Casebook on Ethical Decision-Making in End-of-Life Care
of Older Adults
Moral Distress among Health Professionals: What and Why
- Dr. Helen Chan, Associate Professor (by courtesy), CUHK Jockey Club Institute of Ageing, CUHK
What is moral distress?
Moral distress is defined as the negative experience among health professionals when they know the right thing to do but cannot pursue that course of action due to institutional constraint.1-2 It is different from work stress and compassion fatigue although these may be experienced simultaneously.3-4 The negative emotions that resulted from the initial moral distress would persist as a lingering feeling of unease and accumulate over time.2 The unresolved moral distress can result in health professionals being desensitized to ethical challenges.4
Prevalence and sources of moral distress
The concept of moral distress originated from nursing research, but empirical evidence consistently showed that moral distress is experienced by various types of health professionals, including physicians, pharmacists, social workers, and other allied health professionals.6-7 Studies also found that moral distress is reported across different specialties, such as critical care, surgical care, oncology care and paediatric care, and healthcare settings, including acute care, critical care and long-term care.3-7 There is growing awareness that moral distress is also common in medical students, residents and junior staff.8-9
The major sources of moral distress are providing futile care or care which is not in patients' best interests and witnessing poor quality of care. Other reasons for moral distress are inadequate staffing, working with incompetent co-workers, inappropriate use of healthcare resources, fragmentation of care and poor teamwork.6-10 In 2016, a local survey was conducted to examine the extent of moral distress experienced by nurses in the acute hospital setting in Hong Kong.11 The level of moral distress was measured using Moral Distress Scale-Revised (MDS-R) which is a validated questionnaire with 21 statements describing different ethically challenging situations.5
As shown in Table 1, most of the items with the highest scores were related to end-of-life care. It seems that moral distress arises when nurses perceived a gap between the provision of quality end-of-life care and the care that patients received in practice. Moreover, the findings showed that the level of moral distress of nurses working in various specialties or department, including oncology, surgical and emergency care, were comparable to those in critical care units. Perhaps the increased prevalence of chronic progressive diseases and the ageing population prompt the need to place a greater emphasis on end-of-life care across different units
Table 1. Top five Moral Distress Scale-Revised (MDS-R) items* (N=447).
|Five MDS-R items with the highest frequency score||Mean ± SD|
|Follow the family’s wishes to continue life support even though I believe it is not in the best interest of the patient.||5.61 ± 4.00|
|Carry out the physician’s orders for what I consider to be unnecessary tests and treatments.||5.19 ± 4.05|
|Initiate extensive life-saving actions when I think they only prolong death.||5.14 ± 3.88|
|Continue to participate in care for a hopelessly ill person who is being sustained on a ventilator, when no one will make a decision to withdraw support.||4.39 ± 3.87|
|Work with nurses or other healthcare providers who are not as competent as the patient care requires.||4.20 ± 3.65|
*Respondents were asked how often they encountered these situations in their care practice (frequency) and the level of disturbance they experienced in these situations (intensity) using a 5-point Likert scale respectively. The frequency scale ranged from 0 (never) to 4 (very frequently), whereas the intensity scale from 0 (none) to 4 (great extent). The frequency score and the intensity score are multiplied for each item.
Impacts of moral distress
Clearly, moral distress is an issue highly pertinent to the cost, quality and sustainability of healthcare services. Moral distress may manifest itself as anger, impatience and depression due to emotional exhaustion, frustration, guilt, shame, powerlessness, or distancing from clients and being silent and indifferent towards patients' care.6-7
On the other hand, moral distress can also affect the wellbeing of health professionals, causing somatic symptoms such as palpitations, insomnia, nausea, fatigue, headaches, tearfulness and gastrointestinal upset.7 Evidence suggests that moral distress is significantly associated with burnout in critical care providers. The physical and psychological sequelae intertwine, resulting in poor job satisfaction, low workplace morale, and absenteeism.6 Some studies found that moral distress is associated with poor staff retention, since health professionals may perceive themselves as moral agents who fail to fulfil their moral obligations, resulting in compromised professional integrity.8
Could we address moral distress?
Moral distress may be a communal experience to be interpreted in a broader context, rather than just as an individual experience. Institutional constraint is widely recognized as a contributing factor to moral distress. The implicit and explicit values of the organization affect the attitudes and behaviours of the health care providers in the clinical environment.6, 12-14 Recent literature noted that the socio-political healthcare context driven by government fiscal plan and policies that affect its structure and resources also play a role in shaping the ethical climate of healthcare organizations.3, 15
To mitigate moral distress, relevant interventions should be built into the systems and organizations with the goal of cultivating moral resilience among health professionals so that they could recognize the experience of moral distress and have the internal capacities to uphold their moral obligations.11-16 Following are some suggested ways for addressing moral distress:
The concept of moral distress should be introduced in both the pre-registration training curriculum for health professionals and continuing professional education in order to foster self-awareness towards moral distress. Monrouxe et al. (2017) underscore the importance of developing students’ moral decision-making skills when confronting with ethical dilemmas. Small clinician-led interactive sessions would enable them to understand the ethical complexities and develop confidence and skills in managing the situations.9 However, moral distress cannot be reduced simply through developing ethical competence. Health professionals with a heightened awareness of good healthcare are more susceptible to moral distress when they fail to act on the right course of action. Berger (2014) suggested that training on mediation and communication is also important for health professionals to improve their conflict management skills as well as patient-clinicians relationships.8
A wide range of interventions can be offered by the organization as structural empowerment so as to support health professionals in addressing moral distress. For example, multidisciplinary forums to encourage open discussion about ethical issues and operational constraints that have arisen in clinical care, mentoring for junior staff who may experience dissonance between what they have learnt and what they actually encounter in the clinical setting, regular structured debriefing sessions for ethically challenging situations in individual departments or units, and counselling services.3, 8, 15-17 Through open dialogue in these avenues, health professionals are encouraged to speak up, identify the contributing factors to moral distress and develop appropriate strategies in a collaborative approach. All these interventions indeed are supporting health professionals to co-create a culture of ethical practice. In addition to the aforementioned organizational measures, clinical ethics committees serve as a main resource for clinicians to seek for advice. The role of clinical ethics committees have emerged from formulating ethical guidelines to providing ethics consultation in various formats to support clinicians in clarifying their ethical concerns and moral obligations.18-19
Moral distress is a common phenomenon in day-to-day clinical practice across health care settings. It jeopardizes not only the wellbeing of health professionals, but also the quality and sustainability of health care services. Ethics education is imperative to deepen the moral sensitivity of health professionals. More importantly, the reciprocal influence between the ethical climate of the health care environment and health professionals underscores that there should be proactive interventions or changes in parallel at the organization level to construct a supportive culture for ethical practice.
- Jameton A. Nursing Practice: The ethical issues. Englewood Cliffs, NJ: Prenctice Hall, 1984.
- Jameton A. Dilemmas of moral distress: Moral responsibility and nursing practice. AWHONNS Clin Issues Perinat Women’s Health Nurs. 1993;4:542-551.
- Varcoe C, Pauly B, Webster G, Storch J. Moral distress: Tensions as springboards for action. HRC Forum. 2012;24:51-62.
- Austin W. Moral distress and the contemporary plight of health professionals. HEC Forum. 2012;24:27-38.
- Harmic AB, Borchers CT, Epstein EG. Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research. 2012;3:1-9.
- Whitehead PB, Herbertson RK, Hamric AB, Epstein EG, Fisher JM. Moral distress among healthcare professionals: Report of an institution-wide survey. J Nurs Scholars. 2015;47:117-125.
- Epstein EG, Hamric AB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics. 2009;20:330-342.
- Berger JT. Moral distress in medical education and training. J Gen Intern Med 2014;29:395-8.
- Monrouxe L, Shaw M, Rees C. Antecedents and consequences of medical students’ moral decision making during professionalism dilemmas. AMA J Ethics. 2017;19:568-77.
- Lutzen K, Kvist BE. Moral distress: A comparative analysis of theoretical understandings and inter-related concepts. HEC Forum. 2012;24:13-25.
- Chan HYL , Lai KF, Lau CK. Examining moral distress among nurses in Hong Kong. Presented in the C U Medical Education Conference. Hong Kong, 2017.
- Russell AC. Moral distress in neuroscience nursing: An evolutionary concept analysis. Am Asso Neurosci Nurs. 2012;44:15-24.
- Sporrong SK, Arnetz B, Hansson MG. Developing ethical competence in health care organizations. Nurs Ethics. 2007;14:825-837.
- Harmic AB, Baclhall LJ. Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. Crit Care Med. 2007;35:422-429.
- Musto LC, Rodney PA, Vanderheide R. Toward interventions to address moral distress: Navigating structure and agency. Nurs Ethics. 2015;22:91-102.
- Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and addressing moral distress and ethical climate. Dimen Crit Care Nurs. 2014;33:234-245.
- Rushton CH. Cultivating moral resilience: shifting the narrative from powerlessness to possibility. Am J Nurs. 2017;117:S11-5.
- Austin W. What Is the Role of Ethics Consultation in the Moral Habitability of Health Care Environments? AMA J Ethics. 2017;19:595-600.
- Annas G, Grodin M. Hospital ethics committees, consultants, and courts. AMA J Ethics. 2016;18:554-9.