The use and misuse of moral distress in neonatology.

The neonatal intensive care unit is recognized as a stressful environment; the nature of caring for sick babies with uncertain outcomes and the need to make difficult decisions results in a work place where moral distress is prevalent. According to the prevailing definition, moral distress occurs when the provider believes that what is "done" is not the right course of action, with an element of constraint: the provider has no choice but to act this way. This can lead to adverse outcomes, including burnout and a change of career. Traditionally, moral distress was considered to represent a misuse of power that forced nurses (typically) to provide burdensome treatments they believed not in the patient's best interests. Today, with shared decision-making, it is rare for physicians to act in a purely paternalistic fashion and impose management strategies on a team and parents. However, in the grey zones, it is not unusual for individuals with different values to disagree on a course of treatment. Healthcare professionals across all disciplines may feel constrained despite there being no identified misuse of power. We argue for a broader understanding of moral distress and an awareness that maladaptive responses to moral distress may result in "transference" of moral distress on to other healthcare professionals and even on to the families of babies for whom we have a duty of care. Strategies for dealing with moral distress exist. An appreciation of these dynamics will enable providers to reduce the negative impacts of moral distress while also using it as a vehicle for constructive discussion and progressive thought that will better serve our patients and our colleagues.