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Moral distress


As a 3rd year medical student, I am a junior member (also known as a clinical clerk) of a large health care team. Throughout my rotations, situations arise where – if I was in charge – I would do things differently.  Most of the time, these differences in style or approach are minor in nature and not worth talking about.  Every so often, however, an incident occurs where things are done so contrary to my own values that it can be quite upsetting.  In health care, we call this feeling “moral distress.”

Moral distress is the stress that “occurs when one [believes one] knows the right thing to do, but institutional or other constraints make it difficult to pursue the desired course of action.”  This concept was first established in nursing literature in the 1980s and has been established as a leading cause of nursing burnout and attrition.  Nurses have been found to be particularly vulnerable due to the fact that they are simultaneously equipped with knowledge that may impact patient care, but have very little decision-making power.  According to a 2007 study in the journal Nursing Economics, nurses reported feeling “below” physicians.  They felt that their opinions and concerns were not heard by doctors.  Moreover, they experienced the burden of living with the results of decisions made by others.

Moral Distress in Delivering End of Life Care – Palliative Care from Canadian Virtual Hospice on Vimeo.

More recently, several studies have found that health professionals from various other disciplines also experience significant moral distress. Included in these newly identified groups are medical students, who face a quandary similar to that of nurses.  While medical students feel a sense of responsibility for their patients, they are often constrained from action by their position in the hierarchy, their desire for good evaluations (i.e. fear of reprisal), and a lack of confidence in the knowledge they have acquired so far.

A 2009 study in The American Journal of Surgery found that students face choices between intervening in morally hazardous situations or else going along with the decisions of their superiors. The resultant moral distress has been linked with cynicism and burnout.  Improper communication was identified as the biggest issue that caused distress amongst third year medical students, with both physician-patient and physician-physician interactions cited as having communication problems.  This would include, for example, a physician failing to demonstrate empathy when delivering bad news to a patient.  Another common problem is “badmouthing,” wherein physicians or others speak in a derogatory manner about patients when they are thought to be out of earshot.

Medical students have been found to feel uncomfortable with challenging medical team members regarding unethical behaviour because they felt that they were either ignorant of clinical circumstances or that they lacked the experience to make relevant decisions.  A 1994 study of medical students found that 80% of respondents reported having done something that they believed to be unethical. Over 60% of participants reported having witnessed unethical behaviour by other members of the medical team, and of these respondents, more than half felt like accomplices. Disturbingly, nearly all students surveyed had heard physicians refer to patients in a derogatory manner.  Medical students perceived that their own unethical behaviour occurred in the context of wide acceptance of such behaviour, which they felt was influenced by specific social pressures:

  • The pressure and desire to be a team player.  Medical students felt a need to function proficiently and adhere to the status quo.  Furthermore, unethical behaviour was sometimes rationalized as a display of loyalty to other team members.
  • The desire for a good evaluation from team members.  Forty percent of respondents reported having done something unethical for fear of a poor evaluation.

As evidenced by these examples, a large contribution to the moral distress felt by medical students is due to the culture of medicine, or, as it is sometimes referred to in the literature, as the hidden curriculum of medical school.  This is the “commonly held ‘understandings,’ customs, rituals and taken-for-granted aspects of what goes on in the life-space we call medical education.”

After medical school, graduates move on to additional training in residency programs.  As highlighted in a study in the journal Medical Education, many of these programs are currently focused on “competencies,” implying that the subject and practice of medicine are “master-able”. This approach fails to take into account the challenge and complexity of true professionalism.  Paradoxically, so-called “practical wisdom” is identified in curricula as being important to future doctors, yet the tools necessary to make complex decisions are not given sufficient attention in the competency based model.  It is therefore essential that the elements of a physician’s practice that lay beneath observable performance are both valued and nurtured appropriately.  Unfortunately, the word “professionalism” is often scattered throughout curricula, with little to no indication of what it actually means or how it is going to be taught.

Although medical curriculum reform has increasingly stressed the importance of ethics, some investigators have found that the moral reasoning of medical students does not compare favourably to that of students of similar age and education from other disciplines.  “There is concern that medical students and residents display regression of moral development during training, rather than moral growth.” While eliminating moral distress from the medical student experience may not be possible, it can certainly be reduced through discussion and reflection when students are given an open forum to discuss their concerns.  Some American medical schools have tentatively begun to introduce such forums into their teaching.  The idea behind these initiatives is that open and confidential discussion of these issues acts as an effective form of “group therapy.”  This may lead to solutions to some of these problems as well as prevention of “moral residue,” that bad taste in one’s mouth that can linger long after a distressing incident.  Similar approaches have been adopted by paramedics and other first responders following a disturbing call.  They refer to these sessions as “critical incident stress debriefings.”  However, this idea is still fairly novel and far from being universally applied in hospital settings.

On a personal note, I can confirm that nothing distresses me more that hearing other health care workers speak ill of patients, especially my patients.  Sometimes it is almost as if others feel the need to counteract the air of empathy they display in front of patients with a rectifying display of cynicism in front of their peers.  I don’t want to create the wrong impression: those who behave this way are in the minority.  But there are enough of them that sometimes they can transform a great day into a terrible one.  As I understand it, this is largely a symptom of professional burnout, which, as a system, we need to do a much better job of preventing, identifying, and addressing.

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15 comments

  1. Chris Byrne

    Great article Ryan! I start my third year in September, but have experienced the very distress you speak of in my limited clinical experience. It can be something as simple (yet important) as a health care worker failing to wash his or her hands before approaching and after leaving the patient’s bedside. Despite the “ick factor”, I rationalize not speaking up by acknowledging this kind of thing is a systemic or cultural problem and the best I can do at this stage of the game is make sure I am washing my hands. You know, lead by example. Lately, I have been doing my best to educate patients on the importance of hand washing in the hospital and encourage them to make sure those looking after them are practising proper hand hygiene. I feel like I should be doing more (e.g., confronting offenders), but at the same time feel like I need to pick my battles. I have learned a lot about politics recently and if it is any indication of change in professional culture, these things take time.

  2. Catherine Richards

    Ryan, I gladly and gratefully second Chris Byrne’s comment about your article – it is truly great! Yours is one of the most thoughtful and thought provoking opinion pieces I have ever read – anywhere!

    I hope many, many people will read it and consider the importance of moral distress and how it factors into and influences decisions of healthcare workers. While I am certain the phenomenon is present in numerous circumstances outside of healthcare, there is no place where it has the potential to adversely affect people’s lives more dramatically than in healthcare settings where life and death decisions are made.

    As a patient and as an advocate both, I have been placed in situations where I suspect there was a lot or moral distress felt by healthcare workers involved. When they decided not to listen to and be guided by the wisdom of their interior voices of reason and conscience and instead chose to act in unison with the mindless chorus of the popular crowd to spare themselves consequences, they surrendered their own will to the external powers at play. By doing so they essentially guaranteed that the vulnerable person(s) at the centre of their moral distress was left to live or die at their mercy. When one struggles and yields to the pressures identified in situations where moral distress is present and morality tested, the moral residue is felt by more than just the person actively engaged in the battle.

    Thank you for presenting your stellar opinion, Ryan! I know you will make a fabulous doctor and by your example you will teach many others important lessons that go well beyond the parameters of healthcare. A very bright future is calling your name!

    Regards,
    Catherine Richards
    Cause for Concern: Ontario’s Long Term Care Homes (Facebook)

    • Andrew Holt

      Over the years I have worked along side many health professionals, teams and health care programs and organizations. Ryan your observations are very insightful – well done.

      I have observed that those individuals, teams, programs, health care organizations, regulators, policy analysts, politicians and academic researchers that understand and actively engage in working through all the ramifications of moral distress are those we often see and experience as being stellar examples. Those which don’t or disregard this fundamental issue have missed the primary underpinning of why health and social services were created in the first place and continue to receive wide spread public support – despite many follies reported in the media.

      Thank you for highlighting a very important issue that, if left unattended, can corrode our individual and collective capacity to actually provide the health and social services we all claim as our primary mission.

    • Ryan Herriot

      Thank you for your kind words. It’s perhaps fitting that in all this discussion I neglected to address the impact that this has on patients! I guess you call that “life long learning.” The sad thing here is that health care workers often seem to think that patients don’t know what we really think of them. But they know. It’s obvious, and not only does it hurt feelings, it also impacts the quality of care.

      As a patient, of course the onus is never on oneself to address this problem. However, if you’re feeling bold enough, I do think that sometimes it helps to (gently) point out when you are receiving substandard care or treatment. Sometimes, that can be all it takes to snap someone out of their jadedness.

  3. Ada Giudice-Tompson

    Thank you for this very candid article Ryan.
    In addition to burnout, the lack of a clear and cogent “Code of Ethics” for doctors in Ontario is a great contributor to moral distress. Compare the CPSO’s Code of Ethics to Quebec’s and you will see what I mean.

  4. Mary Ferguson-Paré

    Bravo Ryan for illuminating this disturbing and omnipresent issue of moral distress among health professionals. Thank you for referencing the body of literature underscoring the debilitating effects this has on nurses and for expanding the focus of your examination of this topic to demonstrate that a broad range of students and health professionals suffer moral distress. This does not go unnoticed by the clients/patients/residents/families we serve. The sting of the cynicism and disregard engendered by the professional communication and attitudes you refer to are at the heart of our failure to excel in our relationships with those we serve and to consistently deliver safe, high quality, patient-centered care.

  5. Ryan Herriot

    Thanks for your kind comment, Ben. Of course we all have to strike a delicate balance as to when, where, and how to speak up (and to whom). I think that the most important thing for us as students is to graduate without any moral residue. We may not be able to change a situation or speak up, but, somehow, we must address those sentiments. Otherwise, we run the risk of losing our moral compass somewhere along the way, and will no longer be in a position to be a good role model by the end.

    To me, the way that we do this is by not suffering in silence. Not to sound patronizing or facile, but it is important that we all find trusted friends, colleagues, counselors, and other allies in which we can confer. Identify them early and make use of them. This “checking in” process is invaluable. I have often thought that – absent any serious curriculum reform – it might be nice for students to create a secure online repository for confidential discussions of these matters. I have no internet skills to speak of and I am not sure that this would fly ethically (or that it wouldn’t devolve into a gossip session), but it’s a thought I keep coming back to.

    To use a (deliberately nonspecific) example, I can remember a time when my approach to a patient would have been diametrically opposed to that of my attending. On this particular instance, I respectfully voiced my concerns and laid out an alternative. It achieved nothing, in the sense that the physician proceeded with his plan unaltered. But it made me feel enormously better. To this day, I feel pretty ok about that situation, even if I feel sorry for the patient. More important from a future patient’s perspective, this experience has made me feel more confident in my approach and more likely to apply it in the future.

    All the best next year. Please get in touch if you’d ever like to chat.

    • Ryan Herriot

      Oooops, this is supposed to appear under Chris’ comment and it’s supposed to say Chris, not Ben. Oh well.

  6. Ada Giudice-Tompson

    Well Quebec’s Physicians code of ethics is more detailed, patient centred and provides a stronger “written” ethical foundation from which to begin than Ontario’s very skimpy, general & less patient centred code. Whether “ethics” on paper translates to action resulting in less moral distress in Quebec…. who knows….but I’m sure it can’t hurt.

  7. Tap Off

    Mary,
    Yes Ryan exposed a long overdue topic area for discussion. Hopefully it will continue to be shared in many open ‘blogs’ such as this. To borrow a phrase, this moral distress ‘trickles through’ the entire work environment. It affects dedicated academics and other professionals who are not directly clinically involved; yet are directly involved with health care and health delivery, and the important work of understanding health, the health care system and how to make Canada’s Health System work for Canadians Health and Prosperity now and for the future. These people also notice the “by-products” of this moral distress and its socialized acceptance (team player integration down to the student level). Often these other professionals are also victims.

  8. Ritika

    Thanks for this Ryan. I recall my first experience as a medical student hearing my staff not just insult, but actively make fun of the patient with the team, almost as though to impress us. I remember feeling sickened that I had been exposed to the behind the scenes world of healthcare in which patients are actually not respected. The worst fears I would have had as a patient, vulnerable and dependent on my healthcare team for respect and understanding, had come true. And as a student, I felt powerless to do anything about it. Good for you for talking about this – it’s not easy. Only by discussing this openly and honestly can we change this toxic culture.

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