1. Critical Care Nurses' Perceptions of Futile Care and Its Effect on Burnout
Lilia Susana Meltzer and Loucine Missak Huckabay
Am J Crit Care 2004;13:202-208
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2. CE Online
CRITICAL CARE NURSES’ PERCEPTIONS OF
FUTILE CARE AND ITS EFFECT ON BURNOUT
By Lilia Susana Meltzer, RN, MSN, A/G NP, and Loucine Missak Huckabay, RN, PNP, PhD.
From Department of Nursing, California State University, Long Beach, Calif.
• BACKGROUND Nurses’ perceptions of futile care may lead to emotional exhaustion.
• OBJECTIVES To determine the relationship between critical care nurses’ perceptions of futile care and
its effect on burnout.
• METHODS A descriptive survey design was used with 60 critical care nurses who worked full-time and
had a minimum of 1 year of critical care experience at the 2 participating hospitals (350-470 beds).
Subjects completed a survey on demographics, the Moral Distress Scale, and the Maslach Burnout
Inventory. Six research questions were tested. The results of the following question are presented: Is there a
relationship between frequency of moral distress situations involving futile care and emotional exhaustion?
• RESULTS A Pearson product moment correlational analysis indicated a significant positive correlation
between the score on the emotional exhaustion subscale of the Maslach Burnout Inventory and the score
on the frequency subscale of the Moral Distress Scale. Moral distress accounted for 10% of the variance
in emotional exhaustion. Demographic variables of age, education, religion, and rotation between the
critical care units were significantly related to the major variables.
• CONCLUSIONS In critical care nurses, the frequency of moral distress situations that are perceived as
futile or nonbeneficial to their patients has a significant relationship to the experience of emotional
exhaustion, a main component of burnout. (American Journal of Critical Care. 2004;13:202-208)
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N
urses working in critical care often encounter
a great deal of pain and suffering as they
journey with patients through weeks and
months of life support and burdensome treatments
and care that nurses perceive as being futile or nonbeneficial to the patients. These nurses are often faced
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202
with ethical dilemmas associated with the management of patients’ care, because increasingly, advanced
technology and changes in healthcare delivery combine to create difficult treatment decisions and add
new responsibilities to nurses’ roles as caregivers and
patients’ advocates.1-3
Ethical decisions affect not only patients’ family
members but also caregivers at an intellectual and
emotional level.4,5 Many investigators6-11 have recognized the effects on nurses, in terms of emotional
attachment and bonding, of caring for patients physically and emotionally for 12 hours at a time. Hoyt12
contended that although with education and adequate
time most patients’ families are able to accept an irreversible diagnosis, situations arise when patients’ families, or less often patients, demand inappropriate or
futile treatment, treatment to be provided against the
will and best judgment of the medical team.
AMERICAN JOURNAL OF CRITICAL CARE, May 2004, Volume 13, No. 3

3. In an attempt to expand nurses’ insights on these
issues and ascertain some of the possible factors that
may contribute to the experience of moral distress and
burnout in critical care nurses, we conducted a study to
determine the relationship between critical care nurses’
perceptions of futile care and the effect of futile care on
burnout. Six research questions were tested. Of the 6
questions, 3 concerned the relationship between the frequency of moral distress situations involving futile care
and the 3 components of burnout (emotional exhaustion,
depersonalization, and diminished personal accomplishment); the other 3 questions concerned the relationship between the intensity of the experience of painful
feelings related to situations involving futile care and
the 3 components of burnout (as noted previously).
However, in this article, we deal solely with the following research question: Is there a relationship between
frequency of moral distress situations involving futile
care and emotional exhaustion?
The Concept of Futile Care
Futility is a complex concept associated with the
accomplishment of goals. An act is considered futile if
its goals are not achievable or its degree of success is
empirically implausible.13,14 Among the challenges presented by futile care is its effect on professional caregivers. Many investigators have articulated concern
about overtreatment of dying patients and the negative
effect of such treatment on staff members. In a survey
of 759 nurses and 687 physicians by Solomon et al,5
50% of nurses, 30% of attending physicians, and 70%
of house staff reported treating patients against the
caregivers’ standards and conscience. According to a
1991 survey by the American Association of CriticalCare Nurses (as cited in Hartwell and Lavandero15), of
1100 critical care nurses across the United States, ethical
dilemmas were among the most difficult issues encountered. One half of the participants rated the decision to
withdraw or withhold life support as the second most
significant issue in their profession; the most significant
issue was authority to make decisions about patients,
which received a 69% rating. Soderberg and Norberg2
reported that critical care nurses were concerned that
patients received meaningless and excessive care.
The determination of medical futility can be made
only within the context of the individual clinical situation. For example, performing cardiopulmonary resuscitation on a patient with multiple organ dysfunction
would be a “physiologically” futile act, and cardiopulmonary resuscitation may be withheld on these grounds
because the probability of success is truly zero; however, resuscitating a patient whose chances for survival are small, but existent, would not be considered
futile care.16 Controversy exists, of course, on whether
heroic treatments in cases such as the first example are
to be viewed as prolongation of life or prolongation of
dying. This issue has no easy or correct answer.
For the purpose of our study, futile care was operationalized as life-sustaining interventions and treatments that have no medical benefit for a patient because
the interventions and treatments cannot end dependence on intensive medical care.
In one survey, 50% of nurses and 70%
of house staff reported treating
patients against the caregivers’
standards and conscience.
Review of the Literature
Burnout in critical care nurses is a phenomenon
that has been examined in numerous research studies.
Personal and occupational factors, or the combination
of the two, have been identified as the main components involved in the burnout syndrome.11,17-19 Personal
factors and personality variables that have been related
to feelings of burnout include lack of hardiness, lack of
assertiveness in dealing with others, diminished coping
skills, family demands, health problems, and lack of
social support.11,18,20,21 Major occupational sources of
stress affecting critical care nurses that may lead to
burnout include a difficult workload, conflict with colleagues and management, inadequate staffing and
resources, emotional demands of patients and patients’
families, dealing with the ethical aspects of life-sustaining technology, and exposure to death and dying.7,10,11,18,19
In a controversial study, Asch6 examined critical
care nurses’ attitudes and practices with regard to the
nurses’ role in euthanasia and assisted suicide. He
pointed out that because nurses working in critical care
often encounter patients who are terminally ill and who
wish to die, the nurses are in a position to meet these
patients’ needs and hasten the patients’ deaths. Asch’s
dramatic findings indicated that 40% of the nurses in
the study considered engaging in such practices but
refrained for different reasons, often for fear of being
caught, and that an additional 20% had, at some point
in their career, participated in these practices. Reasons
for nurses’ engagements in these practices were an
overwhelming sense of responsibility for patients’ welfare, a desire to relieve patients’ suffering, a sense of frustration due to lack of physicians’ responsiveness to that
suffering, and concern about the excessive use of lifesustaining measures near the end of life.
AMERICAN JOURNAL OF CRITICAL CARE, May 2004, Volume 13, No. 3
203

4. Nurses working in critical care units are faced
with complex ethical dilemmas more often than are
nurses working in other acute care settings.22 Working
in such emotionally charged environments where lifeand-death issues are encountered on a daily basis could
become highly stressful and could contribute to the
experience of moral distress.7,23 Moral distress results
when a person perceives that the right course of action
cannot be implemented because of institutional constraints.24 Corley7 found that moral distress was a stress
response experienced by nurses dealing with the ethical
challenges of critical care, such as giving pharmacological treatment during a cardiac arrest but withholding chest compressions or intubation.
Conceptual Framework
Burnout has been described as an occupational hazard of the helping professions. Healthcare providers are
predisposed to burnout when clients’ needs, because of
either the intensity or the complexity of the circumstances, surpass the resources of the care providers.25
Maslach and Jackson26 identified 3 main components associated with burnout: emotional exhaustion,
depersonalization, and diminished personal accomplishment. Emotional exhaustion results in apathy and loss
of concern; as emotional resources are depleted, helping professionals feel they cannot give of themselves
at a psychological level. Depersonalization is characterized by the development of negative and cynical attitudes toward the recipient of care. Diminished personal
accomplishment is characterized by the tendency to
evaluate oneself negatively, particularly in relation to
one’s work with patients. This definition is consistent
with the burnout model of Pearlman and Hartman27 in
which burnout is conceptualized as a response to chronic
emotional stress that has 3 major components: emotional exhaustion, lowered job productivity, and depersonalization.
The burnout model proposed by Pearlman and
Hartman27 was selected for this study because of its
cognitive/perceptual focus, which encompasses a wide
array of personal and occupational variables. The
model depicts a progression of 4 stages of stress leading to burnout: the degree to which a situation is conducive to stress, the individual’s perception of stress,
the response to stress, and the outcome of stress.
Methods
A descriptive survey design was selected to represent the population of critical care nurses through a
convenience sample (N = 60) of all available staff
nurses who fit the criteria of having worked full-time
in an adult intensive care unit (ICU), coronary care
204
unit, or neurological ICU for a minimum of 1 year at
the 2 participating hospitals (350-470 beds) in Southern California where this study took place.
Extraneous variables of age, sex, marital status,
religion, educational background, years of critical care
experience, and whether the nurses worked in the different critical care units in rotation or always worked
in the same unit were not controlled; however, the
relationship of these variables to the major variables,
if any, was taken into consideration.
Instruments
Subjects were asked to complete a sociodemographic data survey we developed, the Moral Distress
Scale (MDS), and the Maslach Burnout Inventory (MBI).
Demographic data were collected to determine if a
relationship existed between demographic variables and
nurses’ perceptions of stressors that lead to burnout.
The MDS was developed by Corley7 to measure the
level of moral distress experienced by critical care nurses
and to determine the issues that most often lead to moral
distress. For the purpose of our study, Corley was contacted and permission was obtained to exclude 4 questions (numbers 11-14) from the MDS. Of the 4 excluded
questions, 2 involve medical students’ situations and 2
are related to pediatrics. After exclusion of the 4 questions, the Cronbach α was calculated for both subscales
of the MDS to determine reliability. The reliability coefficients were still high: .95 for the painful feelings intensity subscale and .96 for the frequency subscale.
This MDS includes items such as prolongation of
dying (“Initiate extensive life-saving actions when I
think it only prolongs death” and “Follow the family’s
wishes to continue life support even though it is not in
the best interest of the patient”) and overtreatment by
physicians (“Prepare a terminally ill elderly patient on a
respirator for surgery to have a mass removed”). Each
statement is scored in 2 dimensions: frequency and
intensity. Each set is scored on a 7-point Likert scale,
with 1 indicating none or never and 7 indicating great
extent or very frequently. Because there are 28 question
items, each with a score ranging from 1 (none) to 7
(great extent), potential subscale scores are 28 to 196.
The MBI, which consists of 22 items, was designed
by Maslach and Jackson26 to measure the 3 components
of burnout: emotional exhaustion, depersonalization,
and personal accomplishment. Each of these components is measured by using a separate subscale based
on a 6-point response format as an expression of frequency (0 through 6, indicating never or every day,
respectively). The emotional exhaustion subscale is
used to measure the inability of healthcare professionals to cope with chronic emotional occupational stres-
AMERICAN JOURNAL OF CRITICAL CARE, May 2004, Volume 13, No. 3

5. sors because the caregivers are no longer able to give
of themselves at a psychological level. The depersonalization subscale is used to assess negative attitudes, loss
of concern, and feelings of cynicism toward the recipients of care. The personal accomplishment subscale is
used to assess the tendency to evaluate oneself negatively,
especially in relationship to one’s work with clients.
and scores on the MBI were significant, t tests for sex
and analysis of variance for the other demographic
variables were performed. In addition, if the results of
the analysis of variance were significant, post hoc
Scheffé tests were conducted to determine the difference between the specific groups.
Results
Procedure
Characteristics of the Sample
Before data were collected, permissions were
obtained from the institutional review boards of both
hospitals and from California State University, Long
Beach, where we are affiliated. Additionally, a written
consent form was obtained from each participating
nurse. The nurse managers made announcements about
the study to the nursing staff in the critical care units,
and we made presentations at staff meetings and during shift report time. Informational sessions were held
on all shifts, as well as on weekends, to facilitate optimal participation by staff who worked in the units in
rotation and by staff who worked the night shift. The
content of the presentations was based on the information stated in the consent form.
Subjects were asked to complete the MDS, the
MBI, and the sociodemographic data survey. A postagepaid envelope containing the letter of informed consent
and the 3 instruments was given to all staff nurses who
fulfilled the inclusion criteria of having worked fulltime for at least 1 year in the adult critical care units at
the 2 participating institutions.
Potential participants were told that the information
they provided would be treated confidentially, and they
were guaranteed anonymity. The nurses were asked to
return the completed instruments in the postage-paid
envelope within 2 weeks of the study presentation. Data
collection in both hospitals took a total of 6 months.
The sample consisted of 51 women and 9 men.
Most of the participants (50.0%) were 31 to 45 years old,
and the majority of the sample (70.0%) were married.
The mean number of years in critical care was 11.79. A
total of 41.7% had an associate degree in nursing and
43.3% had a bachelor’s degree or higher in nursing.
The majority of the sample (68.3%) indicated that religion was very important in their lives. The majority of
the sample worked 12-hour shifts (98.3%) and worked
in the medical/surgical ICU, the coronary care unit, and
the neurological ICU in rotation (76.7%) (Table 1).
Moral Distress and Emotional Exhaustion
The frequency with which critical care nurses
encountered moral distress situations involving futile
care was directly and significantly related to the experience of emotional exhaustion. A Pearson product
moment correlational analysis indicated a significant
positive correlation (r = 0.317, P = .05) between scores
on the MBI emotional exhaustion subscale and scores
on the MDS frequency subscale (Table 2). Linear
regression analysis also indicated significance; scores
on the MDS frequency subscale were significantly
associated (r2 = 0.10; accounting for 10% of the variance) with scores on the MBI emotional exhaustion
subscale (F = 6.47, df = 1,58, P = .01).
Data Analysis
Frequency and percent distributions were used to
present the demographic characteristics of the subjects. The main research question was tested by using
the Pearson product moment correlation to determine
if any significant relationship existed between scores on
each of the 3 subscales of the MBI (emotional exhaustion, depersonalization, and personal accomplishment)
and scores on the 2 subscales of the MDS (frequency
and intensity of painful feelings). Additionally, linear
regression analysis was performed to determine if
scores on the MDS subscales could actually be used to
predict burnout as indicated by scores on the MBI
subscales. In order to determine if any differences
between the different demographic groups and moral
distress and between the different demographic groups
Moral distress associated with providing
futile care led to emotional exhaustion.
Additional Findings
Age. Analysis of variance indicated no significant
association between age and scores on the MBI depersonalization subscale (F = 2.32, P = .08). A post hoc
test of least significant difference was used to determine what age groups accounted for the existing differences. The results indicated that nurses 18 to 30 years
old scored significantly higher on the depersonalization
subscale than did nurses 46 to 60 years old.
AMERICAN JOURNAL OF CRITICAL CARE, May 2004, Volume 13, No. 3
205

6. Table 1 Demographic characteristics of the sample (N = 60)
Frequency
%
Sex
Female
51
85.0
Age, years
18-30
31-45
46-60
61+
9
30
19
2
15.0
50.0
31.7
3.3
Characteristic
Marital status
Single
Married
Separated
Divorced
Education
Diploma
Associate degree in nursing
Bachelor’s degree in nursing
or higher
Other
Religion
Not important
Somewhat important
Very important
Area employed
Medical-surgical intensive
care unit
Coronary care unit
Neurological intensive care
unit
3 units in rotation
Shift worked
12 hours
Other
Discussion
Moral Distress and Emotional Exhaustion
9
42
1
8
15.0
70.0
1.7
13.3
6
25
26
10.0
41.7
43.3
3
5.0
3
16
41
5.0
26.7
68.3
2
3.3
11
1
18.3
1.7
46
76.7
59
1
98.3
1.7
Education. Analysis of variance with post hoc
Scheffé tests were conducted with scores on the MDS
painful feelings subscale as the dependent variable and
education as the independent variable. The results indicated that nurses with a bachelor’s degree in nursing or
higher had significantly higher scores (F = 4.27, P = .009)
on the MDS painful feelings subscale (mean = 154.19,
SD = 30.10) than did nurses with an associate degree in
nursing (mean = 126.58, SD = 34.87).
Rotation Within the Critical Care Units Versus No
Rotation. An indirect relationship indicated that nurses
who did not work the critical care units in rotation scored
significantly higher (t = 2.00, P = .05) on the personal
accomplishment subscale (mean = 40.07, SD = 9.76)
than did nurses who worked the different units in rotation (mean = 35.59, SD = 6.49). Nurses who always
worked in the same type of unit scored significantly
206
lower on the depersonalization subscale than did those
who worked the units in rotation (t = -3.114, P = .004).
Religion. Nurses who considered religion to have
no importance in their lives had significantly higher
scores (F = 3.43, P = .05) on the MBI emotional exhaustion subscale (mean = 37.33, SD = .5774) than did
those who reported that religion was very important in
their lives (mean = 24.56, SD = 13.58).
The frequency with which critical care nurses
encountered moral distress situations involving futile
care was directly and significantly related (accounting
for 10% of the variance) to the experience of emotional
exhaustion, 1 of the 3 components of the burnout syndrome as postulated by Maslach and Jackson26 and by
Pearlman and Hartman.27 This finding can be explained
in accordance with Pearlman and Hartman’s theoretical
formulation27 of the burnout phenomenon, as manifested in the form of emotional exhaustion. Emotional
exhaustion occurs when a person’s appraisal of occupational stressors exceeds his or her coping capabilities or
they conflict with the person’s values and belief system
so that he or she cannot cognitively reconcile with the
stressors or cope.
Younger nurses and nurses who
rotated between different ICUs had
greater feelings of depersonalization
than did older nurses and nurses who
worked in a single ICU.
Additional Findings
Age. Younger nurses appeared to have somewhat
more feelings of depersonalization than did older
nurses. Consistent with this finding, in the model of
Pearlman and Hartman,27 4 stages of stress progress to
burnout, indicating that in the first stage a person’s
skills and abilities may not be sufficiently developed to
adequately cope with perceived or actual work-related
stressors. Similarly, Maslach and Jackson26 found that
younger healthcare providers were more susceptible to
burnout than were older healthcare providers. Moreover,
younger age was a significant predictor of emotional
stress in previous research19,28 on burnout in critical
care nurses.
Education. We found a significant relationship
between educational level and moral distress, indicating
that nurses with a bachelor’s degree or higher experi-
AMERICAN JOURNAL OF CRITICAL CARE, May 2004, Volume 13, No. 3

7. Table 2 Pearson product moment correlations for MDS and MBI subscales
Subscale
MDS painful feelings
MDS frequency
MBI emotional exhaustion
MBI depersonalization
MBI personal accomplishment
MDS
MDS
MBI
MBI
painful feelings frequency emotional exhaustion depersonalization
1.00
0.370*
0.02
-0.107
0.049
1.00
0.317†
0.243
-0.205
1.00
0.610*
-0.353*
1.00
-0.343*
MBI personal
accomplishment
1.00
Abbreviations: MBI, Maslach Burnout Inventory; MDS, Moral Distress Scale.
*Significant at P = .01.
†Significant at P = .05.
enced more painful feelings when confronted with situations of medical futility than did nurses with an associate
degree. This result is in agreement with the theoretical
formulation of Pearlman and Hartman27 related to the
perception and impact of job stress, pointing out that a
person’s work may not meet his or her values and expectations. Similarly, in their investigation of the relationship
between ethical decision making and stress in ICU
nurses, Erlen and Sereika1 found that nurses with a bachelor’s degree or higher had higher stress-related scores
than did nurses with an associate degree.
Rotation Within the Critical Care Units Versus No
Rotation. We found a significant inverse correlation
between nurses who rotated between different ICUs and
nurses who did not. Nurses who worked in only a single
type of critical care unit experience fewer feelings of
personal accomplishment than did nurses who worked
in the different units in rotation. A possible explanation
is that working in certain areas of intensive care may be
less rewarding than working in other areas in terms of
satisfactory outcomes of patients. However, this explanation is a speculation because we did not measure the
actual number of patients who received futile care. For
example, van Servellen and Leake19 found that nurses
working in medical ICUs reported lower levels of personal accomplishment than did nurses working in other
hospital areas such as oncology and special care units
for patients with acquired immunodeficiency syndrome. In addition, the importance of job satisfaction
and meaningfulness of work in critical care nurses has
been reported in previous research. Stechmiller and
Yarandi11 reported that meaningfulness of work and
opportunities for advancement are the most important
aspects of job satisfaction among critical care nurses.
Another finding of interest was that nurses who
worked in the different critical care units in rotation
experienced higher feelings of depersonalization than
did those who always worked in the same unit. Along
this line, Spencer10 researched ways in which critical
care nurses deal with grief when a patient dies and
found that peer support was crucial for effective coping.
Nurses who reported receiving higher support had
worked in the unit longer and therefore had more meaningful relationships among themselves.10
Religion. The last significant additional finding was
that of an indirect relationship between religion and
emotional exhaustion. The results suggest that nurses
who viewed religion as important in their lives experienced fewer feelings of emotional exhaustion when
confronted with ethical dilemmas than did nurses for
whom religion was not so important. A possible explanation for this finding is that nurses with strong religious beliefs see hope and the end of life differently
than do nurses without such religious beliefs.
Nurses who viewed religion as
important experienced less emotional
exhaustion than did nurses to whom
religion was less important.
Limitations
The research reported here has several limitations.
The descriptive design of the study and the convenience
method of sampling limit the generalizability of the
results; thus, the findings should be viewed cautiously.
Our findings may reflect a particular response bias
because nurses experiencing high levels of burnout may
have lacked motivation to participate in the study. In
addition, because of the descriptive nature of the study,
we used only standardized measures to examine relationships. Therefore, the results may not reveal the true
causal relationship between medical futility and burnout
or emotional distress in critical care nurses.
AMERICAN JOURNAL OF CRITICAL CARE, May 2004, Volume 13, No. 3
207

8. Implications
Our major finding suggests that feelings of emotional exhaustion leading to burnout in critical care nursing are highly influenced by the frequency with which
nurses are involved in life-sustaining interventions that
conflict with the nurses’ values and standards in terms
of what the nurses think are ethically appropriate and
can result in improvement in a patient’s condition and
outcome. The clinical significance of this finding cannot
be overlooked. Experiencing feelings of emotional
exhaustion can lead to staff conflicts, absenteeism, lowered morale, and decreased productivity, ultimately culminating in burnout and compromising patients’ care.7,11
In their analysis of the relationship between ethics
in nursing and professionalism, Quinn and Smith29
pointed out that experiencing uncertainty is an inherent component of being a professional. However, it is
essential that nurses address uncertainty through open
communication with colleagues, develop skills in
moral reasoning, and apply ethical principles to clinical situations. Ethical principles such as respect for
others (autonomy), helping others in their best interest
(beneficence), avoiding harm (nonmaleficence), and
fairness (justice) are major components of decision
making in critical care nursing, as well as the objective point of reference on which to base the determination of medical futility.13,30,31
At the hospital administration level, our results
can be used to provide resources to critical care nurses
to discuss ethical dilemmas or particular situations
with patients as the situations occur. These resources
could include interdisciplinary group discussions,
accessibility to ethics committees, and involvement in
the development of organizational policies and guidelines on futility and ethical decision making. At the
unit level, the availability of a counselor, such as a
clinical nurse specialist or a psychiatric liaison, could
help identify problem areas and help nurses change
the perception of stressors. If the sources of stress can
be identified and controlled, the overall effect might
be an improvement in nursing performance, resulting
in optimal care for patients.9,10
ACKNOWLEDGMENTS
We thank Mary C. Corley, RN, PhD, associate professor of nursing at Virginia
Commonwealth University, Richmond, Va, for allowing the use of her instrument,
the Moral Distress Scale, for this research.
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