Moral Distress Part 2: At the Bedside

Core IM Podcast

Time Stamps

• 01:07 Strategies for Moral Distress
• 09:25 Strategies for Addressing Moral Injury
• 20:52 Conclusion

Show Notes

• INTRO
  • Beth Epstein, PhD, RN, HEC-C, FAAN
  • Wendy Dean, MD
• STRATEGIES FOR ADDRESSING MORAL DISTRESS
  • Acknowledgement & validation of concerns
    • First recognizing it yourself
    • Seek out colleagues to clarify/verify experiences
    • Not a YOU problem, it’s a SITUATION or SYSTEMS problem
  • Formal moral distress consultation/team debriefing (KEY QUESTIONS):
    • What are we experiencing? What are the causes of moral distress?
    • What do we think the right thing to do would be?
    • What are the barriers to moral action?
    • What is the clinical team empowered to do right now to find resolution?
    • What needs to be escalated to leadership/other teams?
      • Legal/Risk Management
      • Hospital Security
      • Ethics Committee
      • C-Suite (CEO, CMO, CNO, CPO, CFO, etc.)
    • What policies need creation or revision?
  • Find an ally!
    • Develop an interdisciplinary coalition of affected team members
    • Clarify concerns, utilizing different perspectives
    • Develop clear plans/goals in speaking out
    • Meet regularly (e.g., journal clubs, ad hoc discussion/debriefing, strategy sessions, social gatherings)
    • Find power in numbers (even 2-3 people have a stronger voice than 1)
    • Seek out mentors, resources, and institutional pathways to address the situation and support one another
    • Use collective effort to build the data & arguments needed to effect change
    • Follow through with plans through collective motivation
  • Speak out!
    • Recognize, name, and address moral distress directly
    • ‘Primum non tacere’ – First, do not be silent (even as a medical student!)
    • Seek thoughtfulness and accountability in your response
    • Focus on key actions that will best preserve your moral integrity
    • Participate in discussions & educational activities aimed at preserving values
    • Build pathways for future concerns to be addressed
  • Resolving issues with colleagues
    • Start the conversation! Best opener: “ Help me understand [your perspective]?”
    • More efficient to address directly and openly
    • Bring together different clinical teams to find consensus
• STRATEGIES FOR ADDRESSING MORAL INJURY
  • Move from the INDIVIDUAL to the GROUP/COMMUNITY/SYSTEMS level in approach
    • Individual effort often leads to:
      • Limited impact (less likely to reach goal)
      • Greater risk of frustration, despair, burnout
      • Greater individual career/reputation risks
    • Community/organizational change ultimately facilitates resolution for individuals
    • Emphasize community/cultural change first and foremost
    • Find collective voice and identity (through coalition-building)
  • Seek out a non-morally injurious work environment (defined by several qualities):
    • Wise: Acknowledges the risk of moral injury in medicine; provides education/training in how to mitigate impact
    • Human & Vulnerable: Recognizes imperfection in leadership and the inevitability of some betrayals, with a focus on how resolve issues (from a place of humility and openness)
    • Mentoring: Embraces the critical importance of educating, training, and supporting junior members, helping all members thrive
    • Just: Looks for opportunities to learn/grow rather than punish
    • Courageous: Seeks out genuine feedback – even when negative or difficult – and acts on that feedback; stands up for its workforce when threatened (e.g., by state/federal regulation)
  • Educate trainees in the real BUSINESS and PRACTICE of medicine
    • “Forewarned is forearmed”: Allows us to better select post-training opportunities, without being later blindsighted
    • Learn from the experience of others (many good books on this topic)
  • Focus on the internal moment immediately after experiencing moral distress/moral injury, and act reflectively
    • Am I going to acquiesce to a situation I don’t agree with? Am I suspending or fundamentally changing my moral beliefs/convictions? For how long?
    • Many different potential responses:
      • Rebellion:
        • Rejection or removal of oneself from the situation
      • Acquiescence:
        • Choosing your battles
        • Compartmentalization or loss of conviction
      • Rediscovery:
        • Broadening one’s moral stance to include new perspectives
        • Refining/revising previously held convictions
        • Finding new moral expressions or outlets outside of the specific situation
    • Assess external realities that curtail immediate action/moral autonomy (e.g., limits within current work environment, financial obligations, personal life/family commitments, difficulty finding/transitioning to aspirational work environment)
    • Consciously acknowledge and make a deliberate choice regarding personal values: find effective, authentic, and collective ways of responding (relieves complicity and victimhood)
• Recognize where higher-order political action is necessary
  • Lobbying for state/federal regulation or legislation changes
  • Offer clinician perspective: Bad policy/laws are often developed by those who lack insight or connection with clinical practice
  • Manage expectations: Must be satisfied with slow, incremental improvements (e.g., moving through multiple committees)
• CONCLUSION
  • Core solutions:
    • Naming/validating the issue
    • Debriefing with colleagues
    • Speaking out against bad policy or poor team dynamics
    • Coalition building to effect political/organization change
  • Recognize limits, while remaining authentic & committed to personal beliefs
  • Greater cultural awareness of moral distress/moral injury in medicine => greater potential for change than ever before!
  • REMEMBER: THIS IS ABOUT OUR CORE PROFESSIONAL IDENTITY

* AACN’s 4 “As” model of moral distress (see AACN Position Statement):

1. ASK: Become aware of their moral distress and its effects
2. AFFIRM: Make a commitment to address moral distress
3. ASSESS: Be ready to make an action plan
4. ACT: Preserve their integrity and authenticity

Transcript

Dr: Margot Hedlin: I used to be haunted by moral distress, but it’s an emotion I’ve now learned to live with. I still remember the shock of understanding I experienced my second year of residency, when I first learned the term. There’s a power that comes with knowing what you’re up against: I realized that what I was going through wasn’t burnout, or depression, or self-doubt – instead, I had come to believe that sometimes things go the wrong way. With understanding comes the potential for change. Part of my work these days is as an ethics consultant, and when I take calls I find that while people sometimes struggle to articulate an ethics question, they know when something feels wrong. And guided by their moral intuition, and the values of the patient and family they care for, we work together to define the problem and seek solutions. The care plan doesn’t always change, but gathering and speaking openly is itself a powerful process. Welcome back to At the Bedside – I’m Margot Hedlin, a hospitalist and clinical ethics consultant.

Dr. Jafar Al-Mondhiry: I’m Jafar Al-Mondhiry, a medical oncologist.

Dr. Tamar Schiff: And I’m Tamar Schiff, I trained in internal medicine and am currently a postdoc in bioethics.

Strategies for Moral Distress

Dr. Jafar Al-Mondhiry: In our last episode, we spoke about moral distress – which we defined as the stress we feel when we’re blocked from acting on our moral convictions. We also spoke about other key concepts like moral residue and moral injury, as well as some of their causes and consequences. In Part 2, we want to talk about some strategies for addressing moral distress. We’re back now with Dr. Beth Epstein, professor of nursing and ethics consultant at the University of Virginia, along with Dr. Wendy Dean, a former psychiatrist who has become a leading author, advocate, and podcaster on the topic of moral distress and moral injury in medicine.

Dr. Epstein will help us break down more of those immediate patient care and teams-based issues that bring out moral distress, while Dr. Dean discusses those deeper systemic issues that drive moral distress and moral injury in healthcare as a whole.

But regardless of where we start, the first and most important step in addressing moral distress is the same: Naming it, identifying what we’re actually feeling. Once we do that, we can then work to find a supportive space for individuals and groups to validate their concerns, discuss their experiences, and brainstorm solutions. While many of us do this on an informal basis all the time at work, Dr. Epstein shared her experience at UVA, turning this into a formal consult service available for inpatient healthcare teams.

Dr. Beth Epstein: So we have had a moral distress consult service here since 2006. And our approach is to gather the interprofessional team as interprofessional as we can and sit everybody down. It’s an even table. Everybody has the same voice. It’s confidential, and we discuss what the situation is from as many angles as we can. So I like to try to get a 360 degree view of who sees what, because that’s often enlightening because a lot of people don’t see what other people are seeing. So that itself is really enlightening. Then we identify where the sources of moral distress are coming from. We ask what the barriers are to them doing the right thing, and then at the end of the hour we strategize what can the team do? What is the team empowered to do to resolve this problem? What needs to be escalated? For example, a lot of hospitals are having issues with patient violence, abusive patients, that kind of thing. And while those kinds of situations can be morally distressing if they’re tolerated by administrations. I’ve heard one of my colleagues in Florida said, well, our administration basically said, “suck it up buttercup, sick people aren’t happy people.”

So we strategize what can the team do to help the situation? What kind of expertise do they need, behavioral plans, security, that kind of thing. What kinds of things do we need to escalate to higher levels of administration to legal, to risk management, to hospital security? How can they help? So getting people in a room to talk and helping them, and they just sit there and they realize, I am not the only one who’s really worried about this situation, who’s really frustrated about the situation. A lot of people say, I didn’t even know moral distress was a thing. I thought I was just weak or, so just knowing that, acknowledging the fact that moral distress is actually a thing, a phenomenon, and then acknowledging the fact that they have it and they should have it in this particular situation, even that is helpful.

Dr. Jafar Al-Mondhiry: So when I heard about this model of a highly organized and successful support service, I was blown away—it’s an inspiring example of what a proactive stance to moral distress can look like, with an organizational leadership that’s willing to listen. Truth be told though, most hospitals don’t have this kind of moral distress consult service. But there are some other ways to address moral distress on a local level.

Dr. Beth Epstein: So there are a bunch of things that folks can do. One is find an ally, and you’re not the only one. Be convinced that you are not the only one who has moral distress in any particular situation. So find an ally that you can talk to. We’ve had units do journal clubs just to kind of introduce the idea and to start talking about ethical issues that arise on their units in an interdisciplinary way so that you can kind of gain the comfort with your colleagues from different professions just to kind of talk things out in a safe environment, order some pizza, order, get some donuts or whatever, and just sit and talk. So a journal club is helpful. Discussion groups are helpful, debriefing after morally distressing situations. Some ethics consultants, increasingly they understand what moral distress is and they might be able to help.

So asking for an ethics consult and just kind of talking through what you’re experiencing with them, they may be able to help you. Getting folks together, even if it’s just two or three people to talk through the situation to say, alright, what are we experiencing? What do we think is the right thing to do? Why can’t we do it, and what can we do about it? Those are like four questions. And sometimes when you’re in a morally distressing situation, it feels huge and problematic and multilayered, like you’re peeling the onion, and how am I ever going to get to the bottom of it? But if you ask those questions, what are we feeling? Is it moral distress? Do I feel like I’m doing something wrong? What am I trying to do that’s right? Why can’t I do it and what can I do about it?

That helps to hone in on where you are empowered. And a lot of people do not feel empowered, but I will say that there is power in numbers. So one person may not have a whole lot of individual power, but you get 2, 3, 4, 8, 12, 40 people together to say, this is a problem and we need to address it. And that gets attention, and that is really powerful. Certainly there are lots of things that people can do to recognize it in themselves, recognize it in their colleagues, and then just be allies for each other to recognize that it’s not a weakness and it’s not a you problem, it’s a systems problem.

Dr. Jafar Al-Mondhiry: There are so many ways to be a personal champion on these issues when they come up. When it comes down to it, it’s just about starting the discussion. I know I’ve been caught in a situation where one of my patients was stuck in ICU, and we had a consultant who was refusing to do a critical intervention for unclear reasons. It left me baffled and really angry about why we couldn’t work together to get to the best solution for the patient. But the solution started when I was able to open up that conversation in a non-confrontational way.

Dr. Beth Epstein: I think the three magic words often are, help me understand, because you put the onus on you rather than say, why are you doing this? That usually goes nowhere. But to say, I see what we’re doing. I’m struggling to understand all the ins and outs of it. Can you help me understand your perspective and where you’re coming from and that kind of thing? And can I tell you what I’m seeing? Because I want you to know as somebody who’s on this team that what I’m seeing is really troubling me and I want you to know about it. So that’s a place to start, but help me understand are three magical words.

Dr. Jafar Al-Mondhiry: Trying to start these conversations may feel difficult and time consuming, but that may ultimately be the most efficient path towards a solution.

Dr. Beth Epstein: It was hard before the pandemic and now it’s really, it just really is hard. Especially for the complicated patients because those things go, those situations can go on forever and without real clear goals of care conversations and that kind of thing, and lots of discontinuity because everybody’s changing, going on service, coming off service. If that happens over months, you just kind of lose track of where you’ve been and where you’re going. Sometimes it feels like there are 14 different siloed conversations happening and no, everybody in the room, can we just get in the room for half an hour and just talk through this? I feel like that gets teams a little bit further than having one-offs and playing telephone.

Strategies for Addressing Moral Injury

Dr. Jafar Al-Mondhiry: Ultimately, the strategy that came up over and over again in our discussions with Dr. Epstein and Dr. Dean is that the individual experience of Moral Distress and Moral Injury needs to be solved on a group level.

Dr. Wendy Dean: When we’re talking about the professional obligations that we have that we enjoined with our society, and when those are being betrayed, that starts to speak to a fraying of our community fabric. Repairing that community fabric can’t happen on an individual level. It didn’t start necessarily on an individual level. It means that somehow our collective values are no longer as tightly aligned as they used be. That also means that the repair has to come first through community. It has to be a community repair before individuals can start feeling as though they’ve been heard and have a good solution.

Dr. Jafar Al-Mondhiry: This is ultimately something organizational leaders should understand and work to address through supporting such communities. Dr. Dean talks about what a healthy organization looks like in its response to moral distress—lessons that may help all of us in evaluating if we’re working in a good system.

Dr. Wendy Dean: We did a study in the spring that was really focused on what creates a non-moral injurious organization. It was a Delphi survey, and we asked about more than 50 folks around the world who spend a lot of their either academic or clinical time thinking about moral injury, addressing moral injury. And they came up with a very clear, highly agreed upon structure for what a non-morally injurious organization looks like. It is wise. So it recognizes that in medicine there is an inherent risk of moral injury. And so they educate around it, and those organizations provide training and education around the fact that it may come up and how to talk about it as a mitigation strategy. It is human and vulnerable and realizes that it’s not perfect, that we are all human and we will betray and we will be betrayed. And the importance is not whether or not we do it, but how we address it afterwards.

It’s mentoring. It recognizes the critical importance of the next generation and helping them understand the environment that they’re coming up in, that they’re supported along the way. It is just. So it looks for opportunities for learning rather than for punishment when something goes wrong. And it’s courageous, it asks for real genuine feedback no matter how difficult that feedback may be, and it acts on that feedback. At the same time, it also stands up for its workforce externally. So for example, if there are state or federal regulations that threaten the workforce or put them at higher risk for moral injury, these organizations are courageous enough to stand up and push back.

Dr. Jafar Al-Mondhiry: Now, most of us aren’t at the top of our institutional structures or leadership, but when deciding between jobs it may be worth seeking out clinician-led organizations.

Dr. Wendy Dean: It’s really difficult now for organizations to get every part of this correct. There are a lot of organizations that are doing parts of it really well. A lot of them tend to be private practices, not always small, sometimes really large, but they’re largely driven and led by clinicians or physicians who have been on the front lines, who really know what practicing means, where the challenges lie, and what those organizations need to do to support the clinicians on the front line. They’re also the decision makers, so there’s no convincing. They’re ones who are deciding.

Dr. Jafar Al-Mondhiry: While Dr. Dean stressed the need for systemic solutions, there are ways that, as individuals, we can feel more prepared.

Dr. Wendy Dean: And I think one of the interesting things that I’ve seen folks talk about a fair amount is that transition between resident to attending, and it can be made easier or harder based on how folks are trained. So if you are trained in how the business of medicine works and these potential constraints and challenges, forewarned and forearmed. You can go out into practice and understand, expect that those things are going to happen or might happen, and sort of prepare yourself for how you’ll face them. What I’ve heard from some young attendings is that they had no idea what they were getting out into and felt very blindsided, and that feels like a betrayal to them of their mentors or of their organization that trained them.

Dr. Jafar Al-Mondhiry: In Dr. Dean’s book she goes through her own experiences learning these hard truths, along with many others she interviewed, who talk about their own challenging experiences in the U.S. healthcare system. One of those core lessons is what we do during key moments after experiencing moral injury.

Dr. Wendy Dean: Typically when we talk about it, there’s betrayal by a legitimate authority in a high stakes situation. And after that happens, you have a moment, and it may not be an instant, it may be days, weeks, months, but there’s a moment to decide whether or not you are going to acquiesce to that betrayal and transgress your own deeply held beliefs and expectations. I also recognize that most people, for most people, that is not a free choice. You have obligations, medical debt, medical education debt. You have family obligations. You need to keep a roof over your head, you need to pay a mortgage, you need to educate your children. There are all those things that impinge on your ability to stand up and speak out. But I also think it’s helpful for us to acknowledge I’m, I’m challenged that my professional obligations are at risk here. It is important to me to acknowledge that that’s the case, and then rather than react to it on a sort of subconscious level, I’m going to decide about it. And maybe I can’t change where I am right now, but maybe I can start making plans to shift to something that I think is more congruent with my personal and professional values.

Dr. Jafar Al-Mondhiry: Part of that moment is again just first recognizing what is happening to our core values, our core sense of self, and finding effective, collective, and authentic ways of responding.

Dr. Wendy Dean: I think the sense of victimhood is really based in that sense of complicity. And so the way to get out of that dynamic is to recognize what those situations are that are causing you to feel like you’re being betrayed. At some level, your professional obligations are threatened, and then start taking action in whatever way you can to push back, to stand up, to change that situation. That allows you to no longer be complicit and it allows you to not feel the victim.

I think one of the things that training for physicians in particular makes us vulnerable to, is this sense that we have to fix the system ourselves. We have to take it on, like Don Quixote and the windmill. We absolutely must start working together on these, or we are going to fling ourselves at a wall and fall exhausted at the foot of it. So we really need to come together and start breaking down those silos between individual colleagues, between departments, between hospitals in a system to start saying, what is our collective experience? And how do we, as a collective, start speaking back?

I appreciate that people really want to change this and that we get fired up to make change, and then we go out there and we start flinging ourselves at some problem. But the problem is when we do that by ourselves, we put ourselves at greater risk in our careers. We put ourselves at greater risk with our colleagues, and we put ourselves at greater risk of not achieving what we hope to achieve. So the first place I would start is by trying to build a coalition. It can be a coalition of five people in your department, but it’s more powerful when you’re together. So what I say often is that the bad news is that there’s a lot wrong with healthcare right now.

The great news is that there’s a lot wrong with healthcare right now. So kind of no matter where we start to try to make inroads, if we change anything, it’s going to be better. And there are solutions from just identifying what are the pebbles in your shoes right now in your department, in your local neck of the woods that need to change? Who else is experiencing that? Who are the decision makers in that challenge? Go get ’em. Right? Work together as a collective to go make that change, to make your case for that change. Find out who you need to talk to, who can help you build the data or build the story for why that thing needs to change.

Dr. Jafar Al-Mondhiry: Unfortunately, there are many issues that go well beyond our individual organizations, up at the higher levels of government and legislation, where we may have be patient and satisfied with slow change

Dr. Wendy Dean: It’s sort of pick and choose what really sits best with you and how you approach the world. Because the other option is to start getting politically active. And I don’t mean that you have to become an activist and get out there on a picket line or whatever, but a lot of the challenges that we face are legislative.

Part of the problem with that legislation is that the legislators aren’t fully educated about what the problems are. So if we take the time, those of us who are along that bent, if we take the time to start educating the people around us who are decision makers, not saying this has to change tomorrow, but giving them our experience. This is what it’s like practicing medicine now. This is why it’s so hard. This is what could help us if we changed it is a really great approach. And whether you do that on a state level or on a national level through your professional societies, your local medical societies, any of that helps.

I think this is where as physicians we’re a little bit unrealistic about the time horizon of challenge. We have been spoiled in our profession in the best possible way that when we ask for a change in a treatment plan, it happens today because that patient’s life and that patient’s outcome depends on it. And so the urgency of our requests and the timeline for our requests is dramatically accelerated from most of the rest of the world. What that means is when we go out to make change in other parts of our lives – that’s not a treatment plan and not patient care – it is intensely frustrating that we ask for change, we make a good case for it, and oh my gosh, we need to ask for it 12 times with 13 different people. And that happens in meetings that take place over a year–what?

Dr. Jafar Al-Mondhiry: So there’s a lot we can do, but we do need to manage our expectations.

Conclusion

Dr. Tamar Schiff: In our last episode, part 1 on moral distress and moral injury, we defined the terms, along with some of their causes and consequences, and in this part 2 episode, we tried to review some solutions: naming the issue, debriefing with close friends, speaking out when we’re frustrated or confused, and coalition building to effect organizational and political change. Ultimately, while there are many things that may sit beyond our immediate control, the goal is to try to find different ways to be authentic to our true values, recognizing that it’s not easy.

Dr. Beth Epstein: People who are morally distressed, who are astute enough to sense to identify moral distress are the ones who want to solve and resolve the problems with patient care that cause the moral distress in the first place. And I think that’s important for people to recognize that it’s not a sign of weakness. I see engagement, willingness to collaborate. I see a lot of people who are willing to risk themselves to put themselves out there in front of their colleagues to say, yes, this is morally distressing and we need to resolve this. Being able to think through what is causing your moral distress in situations and being able to resolve it or acknowledge it, have it acknowledged by your peers or your colleagues, and being able to resolve it, even if it’s just a tiny smidge edge, is really very, very powerful and very impactful.

Dr. Tamar Schiff: These experiences can be deeply troubling, and while the toll they take on individuals and healthcare as a whole is enormous, Dr. Epstein and Dr. Dean helped us highlight that there are also reasons to be hopeful.

Dr. Beth Epstein: Are we in a better place? I think we are in a much, much better place, believe it or not, because there’s recognition prior to the pandemic and between the 1980s and 2019, I think most people had never heard of moral distress before. Most people, even if they’d heard of it, there was no way to address it. I think organizational leaders are recognizing that it needs to be addressed. Physicians feel it. Social workers have it, PT, OT, social, speech, RTs, nutritionists, pharmacists, they have it in some way or another. And so it’s an organizational problem, and I think that is recognized now, and that is probably the tipping point. The pandemic was horrible in a million different ways, the repercussions and ramifications, the impact that it’s had on healthcare providers has been horrible. But the one thing that I’m hoping comes from this is recognition that we can act and recognition that we need to act together to make this better.

Dr. Tamar Schiff: At the end of the day, we need to advocate for changes that protect our moral integrity in the work that we do.

Dr. Wendy Dean: Physicians have to reclaim our value. That is at the very heart of this, I think we, in losing the decision-making control of healthcare, we have allowed ourselves to question our value. We’ve allowed other people to determine what it is often in terms of productivity and revenue generation. And I think coming back to reclaiming the value of physicians as mediators of the physician-patient relationship is really critical. And I also think it’s really important that we come back to a sense of our own professionalism. And by that I don’t mean how we dress and the kind of earrings we wear and whether we have tattoos, but I mean that essential covenant that we make with society to provide services that society cannot provide for itself. And we don’t talk enough about that with our trainees. We don’t talk about it enough with our learners in medical school. I really think that it is essential that we get back to talking about those critical characteristics of who physicians are, not just what they do.

Dr. Tamar Schiff: Thanks for tuning in! We know these topics can stir up more questions than answers, and we look forward to hearing more about your experiences with moral distress and moral injury. Please continue the conversation with us online at our facebook page, on twitter, or email us directly. Find show notes and contact information for us on our website: coreimpodcast.com

If you enjoyed listening to our show, please give us a review on itunes or whichever podcast app you use; it helps other people find us. We work really hard on these podcasts so we’d love to hear from you. Let us know what we are doing right and how we can improve. And as always opinions expressed in this podcast are our own and do not represent the opinions of any affiliated institutions.

Finally, special thanks to all our collaborators on these episodes, our wonderful audio editor Daksh Bhatia, music editor Solon Kelleher, our illustrator Ariella Coler-Reilly, moral and executive support from Shreya Trivedi, and most importantly thanks to you, our listeners!

References

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• Dean W, Talbot SG, Caplan A. Clarifying the Language of Clinician Distress. JAMA. 2020 Mar 10;323(10):923-924.
• Epstein EG, Hamric AB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics. 2009 Winter;20(4):330-42. PMID: 20120853.
• Kherbache A, Mertens E, Denier Y. Moral distress in medicine: An ethical analysis. J Health Psychol. 2022 Jul;27(8):1971-1990.
• West CP, Dyrbye LN, Sinsky C, Trockel M, Tutty M, Nedelec L, Carlasare LE, Shanafelt TD. Resilience and Burnout Among Physicians and the General US Working Population. JAMA Netw Open. 2020 Jul 1;3(7):e209385.
• The New York Times. The business of healthcare depends on exploiting doctors and nurses. June 8 2019.

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