Journal of Bioethical Inquiry

, Volume 12, Issue 3, pp 437–448 | Cite as

Conflicts in Learning to Care for Critically Ill Newborns: “It Makes Me Question My Own Morals”

  • Renee D. BossEmail author
  • Gail Geller
  • Pamela K. Donohue
Original Research


Caring for critically ill and dying patients often triggers both professional and personal growth for physician trainees. In pediatrics, the neonatal intensive care unit (NICU) is among the most distressing settings for trainees. We used longitudinal narrative writing to gain insight into how physician trainees are challenged by and make sense of repetitive, ongoing conflicts experienced as part of caring for very sick and dying babies. The study took place in a 45-bed, university-based NICU in an urban setting in the United States. From November 2009 to June 2010 we enrolled pediatric residents and neonatology fellows at the beginning of their NICU rotations. Participants were asked to engage in individual, longitudinal narrative writing about their “experience in the NICU.” Thematic narrative analysis was performed. Thirty-seven physician trainees participated in the study. The mean number of narratives per trainee was 12; a total of 441 narratives were available for analysis. Conflict was the most pervasive theme in the narratives. Trainees experienced conflicts with families and conflicts with other clinicians. Trainees also described multiple conflicts of identity as members of the neonatology team, as members of the medical profession, as members of their own families, and as members of society. Physician trainees experience significant conflict and distress while learning to care for critically ill and dying infants. These conflicts often led them to question their own morals and their role in the medical profession. Physician trainees should be educated to expect various types of distress during intensive care rotations, encouraged to identify their own sources of distress, and supported in mitigating their effects.


Physician trainee Neonatal intensive care Ethical conflicts Narrative writing United States 


  1. Alexandra, A., and S. Miller. 2009. Ethical theory, “common morality,” and professional obligations. Theoretical and Medical Bioethics 30(1): 69–80. doi: 10.1007/s11017-009-9097-1.CrossRefGoogle Scholar
  2. Baer, R.A., G.T. Smith, E. Lykins, et al. 2008. Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating samples. Assessment 15(3): 329–342. doi: 10.1177/1073191107313003.CrossRefPubMedGoogle Scholar
  3. Bartunek, J.M. 2011. Intergroup relationships and quality improvement in healthcare. BMJ Quality and Safety 20(Suppl 1): i62–i66. doi: 10.1136/bmjqs.2010.046169.PubMedCentralCrossRefPubMedGoogle Scholar
  4. Bernhardt, B.A., C.H. Rushton, J. Carrese, R.E. Pyeritz, K. Kolodner, and G. Geller. 2009. Distress and burnout among genetic service providers. Genetics in Medicine 11(7): 527–535. doi: 10.1097/GIM.0b013e3181a6a1c2.PubMedCentralCrossRefPubMedGoogle Scholar
  5. Bernhardt, B.A., R. Silver, C.H. Rushton, E. Micco, and G. Geller. 2010. What keeps you up at night? Genetics professionals’ distressing experiences in patient care. Genetics in Medicine 12(5): 289–297. doi: 10.1097/GIM.0b013e3181db82d9.CrossRefPubMedGoogle Scholar
  6. Boss, R.D., N. Hutton, L.J. Sulpar, A.M. West, and P.K. Donohue. 2008. Values parents apply to decision-making regarding delivery room resuscitation for high-risk newborns. Pediatrics 122(3): 583–589. doi: 10.1542/peds.2007-1972.CrossRefPubMedGoogle Scholar
  7. Brosig, C.L., R.L. Pierucci, M.J. Kupst, and S.R. Leuthner. 2007. Infant end-of-life care: The parents’ perspective. Journal of Perinatology 27(8): 510–516. doi: 10.1038/ Scholar
  8. Charon, R. 2001. The patient–physician relationship: Narrative medicine: A model for empathy, reflection, profession, and trust. The Journal of the American Medical Association 286(15): 1897–1902.CrossRefPubMedGoogle Scholar
  9. Chen, D., R. Lew, W. Hershman, and J. Orlander. 2007. A cross-sectional measurement of medical student empathy. Journal of General Internal Medicine 22(10): 1434–1438. doi: 10.1007/s11606-007-0298-x.PubMedCentralCrossRefPubMedGoogle Scholar
  10. Cohn, F.G., J. Shapiro, D.A. Lie, J. Boker, F. Stephens, and L.A. Leung. 2009. Interpreting values conflicts experienced by obstetrics-gynecology clerkship students using reflective writing. Academic Medicine 84(5): 587–596. doi: 10.1097/ACM.0b013e31819f6ecc00001888-200905000-00015.CrossRefPubMedGoogle Scholar
  11. Epstein, R.M. 1999. Mindful practice. The Journal of the American Medical Association 282(9): 833–839.CrossRefPubMedGoogle Scholar
  12. Gaufberg, E.H., M. Batalden, R. Sands, and S.K. Bell. 2010. The hidden curriculum: What can we learn from third-year medical student narrative reflections? Academic Medicine 85(11): 1709–1716. doi: 10.1097/ACM.0b013e3181f57899.CrossRefPubMedGoogle Scholar
  13. Geller, G., C.H. Rushton, C. Francomano, K. Kolodner, and B.A. Bernhardt. 2010. Genetics professionals’ experiences with grief and loss: Implications for support and training. Clinical Genetics 77(5): 421–429. doi: 10.1111/j.1399-0004.2010.01409.x.CrossRefPubMedGoogle Scholar
  14. Gibson, K. 2003. Contrasting role morality and professional morality: Implications for practice. Journal of Applied Philosophy 20(1): 17–29.CrossRefPubMedGoogle Scholar
  15. Gold, K.J., A.L. Kuznia, and R.A. Hayward. 2008. How physicians cope with stillbirth or neonatal death: A national survey of obstetricians. Obstetrics and Gynecology 112(1): 29–34. doi: 10.1097/AOG.0b013e31817d0582.CrossRefPubMedGoogle Scholar
  16. Greenhalgh, T., and I. Heath. 2010. Measuring quality in the therapeutic relationship—part 2: Subjective approaches. Quality and Safety in Health Care 19(6): 479–483. doi: 10.1136/qshc.2010.043372.PubMedGoogle Scholar
  17. Groenhout, R. 1998. Care theory and the ideal of neutrality in public moral discourse. Journal of Medicine and Philosophy 23(2): 170–189. doi: 10.1076/jmep. Scholar
  18. Hatem, D., and E. Ferrara. 2001. Becoming a doctor: fostering humane caregivers through creative writing. Patient Education and Counseling 45(1): 13–22.CrossRefPubMedGoogle Scholar
  19. Hojat, M., J.S. Gonnella, T.J. Nasca, S. Mangione, J.J. Veloksi, and M. Magee. 2002. The Jefferson Scale of Physician Empathy: Further psychometric data and differences by gender and specialty at item level. Academic Medicine 77(Suppl 10): S58–S60.CrossRefPubMedGoogle Scholar
  20. Karnieli-Miller, O., T.R. Vu, M.C. Holtman, S.G. Clyman, and T.S. Inui. 2010. Medical students’ professionalism narratives: A window on the informal and hidden curriculum. Academic Medicine 85(1): 124–133. doi: 10.1097/ACM.0b013e3181c42896.CrossRefPubMedGoogle Scholar
  21. Karnieli-Miller, O., T.R. Vu, R.M. Frankel, et al. 2011. Which experiences in the hidden curriculum teach students about professionalism? Academic Medicine 86(3): 369–377. doi: 10.1097/ACM.0b013e3182087d15.CrossRefPubMedGoogle Scholar
  22. Kind, T., V.R. Everett, and M. Ottolini. 2009. Learning to connect: students’ reflections on doctor–patient interactions. Patient Education and Counseling 75(2): 149–154. doi: 10.1016/j.pec.2008.09.011.CrossRefPubMedGoogle Scholar
  23. Krasner, M.S., R.M. Epstein, H. Beckman, et al. 2009. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. The Journal of the American Medical Association 302(12): 1284–1293. doi: 10.1001/jama.2009.1384.CrossRefPubMedGoogle Scholar
  24. Kumagai, A.K. 2008. A conceptual framework for the use of illness narratives in medical education. Academic Medicine 83(7): 653–658. doi: 10.1097/ACM.0b013e3181782e17.CrossRefPubMedGoogle Scholar
  25. McCabe, M.E., E.A. Hunt, and J.R. Serwint. 2008. Pediatric residents’ clinical and educational experiences with end-of-life care. Pediatrics 121(4): e731–e737. doi: 10.1542/peds. 2007-1657.CrossRefPubMedGoogle Scholar
  26. Moores, T.S., K.L. Castle, K.L. Shaw, M.R. Stockton, and M.I. Bennett. 2007. “Memorable patient deaths”: Reactions of hospital doctors and their need for support. Medical Education 41(10): 942–946. doi: 10.1111/j.1365-2923.2007.02836.x.CrossRefPubMedGoogle Scholar
  27. Neumann, M., F. Edelhauser, D. Tauschel, et al. 2011. Empathy decline and its reasons: A systematic review of studies with medical students and residents. Academic Medicine 86(8): 996–1009. doi: 10.1097/ACM.0b013e318221e615.CrossRefPubMedGoogle Scholar
  28. Novack, D.H., A.L. Suchman, W. Clark, R.M. Epstein, E. Najberg, and C. Kaplan. 1997. Calibrating the physician: Personal awareness and effective patient care: Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. The Journal of the American Medical Association 278(6): 502–509.CrossRefPubMedGoogle Scholar
  29. Ogur, B., and D. Hirsh. 2009. Learning through longitudinal patient care narratives from the Harvard Medical School–Cambridge Integrated Clerkship. Academic Medicine 84(7): 844–850. doi: 10.1097/ACM.0b013e3181a85793.CrossRefPubMedGoogle Scholar
  30. Pearson, A.S., M.P. McTigue, and J.L. Tarpley. 2008. Narrative medicine in surgical education. Journal of Surgical Education 65(2): 99–100. doi: 10.1016/j.jsurg.2007.11.008.CrossRefPubMedGoogle Scholar
  31. Redinbaugh, E.M., A.M. Sullivan, S.D. Block, et al. 2003. Doctors’ emotional reactions to recent death of a patient: Cross sectional study of hospital doctors. British Medical Journal 327(7408): 185. doi: 10.1136/bmj.327.7408.185.PubMedCentralCrossRefPubMedGoogle Scholar
  32. Rushton, C.H., R. Boss, K. Hallett, et al. 2013. The many faces of moral distress among clinicians. Narrative Inquiry in Bioethics 3(2): 89–93. doi: 10.1353/nib.2013.0039.CrossRefPubMedGoogle Scholar
  33. Salih, Z.N., and D.W. Boyle. 2009. Ethics education in neonatal-perinatal medicine in the United States. Seminars in Perinatolology 33(6): 397–404. doi: 10.1053/j.semperi.2009.07.008.CrossRefGoogle Scholar
  34. Serwint, J.R., L.E. Rutherford, and N. Hutton. 2006. Personal and professional experiences of pediatric residents concerning death. Journal of Palliative Medicine 9(1): 70–81. doi: 10.1089/jpm.2006.9.70.CrossRefPubMedGoogle Scholar
  35. Tong, R. 1998. The ethics of care: A feminist virtue ethics of care for healthcare practitioners. Journal of Medicine and Philosophy 23(2): 131–152. doi: 10.1076/jmep. Scholar
  36. Tschudy, M.M. 2008. The sound of silence. Ambulatory Pediatrics 8(2): 86. doi: 10.1016/j.ambp.2008.01.006.CrossRefPubMedGoogle Scholar
  37. Verkerk, M., H. Lindemann, E. Maeckelberghe, E. Feenstra, R. Hartoungh, and M. De Bree. 2004. Enhancing reflection: An interpersonal exercise in ethics education. The Hastings Center Report 34(6): 31–38.CrossRefPubMedGoogle Scholar
  38. Wald, H.S., J.M. Borkan, J.S. Taylor, D. Anthony, and S.P. Reis. 2012. Fostering and evaluating reflective capacity in medical education: Developing the REFLECT rubric for assessing reflective writing. Academic Medicine 87(1): 41–50. doi: 10.1097/ACM.0b013e31823b55fa.CrossRefPubMedGoogle Scholar
  39. Wanzer, M.B., A.M. Wojtaszczyk, and J. Kelly. 2009. Nurses’ perceptions of physicians’ communication: The relationship among communication practices, satisfaction, and collaboration. Health Communication 24(8): 683–691. doi: 10.1080/10410230903263990.CrossRefPubMedGoogle Scholar
  40. Wear, D. 2002. “Face-to-face with it”: Medical students’ narratives about their end-of-life education. Academic Medicine 77(4): 271–277.CrossRefPubMedGoogle Scholar
  41. Weissman, D.E., and S.D. Block. 2002. ACGME requirements for end-of-life training in selected residency and fellowship programs: A status report. Academic Medicine 77(4): 299–304.CrossRefPubMedGoogle Scholar

Copyright information

© Journal of Bioethical Inquiry Pty Ltd. 2015

Authors and Affiliations

  • Renee D. Boss
    • 1
    Email author
  • Gail Geller
    • 2
  • Pamela K. Donohue
    • 3
    • 4
  1. 1.Division of Neonatology, Department of PediatricsJohns Hopkins University School of Medicine and Berman Institute of BioethicsBaltimoreUSA
  2. 2.Johns Hopkins University School of MedicineBerman Institute of BioethicsBaltimoreUSA
  3. 3.Department of PediatricsJohns Hopkins University School of MedicineBaltimoreUSA
  4. 4.Department of Population, Family and Reproductive HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA

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