In 2019, 9.3% of all newborns, or 349,290 infants, were admitted to a neonatal intensive care unit (NICU).1 While tremendous advances have been made in the resuscitation and initial care of infants born with critical illnesses, some will unfortunately die from complications related to their condition (in 2018, the mortality rate was 5.6 per 1000),2 while others will go on to develop complex chronic health conditions that require ongoing intensive therapies and extended hospital stays. Caring for infants and their families during this time can be very challenging work, and neonatal nurses can often find themselves in situations where the potential development of ethical dilemmas and moral distress exists. These situations are common in the NICU, and there are several reasons why they occur.3 The NICU is stressful by nature where the vulnerability of patients and decision making by proxy intersect in a place where prognostication can be difficult and the many different perspectives of stakeholders (nurses, physicians, parents, family members, etc) regarding medical futility and course of treatment may create conflict amongst team members. Nurses may also experience moral distress in the face of balancing patient-parent autonomy against harm and suffering and/or may feel ill-prepared to care for infants and their families because of a lack of education, training, or experience. Finally, a sense of failure might be felt by the nurse if the infant dies, especially if the infant was a primary patient. Regular exposure to these situations and feelings that may cause moral distress can lead to burnout and compassion fatigue, especially if nurses are not supported to process their feelings, promote their own self-care, and develop strategies for resiliency.

In 2016, the Critical Care Societies Collaborative (CCSC) published a call to action to bring awareness to the problem of burnout syndrome that has been increasing among those employed in high-stress positions, including all types of healthcare professionals.4 Unfortunately, critical care healthcare professionals have one of the highest rates of burnout syndrome, which can adversely affect the ability to properly care for patients and families over time. These authors urged the development of interventions to mitigate the effects of burnout syndrome, and professional societies were called out as a key stakeholder that could educate and inform their members of risks of burnout syndrome and compassion fatigue.4

Furthermore, the National Association of Neonatal Nurses (NANN) position statement #3067 NICU Nurse Involvement in Ethical Decisions (Treatment of Critically Ill Newborns),5 originally published in May 2016 and reaffirmed in June 2021, states that "the process of making ethical decisions in the NICU should incorporate family desires, infant conditions, and the ability of the healthcare team to provide meaningful care" and advocates for NICU nurses to be part of the multidisciplinary team that makes these types of decisions.5 NANN also recommends "education for nurses in the theory and practice of ethics in healthcare, conflict resolution, and bereavement support training."5

Having the ability to recognize and then address any ethical issues that are encountered is an essential skill for nurses to embrace as it will enable them to advocate for and provide safe and ethical care for their patients, while also protecting themselves from burnout and compassion fatigue.6 Nurses can improve their knowledge and overall understanding of ethics and increase their resiliency by seeking out opportunities to learn and grow from the challenging clinical situations that they face.6

This is an area of critical attention to promote the health and well-being of neonatal nurses while acknowledging the infants and families we care for. I believe that Advances in Neonatal Care can provide the perfect forum for the presentation of articles to inform and educate neonatal nurses, along with other healthcare professionals, how to identify and manage ethical issues and dilemmas in the NICU that have the potential to lead to burnout and compassion fatigue. Nurse authors can share their experiences, and those who seek information may earn and grow from their processes and outcomes. Articles may be research-based, opinion pieces, or debates about choosing a course of action. Dilemmas may be related to challenges in the care of the mother and the fetus or the infant. Controversies in social impact of maternal behavior on the pregnancy are included. Nurses' feelings about provision of care to neonates who are very young, sick, or genetically impaired may be reported. Reports on special programs to provide palliative, hospice, and/or end-of-life care to newborns would also be of great interest. Creating continuing education opportunities from submitted articles might also be possible.

If you have experienced a challenging ethical dilemma that you think might make for an interesting case study or opinion piece to share with your neonatal colleagues, or if you have original research, evidence-based practice project, literature review, or other type of project, I hope you might consider submitting your work for the Ethical Issues in Neonatal Care section. If you have any questions regarding a potential submission, please contact me at mailto:[email protected] to discuss.

Christine A. Fortney, PhD, RN

Section Editor, Ethical Issues in Neonatal Care

References