Moral distress in health care professionals

Thousands of health care providers currently live and practice in Canada,1 and each day these providers are presented with new situations from their patients and clients. Many of these situations require much contemplation, and often both personal and professional judgment is used to come to a conclusion. In many cases, the decision-making process becomes difficult due to personal and professional beliefs, as well as institutional and legal requirements placed upon the health care provider. This phenomenon, known as moral distress, is “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action”.2 This work provides a brief introduction to the topic of moral distress, the systemic factors that can lead to the development of moral distress, how it manifests in health care providers, and coping mechanisms used by health care providers to manage their moral distress. introduction In the year 2001, more than 1.1 million (or one in ten employed) individuals worked in health care in Canada.1 These health care providers face a myriad of challenges in their day-to-day work, many of which require considerate and confident decision-making skills, as well as the ability to understand the shortand long-term implications of those decisions. First-line professionals must make important decisions about priority setting in their day-to-day work.3 The decisions they make are complex, as they must often consider a variety of factors, such as: the best procedure or treatment for an individual to undergo, both the present and future needs of the individual, and the social determinants of health that may largely affect this individual, such as their socioeconomic status.3 As a result of making these decisions, health care providers may experience moral distress, potentially further affecting their decision-making and causing a multitude of negative physical, emotional, and psychological effects.4,5 what is moral distress? Moral distress has been described as one of the most substantial problems facing health providers.4 Over the years, a range of definitions have been used to define moral distress, resulting in a lack conceptual clarity.6 Jameton presented the first definition of moral distress in 1984, stating: “Moral distress arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action”.2 Raines later modified the definition by Jameton, and explained that constraints could be more than institutional in nature.7 From Raines’ definition, multiple works have outlined additional barriers such as internal barriers, including a lack of confidence, or external barriers, such as legal constraints and fear of professional reprimands.8-11 what effects does moral distress have on health professionals? Researchers have documented that a significant number of negative effects stem from moral distress, such as physical, emotional, and psychological symptoms. Moral distress manifests physically with symptoms such as headaches and diarrhea, and emotionally with symptoms such as excessive crying.5 In addition, health care providers have also experienced psychological symptoms, such as anxiety and depression, as a result of moral distress.4 As an example, in a study of nurses experiencing moral distress, many nurses reported that moral distress affected their personal relationships and manifested in ways such as a loss of self-worth, development of depression, and nightmares.5 These negative symptoms pose an issue for both health care providers and those that they care for, as they have the potential to interfere with patient care. This study also found nurses to be divided in believing that the care they were giving was better, worse, or the same while experiencing moral distress.5 However, it was speculated that the patients were more affected than nurses perceived them to be because (1) nurses perceived themselves as ‘good nurses’ and did not want to consider themselves as bad care givers, (2) when considering quality of care, they may have only considered physical aspects, and (3) they may have believed their quality of care was based on the amount of care they gave, rather than patient outcomes.5 As well, the participants in this study admitted that their personal and professional relationships and sense of self had been damaged as a result of experiencing moral distress.5 Additionally, to further illustrate how moral distress has a negative effect on health care providers, Lazzarin, Biondi & Di Mauro found that experiencing moral distress has previously caused individuals to leave their line of work.4 In their study, 13.7% of participants said they had changed their unit or hospital due to moral distress.4 In addition, 15.2% of participants said that they had thought about changing sectors due to moral distress stemming from institutional obstacles, such as lack of time, medical power, legal limits, and institutional policy, all factors that made it difficult for them to work in a more ethical manner.4 For example, health professionals encountered distress when they were unable to “act in agreement with their personal and professional values”.4 It is extremely problematic when professionals change sectors or move, as it disrupts continuity of patient care—that is, patients having consistency in the health care professionals that they see. Researchers have found that patients that had the most clinical continuity were less likely


introduction
In the year 2001, more than 1.1 million (or one in ten employed) individuals worked in health care in Canada. 1 These health care providers face a myriad of challenges in their day-to-day work, many of which require considerate and confident decision-making skills, as well as the ability to understand the short-and long-term implications of those decisions.First-line professionals must make important decisions about priority setting in their day-to-day work. 3he decisions they make are complex, as they must often consider a variety of factors, such as: the best procedure or treatment for an individual to undergo, both the present and future needs of the individual, and the social determinants of health that may largely affect this individual, such as their socioeconomic status. 3 As a result of making these decisions, health care providers may experience moral distress, potentially further affecting their decision-making and causing a multitude of negative physical, emotional, and psychological effects. 4,5at is moral distress?Moral distress has been described as one of the most substantial problems facing health providers. 4Over the years, a range of definitions have been used to define moral distress, resulting in a lack conceptual clarity. 6Jameton presented the first definition of moral distress in 1984, stating: "Moral distress arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action". 2 Raines later modified the definition by Jameton, and explained that constraints could be more than institutional in nature. 710][11] what effects does moral distress have on health professionals?
Researchers have documented that a significant number of negative effects stem from moral distress, such as physical, emotional, and psychological symptoms.Moral distress manifests physically with symptoms such as headaches and diarrhea, and emotionally with symptoms such as excessive crying. 5In addition, health care providers have also experienced psychological symptoms, such as anxiety and depression, as a result of moral distress. 4As an example, in a study of nurses experiencing moral distress, many nurses reported that moral distress affected their personal relationships and manifested in ways such as a loss of self-worth, development of depression, and nightmares. 5These negative symptoms pose an issue for both health care providers and those that they care for, as they have the potential to interfere with patient care.This study also found nurses to be divided in believing that the care they were giving was better, worse, or the same while experiencing moral distress. 5However, it was speculated that the patients were more affected than nurses perceived them to be because (1) nurses perceived themselves as 'good nurses' and did not want to consider themselves as bad care givers, (2) when considering quality of care, they may have only considered physical aspects, and (3) they may have believed their quality of care was based on the amount of care they gave, rather than patient outcomes. 5As well, the participants in this study admitted that their personal and professional relationships and sense of self had been damaged as a result of experiencing moral distress. 5dditionally, to further illustrate how moral distress has a negative effect on health care providers, Lazzarin, Biondi & Di Mauro found that experiencing moral distress has previously caused individuals to leave their line of work. 4In their study, 13.7% of participants said they had changed their unit or hospital due to moral distress. 4In addition, 15.2% of participants said that they had thought about changing sectors due to moral distress stemming from institutional obstacles, such as lack of time, medical power, legal limits, and institutional policy, all factors that made it difficult for them to work in a more ethical manner. 4For example, health professionals encountered distress when they were unable to "act in agreement with their personal and professional values". 4It is extremely problematic when professionals change sectors or move, as it disrupts continuity of patient care-that is, patients having consistency in the health care professionals that they see.Researchers have found that patients that had the most clinical continuity were less likely feature article to have future hospitalizations than those with low clinician continuity. 124][15] This loss of health care professionals is problematic as we currently have an insufficient number of trained professionals practicing in Canada. 16It is therefore evident that more needs to be done to mitigate the negative effects of moral distress so that patients are able to access care from providers in the future.
how do health care professionals cope with moral distress?
Health care providers have been shown to cope with moral distress in a multitude of ways, including: breaking administrative rules, breaking the law, avoiding particular patients, and purposely avoiding specific duties. 3,5Wilkinson specifically found that nurses had 2 dominant ways of coping: deny responsibility for their actions, or act as if they had some control over the situation causing them stress. 5In a study conducted by Lievrouw et al., 17 oncologists and 18 oncology nurses from different departments (internal medicine, gastrointestinal surgery, and day clinic) were interviewed and discussed how they coped with moral distress. 17While there was no difference in coping style based on the department they worked in, it was found that there were coping differences between physicians and nurses.In particular, it was found that nurses focused on their feelings and experiences while coping, while physicians used a rational approach. 17at systemic factors lead to moral distress?
While the type of situation and coping style affects how an individual experiences moral distress, as previously stated, there are institutional constraints that, in many cases, lead to the development of moral distress in the first place.Although there are a variety of systemic factors that can contribute to the development of moral distress, this paper will specifically examine 3 of the most common factors that were brought forward in the literature: understaffing, a lack of resources, and providing care for terminal patients. 5,13,14hen speaking to staffing and resource management, it was found that many of the health care settings where participants worked were understaffed, leading to increased workloads, increased stress, and the inability to provide quality care to their patients. 3,13Additionally, workplaces with poorly trained staff also led to difficulty in ensuring quality patient care from these health care providers. 13Institutional constraints are also significant systemic factors that contribute to moral distress. 3,7,18Examples include budget cuts that lead to understaffing and longer work hours, and institutional requirements, such as administering life-sustaining treatment when it may not be useful.Also, in having no control over these institutional constraints, the stress of the staff can be compounded.Lastly, moral distress also frequently arises in caring for patients who have been deemed terminal. 5,15,19Wilkinson specifically found that performing unnecessary procedures, and unnecessarily prolonging a patient's life were common causes of moral distress. 5These findings were also reflected in two other studies that found the greatest cause of moral distress to be the administering of aggressive treatment to patients who would not benefit from this care. 15,19Additionally, it was found that in caring for terminally ill patients, moral distress emerged when nurses had to manage pain symptoms, as they were concerned that the treatment they administered could potentially hasten death. 19Distress also emerged when communicating with patients about their impending death, as they did not want to deter their patients' hope of recovery. 19w can the health care system mediate the effects of moral distress?
In order to mitigate the negative effects of moral distress, it is imperative that organizations provide staff with support resources to help them cope, as well as training in ethics.Researchers have advocated that health professionals should not try and ignore their moral distress, but instead they should acknowledge it and be offered support on the job to deal with their feelings in constructive ways. 6In addition, providing health care professionals with on-thejob training in ethics is critical.These training sessions will allow them to discuss the ethics around various patient situations and teach them about the different ways of reasoning. 3This knowledge is important as it could aid professionals to "understand better their own process of ethical decision making and create greater readiness for related situations". 3nclusion In sum, moral distress is a phenomenon that affects many health care providers in their day-to-day work.This paper has only discussed a small portion of the effects of moral distress and the factors involved in the development of moral distress, as well as how it can be mitigated.It is imperative to recognize that additional research is warranted to study this phenomenon, in order to fully understand the effect that it has on health care providers, how systemic factors contribute to the development of moral distress, and how health administration can develop and improve on supports and services available to health care providers.