Health Care Review — Combating Moral Distress in Health Care
By Dawn Whitten, DSW
Social Work Today
Vol. 20 No. 3 P. 10

Educating health care professionals about moral distress and moral courage can improve competency and empowerment of clinical teams, enabling action that facilitates organizational change. Moral distress and moral courage are not new concepts in health care, yet some health care professionals are unfamiliar with these terms, their meaning, and how they impact the way care is provided. Although originally identified as a phenomenon in the nursing profession, moral distress can affect many other professions, including social work.

Moral distress was first defined as arising when one knows the right action to take, but internal and external constraints make it difficult to take such action (Jameton, 1984). Over time, repeated exposure to morally distressing situations can take a physiological, psychological, and emotional toll on social workers and those in many other caring professions.

Effects of Moral Distress
Moral distress can cause extensive physical manifestations in health care professionals, social workers, and those in other caring professions. When an individual fails to take what they believe is the morally right course of action on behalf of a patient, it can result in crying, loss of sleep, irregular heartbeats (palpitations), gastrointestinal disorders, headaches, and muscle pain. Common psychological ramifications of moral distress are feelings of frustration, powerlessness, anxiety, anger, guilt, and resentment (Dalmolin et al., 2012). These emotional effects can cause sleep disorders, mood disorders, excessive eating, fatigue, and alcohol and drug misuse, all of which can lead to poor work attendance due to increased use of sick time, poor work performance, decreased job satisfaction, and high employee turnover rates (Pauly et al., 2012).

Unresolved moral distress can impact quality of life for many social workers. Countless professionals adopt feelings of powerlessness to combat constraints that they perceive as a function of their job. It is not unusual for these professionals to be skeptical, indifferent, and have low self-worth—and, in some cases, to experience anxiety, depression, and hopelessness.

Constraints Involved in Moral Distress
Individuals can have internal constraints that prevent them from taking the appropriate action in a distressing situation. These constraints can include lack of assertiveness, insecurity, perceived helplessness, and being socialized to follow orders (Lamberson, 2016). Internal constraints arise in the health care setting to varying degrees and differ among professionals. Like that of their nurse colleagues, social workers often feel inferior, not speaking up against a physician or their superiors, which often leads to feelings of powerlessness when faced with a morally distressing situation.

In health care settings, there are several external constraints that can prevent a social worker from taking the right course of action. Governing health care agencies often direct the expectations of how health care is to be delivered in any given organization. It is not uncommon for the policies they impose to conflict with the professional codes of ethics of many health care professions. For instance, medical social workers often face balancing the morally correct action for the patient vs. their responsibility to facilitate rapid hospital discharges enabling maximum financial reimbursement for services rendered. Each additional day the patient remains unnecessarily hospitalized impacts the hospital financially. The increased demand for efficiency often inhibits the social worker from devoting much-needed time to their clients. More and more organizations have been pushing social workers to maximize profit and increase productivity (Janssen, 2016). The question here is, “at what cost comes this profit?” For health care professionals such as medical social workers it can be at the cost of their mental, psychological, and physiological well-being.

Institutional policies and priorities can also conflict with the way in which social workers interact with patients and their families. Many organizations and practitioners are so preoccupied with fears of litigation that they are fearful about disclosing health care errors (Lamberson, 2016). This causes moral distress for frontline care providers, as they fear retaliation or losing their jobs should they disclose inaccuracies or miscommunications in care. This fear of reprisal and retribution due to lack of administrative support can lead to moral distress for many health care professionals and prevent them from taking the right course of action when caring for a patient (LaSala & Bjannason, 2010).

Moral Courage
Moral courage is when an individual stands up for their ethical values to help others regardless of their own personal risks (Murray, 2010). Very often professionals lack the self-confidence to stand up for the moral or ethical actions necessary to safeguard the rights of the patient. Research indicates 84% of health care professionals report observing colleagues taking unsafe shortcuts when providing patient care. Remarkably, less than 10% report speaking up about their concerns (Maxfield et al., 2011).

In health care there are often barriers that counteract an individual’s desire to express moral courage. These barriers include organizational culture, lack of colleague concern, loss of independent thinking, and redefining unethical acts as acceptable. Individuals who demonstrate moral courage have acquired a robust moral resolve when faced with ethically difficult situations (Lachman et al., 2012). Social workers are equipped with a unique skillset that qualifies them to become leaders in demonstrating moral courage. In all aspects of the social work field these professionals are often observed standing up against the majority, advocating for those who cannot advocate for themselves. The moral resilience of social workers is what makes them stand out in a climate of conformism.

In the health care setting, social workers can help transform the moral climate as they model morally courageous behaviors and set the stage for opening the lines of communication and collaboration between health care team members. They can advocate for the structural and behavioral changes necessary for promoting a positive moral climate that supports open, respectful collaboration and communication among health care professionals.

Health care organizations must employ structural factors that support the development and enactment of moral courage. Organizations that empower their employees through modeling courageous behaviors, communication, support, professional development, and adequate resources to do their jobs position themselves for having increased group cohesion that enhances organizational goals. Facilities with an environment of shared responsibility and accountability are credited with promoting teamwork and shared commitment to providing the highest level of quality patient care.

ASCR: A Framework for Change
Social workers have an opportunity to be champions for combating moral distress in health care. They can aid in the design of education programs that are intended to maintain a consistent, supportive milieu that cultivates open communication, shared responsibility, discussion of conflict, and supportive acknowledgment of the health care team. Awareness, support, consistency, and respect, or ASCR, supports the development of professional regard (Whitten, 2019).

Education and training on moral distress and the skills of moral courage can increase professional awareness. Professionals in the health care hierarchy need to become more aware of how their behaviors affect others on personal and professional levels. It is helpful to provide clear, relatable examples of how these behaviors impact patient care delivery. It is vital to allow professionals to reflect on their own experiences and their associated impact—personally, professionally, or both. This can facilitate open discussion of the skills necessary to combat moral distress and support morally courageous behaviors. Social workers are ideal candidates to lead such interdisciplinary discussions, as their education and training includes the skillset for group work and mediation.

Enacting policies, procedures, and programs that support morally courageous behaviors and discourage moral distress include employee shadowing, debriefings, case discussions, and acknowledgment programs. These activities can promote supportive forums for active collaboration, communication, and modeling opportunities. It is crucial that organizations outline a clear process for combating moral distress that inspires autonomy, uniform accountability, and action. Often, lack of peer and administrative assistance and action can leave professionals with feelings of disempowerment. Activities such as these can decrease system barriers that interrupt the clinical flow in many organizations. Reducing these barriers can initiate the endorsement of consistency.

Administrative leadership needs to consistently adhere to guidelines holding all health care professionals accountable regardless of their standing in the health care hierarchy. Failing to adhere to these guidelines can undermine facilities’ efforts to create accountability among employees. Consistency here helps reinforce the expectation of teamwork and open communication. Universal accountability can reduce fears of retaliation in many instances, paving the way to a culture which embraces collaboration, communication, and professional respect.

Collaboration
When multidisciplinary teams jointly participate in open communication and decision-making activities true collaboration becomes the standard (Wood, 2012). Teams that are genuinely cohesive tend to hold each member in the highest esteem for their unique knowledge, skills, and abilities. The merge between education, supportive systems, and consistency will shift the organizational culture and nurture professional regard.

This cultural shift initiates a trickle-down effect that will reach patients, families, and the communities served. Multidisciplinary respect will enable the health care team to function as a cohesive entity that ultimately improves patient care outcomes, as well as employee and patient satisfaction. Social workers are formally trained to facilitate communication, collaboration, and self-reflection exercises with their clients. These skills position them as leaders in the battle against moral distress and health care reform.

Social workers possess the knowledge and skills capable of engaging other health care disciplines in collaborative efforts to inspire organizational changes that shape the future of the health care landscape.

— Dawn Whitten, DSW, is a medical social worker at Sharon Hospital-Nuvance Health.

References
Dalmolin, G. D., Lunardi, V. L., Barlem, E. L. D., & da Silveira, R. S. (2012). Implications of moral distress on nurses and its similarities with burnout. Texto & Context - Enfermagem, 21(1), 200-208. https://doi.org/10.1590/S0104-07072012000100023

Jameton, A. (1984). Nursing practice: The ethical issues. Prentice Hall.

Janssen, J. S. (2016). Moral distress in social work practice — when workplace and conscience collide. Social Work Today, 16(3), 18-22.

Lachman, V. D., Murray, J. S., Iseminger, K., & Ganske, K. M. (2012, May 11). Doing the right thing: Pathways to moral courage. American Nurse. https://www.myamericannurse.com/doing-the-right-thing-pathways-to-moral-courage/

Lamberson, B. (2016). What is moral distress? An overview. National Association of Catholic Chaplains. https://www.nacc.org/vision/2016-mar-apr/what-is-moral-distress-an-overview/

LaSala, C. A. and Bjarnason, D. (2010). Creating workplace environments that support moral courage. The Online Journal of Issues in Nursing, 15(3), Manuscript 4. http://ojin.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/Courage-and-Distress/Workplace-Environments-and-Moral-Courage.html

Maxfield, D., Grenny, J., Lavandero, R., & Groah, L. (2011). The silent treatment: Why safety tools and checklists aren’t enough. American Association of Critical Care Nurses. https://www.aacn.org/WD/hwe/docs/silent-treatment-executive-summary.pdf

Murray, J. S. (2010). Moral courage in healthcare: Acting ethically even in the presence of risk. The Online Journal of Issues in Nursing, 15(3), Manuscript 2. https://ojin.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/Courage-and-Distress/Moral-Courage-and-Risk.html

Pauly, B. M., Varcoe, C., & Storch, J. (2012). Framing the issues: Moral distress in healthcare. HEC Forum, 24(1), 1-11. https://doi.org/10.1007/s10730-012-9176-y   

Wood, D. (2012, April 25). Collaborative healthcare teams a growing success story. AMN Healthcare. https://www.amnhealthcare.com/latest-healthcare-news/collaborative-healthcare-teams-growing-success-story/  

Whitten, D. M. G. (2019, April). Moral distress: Inspiring organizational change in one rural community hospital. ProQuest. https://search.proquest.com/openview/024151d6c67e217fa475399c497fea75/1?pq-origsite=gscholar&cbl=18750&diss=y