title: A qualitative study exploring moral distress in the ICU team: the importance of unit functionality and intrateam dynamics.
abstract: OBJECTIVE
  Our study objectives were to determine the key sources of moral distress in diverse critical care professionals and how they manage it in the context of team-based models.
  
  
  METHODS
  Qualitative case study methodology using three recently resolved clinical cases.
  
  
  METHODS
  A medical and surgical adult ICU in a 900-bed academic, tertiary Houston hospital.
  
  
  METHODS
  Twenty-nine ICU team members of diverse professional backgrounds interviewed between March 2013 and July 2013.
  
  
  METHODS
  None.
  
  
  RESULTS
  All members of the ICU team reported experiencing moral distress. Intrateam discordance served as a key source of distress for all healthcare disciplines. Interviewees identified two situations where intrateam discordance creates moral distress: 1) situations involving initiation or maintenance of nonbeneficial life-sustaining treatments and 2) situations involving a lack of full disclosure about interventions. Healthcare professionals engaged in a variety of management techniques, which can be grouped according to maladaptive behaviors (pas-de-deux, "fighting," and withdrawing) and constructive behaviors (venting, mentoring networks, and building team cohesion). Maladaptive behaviors were more common in the surgical ICU. Constructive behaviors were more prevalent in the medical ICU and typically used by nurses and ancillary staff members. Physicians report becoming detached as morally distressing cases unfold, whereas nurses report becoming more emotionally invested.
  
  
  CONCLUSIONS
  This study identified the ways in which moral distress manifests across critical care disciplines in different ICU environments. Our results have potential implications for patient care. First, when clinicians alter the content of their goals-of-care conversations with patients or families to accommodate intrateam discordance (as part of the "pas-de-deux"), subsequent decisions regarding medical care may be compromised. Second, when different team members respond differently to the same case-with nurses becoming more emotionally invested and physicians becoming more withdrawn-communication gaps are likely to occur at critical moral distress junctures. Finally, our findings suggest that physicians and any healthcare professionals in surgical units might be susceptible to unmitigated moral distress because they report less engagement in constructive behaviors to recalibrate their distress.
authors.affiliation: 1Center for Medical Ethics and Health Policy, Department of Medicine, Baylor College of Medicine, Houston, TX. 2Houston Methodist Hospital System, Houston Methodist Hospital System Biomedical Ethics Program, Houston, TX. 3Weill Cornell Medical College, New York, NY. 4Houston Methodist Research Institute, Department of Medicine, Houston Methodist Hospital, Houston, TX. 5Critical Care Division, Department of Medicine, Houston Methodist Hospital, Houston, TX.
authors.forename: Courtenay R
authors.initials: CR
authors.lastname: Bruce
authors.forename: Susan M
authors.initials: SM
authors.lastname: Miller
authors.forename: Janice L
authors.initials: JL
authors.lastname: Zimmerman
mesh_terms: D003422:Critical Care / Q000523:psychology*; D034462:Dissent and Disputes; D005260:Female; D006126:Group Processes; D006801:Humans; D007400:Interprofessional Relations; D007406:Interview, Psychological; D008297:Male; D010348:Patient Care Team; D011368:Professional-Family Relations