Moral Agents on the NICU Stage

Abstract

T he target article (Barr, 2022) brings the reader to a theatre in which the NICU is on stage. There’s a cast of characters, including neonatologists, surgeons, cardiologists, nurses, therapists, and parents. Despite their shared purpose -to provide care for the babies -collisions occur on this stage, within and between the different specialties and interests represented by each group. Continuing with our theatre metaphor, Peter Barr’s research aims the spotlight on the NICU nurses. They are the essential protagonists, whose central roles are played while providing continuous, 24/7 care to the babies and serving as the interface with parents. The nurses’ role is crucially important and can be exceedingly difficult to play. Indeed, we learn that NICU nurses are the players most vulnerable to moral distress and burnout. Yes, this is a morality play! If there were a script or a Playbill, morals and ethics would pervade the lines. Everyone in the cast is a moral being. Each brings a personal moral code to the shared stage. We would note that the stage is part of a larger theatre in which actors, numerous creative specialists, stagehands and administrators all perform according to standards traceable to ethical codes and moral foundations. With so many players and priorities, it is inevitable that some situations evoke different and conflicting -but ethically based responses. Hence, moral dilemmas arise. When such dilemmas go unresolved, accumulate, and reoccur, moral distress can emerge. Like other forms of stress, it can become toxic. (Barr’s definition focuses on institutional barriers to human action, but we recognize both institutional barriers and differences between individuals, are all morally driven.) In addition to moral distress, burnout occurs. There are instruments to measure burnout. Barr used one with which he distinguished among three dimensions of burnout: Demoralization, Exhaustion, and Loss of Motive. Barr has been sleuthing around emotional, personal, and moral dimensions of the NICU.1, 2, 3 His studies in Australia and by others in Italy and the U.S. have documented moral distress and burnout in NICU nurses. Such effects are more prevalent and damaging to nurses than to other NICU professionals. Overall, we see the deep questions unfold: how does the provision of life-saving and loving care become harmful to a professional provider’s physical and mental health? Here, the plot thickens, becoming both drama and a detective story. Methodologically, Barr’s (2022) work is “state-of-the-art”. He collected survey data from a cohort of nurses in six, Level 3 and Level 4 NICUs in New South Wales, Australia. There were 142 respondents, representing 24% of those eligible to participate in a standardized and validated written survey called the pediatric Moral Distress Scale (MDS-R), along with another scaling instrument aptly named the Burnout Measure (BM). In all, there were some 38 survey items, each answered with 5 – 7 “levels” or weightings. Thus, each respondent provided a large set of values. The combined mass was voluminous and complex. Barr then applied a series of computer-based analyses that addressed the statistical associations among the various survey elements. Table 1 shows examples of events selected by Barr that could conflict with a nurse’s morals or professionalism and lead to moral distress. Think of each descriptor as an item in one of the surveys. Then note the three dimensions of care: Futile, Compromised, and Untruthful Care. They were used as “factors” and appear as headings in Table 1. Each factor was tested for its association with each kind of event. You can understand a factor’s meaning from the items beneath each one. Before the factor analysis is completed, each kind of event is examined in relation to each of the factors. The strength of these many associations are analyzed by calculating “regressions” which examine whether one variable changes systematically in relation to changes in another. When strong relations are found this way, it helps identify significant associations. This is a statistical method that can reduce a large and unwieldy set of numbers into a smaller set of “factors” which, can bring helpful order and clarification to an otherwise bewildering set of results. In the Australian hospitals, about S C I E N C E D E S K – T H R O U G H A N E T H I C A L L E N S Moral Agents on the NICU Stage Target Article: Peter Barr (2022) Moral distress and burnout in NICU Nurses, Journal of Obstetric, Gynecologic, & Neonatal Nursing. 51, 461-449. https://doi.org/10.1016/j.jogn.2022.04.007 DOI: 10.14434/DO.V16I2.36239 Jeffrey R. Alberts, PhD Indiana University, USA, NFI Science Committee, Associate Editor for Science David H. Smith, PhD Indiana University, Professor, Director Emeritus, Poynter Center for the Study of Ethics, USA