Maximize
Using Mediation and Facilitation to Improve Patient Safety" is
the topic that will be discussed during a special preconference session at
AACN's 2003 National Teaching Institute and Critical Care Exposition, May 17
through 22 in San Antonio, Texas.
AACN is being joined by other members of the Nurse Manager
Leadership Collaborative, the American Organization of Nurse Executives and the
Association of periOperative Registered Nurses in sponsoring this full-day
session on Sunday. Presenters Debra Gerardi, RN, MPH, JD, and Ginny Morrison,
JD, will discuss the importance of managing competing interests in the creation
of a culture of safety.
Geared to all levels of clinicians, this session will focus on
skills that are applicable for managing conflicts involving patients, families
and clinical team members. Techniques used in mediation and facilitation will be
applied to the creation of a critical care patient safety team to demonstrate
how conflict management techniques can be used to overcome the barriers that can
prevent the implementation of safe clinical practices.
The participants will have the opportunity to practice the skills
needed to resolve conflict as they rehearse a crucial conversation involving
disclosure of a clinical error. Areas that will be covered include an effective
patient safety program, JCAHO requirements for patient safety, common conflicts
that can lead to unsafe clinical practices, the symptoms of conflict, the
importance of confidentiality in mediation, and the important components of a
For additional information about or to register for NTI 2003,
call (800) 899-2226 or visit the NTI Web site at
> NTI. The discounted, early-bird registration deadline is April 8.
PACEP Level II Topics Debut Online
Level II topics for the Pulmonary Artery Catheter Education
Project are now available. PACEP is a state-of-the-art educational program on
how to use the pulmonary artery catheter in the clinical environment and measure
learning outcomes for the end-user. The goal is to provide efficient
transformation of useful hemodynamic information to allow the clinician to
practice in a safe and competent fashion through Web-based technology.
Level II topics are Physiologic Concepts of Hemodynamic
Monitoring Part II, Interpretation of Hemodynamic Information Part II,
Therapeutic Interventions Part II, Hemodynamic Waveforms: Abnormal Waveform
Values and Patterns Part II, and Technical Aspects of Hemodynamic Monitoring
PACEP is a collaborative education effort by AACN, the American
Association of Nurse Anesthetists, the American College of Chest Physicians, the
American Society of Anesthesiologists, the American Thoracic Society, the
National Heart Lung Blood Institute, the Society of Cardiovascular
Anesthesiologists and the Society of Critical Care Medicine. It is not intended
to be a credentialing tool or a means of determining individual competency.
Although there is a fee to obtain continuing education credit, access to PACEP
is free. Visit
to register and explore this comprehensive educational program.
Practice Resource Network
Q: I know that transducers need to
be leveled at the phlebostatic axis when monitoring, but I am getting
conflicting information about where the phlebostatic axis is located. What is
the phlebostatic axis and how do I locate it?
A: The phlebostatic axis is an
external landmark for locating the left ventricle and aorta. When using a
transducer to monitor pressures in the circulatory system, systemic or
intracardiac, the stopcock instead of the transducer is used as the zeroing
point, and must be referenced to the phlebostatic axis. Davoric recommends that
the stopcock closest to the transducer be used as the zeroing port.1
The vertical distance between the catheter tip and the transducer
creates a hydrostatic pressure in the fluid-filled system. If the zero point is
not level with the phlebostatic axis, the fluid in the system will create an
increase or decrease in the pressure being applied to the transducer.1-3
For every inch of deviation from the phlebostatic axis, the
change in pressure is approximately 1.82mm/Hg. For example, placement 1 inch
above the phlebostatic axis will cause the pressure to be 1.82 mm/Hg lower than
actual, and 1 inch below the phlebostatic axis will cause the pressure to be
1.82mm/Hg higher than actual.
To determine the phlebostatic axis, place the patient in a supine
position. Draw an imaginary vertical line down the patient's chest from the
fourth intercostal space at the sternal angle; then draw an imaginary horizontal
line midway between the patient's anterior and posterior chest wall. The
intersection of the two lines is the phlebostatic axis. To ensure that the
reference point remains consistent and pressures are accurately trended, mark
the location with an indelible marker.1,2
Q: What is the recommended method of
securing or stabilizing the transducer and the zeroing stopcock?
A: Different methods can be used to
stabilize the transducer system. When establishing the standard for your
hospital, consider factors, such as ease of leveling the zeroing point to the
phlebostatic axis, visibility of the transducer system, potential contamination
of the system, potential artifact related to movement of the transducer and
In one method, the transducer(s) is positioned on a transducer
holder and mounted to an IV pole. This method allows for leveling the
transducer(s) at one time and keeps the transducer system visible. However, it
requires that the system be releveled each time the patient is repositioned.
Another method involves taping the transducer to the patient at
the phlebostatic static axis.1 With this method, the zero point moves with the
patient but may require taping multiple transducers to the patient, increasing
the potential for contamination when the system is opened for zeroing, causing
discomfort when the patient is turned to the side of the transducer and
requiring that a portion of the patient's chest be continually exposed so the
system remains visible.
A third method involves securing the transducer(s) to a rolled
towel that is placed on the mattress at the level of the phlebostatic axis.1
This method also allows for leveling the transducer(s) at the same time and
keeping it visible. However, it requires that the tranducer(s) be releveled with
changes in patient position and may increase the potential of contamination when
the system is opened for zeroing.
1. Darovic GO. Hemodynamic Monitoring: Invasive and Noninvasive
Clinical Application. 3rd ed. Philadelphia, Pa: WB Saunders Co; 2001:125-128.
2. McHale DJ, Carlson KK, eds. AACN Procedure Manual for Critical
Care. 4th ed. Philadelphia, Pa: WB Saunders; 2001:479-480.
3. Keckeisen M. Pulmonary Artery Pressure Monitoring [AACN
Protocols for Practice]. Aliso Viejo, Calif: AACN; 1998:10-12.
Myth vs. Reality: While You Were Sleeping�Do Patients Feel
By Susan Barnason, RN, PhD, CCRN, CS
Research Work Group
Myth: When a critically ill patient has received sedation, they
"appear" to be sleeping and therefore are not experiencing pain.
Reality: When sedation is used for the critically ill patient,
additional vigilance in the assessment and management of pain is warranted.
Sedation can be a necessary adjunct to nonpharmacological
interventions to manage critically ill patients, such as to manage mechanical
ventilator dysynchrony, relieve anxiety and dyspnea or reduce patient's oxygen
consumption.1-3 There is no best way to sedate a patient.
However, research is being reported on evidence-based practices
that can optimize sedation of the critically ill patient. An example is a
recently published algorithm for sedation and analgesia of the mechanically
ventilated patient.1 Even in this sedation protocol exemplar, best practices
indicate there is a need to assess if the patient is comfortable and if the
patient has met his goal. If the response is "no," the clinician is directed,
per the algorithm, to reassess the patient for pain, agitation and anxiety, and
delirium. These frequently occurring problems, which often cluster, challenge
nurses to become more analytical in the management of multifaceted patient
Establishing an optimal sedation goal based on the underlying
trigger for use of sedation is important. The critical care nurse should
consider whether patients are experiencing pain or experiencing other
physiological or psychological disruptions, such as hypotension, delirium and
sleep deprivation, which need to be addressed. Nurses' management of patient
sedation should be guided by assessment of both the level and the effectiveness
of sedation in attaining or maintaining the sedation goal.4
Nurses can evaluate a patient's level of sedation by several
means. Some of the sedation assessment tools that are available are the Ramsey
Sedation Scale, Motor Activity Assessment Scale, Riker Sedation-Agitation Scale
and Vancouver Interaction and Calmness Scale.
More recently, the use of technologies, such as the BiSpectral
Index Monitor, have gained attention as a potentially more objective means to
evaluate level of sedation.3 The BIS was originally developed for use with the
anesthetized patient by measuring EEG signal changes over time. The BIS score
can range from 0 to 100, with a higher value indicating higher levels of
consciousness. Although studies have recognized the usefulness of BIS monitoring
with patients who are receiving both sedatives and neuromuscular blocking
agents, additional research is needed to determine the optimal levels of BIS
scores that correlate to levels of sedation.
In evaluating sedation effectiveness, critical care nurses must
carefully consider other patient factors, such as pain, that can impact sedation
effectiveness. The experience of pain can often have a cumulative effect and
contribute to further physiological and psychological deterioration. In fact, a
large number of critically ill patients are not able to use a numeric or verbal
rating scale to indicate pain intensity, particularly when the patient is also
sedated. Pain assessment can be augmented with other pain assessment tools, such
as the Behavioral Pain Scale,5 which evaluates facial expression, upper limb
movement and compliance with ventilation. Equally important are other conditions
the patient has or is experiencing that could induce pain. All these factors
need to guide critical care nurses in determining the use of analgesics in
conjunction with sedation therapy.
The myth that the "sleeping" or sedated patient feels no pain
must be unraveled. The sedated critically ill patient is a challenge that can be
best managed initially by a comprehensive approach to patient assessment and,
ultimately, the patient's response to sedation management.
1. Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D,
Wittbrodt ET, Chalfin DB, Masica MF, Bjerke S, Coplin WM, Crippen DW, Fuchs BD,
Kellerher RM, Marik PE, Nasraway SA, Murray MJ, Peruzzi WT, Lumb PD. Clinical
practice guidelines for the sustained use of sedatives and analgesics in the
critically ill adult. Crit Care Med. 2002;30:119-141.
2. Arbour R. Sedation and pain management in critically ill
adults. Crit Care Nurse. 2000; 20:39-58.
3. McGaffigan PA. Advancing sedation assessment and promote
patient comfort. Crit Care Nurse. February 2002; (suppl):29-36.
4. Weinert CR, Chlan L, Gross C. Sedating critically ill
patients: factors affecting nurses' delivery of sedative therapy. Am J Crit
Care. 2001; 10:156-167.
5. Payen J-F, Bru O, Bosson J-L, Lagrasta A, Novel E, Deschaux I,
Lavagne P, Jacquot C. Assessing pain in the critically ill sedated patient by
using a behavioral pain scale. Crit Care Med. 2001; 29:2258-2263.
To Build a Collaborative Practice, APNs Must Promote Their
By Linda Griego Martinez, RN, MSN, CS, CCRN
Advanced Practice Work Group
Using advanced practice nurses as part of a variety of medical
practices is not new. However, many physicians still neither understand what
APNs do or how they can benefit their practices nor are they able to
differentiate between the different types of APNs.
The first step in building a role for yourself within a practice
is to articulate clearly what type of APN you are. Talk with your physician
colleagues about your educational background and what your education and
licensure allow you to do. The next step will be to explain how you can promote
the practice and enable them to provide optimal care.
Having a written proposal describing how you would fit into the
practice is a good idea. Because this proposal should include how billing would
be handled, you must be familiar with the laws concerning billing for the type
of practice model you are proposing.
Demonstrate how performing certain tasks, such as taking
histories and physicals, can save the physicians time. Reassure them that you
will need them to validate your competence for whatever procedures and orders
you write. This will also give them an idea of what your advanced degree allows
you to do.
Even after a practice decides that an APN will be useful, the
actual work may be slow at first. Physicians who have been accustomed to
practicing on their own may have a hard time knowing when to delegate tasks to
you. Again, take the initiative. Volunteer to do certain tasks for them such as,
"I'll be happy to round at skilled unit X on my way into work and check on Mrs.
Y's pacer incision for you." Accept whatever is agreed to with enthusiasm.
Some of the procedures or tasks they decide to delegate may be
those that they don't like to do or find too time consuming. Accept them with
enthusiasm, taking advantage of every opportunity to demonstrate that you are
knowledgeable and responsible. As you gain their trust, they will listen to your
suggestions more and more.
My physician colleagues not only have come to trust my physical
assessments, but now also rely on my ability to help them deal with any complex
psychosocial issues. This is one area where advanced education in family theory
and counseling has helped immensely.
Referring physicians and emergency department physicians are also
important to the practice. Again, being able to articulate who you are and what
your role is within the practice will help these other physicians understand how
to interact with you. Most are eager to have their patients' needs met in a
timely fashion. Always conduct yourself in a professional manner and ask
intelligent questions that show you understand what they need. You will find
them seeking you out because they know you are readily accessible and will act
Pharmacology Content Available for First Time at API in San
4 Sessions Designated for CE credit
Now, advanced practice nurses can earn CE contact hours with
pharmacology content at AACN's National Teaching Institute and Critical Care
Beginning with the 2003 Advanced Practice Institute, scheduled in
conjunction with the 2003 NTI in San Antonio, Texas, pharmacology content will
be offered at designated educational sessions. For 2003, these sessions are
"Pharmacological Paralysis: Look for the Twitch," "Scary, Scary Drug
Interactions, "The ABC's of Cardiac Pharmacology" and "Optimizing Hemodynamics:
Quick Tips for Drug Titration."
The NTI is scheduled for May 17 through 22.
A total of 6.0 hours of pharmacology content will be designated
in the "Rx" category and available to APNs who require this content for
licensure or recertification.