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Abstract

Background

Encounters of moral distress have long-term consequences on healthcare workers’ physical and mental health, leading to job dissatisfaction, reduced patient care, and high levels of burnout, exhaustion, and intentions to quit. Yet, research on approaches to ameliorate moral distress across the health workforce is limited.

Research Objective

The aim of our study was to qualitatively explore multi-professional perspectives of healthcare social workers, chaplains, and patient liaisons on ways to reduce moral distress and heighten well-being at a southern U.S. academic medical center.

Participants & Research Context

Purposive sampling and chain-referral methods assisted with recruitment through hospital listservs, staff meetings, and newsletters. Interested participants contacted the principal investigator and all interviews were conducted in-person. Consent was attained prior to interviews. All interviews were recorded and transcribed verbatim.

Research Design

Directed content analysis was used to deductively organize codes and to develop themes in conjunction with the National Academy of Medicine’s National Plan for Health Workforce Well-Being. Rigor was attained through peer-debriefing, data triangulation methods, and frequent research team meetings.

Ethical Considerations

Ethics approval was obtained from the university and medical center institutional review boards.

Findings

Themes demonstrate that rather than offering interventions in the aftermath of moral distress, multilevel daily practices ought to be considered that pre-emptively identify and reduce morally distressing encounters through (1) the care team, (2) management and leadership, and (3) the health care industry. Strategies include interdisciplinary decision-making, trusting managerial relationships, and organizational policies and practices that explicitly invest in mental health promotion and diverse leadership opportunities.

Conclusion

Moral distress interventions ought to target short-term stress reactions while also addressing the long-term impacts of moral residue. Health systems must financially commit to an ethical workplace culture that explicitly values mental health and well-being.

Keywords

moral injury health systems social work spiritual care ethical climate psychological safety

Introduction

Moral distress is when institutional practices and policies constrain an individual into violating their personal and/or professional ethics; their complicit engagement in moral wrongdoing triggers psychological disequilibrium.^1,2 Prominent examples of moral distress in healthcare settings include the withdrawal or administration of life-sustaining interventions, ineffective pain and/or symptom management, or the inappropriate use of medical resources. Moral distress can lead to short-term stressors, including physical (e.g., headaches, nausea, heart palpitations), emotional (e.g., anger, frustration, guilt), psychological (e.g., depression, anxiety), and occupational (e.g., apathy) sequalae.³ Moral residue, repeated and unresolved moral distress, may diminish professional efficacy, job satisfaction, and patient care.⁴ Moral distress has been attributed to patient disengagement,⁵ withdrawal from colleagues and peers,^6,7 and intentions to quit,⁸ costing health systems billions of dollars to repair nursing retention, burnout, and fatigue.⁹

Moral distress intervention strategies

There are few evidence-based interventions that are shown to effectively reduce moral distress across health systems.¹⁰ Individual-centered educational events occur largely in the aftermath of a morally distressing event; a series of ongoing, largely unstructured, sessions are aimed at educating participants and offering small group reflective facilitation or narrative journaling. In a recent scoping review, 76% of studies used education and reflection to ameliorate nurses’ moral distress.¹¹ Moral distress education is often employed when clinicians are already showing deleterious stress responses and adverse occupational engagement.

Collaborative approaches are “bundle interventions” that comprise both educational sessions and critical debriefing (with a licensed grief counselor), yoga and mindfulness-based stress reduction, or work-life balance programs through a series of interactive formal workshops (e.g., Mindful Ethical Practice and Resilience Academy or Clinical Ethics Residency for Nurses). Other interventions may include hosting multidisciplinary rounds to clarify decision-making or offering specialist consultation service programs, such as moral distress-focused consultation services, unit-based ethical deliberations, and panel presentations facilitated by and for clinicians. Each of these interventions requires significant financial investment and training that may not be feasible in all health systems, especially those in underserved or more rural settings.¹²

Scholarship demonstrates that education is a key strategy to better understand moral distress and to facilitate decision-making processes across teams. The gap in current educational opportunities is that they perpetuate siloes by serving one clinician group either through offering specific unit or staff sessions or through specific assessments and practices informed by professional associations (e.g., the 4 A’s to Rise Above Moral Distress). Future approaches ought to “include all healthcare clinician groups involved in acute care of patients and embed interventions into clinical practice to capture the changing dynamics within the care team.”¹³ When intervention-based research on moral distress is primarily targeted to critical care nursing and nurse management, there is an exclusion of diverse perspectives to enhance knowledge and practice. There is a necessity to identify the perspectives of other health-related disciplines to inform effective daily strategies that can be integrated into health systems to encourage disclosure and alleviate negative sequalae.

Research rationale

The aim of our study was to explore social work (SW), chaplain, and patient liaison (PL) perspectives to broaden interdisciplinary strategies to reduce moral distress. The consideration of SWs, chaplains, and PLs is intentional. SWs and chaplains work alongside nurses as critical members of care teams and often facilitate nursing debriefs, educational sessions, and stress reduction programs related to moral distress and well-being. The Cleveland Clinic, for example, instituted “Code Lavender,” to request chaplaincy support for staff members after morally distressing or stressful situations.¹⁴ SWs and chaplains are licensed/board certified professionals who hold graduate degrees from accredited universities. SWs and chaplains provide direct care through manualized spiritual care and counseling interventions, crisis response, bereavement support, and trauma-informed practice. To broaden and enhance moral distress scholarship, the perspectives of SWs and chaplains can offer a comprehensive approach that is inclusive of other health professionals who care for patients and families at bedside.

PLs, or patient advocates, work directly with patients and families when there is ongoing disagreement, frustration, or anger; they work closely with health teams who have experienced moral distress and often have a keen observation on effective strategies to reduce healthcare workers’ stress given their solution-focused competencies. Interprofessional healthcare models posit that sharing roles is not unusual between SWs, chaplains, and PLs, given overlapping competencies and skills in holistic care and therapeutic support.

Through process-oriented approaches, SWs, chaplains, and PLs hold important observations on effective mechanisms that alleviate moral distress.¹⁵ Moreover, their evidence-informed practice in interpersonal communication, crisis intervention, and conflict resolution are essential to help identify and propose resolutions that align with sound moral judgment. Their perspectives can enhance understanding of what constitutes effective system-wide interventions to reduce moral distress and contribute to an important multi-professional dialogue in nursing and nurse management ethics.

National Academy of Medicine’s model of well-being

The National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience was formed to initiate collective action to examine factors across health organizations that may contribute to burnout and moral distress. The model “recognizes the challenges facing health workers as systemic, complex, and longstanding.” Improving the well-being of the healthcare workforce is a shared mission that necessitates involvement of all stakeholders across the U.S. health system. NAM’s report addresses three areas of focus to improve well-being and mitigate moral distress: (1) care teams, (2) leadership and management, and (3) health care industry.¹⁶ To consider how to reduce the negative sequalae of moral distress, the perspectives of all those invested in health ought to be considered. Supported by the National Plan, the purpose of the current study is to consider multi-professional allied health perspectives to support health system change.

Methods

This study explored multifactorial strategies to reduce moral distress from SWs, chaplains, and PLs at a large tertiary academic medical center in the southern United States (U.S.) that has intensive care units (ICUs), including cardiovascular, neurosurgical, and medical ICUs; nursing units for stable and long-term hospitalizations; transplant teams; and hospice/palliative care teams. The hospital has approximately 924 patient beds, a 24/7 ethics consultation service, and an in-house ethics committee.

Ethical Considerations

The study received IRB approvals from the research team’s home university and the study’s affiliated academic medical center add IRB name and project number. The principal investigator (PI) was a postdoctoral clinical ethics fellow at the time of the study. The PI was contracted by the academic medical center and clinically supervised by senior ethicists on staff. As a clinical ethicist, the PI was often consulted to facilitate moral distress debriefs across healthcare teams. The PI had no pre-existing relationships with healthcare staff and did not hold any leadership or administrative position, which reduced any potential power imbalances. The PI informed respondents that participation was purely voluntary and only aggregated findings would be disseminated with participants and across the health system. Participants could withdraw up until data analysis was initiated. All participants provided both written and oral consents prior to the interview. The PI reviewed the informed consent with each participant at the start of each interview. A unique identifier was given to each participant to be used for interview data to protect confidentiality. All data were stored on a secure, encrypted password-protected server of the research team’s home university and participant information (e.g., informed consents/demographics) was stored separately from interview data.

Recruitment and sample

Participants were recruited through listserv emails, staff meetings, and hospital newsletters through purposive sampling and chain-referral methods. Interested employees contacted the PI through email and an initial call was arranged. Participants were employed in the health system as either a full-time or part-time SW, chaplain, or PL and were fluent in English. Stratified sampling was used to include participants with a range of practice experience.

Data collection

In-depth semi-structured interviews (30–60 min) were conducted by the PI with SWs (n = 16), chaplains (n = 9), and PLs (n = 4). Although not every employee participated, the sample in each category mirrors the number of hired employees (e.g., SW is the largest discipline when compared to chaplaincy and PL). A semi-structured interview guide was developed based on prior scholarship and in conjunction with NAM’s National Plan. Example interview questions included: “given your experience, what are ways to mitigate or prevent moral distress?”; “what do you think leadership can do to alleviate encounters of moral distress?” and “how has your practice experience influenced how you react to moral distress?” along with detailed probes. Interviews were recorded and transcribed verbatim; all identifying data were redacted.

Data analysis

Directed content analysis is a flexible text-based analytical method to examine specific phenomena using transcript data.¹⁷ We followed Hsieh and Shannon’s approach by first reading the transcript without highlighting text and then deductively identified and categorized text using a predetermined codebook developed from the NAM report: (1) care team members, (2) leadership and management, and (3) health care industry. Data were reanalyzed twice after initial coding¹⁸ and inductive categories that emerged were organized into sub-themes. Transcripts were divided between three research team members (SF, RC, LH). Rigor was established by: (1) triangulating data within and across participant narratives to validate emerging themes from multiple perspectives on moral distress; (2) peer debriefing with moral distress scholars and members of the health workforce; (3) memo-writing during data collection and analysis; and (4) team meetings to discuss emerging patterns and reach consensus on discrepancies.

Results

A total of 30 participants were interviewed. Of SWs, the mean age was 35 years (26 to 56 years). 93% were female (n = 15); eight participants were White (50%), three were Black (18%), two were Hispanic (12.5%), and one did not disclose. All had Master of Social Work (MSW) degrees and, of those reported, nine were licensed clinical SWs (LCSW) and six were licensed MSWs (LMSW). The mean years of practice was 7.4 years (1 year to 17 years). Of chaplains, the mean age was 57 years (43 to 72 years). 62.5% of participants were male (n = 5); four participants were Black (44%), three were White (33%), and one was Mixed race (11%). Six participants had master’s degrees (67%) and three had doctorates (33%). The mean years of practice was 10.5 years (5 to 25 years). Of patient liaisons, the mean age was 42 years (25 to 59 years). Three out of four participants were White (75%), and one was Hispanic (25%). All four participants held bachelor’s degrees. The mean years of practice was 9.75 (2 to 25 years). Participants worked in diverse units, including critical care units, the Emergency Room (ER), nursing units, and specialty divisions such as palliative and hospice.

Findings underscore three levels in which to reduce moral distress: (1) care team members, (2) leadership and management, and (3) health care industry.

Care team members

Collegial support

Trusted peers and experienced colleagues act as role models to “learn from people who have been there” on how to diffuse moral distress. Peer debriefing is the provision of confidential, judgment-free space without fear of retribution; being “there to listen to you, understand, help you to see what you did that was beneficial, think about what you could have done differently, and then go on with your day…to have an echo chamber.” As participants reflected on what they have seen on the different units and floors, moral distress was mitigated through trustworthy and therapeutic relationships with colleagues. The advice was to “learn the strengths of those with whom you work and focus on those.”

Relationships were considered instrumental in identifying and reflecting on moral distress: “to debrief with other coworkers and let them know this is what’s happening. By being able to be real and raw.” Participants reported that isolation from others and shame fueled silence. Trustworthy collegial relationships reduced moral distress by establishing open communication in the moment a violation occurred and before the emotional and psychological consequences emerged.

Care team support

Participants explained that moral distress can arise from miscommunication among team members, limited familiarity with interdisciplinary or multi-professional roles, and underappreciation of diverse attitudes and perspectives. The development of psychological safety across care teams can reduce siloes to improve collaborative ethical decision-making and shared value: “it takes more than just one person; it takes all of us as a team. The chaplains, the occupational therapist, the respiratory therapist, the speech therapist, the case manager, social workers, physicians, all of us as a team…. [to] have an open mind and listen, learn, and receive.” Part of this layer of support was through establishing small unit debriefs after morally distressing encounters: “It just seems like you have to find help. It would be nice if a whole department or a whole unit came together as a debriefing to talk about how this one experience was.”

Professional efficacy can be enhanced by respecting team competencies and skills and building relationships to enhance psychological safety and encourage ethical practice and self-care; it is to see yourself as “another layer of support and establish a very strong rapport with nursing leadership, social work, case management, physicians…. [to be] successful and congregating. I think the foundation is a relationship with the staff; rapport and progress is made when people can collaborate well together.”

Participants indicated that shared interest, mutual respect, and collaborative decision-making strengthened moral resilience to provide effective and high-quality patient care.

Leadership and management support

Managerial support

Participants described that clinicians often minimize encounters of moral distress and fail to speak up to their managers due to retribution or blame. Participants described that supportive and accessible management styles can encourage disclosure by “being relatable and personable.” A participant described how “a manager takes time to listen to their employee. A manager is a good listener and a good problem solver…so we can express ourselves. [They] lead by example. They maintain a certain composure that’s a model for us…teaches us how we’re supposed to react.”

Participants identified that transparency, effective listening, and respect are fundamental to ethical managerial practices. It is about being “empathetic and [having] a lot of knowledge and resources they can pass along [and] who is a good mentor.” Mentorship can cultivate professional development: “talking to my manager and seeing that they have my back…even if I may have made a mistake, they’re not there to chastise me. They’re there to assist me and help me.” Similarly, “it’s important for management to remember their roots, where they came from, because they were once worker bees; it’s easy to forget that when you move up the chain.”

Participants shared concrete strategies to enhance managerial support: “I think being more present…not just attending rounds once but coming in a couple times a month so that you get a sample of the different patients who come and go.” Managers ought to be knowledgeable about their employee’s daily professional responsibilities and competencies to preemptively identify constraints that may trigger moral distress. The idea of having a manager visit the unit/floor afforded opportunities to “just sit down and have a debrief and ask, ‘What are your thoughts on this?’” Managers must be “willing to come and reorientate themselves, every six months or so…follow you in your role, see exactly what you’re doing, and debrief with you about what have been some of the struggles, listening to your concerns. Validating emotions and just sitting down and listening for 30 minutes.”

Managers ought to be trained to support employees and enhance psychological safety for care team members to encourage opportunities to identify and address moral distress.

Leadership support

Participants articulated two strategies leadership ought to integrate across health systems to promote an ethical workplace: (1) support diverse leadership opportunities and (2) invest in mental health programming.

Participants acknowledged that administrative policies and practices are often decided with only a few members of the healthcare workforce. Moral distress can be reduced by having a diverse leadership team that understands unique roles and constraints. A SW, for example, requested “a seat at the table so I could tell you what we do and how [we] can help you.” It is leadership’s responsibility “to really understand what our role is and what our job is and what our limitations are so that they can support us.” PLs articulated similar thoughts about being included in policy development. In recalling a specific incident, a participant noted that “liaisons weren’t even consulted. We were just thrown into this procedure. I wish we would have been brought in on that. Asking our input, how we can improve.” All members of the healthcare workforce ought to participate in policy and practice development to promote an ethical workplace that demonstrates the explicit acknowledgment “that we are vital to the success of this cooperation, being able to hear them say that really makes a difference.” Participants called for leadership to outwardly embrace multi-professional perspectives in decision-making practices.

Participants stated that leadership ought to assume responsibility: “The hospital in general could take more ownership that this is a reality, this is a part of what a lot of our employees face regardless of your position.” Some participants, for example, called for leadership to “build investment versus go home, take care of it, we are not involved in fixing your moral distress. That’s your responsibility. We like to see more of a workplace culture.”

Participants demonstrated that diverse leadership opportunities, explicit appreciation for the healthcare workforce, and investment in employees’ health and well-being are approaches that demonstrate moral distress is a chronic occupational stressor that ought to be addressed.

The health care industry

Educational initiatives

In-service hospital education, rather than siloed opportunities, can “try to figure out how to educate each other on how to work together” by building competencies across the healthcare workforce that lead to effective collaboration and quality patient care: “It would be helpful to have more administration, more staff, work more in collaboration with different units.” Shared educational events, that include administration, staff, and leadership, can increase knowledge and familiarity of different disciplines to reduce inaccurate consults and power imbalances. In-service education on moral distress, clinical ethics, and ethical decision-making more specifically was perceived as a benefit: “more seminars of ethical issues here in the hospital, would really be beneficial and how we approach these ethical issues and process them personally.”

Education was described as a system-wide approach to be integrated across health systems to promote comprehensive training and interprofessional knowledge. Shared educational events overall can support collaborative ethical decision-making, enhance familiarity with job roles and clinicians’ scope of practice, and reduce encounters of moral distress.

Counseling investment

The provision of formal counseling opportunities, increased staffing to support vacation/mental health days and short-term breaks, and institutional programming requires financial investment: “mental health doesn’t really bring in a lot of money [and] that is why it is not super important. I think that plays a factor in the employees’ mental health.” Participants described that financial investment in formal counseling opportunities can include a “trained, qualified, competent, proven therapist to be on the property once a quarter and offer 60-minute sessions.” This went above and beyond the employee assistance program (EAP): “that there’s a counselor on staff where people can sign up and it be kept confidential. That they can go to that person, and it’s encouraged. We talk about EAP. Well, no. How can I deal with it right now? I don’t have time to call EAP.” Limitations were described as a lack of financial incentives by a health care industry that overlooks and devalues frontline workers’ mental health.

Other participants described financially investing in programs that encouraged formal narrative storytelling. A participant explained:

we need to have programs where we can get connected to each other. I think storytelling is such a powerful thing…an opportunity to just come in and share that experience where people are just listening, being supportive, not being judgmental, and just help you process and let it go.

A participant reported that “having some institutional program would really help on a regular basis. ‘This is your time. We approve if you’re not doing work right now for the next one or two hours.’” However, because of cost pressures from the health care industry, participants acknowledged that incentives need to be disseminated to hospitals that actively invest in mental health to encourage progress. Financial investment is necessary to institute resources that decrease work demands, promote mental health, and broaden educational opportunities.

Discussion

Findings from our study demonstrate a multilevel approach to cultivate moral resiliency across healthcare teams. Incorporating the perspectives of SWs, chaplains, and PLs who have both experienced and consulted on moral distress demonstrate that daily mechanisms across health systems can pre-emptively counter moral distress rather than one-time activities instituted to alleviate negative sequelae and reduced efficacy. A novelty of our findings overall is the contribution of a nuanced perspective to understand moral distress as it arises across health systems. Extant scholarship tends to approach moral distress from a silo perspective, often aimed at underscoring experiences from the lens of one healthcare discipline. In turn, efforts to target moral distress are designed for specific populations, often comprising disciplines that provide direct medical interventions. Our findings offer a broader multi-professional understanding of moral distress that is inclusive of diverse health professionals. The current study can build on what is already known to inform organizational and system-based interventions to alleviate negative sequalae for other health disciplines and expand considerations for clinical nursing.

Our findings align with several factors identified in the NAM’s report on clinician well-being and resilience.¹⁹ The aim of NAM’s model is to reduce clinician burnout, trauma, and stress; to understand obstacles and challenges to well-being; and to use evidence-based multi-professional approaches to make systematic changes across agencies and organizations. Connecting our findings to the NAM model may be helpful for healthcare leaders to contextualize results and apply empirical evidence to address moral distress and its associated sequalae.

Clinical setting

Peer support was an effective coping mechanism to enhance professional efficacy and heighten moral resilience, as echoed in prior research.^20,21 In a recent study on moral distress of operating room personnel, trust in coworkers along with more formal support systems were effective at reducing moral distress.²² Our findings indicate that although trusted peer relationships helped novice clinicians with self-confidence and professional development, formal managerial support was a necessary component to alleviate moral distress. Managers who role modeled active listening, respect, trust, and compassion were more likely to reduce negative stress responses of their staff. Those who provided ample time for debriefs, visited healthcare members on their units, and were solution-focused were better equipped to ameliorate repeated encounters of moral distress and, in turn, moral residue.

Research on team-based resilience shows that collective solidarity and trust can resolve occupational challenges²³ and support health and well-being.²⁴ Team support can ameliorate burnout, emotional exhaustion, and moral residue.^25,26 NAM’s model endorses these results by demonstrating that collegial, managerial, and team relationships; collaborative, rather than competitive, environments; and leadership and staff engagement are fundamental to promote well-being and resilience.¹⁹In practice, small group debriefs may facilitate team interactions and trustworthy professional relationships to enhance collaboration, workflow, and resource allocation through task distribution. Peer, team, and managerial support can enhance a form of perspective-taking that elicits strong working relationships to reduce inappropriate consultations and strengthen interdisciplinary collaboration.²⁷

Systems-level

At the systems-level, educational programming, diverse leadership opportunities, and mental health investment can reduce moral distress. Prior scholarship indicates that “collaborative education” can inform “resilient collaborative-ready practitioners.”²³ In-service educational activities can meet clinicians where they are at and ensure there are mechanisms in place to teach moral distress and opportunities to invest in knowledge about interdisciplinary roles and competencies.

Moreover, diverse leadership opportunities that uphold space for healthcare workers and create mission statements that reflect well-being and mental health can ameliorate experiences of moral distress by resolving power differentials, alleviating job dissatisfaction, and cultivating ethical workplaces.²⁸NAM’s model calls for the importance of aligning organizational structures and processes with the values of healthcare workers, forming cross-discipline leadership opportunities, providing adequate resources, and building infrastructure that supports mental health provision for psychological safety. Our findings emphasize that explicit financial investment may enhance workload performances by offering formal mental health programming to systemically invest in clinician well-being and healthy workplaces.²⁹ There are important systemic changes to prevent moral residue and to explicitly value mental health and well-being.

Limitations

This was one of the first U.S. studies to explore perspectives of moral distress interventions among healthcare SWs, chaplains, and PLs. These three multi-professional disciplines are valued members of care teams, but their perspectives are often overlooked when thinking through health system changes. The small sample size in one academic medical center in a southern U.S. city suggests that future research ought to include comprehensive representation of diverse health systems and health workforces. This was not a program evaluation or intervention study, and we did not empirically measure how these strategies may, in practice, impact moral distress. Widespread agreement exists that moral dilemmas are problematic in healthcare, but no such agreement exists in construct definition or measurement related to moral distress, moral injury, and burnout.

Conclusions

Findings from our study demonstrate that multilevel strategies culminate to strengthen moral resilience and enhance clinician well-being. Moral distress scholarship tends to focus on individual or institutional prevention strategies for nurses rather than targeting a holistic interdisciplinary approach that addresses peer relationships, managerial practices, leadership approaches, and systems-wide investments.³⁰ Health systems need to invest in daily practices that address moral distress and embrace diverse perspectives of those who provide support to patients, families, and clinicians. Implications for healthcare practice are evident through establishing a workplace culture that explicitly promotes expanded leadership opportunities and mental health investment. By being proactive in addressing moral distress and recognizing its impact on patient-centered care, institutions may be able to diminish the longstanding negative impacts on clinician retention, job satisfaction, and health.

Findings from the current study may inform clinical nurses’ engagement in multi-professional training opportunities with other health professionals following exposure to moral distress. Examples may include the dissemination of educational activities on moral distress, incorporating material into undergraduate nursing and nursing residency curricula, and continuing education programming for experienced practitioners. Moreover, clinical nurse supervisors and managers ought to have competencies to identify and address moral distress with their nursing staff. Skilled deliberation can empower clinical nurses to discuss moral distress encounters and to brainstorm approaches to reduce negative sequalae. Clinical nurses must be offered spaces to debrief with peers and colleagues, and to participate in multi-professional team dialogue. To be explicitly valued and respected members of the health system, clinical nurses should be afforded leadership opportunities in policy and practice decision-making to strengthen their professional efficacy and to disrupt hierarchies instilled across health systems. These mechanisms may all importantly build opportunities for the prevention of moral distress in clinical nursing practice.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Funding

The author(s) received no financial support for the research,authorship,and/or publication of this article.

ORCID iD

Sophia Fantus

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