2023 • Developmental Observer • 15 A B S T R A C T — N I D C A P T R A I N E R S M E E T I N G 2 0 2 3 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 neonatolo- gists, 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 differ- ent specialties and interests repre- sented 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 provid- ing continuous, 24/7 care to the ba- bies 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 vul- nerable 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 accord- ing 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 ethi- cally based responses. Hence, moral dilemmas arise. When such dilemmas go unresolved, accumulate, and re- occur, 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 indi- viduals, are all morally driven.) In addition to moral distress, burn- out occurs. There are instruments to measure burnout. Barr used one with which he distinguished among three dimensions of burnout: Demoraliza- tion, Exhaustion, and Loss of Motive. Barr has been sleuthing around emo- tional, personal, and moral dimen- sions of the NICU.1, 2, 3 His studies in Aus- tralia 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 profession- als. 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 col- lected 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 writ- ten survey called the pediatric Moral Distress Scale (MDS-R), along with an- other scaling instrument aptly named the Burnout Measure (BM). In all, there were some 38 survey items, each answered with 5 – 7 “levels” or weight- ings. Thus, each respondent provided a large set of values. The combined mass was voluminous and complex. Barr then applied a series of comput- er-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 professional- ism 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, Compro- mised, 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 ex- amine whether one variable changes systematically in relation to changes in another. When strong relations are found this way, it helps identify signif- icant associations. This is a statistical method that can reduce a large and unwieldy set of numbers into a small- er 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 16 • 2023 • Developmental Observer one-third of the nurses witnessed forms of compromised care. Reports of futile care were fewer, from about 20% of respondents. Factor analysis revealed that moral distress from compromised care was more intense than from futile care and was asso- ciated with various forms of burnout, whereas futile care was associated with exhaustion. Untruthful care was reported much less frequently (5% of respondents) but it predicted burnout demoralization. Using the methods of factor analysis, Barr quantified a spectrum of emotions and perceptions that were affected by NICU procedures and, in turn, could affect the efficacy of their work with babies, families, and colleagues. In the target article, Barr elevates the analyses over that in past work, revealing a “multi-dimension- al” structure to each of the factors. This is partly the “art” of the “science”. Barr (2022) is advancing the field. He sees practical value in improving our understanding of the causes of moral distress. Each step of improved under- standing is a piece of evidence that can help identify precise changes can be enacted to reduce moral distress. When ethicists analyze a situation or evaluate a phenomenon, they often apply specialized conceptual tools. These tools enable them to organize their perceptions, to see patterns embedded in complex systems and identify the components that might be at play. Sometimes the goal is to make interpretations, judgements, or draw conclusions. Other times, the outcome is to pose key questions but leave it to others to answer them. Complex, interactive systems, such as a NICU, are often analyzed with the concept of “agency”. All the players in a NICU are “agents”, i.e., someone who can influence others and events, or be influenced by them. Nurses are arguably the major agents in the NICU, at least in the sense that they spend more time interacting with, and directly treating the babies. In addition, they are responsible for relating with and teaching the fam- ilies. Yet, the nurses’ agency is con- strained by that of the parents and physicians. This may help bring into focus some sources of their moral dilemmas. Barr eloquently noted that “NICUs are ethically complex settings staffed by nurses with different personal strengths and vulnerabilities” (p.447). Consistent with this, but more point- edly, is that nurses are moral agents. But there is a problem of balance within the constraints of their agency. The NICU nurses’ responsibilities are enormous in scope and importance. Their authority, however, is not propor- tionate to their responsibilities. This is apparent from the elements listed in Table 1. There is urgent need to under- stand the phenomena of moral dis- tress, burnout and agency. If nurses suffer moral distress and moral dis- tress leads to burnout, then we must address human suffering that arises in the service of others. If such suffering can be removed, mitigated, or pre- vented – it would be both ethical and practical to do so. It should be done. A NIDCAP perspective brought to the entirety of the issues raised by the Table 1: Events That Might Create Moral Distress in Nurses Futile Care • Initiate extensive life-saving intervention when it seems clear it will only prolong infant’s death • Follow parents’ wishes to continue life support even though it is not in infant’s best interest; • Witness parents’ receiving ‘false hope’ from doctors or nurses • Help maintain hopelessly ill infant on ventilator because no one makes decision to turn it off Compromised Care • Witness poor care quality due to poor communication among team • Work with inadequate levels (of competence or numbers) of staffing • Witness repeated unsuccessful performance of painful procedures on babies • Assist a doctor who is providing incompetent care Untruthful Care • Parents not given sufficient information to ensure informed consent • Follow parents’ unwise choice of care due to fear of litigation • Avoid action when staff colleague fails to report a medical error • Take no action about an ethical breach due to pressure not to report it 2023 • Developmental Observer • 17 target article and this commentary would surely assert that the key ele- ments include the family unit and the nurses. These agents must be brought to center stage. Similarly, through NIDCAP observations and reports, the critical relations in the dynamic agen- cy between nurses and parents would be in the limelight. Physician-nurse relations and the crafting of responsi- bility-authority balance would be next to explore. These extrapolations imply systems change which, handled with ethical care, can facilitate the healthy evolution of NICU culture and practices. References 1. Barr, P. (2017). Compassion fatigue and com- passion satisfaction in neonatal intensive care unit nurses: Relationships with work stress and perceived social support. Traumatology, 23(2), 214-222. https.//doi.org/10.1037/trm0000115 2. Barr, P. (2018). The five-factor model of person- ality, work stress, and professional quality of life in neonatal intensive care unit nurses. Journal of Advanced Nursing, 74(6), 1349-1358. https.// doi.org/10.1111/jan.13543 3. Barr, P. (2020). Burnout in neonatal care unit nurses: Relationships with moral distress, adult attachment insecurities, and proneness to guilt and shame. Journal of Perinatal Medicine, 48(4), 416-422. https.//doi.org/10.1515/pm-2019- 0323 A mother's supporting handNIDCAP Care in the Moment