The Moral Crisis of America’s Doctors

Wendy Dean & Elisabeth Rosenthal

The New York Times

Orignally posted 15 July 23

Here is an excerpt:

Some doctors acknowledged that the pressures of the system had occasionally led them to betray the oaths they took to their patients. Among the physicians I spoke to about this, a 45-year-old critical-care specialist named Keith Corl stood out. Raised in a working-class town in upstate New York, Corl was an idealist who quit a lucrative job in finance in his early 20s because he wanted to do something that would benefit people. During medical school, he felt inspired watching doctors in the E.R. and I.C.U. stretch themselves to the breaking point to treat whoever happened to pass through the doors on a given night. “I want to do that,” he decided instantly. And he did, spending nearly two decades working long shifts as an emergency physician in an array of hospitals, in cities from Providence to Las Vegas to Sacramento, where he now lives. Like many E.R. physicians, Corl viewed his job as a calling. But over time, his idealism gave way to disillusionment, as he struggled to provide patients with the type of care he’d been trained to deliver. “Every day, you deal with somebody who couldn’t get some test or some treatment they needed because they didn’t have insurance,” he said. “Every day, you’re reminded how savage the system is.”

Corl was particularly haunted by something that happened in his late 30s, when he was working in the emergency room of a hospital in Pawtucket, R.I. It was a frigid winter night, so cold you could see your breath. The hospital was busy. When Corl arrived for his shift, all of the facility’s E.R. beds were filled. Corl was especially concerned about an elderly woman with pneumonia who he feared might be slipping into sepsis, an extreme, potentially fatal immune response to infection. As Corl was monitoring her, a call came in from an ambulance, informing the E.R. staff that another patient would soon be arriving, a woman with severe mental health problems. The patient was familiar to Corl — she was a frequent presence in the emergency room. He knew that she had bipolar disorder. He also knew that she could be a handful. On a previous visit to the hospital, she detached the bed rails on her stretcher and fell to the floor, injuring a nurse.

In a hospital that was adequately staffed, managing such a situation while keeping tabs on all the other patients might not have been a problem. But Corl was the sole doctor in the emergency room that night; he understood this to be in part a result of cost-cutting measures (the hospital has since closed). After the ambulance arrived, he and a nurse began talking with the incoming patient to gauge whether she was suicidal. They determined she was not. But she was combative, arguing with the nurse in an increasingly aggressive tone. As the argument grew more heated, Corl began to fear that if he and the nurse focused too much of their attention on her, other patients would suffer needlessly and that the woman at risk of septic shock might die.

Corl decided he could not let that happen. Exchanging glances, he and the nurse unplugged the patient from the monitor, wheeled her stretcher down the hall, and pushed it out of the hospital. The blast of cold air when the door swung open caused Corl to shudder. A nurse called the police to come pick the patient up. (It turned out that she had an outstanding warrant and was arrested.) Later, after he returned to the E.R., Corl could not stop thinking about what he’d done, imagining how the medical-school version of himself would have judged his conduct. “He would have been horrified.”

The info is here, paywalled.

Summary: The article explores the moral distress that many doctors are experiencing in the United States healthcare system. Doctors are feeling increasingly pressured to make decisions based on financial considerations rather than what is best for their patients. This is leading to a number of problems, including:

• Decreased quality of care: Doctors are being forced to cut corners on care, which is leading to worse outcomes for patients.
• Increased burnout: Doctors are feeling increasingly stressed and burned out, which is making it difficult for them to provide quality care.
• Loss of moral compass: Doctors are feeling like they are losing their moral compass, as they are being forced to make decisions that they know are not in the best interests of their patients.

The article concludes by calling for a number of reforms to the healthcare system, including:

• Paying doctors based on quality of care, not volume of services: This would incentivize doctors to provide the best possible care, rather than just the most profitable care.
• Giving doctors more control over their practice:This would allow doctors to make decisions based on what is best for their patients, rather than what is best for their employers.
• Supporting doctors' mental health: Doctors need to be supported through the challenges of providing care in the current healthcare system.

Moral Injury During the CDOVID-19 Pandemic

Borges LM, Barnes SM,  et al. 

Psychol Trauma. 2020 Aug;12(S1):S138-S140. 

doi: 10.1037/tra0000698. Epub 2020 Jun 4. PMID: 32496101.

Here is an excerpt:

Moral injury in COVID-19 may be related to, but is distinct from: 1) burnout, 2) adjustment disorders, 3)

depression, 4) traumatic stress/PTSD, 5) moral injury in the military, and 6) moral distress. Moral injury

may be a contributing factor to burnout, adjustment disorders, or depression, but they are not equivalent. The diagnosis of PTSD requires a qualifying exposure to a traumatic stressor, whereas experiencing a moral injury does not. Moral injury in the military has been addressed in a different population and particularly after deployment, and its lessons may not be generalizable to moral injury during COVID-19, which we are seeing acutely among healthcare workers. Finally, moral distress may be a precursor to moral injury, but the terms are not interchangeable. Previous literature has noted that moral distress signals a need for systemic change because it is generated by systemic issues. Thus, moral distress can serve as a guide for healthcare improvement, and rapid systemic interventions to address moral distress may help to prevent and mitigate the impact of moral injury.

While not a mental disorder itself, moral injury undermines core capacities for well-being, including a

sense of ongoing value-laden actions, competence to face and meet challenges, and feelings of belonging and meaning. Moral injury is associated with strong feelings of shame and guilt and with intense self-condemnation and a shattered core sense of self. Clinical observations suggest that uncertainty in decision-making may increase the likelihood or intensity of moral injury.

In the context of a public health disaster such as the COVID-19 pandemic, acknowledgement of the need

to transition from ordinary standards of care to crisis standards of care can be both necessary and helpful to 1) provide a framework upon which to make difficult and ethically fraught decisions and 2) alleviate some of moral distress and indeed moral injury that may otherwise be experienced in the absence of such guidance. The pandemic forces us to confront challenging questions for which there are no clear answers, and to make “lose-lose” choices in which no one involved ends up feeling satisfied or even comfortable. 

The info is here.

Suicides of two health care workers hint at the Covid-19 mental health crisis to come

Wendy Dean
statnews.com
Originally posted 30 April 2020

Here is an excerpt:

Denial, minimizing, and compartmentalizing are essential strategies for coping with a crisis. They are the psychological tools we reach for over and over to get through harrowing situations. Health care workers learn this through experience and by watching others. We learn how not to pass out in the trauma bay. We learn to flip into “rational mode” when a patient is hemorrhaging or in cardiac arrest, attending to the details of survival — their vital signs, lab results, imaging studies. We learn that if we grieve for the 17-year-old gunshot victim while we are doing chest compressions we will buckle and he will die. So we shut down feeling and just keep doing.

What few health care workers learn how to do is manage the abstractness of emotional recovery, when there is nothing to act on, no numbers to attend, no easily measurable markers of improvement. It is also hard to learn to resolve emotional experiences by watching others, because this kind of intense processing is a private undertaking. We rarely get to watch how someone else swims in the surf of traumatic experience.

Those on the frontlines of the Covid-19 pandemic, especially those in the hardest-hit areas, have seen conditions they never imagined possible in the country with the most expensive health care system in the world. Watching patients die alone is traumatic. Having to choose your own safety over offering comfort to the dying because your hospital or health care system doesn’t have enough personal protective equipment to go around inflicts moral injury. When facing the reality of constrained resources and unthinkable choices, working to exhaustion, and caring for patients at great personal risk, the only way to get through each shift is to do what is immediately at hand.

The info is here.

Moral Distress and Moral Strength Among Clinicians in Health Care Systems: A Call for Research

Connie M. Ulrich and Christine Grady
NAM Perspectives. 
https://doi.org/10.31478/201909c


Here is an excerpt:

Evidence shows that dissatisfaction and wanting to leave one’s job—and the profession altogether—often follow morally distressing encounters. Ethics education that builds cognitive and communication skills, teaches clinicians ethical concepts, and helps them gain communication skills and confidence may be essential in building moral strength. One study found, for example, that among practicing nurses and social workers, those with the least ethics education were also the least confident, the least likely to use ethics resources (if available), and the least likely to act on their ethical concerns. In this national study, as many as 23 percent of nurses reported having had no ethics education at all. But the question remains—is ethics education enough?

Many factors likely support or hinder a clinician’s capacity and willingness to act with moral strength. More research is needed to investigate how interdisciplinary ethics education and institutional resources can help nurses, physicians, and others voice their ethical concerns, help them agree on morally acceptable actions, and support their capacity and propensity to act with moral strength and confidence. Research on moral distress and ethical concerns in everyday clinical practice can begin to build a knowledge base that will inform clinical training—in both educational and health care institutions—and that will help create organizational structures and processes to prepare and support clinicians to encounter potentially distressing situations with moral strength. Research can help tease out what is important and predictive for taking (or not taking) ethical action in morally distressing circumstances. This knowledge would be useful for designing strategies to support clinician well-being. Indeed, studies should focus on the influences that affect clinicians’ ability and willingness to become involved or take ownership of ethically-laden patient care issues, and their level of confidence in doing so.

What is ‘moral distress’? A narrative synthesis of the literature

Georgina Morley, Jonathan Ives, Caroline Bradbury-Jones, & Fiona Irvine

Nursing Ethics

First Published October 8, 2017 Review Article  

https://doi.org/10.1177/0969733017724354

Introduction

The concept of moral distress (MD) was introduced to nursing by Jameton who defined MD as arising, ‘when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’. MD has subsequently gained increasing attention in nursing research, the majority of which conducted in North America but now emerging in South America, Europe, the Middle East and Asia. Studies have highlighted the deleterious effects of MD, with correlations between higher levels of MD, negative perceptions of ethical climate and increased levels of compassion fatigue among nurses. Consensus is that MD can negatively impact patient care, causing nurses to avoid certain clinical situations and ultimately leave the profession. MD is therefore a significant problem within nursing, requiring investigation, understanding, clarification and responses. The growing body of MD research, however, is arguably failing to bring the required clarification but rather has complicated attempts to study it. The increasing number of cited causes and effects of MD means the term has expanded to the point that according to Hanna and McCarthy and Deady, it is becoming an ‘umbrella term’ that lacks conceptual clarity referring unhelpfully to a wide range of phenomena and causes. Without, however, a coherent and consistent conceptual understanding, empirical studies of MD’s prevalence, effects, and possible responses are likely to be confused and contradictory.

A useful starting point is a systematic exploration of existing literature to critically examine definitions and understandings currently available, interrogating their similarities, differences, conceptual strengths and weaknesses. This article presents a narrative synthesis that explored proposed necessary and sufficient conditions for MD, and in doing so, this article also identifies areas of conceptual tension and agreement.

The research is here.

Survey Finds Widespread 'Moral Distress' Among Veterinarians

Carey Goldberg
NPR.org
Originally posted October 17, 2018

In some ways, it can be harder to be a doctor of animals than a doctor of humans.

"We are in the really unenviable, and really difficult, position of caring for patients maybe for their entire lives, developing our own relationships with those animals — and then being asked to kill them," says Dr. Lisa Moses, a veterinarian at the Massachusetts Society for the Prevention of Cruelty to Animals-Angell Animal Medical Center and a bioethicist at Harvard Medical School.

She's the lead author of a study published Monday in the Journal of Veterinary Internal Medicine about "moral distress" among veterinarians. The survey of more than 800 vets found that most feel ethical qualms — at least sometimes — about what pet owners ask them to do. And that takes a toll on their mental health.

Dr. Virginia Sinnott-Stutzman is all too familiar with the results. As a senior staff veterinarian in emergency and critical care at Angell, she sees a lot of very sick animals — and quite a few decisions by owners that trouble her.

Sometimes, owners elect to have their pets put to sleep because they can't or won't pay for treatment, she says. Or the opposite, "where we know in our heart of hearts that there is no hope to save the animal, or that the animal is suffering and the owners have a set of beliefs that make them want to keep going."

The info is here.

Moral resilience: how to navigate ethical complexity in clinical practice

Cynda Rushton
Oxford University Press
Originally posted October 12, 2018

Clinicians are constantly confronted with ethical questions. Recent examples of healthcare workers caught up in high-profile best-interest cases are on the rise, but decisions regarding the allocation of the clinician’s time and skills, or scare resources such as organs and medication, are everyday occurrences. The increasing pressure of “doing more with less” is one that can take its toll.

Dr Cynda Rushton is a professor of clinical ethics, and a proponent of ‘moral resilience’ as a pathway through which clinicians can lessen their experience of moral distress, and navigate the contentious issues they may face with a greater sense of integrity. In the video series below, she provides the guiding principles of moral resilience, and explores how they can be put into practice.



The videos are here.

Who Is Experiencing What Kind of Moral Distress?

Carina Fourie
AMA J Ethics. 2017;19(6):578-584.

Abstract

Moral distress, according to Andrew Jameton’s highly influential definition, occurs when a nurse knows the morally correct action to take but is constrained in some way from taking this action. The definition of moral distress has been broadened, first, to include morally challenging situations that give rise to distress but which are not necessarily linked to nurses feeling constrained, such as those associated with moral uncertainty. Second, moral distress has been broadened so that it is not confined to the experiences of nurses. However, such a broadening of the concept does not mean that the kind of moral distress being experienced, or the role of the person experiencing it, is morally irrelevant. I argue that differentiating between categories of distress—e.g., constraint and uncertainty—and between groups of health professionals who might experience moral distress is potentially morally relevant and should influence the analysis, measurement, and amelioration of moral distress in the clinic.

The info is here.

Culture and Moral Distress: What’s the Connection and Why Does It Matter?

Nancy Berlinger and Annalise Berlinger
AMA Journal of Ethics. June 2017, Volume 19, Number 6: 608-616.

Abstract

Culture is learned behavior shared among members of a group and from generation to generation within that group. In health care work, references to “culture” may also function as code for ethical uncertainty or moral distress concerning patients, families, or populations. This paper analyzes how culture can be a factor in patient-care situations that produce moral distress. It discusses three common, problematic situations in which assumptions about culture may mask more complex problems concerning family dynamics, structural barriers to health care access, or implicit bias. We offer sets of practical recommendations to encourage learning, critical thinking, and professional reflection among students, clinicians, and clinical educators.

Here is an excerpt:

Clinicians’ shortcuts for identifying “problem” patients or “difficult” families might also reveal implicit biases concerning groups. Health care professionals should understand the difference between cultural understanding that helps them respond to patients’ needs and concerns and implicit bias expressed in “cultural” terms that can perpetuate stereotypes or obscure understanding. A way to identify biased thinking that may reflect institutional culture is to consider these questions about advocacy:

1. Which patients or families does our system expect to advocate for themselves?
2. Which patients or families would we perceive or characterize as “angry” or “demanding” if they attempted to advocate for themselves?
3. Which patients or families do we choose to advocate for, and on what grounds?
4. What is our basis for each of these judgments?

The article is here.

Antecedents and Consequences of Medical Students’ Moral Decision Making during Professionalism Dilemmas

Lynn Monrouxe, Malissa Shaw, and Charlotte Rees
AMA Journal of Ethics. June 2017, Volume 19, Number 6: 568-577.

Abstract

Medical students often experience professionalism dilemmas (which differ from ethical dilemmas) wherein students sometimes witness and/or participate in patient safety, dignity, and consent lapses. When faced with such dilemmas, students make moral decisions. If students’ action (or inaction) runs counter to their perceived moral values—often due to organizational constraints or power hierarchies—they can suffer moral distress, burnout, or a desire to leave the profession. If moral transgressions are rationalized as being for the greater good, moral distress can decrease as dilemmas are experienced more frequently (habituation); if no learner benefit is seen, distress can increase with greater exposure to dilemmas (disturbance). We suggest how medical educators can support students’ understandings of ethical dilemmas and facilitate their habits of enacting professionalism: by modeling appropriate resistance behaviors.

Here is an excerpt:

Rather than being a straightforward matter of doing the right thing, medical students’ understandings of morally correct behavior differ from one individual to another. This is partly because moral judgments frequently concern decisions about behaviors that might entail some form of harm to another, and different individuals hold different perspectives about moral trade-offs (i.e., how to decide between two courses of action when the consequences of both have morally undesirable effects). It is partly because the majority of human behavior arises within a person-situation interaction. Indeed, moral “flexibility” suggests that though we are motivated to do the right thing, any moral principle can bring forth a variety of context-dependent moral judgments and decisions. Moral rules and principles are abstract ideas—rather than facts—and these ideas need to be operationalized and applied to specific situations. Each situation will have different affordances highlighting one facet or another of any given moral value. Thus, when faced with morally dubious situations—such as being asked to participate in lapses of patient consent by senior clinicians during workplace learning events—medical students’ subsequent actions (compliance or resistance) differ.

The article is here.

Moral Distress: A Call to Action

The Editor
AMA Journal of Ethics. June 2017, Volume 19, Number 6: 533-536.

During medical school, I was exposed for the first time to ethical considerations that stemmed from my new role in the direct provision of patient care. Ethical obligations were now both personal and professional, and I had to navigate conflicts between my own values and those of patients, their families, and other members of the health care team. However, I felt paralyzed by factors such as my relative lack of medical experience, low position in the hospital hierarchy, and concerns about evaluation. I experienced a profound and new feeling of futility and exhaustion, one that my peers also often described.

I have since realized that this experience was likely “moral distress,” a phenomenon originally described by Andrew Jameton in 1984. For this issue, the following definition, adapted from Jameton, will be used: moral distress occurs when a clinician makes a moral judgment about a case in which he or she is involved and an external constraint makes it difficult or impossible to act on that judgment, resulting in “painful feelings and/or psychological disequilibrium”. Moral distress has subsequently been shown to be associated with burnout, which includes poor coping mechanisms such as moral disengagement, blunting, denial, and interpersonal conflict.

Moral distress as originally conceived by Jameton pertained to nurses and has been extensively studied in the nursing literature. However, until a few years ago, the literature has been silent on the moral distress of medical students and physicians.

The article is here.

Moral distress in physicians and nurses: Impact on professional quality of life and turnover

Austin, Cindy L.; Saylor, Robert; Finley, Phillip J.
Psychological Trauma: Theory, Research, Practice, and Policy, Vol 9(4), Jul 2017, 399-406.

Abstract

Objective: The purpose of this study was to investigate moral distress (MD) and turnover intent as related to professional quality of life in physicians and nurses at a tertiary care hospital.

Method: Health care providers from a variety of hospital departments anonymously completed 2 validated questionnaires (Moral Distress Scale–Revised and Professional Quality of Life Scale). Compassion fatigue (as measured by secondary traumatic stress [STS] and burnout [BRN]) and compassion satisfaction are subscales which make up one’s professional quality of life. Relationships between these constructs and clinicians’ years in health care, critical care patient load, and professional discipline were explored.

Results: The findings (n = 329) demonstrated significant correlations between STS, BRN, and MD. Scores associated with intentions to leave or stay in a position were indicative of high verses low MD. We report highest scoring situations of MD as well as when physicians and nurses demonstrate to be most at risk for STS, BRN and MD. Both physicians and nurses identified the events contributing to the highest level of MD as being compelled to provide care that seems ineffective and working with a critical care patient load >50%.

Conclusion: The results from this study of physicians and nurses suggest that the presence of MD significantly impacts turnover intent and professional quality of life. Therefore implementation of emotional wellness activities (e.g., empowerment, opportunity for open dialog regarding ethical dilemmas, policy making involvement) coupled with ongoing monitoring and routine assessment of these maladaptive characteristics is warranted.

The article is here.

Antecedents and Consequences of Medical Students’ Moral Decision Making during Professionalism Dilemmas

Lynn Monrouxe, Malissa Shaw, and Charlotte Rees
AMA Journal of Ethics. June 2017, Volume 19, Number 6: 568-577.

Abstract

Medical students often experience professionalism dilemmas (which differ from ethical dilemmas) wherein students sometimes witness and/or participate in patient safety, dignity, and consent lapses. When faced with such dilemmas, students make moral decisions. If students’ action (or inaction) runs counter to their perceived moral values—often due to organizational constraints or power hierarchies—they can suffer moral distress, burnout, or a desire to leave the profession. If moral transgressions are rationalized as being for the greater good, moral distress can decrease as dilemmas are experienced more frequently (habituation); if no learner benefit is seen, distress can increase with greater exposure to dilemmas (disturbance). We suggest how medical educators can support students’ understandings of ethical dilemmas and facilitate their habits of enacting professionalism: by modeling appropriate resistance behaviors.

The article is here.

Cultivating Moral Resilience

Cynda Rushton
American Journal of Nursing:
February 2017 - Volume 117 - Issue 2 - p S11–S15
doi: 10.1097/01.NAJ.0000512205.93596.00

Here is an excerpt:

To derive meaning from moral distress, one must first change the relationship with the suffering that it causes. Human beings have the potential to consciously decide what mindset they will bring to a given situation; they have the option to choose a path of mindful awareness and inquiry over one of helplessness and frustration. When people are mired in the “judger pit,” the tone of their conversation is punctuated by negativity, closed thinking, and judgment of themselves and others.40 Alternatively, when in an inquiring mindset, they are more inclined to remain positive—despite their distress—and are able to ask questions that may help reveal unknown or overlooked possibilities.

Shifting the focus from helplessness to resilience offers promising possibilities in designing interventions to help mitigate the effects of moral distress. Resilience—an umbrella concept that has been applied in diverse fields of study—can be psychological, physiologic, genetic, sociologic, organizational or communal, or moral. Although there is no unifying definition, resilience generally refers to the ability to recover from or healthfully adapt to challenges, stress, adversity, or trauma. One definition characterizes it as “the process of harnessing biological, psychosocial, structural, and cultural resources to sustain wellbeing.”

Psychological resilience, for example, “involves the creation of meaning in life, even life that is sometimes painful or absurd, and having the courage to live life fully despite its inherent pain and futility.”

The article is here.

What We Know About Moral Distress

Patricia Rodney
AJN, American Journal of Nursing:
February 2017 - Volume 117 - Issue 2 - p S7–S10
doi: 10.1097/01.NAJ.0000512204.85973.04

Moral distress arises when nurses are unable to act according to their moral judgment. The concept is relatively recent, dating to American ethicist Andrew Jameton's 1984 landmark text on nursing ethics. Until that point, distress among clinicians had been understood primarily through psychological concepts such as stress and burnout, which, although relevant, were not sufficient. With the introduction of the concept of moral distress, Jameton added an ethical dimension to the study of distress.

Background

In the 33 years since Jameton's inaugural work, many nurses, inspired by the concept of moral distress, have continued to explore what happens when nurses are constrained from translating moral choice into moral action, and are consequently unable to uphold their sense of integrity and the values emphasized in the American Nurses Association's Code of Ethics for Nurses with Interpretive Statements. Moral distress might occur when, say, a nurse on a busy acute medical unit can't provide comfort and supportive care to a dying patient because of insufficient staffing.

The article is here.

Moral Distress in Physicians and Nurses: Impact on Professional Quality of Life and Turnover.

C. L. Austin, R. Saylor, and P. J. Finley
Psychological Trauma: Theory, Research, Practice, and Policy, 2016

Abstract

Objective: The purpose of this study was to investigate moral distress (MD) and turnover intent as related to professional quality of life in physicians and nurses at a tertiary care hospital.

Method: Health care providers from a variety of hospital departments anonymously completed 2 validated questionnaires (Moral Distress Scale–Revised and Professional Quality of Life Scale). Compassion fatigue (as measured by secondary traumatic stress [STS] and burnout [BRN]) and compassion satisfaction are subscales which make up one’s professional quality of life. Relationships between these constructs and clinicians’ years in health care, critical care patient load, and professional discipline were explored.

Results: The findings (n = 329) demonstrated significant correlations between STS, BRN, and MD. Scores associated with intentions to leave or stay in a position were indicative of high verses low MD. We report highest scoring situations of MD as well as when physicians and nurses demonstrate to be most at risk for STS, BRN and MD. Both physicians and nurses identified the events contributing to the highest level of MD as being compelled to provide care that seems ineffective and working with a critical care patient load >50%.

Conclusion: The results from this study of physicians and nurses suggest that the presence of MD significantly impacts turnover intent and professional quality of life. Therefore implementation of emotional wellness activities (e.g., empowerment, opportunity for open dialog regarding ethical dilemmas, policy making involvement) coupled with ongoing monitoring and routine assessment of these maladaptive characteristics is warranted.

The article is here.

Fear and Loathing in Bioethics

Carl Elliott
Narrative Inquiry in Bioethics
Volume 6.1 (2016) 43–46

Abstract

As bioethicists have become medical insiders, they have had to struggle with a conflict between what their superiors expect of them and the demands of their conscience. Often they simply resign themselves to the conflict and work quietly within the system. But the machinery of the medical–industrial complex grinds up conscientious people because those people can see no remedies for injustice apart from the bureaucratic procedures prescribed by the machine itself. The answer to injustice is not a memorandum of understanding or a new strategic plan, but rather public resistance and solidarity.

The article is here.

Nurses Say Stress Interferes With Caring For Their Patients

By Alan Yu
NPR.org
Originally posted April 15, 2016

Here is an excerpt:

Almost 20 percent of newly registered nurses leave a hospital within the first year for the same job elsewhere, or a different job in a different organization, according to a 2014 study. Rushton says to her, that means health care organizations aren't investing enough in their nursing staff.

Nurse burnout also is linked to moral distress, Rushton says, from situations where nurses know what they should do for their patients but can't act on it. For example, nurses might have to give a patient at the end of life a treatment that causes suffering without any medical benefit. She just started a program called the Mindful Ethical Practice and Resilience Academy to try to help new nurses deal with moral distress.

It's a series of in-person workshops, some of which involve nurses using simulations to practice how to make their ethical concerns heard at work. One scenario includes a patient with a complex medical condition and a nurse has been caring for him and talking to him for days following the recommended treatment.

The article is here.

Note: There are several significant areas that apply to mental health professionals in terms of stress, moral distress, professional respect, and overwork.

Moral Distress in Medical Education and Training

by Berger, Jeffrey T
Journal of General Internal Medicine, Volume 29, Issue 2
doi: 10.1007/s11606-013-2665-0

Abstract

Moral distress is the experience of cognitive-emotional dissonance that arises when one feels compelled to act contrary to one’s moral requirements. Moral distress is common, but under-recognized in medical education and training, and this relative inattention may undermine educators’ efforts to promote empathy, ethical practice, and professionalism. Moral distress should be recognized as a feature of the clinical landscape, and addressed in conjunction with the related concerns of negative role modeling and the goals and efficacy of medical ethics curricula.

Introduction

Moral distress is the cognitive-emotional dissonance that arises when one feels compelled to act against one’s moral requirements. Moral distress is common in clinical practice, because caring for the ill is an inherently moral activity. Medical students and junior practitioners may be particularly challenged by morally distressing situations. Their development into attending physicians involves a process that is complex intellectually, sociologically, and culturally, and is no less complex in its moral dimensions.

(cut)

Academic health institutions whose leadership presupposes that moral distress affects all of its clinicians will be best positioned to mitigate this stress and to promote moral wellness and professionalism. Programs should expect that their trainees will experience moral distress and trainees should be aware of this expectation.

The entire article is here.

A Pilot Study Examining Moral Distress in Nurses Working in One United States Burn Center

By Jeanie Legget and others
Journal of Burn Care & Research:
September/October 2013 - Volume 34 - Issue 5 - p 521-528
doi: 10.1097/BCR.0b013e31828c7397

Moral distress is described as the painful feelings and psychological disequilibrium when a person believes she knows the morally right action to take and is unable to carry it out because of external or internal constraints. It has been studied in intensive care unit (ICU) nurses, but to the best of our knowledge not in burn ICU nurses. A pilot study was performed to gather initial data on moral distress among nurses treating burn victims. Findings from an intervention aimed at decreasing the level of moral distress in these nurses are reported. Nurses (n = 13) were recruited from one U.S. burn ICU and were randomized into two groups. A separate sample pretest post-test design was used. Group A completed the Moral Distress Scale-Revised (MDS-R) and Self-efficacy (SE) Scale before a 4-week educational intervention involving weekly 60-minute sessions, and Group B completed both scales afterward. Participants also completed written evaluations after each session. The MDS-R and SE Scale were readministered to both groups 6 weeks after the intervention was completed. Given the size and distribution of the sample, nonparametric data analyses were used. The MDS-R median score for Group B (92.0) was significantly different statistically from Group A (40.5) with P = .032 directly after the intervention was completed. No significant difference was found in the median SE scores between Group A (34.5) and Group B (34.0; P = .616). The median for Group B was 69 and Group A was 60.5 (P = .775). At the 6-week follow up, the difference between the two groups was no longer observed. Defining and discussing moral distress may have contributed to increased awareness and higher levels of moral distress in Group B directly postintervention. The changes in moral distress levels postintervention and at the 6-week follow up highlight the need to examine the intervention in a larger sample.

The entire article is here.