Moral Distress and the Contemporary Plight of Health Professionals
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- Austin, W. HEC Forum (2012) 24: 27. doi:10.1007/s10730-012-9179-8
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Once a term used primarily by moral philosophers, “moral distress” is increasingly used by health professionals to name experiences of frustration and failure in fulfilling moral obligations inherent to their fiduciary relationship with the public. Although such challenges have always been present, as has discord regarding the right thing to do in particular situations, there is a radical change in the degree and intensity of moral distress being expressed. Has the plight of professionals in healthcare practice changed? “Plight” encompasses not only the act of pledging, but that of predicament and peril. The author claims that health professionals are increasingly put in peril by healthcare reform that undermines their efficacy and jeopardizes ethical engagement with those in their care. The re-engineering of healthcare to give precedence to corporate and commercial values and strategies of commodification, service rationing, streamlining, and measuring of “efficiency,” is literally demoralizing health professionals. Healthcare practice needs to be grounded in a capacity for compassion and empathy, as is evident in standards of practice and codes of ethics, and in the understanding of what it means to be a professional. Such grounding allows for humane response to the availability of unprecedented advances in biotechnological treatments, for genuine dialogue and the raising of difficult, necessary ethical questions, and for the mutual support of health professionals themselves. If healthcare environments are not understood as moral communities but rather as simulated marketplaces, then health professionals’ moral agency is diminished and their vulnerability to moral distress is exacerbated. Research in moral distress and relational ethics is used to support this claim.
KeywordsHealth ethicsHealthcare reformMoral distressRelational ethics
Moral distress is the name increasingly used by health professionals to refer to experiences of frustration and failure arising from struggles to fulfill their moral obligations to patients, families, and the public. We need to pay attention to these experiences. Such moral distress may constitute what Somerville (2000) terms an “ethical canary.” She suggests that there are issues in a society that act like canaries in a mineshaft, sentinels offering early warning that something is amiss. The professionals resigning from their practice due to moral distress may be an indication that the healthcare environment has become toxic. Although ethical challenges have always been present in health care, as has discord regarding the right thing to do in particular situations, there appears to be amplification of the degree and intensity of the moral distress currently expressed.
In this paper, moral distress and the contemporary plight of health professionals is addressed. Plight is used purposefully as its meaning encompasses not only the notion of pledging, which is what health professionals do when they profess to the public to use their skills and expertise in a fiduciary way, but also notions of predicament and peril. The claim is made that the re-engineering of health care to give precedence to corporate and commercial values is literally demoralizing health professionals. That this re-engineering is occurring during a time of unprecedented innovation in medical treatment (and thus new moral quandaries) has served to deepen the troubles of health professionals. The perspective offered in the paper is grounded in interdisciplinary research in moral distress and relational ethics.
Being a Health Professional
One’s identity as health professional bears an implicit moral claim, a promise to fulfill a fiduciary duty: “A professional is one who ‘professes’ the ability and intention to help others, promising in effect to help those who need it” (Govier 1997, p. 79). The Canadian Nurses Association (CNA) code of ethics explicitly states that “Nurses need to recognize that they are moral agents in providing care” (2008, p. 5, original emphasis). When this foundational component of one’s professional identity is undermined, there are ramifications. Taylor (1989) argues that we orient ourselves in moral space—determine where we stand, so to speak—in terms of who we are. “This orientation,” he writes, “once attained, defines where you answer from….” To lose it, or not to have found it, “means not to know who one is” (p. 29). Moral distress can be a disorienting factor for health professionals. It goes to the heart of professional identity and makes it difficult to face oneself in the mirror. Once, after I gave a brief talk at a local hospital about moral distress, a young nurse approached me to say, “I don’t go home feeling just like a bad nurse; I go home feeling like a bad person.”1 Gordon (2005) notes that nurses told her, “We’re being turned into people we don’t even like” (p. 310).
It is constrained moral response that leads to moral distress; one cannot meet one’s perceived responsibilities (Varcoe and Rodney 2009). This is significant in differentiating moral distress from other types of distress common to healthcare practice. Health professionals may experience distress as they witness life tragedies related to sickness, injury, and death. Chambliss (1996) has pointed out that hospitals differ from other organizations in that “as a normal part of the routine, people suffer and die” (p. 16). Healthcare practice places professionals up close to the most profound aspects of human existence: birth and death, pain and suffering, joy and sorrow. While this place is a privileged one and the source of great reward, it is also the source of great challenge. It is the predicament of health professionals that their roles involve participation in momentous decisions that deeply affect the lives of patients and families, decisions that are ever more difficult as advances in biotechnology are taking us places we have never been. Health professionals learn to live with the paradox that pain can be a necessary part of healing. However, when healing becomes an impossibility, and yet painful treatment continues, it becomes a moral issue for the health professional. As a nurse participant in our study of the moral distress of paediatric intensive care unit (PICU) teams2 told us, “The pain and the discomfort that I caused this boy in caring for him was probably the most difficult experience for me.”
It is true that, although as health professionals we accept responsibility for competent, compassionate, ethical care and treatment, we do not genuinely have control over what unfolds for patients and families. Often responsibility is not aligned with the necessary power, and sometimes the responsibility can be too great and beyond the lone (and lonely) efforts of the individual. It must be recognized that the power of professionals flows from the social structures and relationships in which they practice (MacDonald 2002; Rodney et al. 2002; Storch et al. 2002).
The importance of these social structures and relations is underscored when an extreme example of healthcare institutional practices is considered. Accounts of nurses’ role in the Nazi euthanasia program (e.g., for psychiatric patients) discloses the way some took no responsibility for their patients’ deaths, placing it entirely on physicians or supervisors, such as institutional directors (Benedict and Kuhla 1999; McFarland-Icke 1999). Such an environment diminishes not only the power to practice ethically, but the very idea that one has the individual responsibility to do so. These accounts reinforce Hatab’s (1997) claim that it is a sense of responsibility that animates ethics.
The power to act as a health professional is directly influenced by society as well as the institutions within it. In a qualitative study of the moral distress of mental health professionals (Austin et al. 2008), we found that psychiatrists’ moral distress was often situated in the expectations of society, for instance that psychiatry should deal with (solve, medicate) societal problems such as interpersonal violence (e.g., hospitalize someone who is threatening others) or deal with (e.g., certify as “incompetent”) persons who deviate from the norm or who reject medical advice (e.g., refuse life-sustaining treatments). In the moral distress stories of PICU teams, we found that physicians, at least implicitly, were pressured by the ardent societal message, Don’t let children die. This imperative can evolve into extraordinary interventions to keep alive very ill or injured children. One intensivist in our study said, “I am not comfortable playing God,” and then wondered, “Maybe it’s because I’m young. Or is it inexperienced?” In this physician’s words can be detected the hope that becoming more God-like might yet occur.
Professionals practice not only to professional standards but, to quote MacDonald (2002),“in the face of countervailing pressures from institutional authorities, disagreement with members of other professions, or inappropriate demand on the part of patients or clients or, more generally, the public” (p. 196). In reality, individual professionals can be without freedom to act on their own conscience. The trust that society grants health professionals must be reciprocal. The support and resources necessary for competent, ethical practice have to be available if health professionals are to fulfill their commitments. When it is not forthcoming is where peril lies.
Constraints on Professional Practice
There were all those bloody cuts at the hospital. We lost all our unit managers, all their positions were abolished. All our supervisors have been abolished. The staffing office isrun by [the staffing] clerks.… There was a significant loss there.… [Now] we’re just told there is no money. Like, we had our interdisciplinary meeting last week and, whateverwas brought up, there was no money. But the most distressing thing right now is to see the lack of staff.… A lot of things are missed, you know, and that’s frustrating becauseyou want to provide the care and yet things just fall through the cracks (Austin et al. 2003, p.180).
Similar things were revealed in a study of relationships between family and staff in continuing care settings (Austin et al. 2009b). Families said that it is “the little things” that count for them (“that my mother’s hair is combed and she is sitting comfortably in a chair”). These signs of caring are taken as clues that a family member’s needs are noticed and being met. Staff described feeling terrible because they often struggled to provide just the basics, such as feeding and bathing. They couldn’t get to “the little things” but strongly agreed they mattered. One experienced nurse in this research said she felt pity for the new generation of nurses: “They don’t know the kind of nursing you could do. I mean, right now you are almost like a triage nurse. Like [having to say to patients]”, “If you’re not this sick—sorry.” We found that families recognized the constraints placed on staff, particularly the lack of time and resources. A family member participant said, “If there’s any fault, it’s at the systemic level and not with the individuals working here. I’m convinced of that.”
For members of the PICU teams with moral distress, lack of resources was never mentioned as an issue; rather, one might say the opposite was true. We were told about children kept in artificial comas so they could tolerate all the technical devices attached to their bodies. One member of our research team has pointed out that “to be fixable, the body has to be a kind of machine” (Frank 1995, p. 88). There were stories about attempts to save children who had very little chance of survival, such as the baby who was severely neurologically damaged yet received more than one organ transplant before she died.3 Moral distress among members of PICU teams was often about the suffering of children, grounded in the question “Should we be doing this?” and the ongoing anguish of no clear answer. Their stories suggest that, like Goethe’s sorcerer’s apprentice (Goethe 1797), our society may have sufficient knowledge to create magic but has not achieved the wisdom to control it.
Much of the research in moral distress has been focused on the discipline of nursing. The findings of our interdisciplinary studies of moral distress, however, are congruent with a systematic review (Rittenmeyer and Huffman 2009) of 39 qualitative studies of how professional nurses working in hospitals experience moral distress. Contributors to moral distress were identified as institutional constraints and their impact on nurses’ ability to advocate for patients; inability to influence medical decisions related to patient pain and suffering; and lack of recognition of one’s expertise within the hospital power hierarchy.
At a 2008 conference on moral distress co-sponsored by a provincial college and association of nurses and a provincial health ethics network,4 delegates were asked, “What three factors contribute most to moral distress in your workplace?”A major contributor to moral distress was identified as professional and inter-professional relationships, including challenging team dynamics with no time or structures in place for debriefing, problem solving, relationship building; a perception that one did not have a voice, that management overpowered with a “my way or the highway” attitude, and that the difficulties facing managers went unrecognized. Complex patient and family care that involved inter-professional care differences, threats of legal action, and family distress and demands was also identified, but the most cited factor was resource allocation (both human and material). In terms of material resources, it was generally noted that unavailability of appropriate or best treatment and of equipment (including bed shortages) put patients at risk. Experienced health professionals noted they were unable to maintain the standards of care they once had and that working conditions had deteriorated. Short-staffing placed increasing demands on work time, eliminating breaks and requiring some staff to work as many as 20 days consecutively. Staff shortages and increased demands also made routine patient follow-up difficult. Moreover, a lack of resources for training and mentorship left new recruits being expected to perform beyond their capabilities and without necessary supports. A Canadian study by Pauly et al. (2009) and an American study by Corley et al. (2005) both found the highest frequency and intensity of moral distress experienced by nurses to be correlated with concerns for unsafe staffing practices. A further contributor identified was conflict between policy and practice, which consisted in a lack of negotiability in policy interpretation and generally intractable bureaucracy. Observing unsafe practices and poor care, delegates noted, was distressing, especially as no one at the managerial level seemed to take action. It was pointed out how administrative politics had created a culture of non-reporting and unresponsiveness—a code of silence.
The Inherent Challenge of Caring Work
Although the claim is being made, based on a growing body of anecdotal evidence and a greater presence in the literature, that the degree and intensity of moral distress among health professionals may be increasing, it needs to be acknowledged that there have always been challenges to meeting our responsibilities for treatment and care. Discord has always existed in complex human situations where the question of the right thing to do must answer not only to individual suffering but to the allocation of resources and to the negotiation of public policy. As a nurse, I recognize that professional dilemmas have existed since at least the time of Florence Nightingale, who reflected on what nursing ought to be in her Notes on nursing: What it is, and what it is not (1898).
The constraints on moral action that she and her colleagues experienced while caring for casualties of the Crimean war were largely systemic. A 2007 article in the Guardian discussed these systemic issues and Nightingale’s presence as a nurse who sought to improve conditions for patients and peers alike (Florence Nightingale’s disputed legacy 2007). It is noteworthy that it was not wounds but disease from terrible living conditions that killed most of the soldiers (over half the soldiers who served were killed). As women, the nurses were clearly unwelcome on the front. Supplies such as blankets that were shipped along with them were not issued. They were not allowed onto the wards, waiting daily at the hospitals for a physician to request their assistance. When they finally were able to use their skills to care for patients, they did so under horrendous conditions (e.g., there were 20 chamber pots for 1,000 men). Nightingale and Dr. John Hall, the British Expeditionary Army’s Chief of Medical Staff, had little use for one another. She saw many of the deaths as needless and due to mismanagement—and she reported this to the Minister at War. Hall described Nightingale in letters home5 as an interfering “petticoat imperieuse,” and said anyone who listened to her was obviously ignorant of the situation of an army in the field. In truth, John Hall didn’t have any real power himself to affect things: the rigid bureaucratic system in place (forms had to be filled out for everything) could not be made to work in a time of war. Hall’s real failure was his keeping silent about the problems, denying that things were not good, knowing no other physician would dare contradict him. The constraints on effective care in the war were significantly due to fallout from politics, power struggles, and bureaucratic conflicts. It does seem true that, as the saying goes, plus ça change, plus c’ est la même chose.6
The Need for a Morally Habitable Environment
As a researcher, the very first person I interviewed about moral distress was a nurse, “Jean,” who, like Nightingale, found herself nursing in the dark. Jean’s distress was situated in an inability to provide more than the basic physical care for her psychogeriatric patients. She had no time to stop and offer comfort, but flew from one to the next distributing meds and minimal moments of treatment. Jean spoke of being inspired by a workshop speaker who encouraged staff to “bring in the light” to their institutions, to make them more suitable places for people to heal or finish their life with some comfort and dignity. She was determined to do this in her practice but ultimately felt she had completely failed (Austin et al. 2003).
She told me that she had repeatedly gone to her administrators about issues but felt unheard. For instance, at the start of an afternoon shift, she was trying to receive a new patient with dementia who was resisting admission. As she struggled to help the frail woman, the upset relatives, and the paramedics who needed to take leave of the patient (knowing all the while that the care of her other patients was being left undone), Jean was relieved to see her administrator approaching from down the hall. When the administrator reached the scene, however, she walked around Jean, saying over her shoulder, “I’m going home; do your best.” Jean quit her position after a shift during which there was a power failure and no generator back-up. She left a note for administration which read: “We need bigger flashlights” (Austin et al. 2003, p. 182).
I called the MSF medical department, then the logistics department, then the medical department again. Each reminded me that morphine was supplied in limited quantities in the standard MSF surgical kits. “You will have to cope with what you have in your surgical kit. It’s our standard system.”
“Well, it’s not fucking working for my standard patients,” I screamed into the phone. I called Jules [Pieters, a friend of Orbinski’s who headed the MSF Emergency desk in Holland]. He promised the morphine would be on the next possible cargo flight into Kigali (p. 234).
One of the PICU nurses in our study said, “I want to say to management, ‘Walk in my shoes for a few shifts. Do what I do…. Come and work at the bedside for a while, because you have no idea. If you’ve had experience, you’ve forgotten what it’s like. Your decisions show that you have forgotten.’”8
Yet, many of us know persons in management who have not forgotten. These managers acknowledge the difficulty of enacting policies with which they do not agree. Acting for the organization has its perils, too.
Wolgast (1992), in work on the moral hazards of professions, focuses on the Hobbesian concept of “artificial personhood,” a term used to convey the way a government representative acts in the name of citizens. In the role of artificial person one acts in the name of someone else. This theatrical metaphor illustrates the way the role and the person are separate. Like actors, a representative may do things within a role that they would otherwise refuse. Actions become, in an important way, agent-less, says Wolgast, and responsibility loses coherence as personal character is seen as distinct from the morality of the role.
A psychiatrist in our study of moral distress in mental health settings described trying to cope with morally distressing situations by “making it true” (Austin et al. 2008, p. 96). The notion of “making it true” comes from the manual arts, in the sense of giving something a right form, making it exactly straight, square, or level (Thatcher and McQueen 1971). What this physician did was to gather the team together and try to make the situation straight or square—more honest. He would describe the rationale of what was happening, what he liked and did not like about it, and then he would give others the chance to say what they thought. This opportunity for voicing concerns and gaining a deeper understanding of the decision-making that affects one’s practice may be a necessary part of addressing moral distress.
It seems, however, that this will not be sufficient. For instance, more than one psychologist with moral distress in this same study (Austin et al. 2008) described pleading to keep a particular client on their caseload—they wanted their patients to know they could come back when necessary and to have the sense that familiar assistance was ready-to-hand. Their managers were frank with them that this was not possible: they were required to keep client numbers within a particular range; so, despite the fact that keeping the file open was best for the client and, admittedly, for the system too, files must be closed (Austin et al. 2005). It is difficult to accept that “that is just the way it is” when one feels it is unethical and hurting those for whom we have pledged to care.
[There is a] disconnect between how our organization is changing and what is valued and what is respected. It’s about a direction that is not congruent with what I think is best for patients and families…. [Administrators] say, “You’re being resistant.” After a while you realize that they are not listening; your voice is not wanted. Your opportunity to influence things has been taken away (Austin et al. 2009a).
It can be argued that the increase in moral distress experienced by health professionals is a result of shift of focus from patients and families to the organization itself. In their ethnographic study Rankin and Campbell (2006) describe how this has happened for nurses. Nurses’ primary commitment is now expected to be their employer, the particular healthcare organization in which they practice. These researchers find that people in the organization—patients, families, and staff—have become administrative objects to manipulate in the best interests of the organization.
This radical reframing of allegiance within healthcare has been occurring since the mid-90s, when corporatism drove the re-engineering of healthcare systems. Corporatism brings with it the dominant strategies of commodification, service rationing, streamlining, and measuring of “efficiency”. It is particularly paradoxical that Canadian health care, a tax-based, publically-funded system is being restructured in the image of the marketplace and being McDonaldized. Ritzer (2004) coined this term, using the fast-food company McDonald’s to represent the corporate push toward extreme efficiency, calculability, predictability, and control. It involves contracting out of services, the de-professionalizing of care, downsizing through bed closures and withdrawal of funding from community agencies, layoffs, and standardizing practice (also known as “decreasing variation in the system flow” (Shannon and French 2005)). Much time and effort goes into measurement and quantified evidence of outcomes. At a health ethics conference in which I addressed these issues, pastoral care counsellors told me that they must fill in weekly forms about their practice. When I seemed confused at what they could be measuring in giving spiritual care, they explained: minutes on the phone, time taken in encounters with patients, etc. Do we really believe that this type of time sheet reveals spiritual outcomes?
In the UK in 2005, the Minster of Constitutional Affairs wanted a market path developed for consumers’ access to professional services: she said it should be as easy as buying a tin of beans (Big shake-up for legal profession 2005). That is, a market path would allow people to take control over their own lives, with the bonus that competition among service providers would lead to reduced costs and more innovation. Friedman (2006) disputes the notion that professional services can be provided in this manner. Unlike retail services that involve the provision of products, professional services—Friedman refers to legal services, but healthcare professions can be similarly understood—involve a deeper level of human interaction with less predictable outcomes and in which choices cannot simply be offered like a commoditized package. It is not about choosing between available brands. He notes that when professional services have been packaged like tins of beans, the services are inflexible and do not meet the specific situation of those needing them.
A conference delegate, among those cited earlier who identified policy and practice conflicts as a major contributor to their moral distress, commented that “With a healthcare culture that follows a business model there is a feeling of a lack of humanity, and ‘policies before people.’” Other delegates noted that image seems more important than the care given, and organizational changes seem to have an agenda with “a different moral compass than public service.”9
A change in moral compass that belies health professionals’ fiduciary pledge places them at increasing risk for moral distress. Compassion and empathy that is extrinsically motivated (for good ratings on a patient satisfaction scale or for monetary reward) is made inauthentic. The offered connection is made superficial. It can be literally scripted. When a customer service model was imposed on nurses in a Massachusetts hospital, their primary concern was the scripting of patient communication (Newton–Wellesley RNs 2006). They refused to have their communication and relationships with patients co-opted by marketing consultants. These nurses insisted on being treated like professionals and “not like some audio-animatronics characters in a Disneyworld display.” The nurses in Massachusetts ultimately stood for “loyalty always to the patient, not the institution” (p. 13).
If the level of moral distress in health professionals is like the proverbial canary in a coalmine, it seems to me that there is an urgent need to consider the moral habitability of our practice environments (Peter et al. 2004). Being an ethical health professional will always be immensely challenging. Challenge is inherent in caring work. Healthcare environments must be designed and administered in such a way that the moral agency of health professionals is supported rather than diminished. Health professionals themselves need to reaffirm the values and beliefs fundamental to their practice—particularly those who are leaders of health systems management. A safe environment that supports ethical action and that allows messy ethical questions to be raised and discussed is absolutely essential to a morally habitable healthcare environment. The institutional intolerance of dissent that is becoming the norm places not only health professionals at greater risk for moral distress, but endangers the well-being of patients, families, and the public. Professionals should not have to say, as one of our research participants, a psychologist, did: “This is not a place… where I have the freedom to work ethically, and, really, working with the ethics that I have. This is not a place for me.”10
That healthcare environments need to be moral communities must be an explicit, articulated expectation on the part of health professionals (Austin 2007). Chambliss says that nurses have great admiration for Florence Nightingale because of her “moral strength, her character and perseverance in the face of bureaucratic authority. She did what should be done and did so without being fired” (1996, p.7, my emphasis). He thinks nurses hope to find that courage in themselves. If we are not to lose the most ethically sensitive among us to overwhelming levels of moral distress, health professionals must take heed of the “ethical canary” of moral distress. We must courageously address any and all barriers to ethical practice.
Personal communication, 29 March 2007.
This PICU patient situation is common enough that its description here does not create risk for identification of the baby nor the PICU.
Between a Rock and a Hard Place: When Healthcare Providers Experience Moral Distress, hosted by the Provincial Health Ethics Network and the College and Association of Registered Nurses of Alberta, 23 May 2008, Calgary, Alberta. This conference was so oversubscribed that it was repeated later in 2008—an indication of the local level of interest and concern regarding health professionals’ moral distress.
Available at the library of the Wellcome Trust as MS 8520. See http://library.wellcome.ac.uk/doc_WTX041077.html.
“The more things change, the more they remain the same.”
Doctors Without Borders.
Between a Rock and a Hard Place, 23 May 2008.