Moral Distress in Health Care Providers

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COMPANY PRESENTATION | www.yourdomain.com
Moral Distress
in Health care providers
The Impact, Consequences and Strategies that help.
Vickie Leff, LCSW, BCS, APHSW-C
Clinical Social Work
Duke Hospice

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Objectives
 Look at strategies to
increase moral
resiliency; on
individual & systems
level.
 Identify, define
moral distress.
 Identify impact of
moral distress on
ourselves, colleagues
and patients.

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Whenyou know whatthe right thingto do is, but institutionalconstraints make it nearly impossible to pursue the
right course of action. (Jameton, 1984)
Key Features of Moral Distress
Hasthe possibilityof becoming “a catalystfor positiveaction”.
(A Collaborative State of the Science Initiative:
Transforming Moral Distress into Moral Resilience in Nursing. 2016)

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Not havingproper PPEduringa pandemic.
Providing care whenyou feelit is futile.
Moral Distress Examples
Team members feel they must do as proxies
ask, i.e. provide aggressive treatment in futile
situation
Pt is unresponsive, stafffeel she is suffering,
others disagree.

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Moral Distress & COVID
 Pandemicshiftsfrom a patient-centeredapproach tocommunity-basedapproach.
 Ethicalpriorities may change
 Visitation restrictions
 Pt’s now relying more on caregivers (you) toprovide emotionalsupport
 Do thefamiliesunderstandthe medicalcomplexity, unableto“see” the treatments,vents, etc.?
 Moral uncertainty:does thesurrogate understand?
 Issue of remote decision maker
 Reducedprovision of healthcare services (fewer visits toPCP,etc.) Whatis essential?

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Staff Moral Distress
Examples
 Followingfamilywishes when you believe it’snotin the pt’s best
interest
 Providinginadequatepainrelief
 Lack of truth telling
 Giving false hope
 “Knowing” the outcome when pt arrives

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 Aggressive treatment for terminalpatient
 Recommending rehab for patientunableto participate
 pressure to dischargedying patient
 Lack of truthtelling
 Followingfamilywishes when you believe it’snotin the pt’s best interest
 Giving falsehope
More Examples:

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Impact on you
 Person who experiences moral distress also feels
heightened moral responsibility
Clarifying the ethical issues can help those
involved ascertain what they are and are not
responsible for.

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 Powerless
 i.e. nurses who have high responsibility and low
control
 Feel deeply responsible
 Blame
 Ourselves if we “don’t act with courage” – leading
to remorse and guilt
 Others for their “wrong choice” – fractured
relationships

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Impact on Patient
 Harm to the clinician comes BY WAY OF perceived
harm to the patient
 Feels discouraging and powerless

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Moral Distress Root Causes
 Hamric et al. (2012) proposed three primary causes of moral
distress:
 INTERNAL (such as perceived powerlessness),
 EXTERNAL (such as poor communication among the
health-care team), and
 issues inherent in the immediate clinical situation (such
as witnessing nonbeneficial treatment or lack of truth-
telling)

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Data
No difference between nurses and physicianson top two reasons.

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Nurses and Physicians
 Turnover and Intent to leave:
22% of physicians
35% of nurses
Have left a position in the past, or currently
considering leaving due to Moral Distress.
 Physicians had higher level of MD when they
had higher load of critical care pts
 Risk for moral distress highest between 6 & 10
years of working in Health care
(Austin, Saylor, Finley 2016. APA)

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 2011 study: nurses had highest level of MD, as
compared to physicians. (high demand, low
control)
 “Watching care suffer due to lack of continuity”
 Those with EOL education had higher MD levels.
 (learn best practices but unable to enact?)
Whitehead, et.al. 2014; Dodek 2016

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Goal
“The aim is not to eradicate the phenomenon but rather to mitigate its
negative effects, including preventing caregivers from feeling unable to
provide compassionate patient-centered care, feeling withdrawn, unable to
return to work or continueintheir profession.”
Morley, 2020. Addressing caregiver
moral distress during COVID19
Pandemic

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Top reasons for
moral distress
 Following a family’s wishes for life-sustaining therapies the nurse thought would
not benefitthe patient,
 Observing physiciansbeinguntruthfulabout a patient’s prognosis,
 Participating inacode they thoughtwouldonlyprolongdeath, and
 Havingtheir opinionabout patient care dismissed bythe health-care team.
From nurse survey
responses…

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The Data

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What is
different/challenging
about case management?

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Literature and studies about Burnout in
Case Management…
Search results

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 Moffat, Mary. Reducing Moral
Distress in Case Managers. Prof.
Case Management 19:4. 2014

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Impact on
Health care system
 Overly aggressive, nonbeneficialrx are associated withreduced qolat EOL
 Sx ofPTSD more likelyamong caregivers
 MD isan ethical rootcase ofburnout
 Examinewhat the ethical decisionmakingclimate is(EDMCQ).

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Culture
 How doyou measure“culture”
 Effectof unit, teamleadership?

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Distress v Moral distress
 A nurse wants their terminally ill pt to be comfortable, while not
wanting to hasten death. Worries administering opiod will hasten
death.
 Professional v Personal obligations?

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Personal integrity
 Cliniciansstanding upto overcome constraints take risky action.
 Is it coming up often (i.e. what does that say about the culture? The
organization?)

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Easing our moral distress v
Improving care of the patient
 How do we take care of ourselves and the patient? Self care
will assuage personal distress, but not help the patient

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Preliminary data from DUH
Nursing Units using MDS-HP
 No differencebetween8 nursing units
 Providingaggressive treatment in face of nohopeof survival.

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Some emotional effects of
moral distress
 Anger
 Anxiety
 Disgust
 Demoralization
 Guilt
 Sadness
 Frustration
 Powerlessness
Leading to…
Cynicism
Walling off of emotions (good and bad)
(compartmentalization)

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Consequences
“Nurses coping with unrecognized and untreated moral
distress are at higher risk for detachment, burnout, and
even leavingtheir profession…“
Epstein & Delgado, 2010;
Epstein & Hamric, 2009;
Hamric & Blackhall, 2007;
Hamric et al., 2012

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Rattner, M., Berozz, J.
Witness to Suffering
“…we need to claim some humility in that some form of
sufferingmay also beincurable.”

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Experiencing moral distress
will impact our personal
reactions:
 Get overwhelmed with emotion
 Loose ourboundaries,“get suckedin”
 Have unrealistic expectations ofthe outcome
 Become closed-mindedabout the situation
“Stickingto ourguns”.
 Unable to distinguish ourownsuffering from the pt/family

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The Real Life Impact
 Changes how we speak to each other (us v them)
 Draws on emotionalenergy
 Feels helplessin work that “needs” to feel meaningful
 Often pits oneprovider/professionagainst another
You aren’t ableto be present withthe patient, can’t give the care you know you can.
Takes away focus from the relationship

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The Crescendo effect
 Repeated and unaddressed situations of moral distress over
time cause a gradual crescendo of moral residue, the
lingering feelings of distress that may continue to months.
Hamric 2012
Crescendo effect can undermine the professional
commitment and integrity of the provider

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Moral Resilience
 The ability to recover
 Not getting overwhelmed with negative emotions
 Having boundaries to helpreduce the intensity
”…defined as the capacity of an individual to sustainor restore their integrity in
response to moralcomplexity, confusion, distress, or setbacks”
Rushton, RN, PhD, 2016

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Identifying the ethical issue
1. Emotions: whatare you feeling?
2. Source: whatis the source of theMD?
1. Internal conflict? External?
3. Constraints – name the internal and external constraints to taking action
1. Internal - feeling powerless
2. External - inadequatestaffing or support from colleagues
4. Conflicting responsibilities
1. Help to identify the moral core, namingconflicting responsibilities
5. Possible actions to improve situation for pt, improve distress for yourself?
6. Final action: whataction should you take?
Dudzinski, 2016

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Individual Strategies
 Remain openmindedandcurious
 Resist making conclusions
 Knowwhere our ownsuffering/angst beginsand ends
 Use cognitive reframing to help us understand the plight of the pt (not use all
or nothingthinking)
 Research usingMDS-HP survey

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What’s so great about debriefing?
 Alleviates distress
 Empowers staff
 Facilitates communication
 Develops &Enhances teamwork
 Strengthens social support
 Improves practice
 Decreases burnout
 Leads to organizational change

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enables us to cope with...
 Compassion fatigue
 Moral distress
 Secondary traumatic stress
syndrome
 ...all of which adds to BURNOUT and
feeling distressed

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Variations
 On The Fly: “We are meeting to spend
a few moments to pause and
think about what just happened”
 Monthly Meetings: “We are here to take
time out, pause, and think about the impact
on you, being here on the floor, the things
you do and see; and give voice to the
very difficult situations and events you face”

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System Strategies
 Naming the problem: Moral Distress alleviates shame. This is not burnout. (Not
due to individuallackof copingskills)
 Collaborate withother disciplines(IPE).
 Create opportunitiesfor interdisciplinaryconversations abouttreatment.
 Cultureof ethical practice (committees, debriefs,didactics)
 Develop work environment that fosters reflection and communication, rewards
raising ethical questions

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“Clinicians who are able to view their support of the patient and
his or her preferences as meaningful for the patient and within their
professional obligations may experience less moral distress intensity or be
able to reboundwithoutcollateral damage to their ownwell-being.”
Rushton, RN, PhD 2012 “Ethics in Critical Care”

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How Debriefings Can Help
 Helps to seek/find meaninginourwork
 Tease out personal andsystem issues
 Provides social support
 Helps withreframing assumptions
 Reducesfeelingsof isolation
 Reducesfeelingsof anger
 Groupreflectionhelpsto find insightand value

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Questions for discussion
 What type of situations cause YOUdistress?
 How are they differentfrom other cases?
 Whathas yourworkplace doneto helpwith these situations? i.e.Ethics committee,
debriefings,didactics?
 Whathas/hasn’t worked for youand/or yourworkplace
 What do you think wouldhelp?

Moral Distress in Health Care Providers

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