Moral Distress in the Health Professions

By Connie M. Ulrich and Christine Grady

This is the first book on the market or within academia dedicated solely to moral distress among health professionals. It aims to bring conceptual clarity about moral distress and distinguish it from related concepts. Explicit attention is given to the voices and experiences of health care professionals from multiple disciplines and many parts of the world.  Contributors explain the evolution of the concept of moral distress, sources of moral distress including those that arise at the unit/team and organization/system level, and possible solutions to address moral distress at every level. A liberal use of case studies will make the phenomenon palpable to readers. 

This volume provides information not only for academia and educational initiatives, but also for practitioners and the research community, and will serve as a professional resource for courses in health professional schools, bioethics, and business, as well as in the hospital wards, intensive care units, long-term care facilities, hospice, and ambulatory practice sites in which moral distress originates.

• Language: English
• Publisher: Springer
• Release date: Jan 31, 2018
• ISBN: 9783319646268

Book preview

© Springer International Publishing AG 2018

Connie M. Ulrich and Christine Grady (eds.)Moral Distress in the Health Professions https://doi.org/10.1007/978-3-319-64626-8_1

1. Introduction

Connie M. Ulrich¹, ²   and Christine Grady³  

(1)

Lillian S. Brunner Endowed Chair, University of Pennsylvania School of Nursing, Philadelphia, PA, USA

(2)

Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA

(3)

Department of Bioethics, National Institutes of Health Clinical Center, Bethesda, MD, USA

Connie M. Ulrich (Corresponding author)

Email: [e-mail]

Christine Grady (Corresponding author)

Email: [e-mail]

Crucial ethical issues are involved not just in the great questions of life and death, but also in those clinical decisions that, at first sight, appear to be the simplest and most straightforward. [1]

This book is about moral distress, an increasingly familiar term and a common phenomenon in the daily life of those who work in the healthcare professions. Since its original definition by a philosopher more than 30 years ago, moral distress has been defined and studied by various authors and in various ways. Most understand moral distress to occur when a healthcare professional, as a moral agent, cannot or does not act on his or her moral judgment(s) (or what he or she believes to be right in a particular situation) because of institutional or internal constraints. Addressing moral distress requires attention to the everyday ethical or moral concerns that appear routine but nonetheless can challenge both the patient-clinician relationship and the mental and physical well-being of healthcare providers. Some worry that if the rising tide of moral distress is not addressed, the professional and moral integrity of health professionals is at risk. Addressing moral distress also crucially requires attention to the environments and systems in which healthcare workers care for patients. Some commentators have suggested that it is time to either abandon the negative label of moral distress or to move beyond it to discuss how we can build or promote resilience within constricted working environments. We believe that moral distress is real and here to stay but that it is also sometimes exaggerated or misunderstood. We further believe that compromised integrity is not an inevitable result of experiencing moral distress and that sensitivity to moral challenges can be a source of growth and learning. This book was motivated by a desire to describe the experiences of moral distress and identify commonalities and differences experienced by many diverse healthcare professionals. The aim is to recognize the seriousness of moral distress beyond the nursing discipline, give voice to a community of health professionals facing challenging and complex ethical issues, and promote ongoing dialogue both within and outside academic and clinical communities on the physical and psychological toll of moral distress and strategies for mitigating it.

Healthcare providers are a great and essential asset when sickness occurs. Patients, and the public in general, rely on the substantive body of knowledge and clinical expertise of a team of clinicians dedicated to the care and well-being of patients within designated hospital settings or medical centers. This team includes nurses, physicians, social workers, pharmacists, psychiatrists, researchers, students in training, and many others. This talented group of professionals cares for the young, the old, and the sickest of the sick, often with little fanfare or recognition. Every day these clinicians assess, interpret, analyze, and interact with human health and illness. While caring for patients and their families, healthcare professionals share and reflect on the joys and sorrows that accompany these interactions. And in many ways, they are suffering too.

Today, healthcare clinicians face mounting pressures as they care for their patients, pressures and resulting stress that can impact their own health and well-being. Evidence suggests that clinicians commonly suffer from physical and psychological health-related problems, including but not limited to depression, burnout, fatigue, and moral distress [2–6]. Everyday work within healthcare systems is inherently ethical; clinicians seek to help patients and their families understand complicated diagnoses or procedures, weigh different treatment options and balance medication regimens, and assist with emotionally charged decisions at every stage of life. Healthcare professionals strive to use their knowledge, skills, and expert training to act in the best interests of their patients and families and, at the same time, uphold their professional and ethical values, norms, and principles. But, patient care within the clinical arena is increasingly complex as different groups of stakeholders may have divergent goals, goals that at times seem incompatible, creating unease, ethical tensions, and conflict. The pressures healthcare clinicians face stem not only from the variable and changing demographics and needs of patients and competing demands for often limited resources but also from individual stressors and organizational workplace issues they encounter on a daily basis. Healthcare clinicians often work long hours in fast-paced and complex environments where they are engaged in thorny ethical issues that might seem intractable.

Pavlish and colleagues attribute ethical conflicts to extended life spans, increased technology, the public’s unrealistic expectations of medical care, greater cultural and religious diversity, more emphasis on patient’s rights, shifts in healthcare financing, and limited resources [7]. Indeed, our global society is aging, and healthcare professionals are encountering more racially, ethnically, and culturally diverse patients requiring skilled communication in addressing the preferences and goals of patients and their families. The United States, for example, expects that more than 20% of its population will be 65 years old or older by 2030 [8]. And by 2050, 1.6 billion individuals worldwide will be in this age cohort [9]. Of course, although people are living longer, that does not necessarily mean that they are living healthier [9]. In fact, chronic illness is significant in older populations; and many older adults spend time in intensive care environments at the end of life with costly interventions that provide little benefit. Despite the reality as stated by Atul Gawande that dying and death confront every new doctor or nurse [10], clinicians continue to struggle to guide patients and families with end-of-life decisions, especially when they do not agree with the decisions made. Everyone who intimately cares for patients at the end of life can recognize the glimmer of hope when a laboratory value shows stability or the next treatment improves physiological functioning but can also recognize the dread and sadness when it does not [11]. Initiating difficult conversations regarding transitions in care from curative to palliative can be challenging and stressful for all involved. Studies suggest that the lack of educational preparation on advance care and end-of-life planning for both nurses and physicians hampers their ability to confidently discuss end-of-life concerns with seriously ill patients and their families [12–14].

Ethical issues and conflicts are commonplace in today’s healthcare environment. Arthur Caplan, a prominent bioethicist, noted that the ordinariness of the day-to-day ethical questions and problems within health institutions often appears mundane or banal (p. 38) [15]. Although he was directly speaking about medical residents in nursing homes at the time, the same can be said about nurses, physicians, pharmacists, social workers, and other healthcare providers who spend many hours in the service of caring for patients and families within hospitals and other acute, long-term care and community settings. Day-to-day work-related ethical questions are part of the operational life within these walls and include but are not limited to: Do I have enough staff to safely care for these patients? Should I report a near miss that didn’t harm the patient? Who is going to share the news with my patient that she has advanced cancer for which chemotherapy and other treatments will likely be of little benefit? And what if she insists on aggressive treatment that has little hope? How should I discharge my patient when there is no assistance at home, but the patient’s insurance dictates the number of hospital days covered? What should I do when my patient refuses his medication and has become agitated? Should I tell the family of a patient with Alzheimer’s who have asked my opinion twice about long-term care options what I would do if I were in their position? Should I call the attending physician about a questionable laboratory value and risk potential backlash at 3 am in the morning? Do I suggest that my patient, who doesn’t understand the procedure being proposed and is already scheduled in the operating room, withhold his signature from the informed consent document until the clinical fellow has more time to explain it in detail? How do I help my patient understand the risks and trade-offs of treatment choices? Every day ethical questions arise in the patient-clinician relationship that, as Caplan notes, might seem at odds with how one thinks of ethical or moral questions; but ethics concerns not only questions of life and death but how one ought to live with and interact with others on a daily basis. The ethics of the ordinary is just as much a part of health care ethics as the ethics of the extraordinary (p. 38) [15]. Ulrich and colleagues found that clinicians might question or have concerns about what is morally right or wrong in many commonly encountered clinical situations [5]. Ordinary questions—along with the extraordinary—can challenge professional and ethical practice on a daily basis.

Nurses, for example, identify a host of ethical challenges in clinical care (and research). They often report participation in morally distressing situations, feeling powerless to change or alter the course of certain decisions, and consequently experiencing psychological, physical, and moral stress. The example below is an illustration of moral distress that occurs when healthcare clinicians are placed in a morally undesirable position and suffer from self-directed negative emotions such as anger, guilt, and remorse.

Mr. Roberts is a terminally ill patient with a diagnosis of end-stage lung disease in the intensive care unit. Prior to meeting with Mr. Roberts, the nurse and attending physician met with his family to discuss their concerns. During this meeting, the family insisted that the patient not be told about hospice options or other comfort care options because if he knew his prognosis, he would just give up and die. In a previous conversation earlier that day with Mr. Roberts, however, the nurse caring for him learned that he was in fact aware that he would not receive the lifesaving transplant that he needed and that he knew that he was going to die. The patient was also told by the physician that there were no treatment options for him and that he wouldn’t be able to go home as he wished based on his current level of care needs. The patient was competent, awake, and seemed very aware of what was happening with his care. He was also on high levels of oxygen which made it unsafe for him to eat or drink, although Mr. Roberts continued to ask for food and drink and became increasingly angry when these were denied. The nurse was also worried that any food or drink could cause the patient to arrest, and according to current orders, he remained a full code. Without telling the patient that he could die without the oxygen, the primary nurse for Mr. Roberts explained the risks as much as she could. She also spoke with the family about allowing Mr. Roberts to eat and drink but that he would need to be fully informed of the risks. Again, the family refused, indicating that they did not want him to know all the information surrounding his prognosis. The nurse felt as though she was lying to the patient every time she walked into his room to care for him. She became angry at the family for placing her in a position that went against both her personal and professional values even though it was what the family wanted.

Ethical issues are not isolated to those who are on the wards every day as full-time healthcare employees. Medical residents and students also express unique ethical concerns reflective of their positions with healthcare systems. Similar to their nursing colleagues, they are subject to the decision-making authority hierarchy, sandwiched between an attending physician and others on the healthcare team. They often worry about speaking out; at times questioning their own competency to do so, and fearing the potential consequences that might come their way. It is difficult to expect medical and nursing students to lead—and to become future leaders—if they are not led or given the space to identify, critique, and resolve the moral questions they encounter. The increase in violence perpetrated against healthcare clinicians is also troubling. In fact, in one study, 76% of hospital nurses reported patient and visitor aggression and violence over the past year—emotional, physical, or verbal [16]. Being at the bedside for protracted periods of time increases the potential risk of harm by angry and stressed patients or family members, especially for clinicians who work in emergency or psychiatric settings. Continual exposure to these ethical issues can lead to moral distress, emotional and physical exhaustion, injuries, and, ultimately, declines in a quality healthcare workforce.

1.1 The Organization of the Book

The idea of writing a book on moral distress first percolated in 2008 at a conference at the American Society of Bioethics and Humanities. Although it has taken us some time…indeed, almost 10 years…to bring this to fruition, we hope that this book helps all of those who have faced moral distress in their clinical work and enlightens those who have not, recognizing that moral distress is a present-day reflection of the real-time minute-to-minute and hour-to-hour reality of patient care delivery in complex systems. Since that time, there has been an explosion of scholarly discourse, research, and commentary on moral distress demonstrating that many healthcare clinicians experience this phenomenon, regardless of their professional or practice discipline. Indeed, moral distress is not going away any time soon.

This book seeks to challenge readers on the following questions:

1.

What do we know about moral distress and how has it been defined since its original definition in 1984? Much of the early conceptual and empirical work on moral distress focused on the nursing profession because of nurses’ distinctive position in the healthcare hierarchy. Today, however, we know that many other healthcare disciplines are similarly distressed.

2.

What do we know about moral distress from empirical studies, and where are the gaps? Does the research adequately capture the phenomenon across settings and disciplines? We also need more research that moves beyond mere description of the problem to help get us closer to understanding its impact and ways to prevent or mitigate it.

3.

How should we understand the value of an ethical climate in the workplace, what does this look like, and how should we promote ethical climates in the healthcare workplace? What role do the values of an organization and its leadership play in enhancing or impeding the ethical care of patients and support of healthcare professionals?

4.

What are the lessons we can learn from experiences of moral distress from diverse healthcare disciplines, both domestic and international? Do healthcare clinicians in both the developed and developing worlds share similar yet unique ethical challenges?

5.

What are the most significant or important reasons that healthcare professionals might feel trapped and unable to do what they think is right (hence experience moral distress)? And, what does moral success look like within healthcare institutions today?

The complexity of healthcare institutions, the increasing patient acuity levels and the evolution of societal ills (such as the opioid crisis in the United States and the management of substance abuse patients, and Ebola in the developing world), the corporatization of healthcare, and the continual development of technology (e.g., precision science and genomics) to address some of the most recalcitrant health problems, both domestically and internationally, can all contribute to challenges that result in moral distress for healthcare clinicians as they address the ethical issues before them. Organizations have responsibilities to provide safe working environments for their employees; and, to some degree, organizational systems and the organizational culture should identify successes or failures in preventing and resolving morally distressing situations. Learning from our moral mistakes and successes can also be instructive. Building a culture and climate of open discourse without fear of retribution that is responsive to ethical issues and concerns recognized by nurses, physicians, and others supports the overall health and well-being of those responsible for patients and families who place their trust in these clinicians during their most vulnerable moments. It is our hope that this book will lead to further dialogue, research, and conceptual clarification of moral distress that includes both normative and empirical scholarship as an important area of bioethics inquiry and health services research. What we do in our communities and companies—the public policies we put in place, the ways we help one another—can ensure that fewer people suffer. (p. 11) [17].

References

1.

Truog RD, Brown SD, Browning D, Hundert EM, Rider EA, Bell SK, et al. Microethics: the ethics of everyday clinical practice. Hast Cent Rep. 2015;45(1):11–7.Crossref

2.

Hamric AB, Blackhall 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(2):422–9.CrossrefPubMed

3.

Hamric AB. Moral distress and nurse-physician relationships. Virtual Mentor. 2010;12(1):6–11.CrossrefPubMed

4.

Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573–6.CrossrefPubMedPubMedCentral

5.

Ulrich CM, Taylor C, Soeken K, O’Donnell P, Farrar A, Danis M, et al. Everyday ethics: ethical issues and stress in nursing practice. J Adv Nurs. 2010;66(11):2510–9.CrossrefPubMed

6.

Ulrich C, O’Donnell P, Taylor C, Farrar A, Danis M, Grady C. Ethical climate, ethics stress, and the job satisfaction of nurses and social workers in the United States. Soc Sci Med. 2007;65(8):1708–19.CrossrefPubMedPubMedCentral

7.

Pavlish C, Brown-Saltzman K, Jakel P, Fine A. The nature of ethical conflicts and the meaning of moral community in oncology practice. Oncol Nurs Forum. 2014;41(2):130–40.CrossrefPubMed

8.

Ortman JM, Velkoff VA, Hogan H. An aging nation: the older population in the United States population estimates and projections: current population reports. https://​www.​census.​gov/​prod/​2014pubs/​p25-1140.​pdf; 2014.

9.

Cire B. World’s older population grows dramatically. Retrieved from https://​www.​nia.​nih.​gov/​news/​worlds-older-population-grows-dramatically; 2016.

10.

Gawande A. Being mortal: medicine and what matters in the end. 1st ed. New York: Metropolitan Books: Henry Holt & Company; 2014. 282 p.

11.

Ulrich C. End of life futility conversations: when language matters. Perspectives in Biology and Medicine. 2017;60(3): 433–7. (in press)

12.

Institute of Medicine (U.S.) Committee on Approaching Death: Addressing Key End-of-Life Issues. Dying in America: improving quality and honoring individual preferences near the end of life, vol. xxv. Washington, D.C.: The National Academies Press; 2015. 612 p.

13.

Long AC, Downey L, Engelberg RA, Ford DW, Back AL, Curtis JR. Physicians’ and nurse practitioners’ level of pessimism about end-of-life care during training: does it change over time? J Pain Symptom Manag. 2016;51(5):890–7.e1.Crossref

14.

Visser M, Deliens L, Houttekier D. Physician-related barriers to communication and patient- and family-centred decision-making towards the end of life in intensive care: a systematic review. Crit Care. 2014;18(6):604, 1–19.

15.

Caplan AL. The morality of the mundane: Ethical issues arising in the daily lives of nursing home residents (pp. 37–50). In RA Kane and AL Caplan (Eds). Everyday ethics: resolving dilemmas in nursing home life, vol. xvii. New York: Springer; 1990. 331 p.

16.

Speroni KG, Fitch T, Dawson E, Dugan L, Atherton M. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. J Emerg Nurs. 2014;40(3):218–28.

17.

Sandberg S, Grant AM. Option B: facing adversity, building resilience, and finding joy. 1st ed. New York: Alfred A. Knopf; 2017. 226 p.

© Springer International Publishing AG 2018

Connie M. Ulrich and Christine Grady (eds.)Moral Distress in the Health Professions https://doi.org/10.1007/978-3-319-64626-8_2

2. What We Know About Moral Distress

Lynn Musto¹   and Patricia Rodney²

(1)

School of Nursing, Trinity Western University, Langley, BC, Canada

(2)

UBC School of Nursing, W. Maurice Young Centre for Applied Ethics, UBC, Vancouver, BC, Canada

Lynn Musto

Email: [e-mail]

Keywords

Moral distressRelational agencyReciprocityStructure and agency

2.1 Moral Distress: Evolution of the Concept

When theory and practice in healthcare ethics started to evolve in the late 1970s, there emerged a growing consensus about how ethical principles ought to guide healthcare delivery [1, 2], yet the well-being of healthcare providers received relatively little attention. This lack of attention started to change with American philosopher Andrew Jameton’s groundbreaking writing about moral distress in his book on nursing ethics [3]. Jameton’s book, his subsequent publications, and the early related research work by nurse scholars such as Fry, Harvey [4], Hamric [5], and Wilkinson [6] initiated an important conceptual and practical shift. This shift has helped all of us involved in healthcare to recognize that the moral experiences of healthcare providers affect the quality of healthcare delivery and also the well-being of the providers themselves [7–9].

In this chapter, we offer a further contribution to growing contemporary commentaries on how the concept of moral distress has evolved and how it has been applied, including its pitfalls and promises. Our intent is to continue to support what we see as a lively and promising dialogue about moral distress in nursing, other healthcare provider groups, and healthcare ethics in general. On the basis of our experiences in practice and research, it is our conviction that continuing to wrestle with the clarity of the concept, its application, and the implications for practice (including leadership) in healthcare remains important. We believe that supporting nurses and all other healthcare providers as moral agents operating in complex organizational structures is prerequisite to offering effective and ethical healthcare and fostering a sustainable healthcare workforce.

We will therefore provide an overview of the evolution of the definition of moral distress, outline some of the critiques of the concept that have shaped our exploration, and point to areas for further research and development. We close our chapter with conceptual and practical recommendations for nursing, other healthcare provider groups, and for the structure and delivery of healthcare. It is important to note that while the study of moral distress was initiated in the United States, it is now also increasingly being addressed by colleagues from diverse parts of the globe—including, for instance, Australia [10, 11], Brazil [12], Canada [13], Ireland [14], and Iran [15]. While we will not be undertaking a full international analysis of the concept of moral distress, we will point to some of the implications of the expanding global interest in the concept toward the end of this chapter.

2.2 Conceptual Origin and Evolution of the Definition

Healthcare ethics evolved in response to the significant values-based challenges that healthcare providers faced in trying to provide competent, effective, and equitable care in the face of decisions regarding the effective deployment of healthcare technology and equitable access to healthcare resources¹ [2, 18]. As we have noted in our introduction to this chapter, attention to the well-being of healthcare providers started to emerge more directly when Andrew Jameton, a philosopher, was working with nurses and observed that moral and ethical problems in the hospital could be sorted into three different types, moral uncertainty, moral dilemmas, and moral distress [3]. Jameton’s original definition of moral distress stated that the experience arose when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action [3]. In identifying moral distress, Jameton put into words a collective experience that occurred when nurses confronted situations that created a conflict in their professional values—a conflict that often ultimately left the nurse with the sense that they had failed to live up to their moral obligations to the patient.

Although identification of the concept captured the attention of nursing scholars, when nurse researchers and researchers in other disciplines began to operationalize the definition, it soon became clear that there were gaps. As research on moral distress progressed, scholars articulated some of those gaps, including potential conflation of moral distress and psychological or emotional distress, leading to a call for researchers to focus on the ethical component of moral distress [14, 19]; the view of moral distress as a linear process [20, 21]; the need