Abstract
Within this paper, we discuss Moral Distress Reflective Debriefs as a promising approach to address and mitigate moral distress experienced by healthcare professionals. We briefly review the empirical and theoretical literature on critical incident stress debriefing and psychological debriefing to highlight the potential benefits of this modality. We then describe the approach that we take to facilitating reflective group discussions in response to morally distressing patient cases (“Moral Distress Reflective Debriefs”). We discuss how the debriefing literature and other clinical ethics activities influenced the development of our approach. In particular, we focus on the role of the clinical ethicist as a facilitator with particular emphasis on encouraging perspective-taking and nurturing ethical attunement in a supportive manner. We suggest that this approach reduces the narrowing effects of frustration and anger that are often reported when individuals experience moral-constraint distress. Finally, we provide an example of Moral Distress Reflective Debriefs, elucidating how this supportive process complements ethics consultation and can mitigate the negative effects of moral distress.
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Notes
All names are pseudonyms and some facts of the case have been altered to maintain anonymity.
Because we are adopting a broad definition of moral distress, we are subcategorizing different types of moral distress as suggested by Morley. We are interpreting the type experienced from Maggie’s description of the moral events and the emotions she seemed to be expressing.
References
American Society for Bioethics & Humanities, ASBH. (2011). Core competencies for healthcare ethics consultation. Chicago: American Society for Bioethics and Humanities.
Batson, C. D., Fultz, J., & Schoenrade, P. A. (1987). Distress and empathy: Two qualitatively distinct vicarious emotions with different motivational consequences. Journal of Personality, 55(1), 19–39. https://doi.org/10.1111/j.1467-6494.1987.tb00426.x|.
Browning, E. D., & Cruz, J. S. (2018). Reflective debriefing: A social work interventions addressing moral distress among ICU nurses. Journal of Social Work in End-of-Life & Palliative Care, 14(1), 44–72. https://doi.org/10.1080/15524256.2018.1437588.
Burgart, A. M., & Kruse, K. E. (2016). Moral distress in clinical ethics: Expanding the concept. American Journal of Bioethics, 16(1), 1.
Everly, G. S., & Boyle, S. H. (1999). Critical incidet debriefing (CISD): A meta-anaysis. International Journal of Emergency Mental Health, 1(3), 165–168.
Fourie, C. (2017). Who is experiencing what kind of moral distress? Distinctions for moving from a narrow to a broad definition of moral distress. AMA Journal of Ethics, 19(6), 578–584. https://doi.org/10.1001/journalofethics.2017.19.6.nlit1-1706.
Fricker, M. (2007). Epistemic injustice: Power and the ethics of knowing. New York: Oxford University Press.
Haidt, J. (2001). The emotional dog and its rational tail: A social intuitionist approach to moral judgment. Psychological Review, 108(108), 814–834.
Hamric, A., Borchers, C., & Epstein, E. (2012). Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research, 3(2), 1–9.
Hanna, D. R. (2004). Moral distress: The state of the science. Research and Theory for Nursing Practice: An International Journal, 18(1), 73–93. https://doi.org/10.1891/rtnp.18.1.73.28054.
Helft, P. R., Bledsoe, P. D., Hancock, M., & Wocial, L. D. (2009). Facilitated ethics conversations a novel program for managing moral distress in bedside nursing staff. JONA’S Healthcare Law, Ethics and Regulation, 11(1), 27–33.
Hollister, R. (1996). Critical incident stress debriefing and the community health nurse. Journal of Community Health Nursing, 13(1), 43–49.
Janvier, A., Prentice, T., Wallace, J., Robson, K., Mann, P., & Lantos, J. D. (2019). Does it matter if this baby is 22 or 23 weeks? Pediatrics, 144(3), e20190113. https://doi.org/10.1542/peds.2019-0113.
Jimmerson, C. (1998). Critical incident stress debriefing. Journal of Emergency Nursing, 14(5), 43–45.
Kolb, D. A. (1984). Experiential learning. Upper Saddle River, NJ: Prentice Hall.
Laws, T. (2001). Examining critical are nurses’ critical incident stress after in hospital cardiopulmonary resuscitation (CPR). Australian Critical Care, 14(2), 76–81.
Maben, J., Taylor, C., Dawson, J., Leamy, M., McCarthy, I., Reynolds, E., et al. (2018). A realist informed mixed-methods evaluation of Schwartz Center Rounds® in England. Southampton (UK): NIHR Journals Library.
McNally, R., Bryant, R., & Ehlers, A. (2003). Does early psychological intervention promote recovery from posttraumatic stress? Psychological Science in the Public Interest, 4(2), 45–79.
Mitchell, A. M., Sakraida, T. J., & Kameg, K. (2003). Critical incident stress debriefing: Implications for best practice. Disaster Management & Response, 1(2), 46–51. https://doi.org/10.1016/S1540-2487(03)00008-7.
Molewijk, B., Kleinlugtenbelt, D., Pugh, S. M., & Widdershoven, G. (2011a). Emotions and clinical ethics support. A moral inquiry into emotions in moral case deliberation. HEC Forum, 23(4), 257–268. https://doi.org/10.1007/s10730-011-9162-9.
Molewijk, B., Kleinlugtenbelt, D., & Widdershoven, G. (2011b). The role of emotions in moral case deliberation: Theory, practice, and methodology. Bioethics, 25(7), 383–393.
Morley, G. (2018). What is “Moral Distress” in nursing and how should we respond to it? [unpublished thesis]. https://research-information.bris.ac.uk/ws/portalfiles/portal/175857763/Final_Copy_2018_09_25_Morley_G_PhD_Redacted.pdf. Accessed 19 January 2021.
Morley, G., & Ives, J. (2017). Reflections on how we teach ethics: Moral failure in critical care. AACN Advanced Critical Care, 28(4), 384–390.
Morley, G., & Shashidhara, S. (2020). Debriefing as a response to moral distress. The Journal of Clinical Ethics, 31(3), 283–289.
Morley, G., Bradbury-Jones, C., & Ives, J. (2019). What is ‘moral distress’ in nursing? A feminist empirical bioethics study. Nursing Ethics, 27(5) 1297–1314. https://doi.org/10.1177/0969733019874492.
Morley, G., Bradbury-Jones, C., & Ives, J. (2021). Reasons to redefine moral distress: A feminist perspective. Bioethics, 35(1), 61–71.
Powell, T. L., Parker, L., Dedrick, C. F., Barrera, C. M., Di Salvo, D., Erdman, F., et al. (2012). Decisions and dilemmas related to resuscitation of infants born on the verge of viability. Newborn and Infant Nursing Reviews, 12(1), 27–32. https://doi.org/10.1053/j.nainr.2011.12.004.
Reed, P. G., & Rishel, C. J. (2015). Epistemic injustice and nurse moral distress: Perspective for policy development. Nursing Science Quarterly, 28(3), 241–244.
Rose, S., Bisson, J., Churchill, R., & Wessely, S. (2002). Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews, 2, CD000560. https://doi.org/10.1002/14651858.CD000560.
Rose, S., Wessley, S., & Bisson, J. (1998). Brief psychological interventions (“debriefing”) for trauma-related symptoms and prevention of post traumatic stress disorder. Cochrane Database of Systematic Reviews, 2, 1–30.
Rushton, C., Kaszniack, A. W., & Halifax, J. S. (2003a). A framework for understanding moral distress among palliative care clinicians. Journal of Palliative Medicine, 16(9), 1–6. https://doi.org/10.1089/jpm.2012.0490.
Rushton, C., Kaszniack, A. W., & Halifax, J. S. (2003b). Addressing moral distress: Application of a framework to palliative care practice. Journal of Palliative Medicine, 16(9), 1–9. https://doi.org/10.1089/jpm.2013.0105.
Shashidhara, S., & Kirk, S. (2020). Moral distress: A framework for offering relief through debrief. The Journal of Clinical Ethics, 31(4), 364–371.
Svantesson, M., Silen, M., & James, I. (2018). It’s not all about moral reasoning: Understanding the content of moral case deliberation. Nursing Ethics, 25(2), 212–229. https://doi.org/10.1177/0969733017700235.
Van Emmerik, A. A., Kamphuis, J. H., Hulsbosch, A. M., & Emmelkamp, P. M. (2002). Single session debriefing after psychological trauma: A meta-analysis. The Lancet, 360(9335), 766–771. https://doi.org/10.1016/S0140-6736(02)09897-5.
Williams, B. (1965). Ethical consistency. Proceedings of the Aristotelian Society, 39, 103–138.
Zigmont, J. J., Kappus, L. J., & Sudikoff, S. N. (2011). The 3D model of debriefing: Defusing, discovering, and deepening. Seminars in Perinatology, 35(2), 52–58. https://doi.org/10.1053/j.semperi.2011.01.003.
Acknowledgements
The authors would like to acknowledge Mahwish Ahmad, Marguerite Augustine, Jane Jankowski and Hilary Mabel, Staff Clinical Ethicists at the Cleveland Clinic (Center for Bioethics) for the ethical guidance and expertise they provided during these challenging clinical ethics cases and for kindly reviewing this paper. We also want to acknowledge and thank Laura Longbrake, LISW-S (Cleveland Clinic) for the collaboration and expertise she has provided in developing Moral Distress Reflective Debriefs, her work in continued facilitation as well as her feedback on an earlier version of this manuscript.
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Morley, G., Horsburgh, C.C. Reflective Debriefs as a Response to Moral Distress: Two Case Study Examples. HEC Forum 35, 1–20 (2023). https://doi.org/10.1007/s10730-021-09441-z
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DOI: https://doi.org/10.1007/s10730-021-09441-z