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Moral Distress among Health Professionals: What and Why
Casebook on Ethical Decision-Making in End-of-Life Care
of Older Adults (只備英文本)
Moral distress among health professionals: What and Why
- Dr. Helen Chan, Associate Professor (by courtesy), CUHK Jockey Club Institute of Ageing, CUHK
What is moral distress?
Moral distress is defined as the negative experience among health professionals when they know the right thing to do but cannot pursue that course of action due to institutional constraint.1-2 It is different from work stress and compassion fatigue although these may be experienced simultaneously.3-4 The negative emotions that resulted from the initial moral distress would persist as a lingering feeling of unease and accumulate over time.2 The unresolved moral distress can result in health professionals being desensitized to ethical challenges.4
Prevalence and sources of moral distress
The concept of moral distress originated from nursing research, but empirical evidence consistently showed that moral distress is experienced by various types of health professionals, including physicians, pharmacists, social workers, and other allied health professionals.6-7 Studies also found that moral distress is reported across different specialties, such as critical care, surgical care, oncology care and paediatric care, and healthcare settings, including acute care, critical care and long-term care.3-7 There is growing awareness that moral distress is also common in medical students, residents and junior staff.8-9
The major sources of moral distress are providing futile care or care which is not in patients' best interests and witnessing poor quality of care. Other reasons for moral distress are inadequate staffing, working with incompetent co-workers, inappropriate use of healthcare resources, fragmentation of care and poor teamwork.6-10 In 2016, a local survey was conducted to examine the extent of moral distress experienced by nurses in the acute hospital setting in Hong Kong.11 The level of moral distress was measured using Moral Distress Scale-Revised (MDS-R) which is a validated questionnaire with 21 statements describing different ethically challenging situations.5
As shown in Table 1, most of the items with the highest scores were related to end-of-life care. It seems that moral distress arises when nurses perceived a gap between the provision of quality end-of-life care and the care that patients received in practice. Moreover, the findings showed that the level of moral distress of nurses working in various specialties or department, including oncology, surgical and emergency care, were comparable to those in critical care units. Perhaps the increased prevalence of chronic progressive diseases and the ageing population prompt the need to place a greater emphasis on end-of-life care across different units
Table 1. Top five Moral Distress Scale-Revised (MDS-R) items* (N=447).
Five MDS-R items with the highest frequency score | Mean ± SD |
Follow the family’s wishes to continue life support even though I believe it is not in the best interest of the patient. | 5.61 ± 4.00 |
Carry out the physician’s orders for what I consider to be unnecessary tests and treatments. | 5.19 ± 4.05 |
Initiate extensive life-saving actions when I think they only prolong death. | 5.14 ± 3.88 |
Continue to participate in care for a hopelessly ill person who is being sustained on a ventilator, when no one will make a decision to withdraw support. | 4.39 ± 3.87 |
Work with nurses or other healthcare providers who are not as competent as the patient care requires. | 4.20 ± 3.65 |
*Respondents were asked how often they encountered these situations in their care practice (frequency) and the level of disturbance they experienced in these situations (intensity) using a 5-point Likert scale respectively. The frequency scale ranged from 0 (never) to 4 (very frequently), whereas the intensity scale from 0 (none) to 4 (great extent). The frequency score and the intensity score are multiplied for each item.
Impacts of moral distress
Clearly, moral distress is an issue highly pertinent to the cost, quality and sustainability of healthcare services. Moral distress may manifest itself as anger, impatience and depression due to emotional exhaustion, frustration, guilt, shame, powerlessness, or distancing from clients and being silent and indifferent towards patients' care.6-7
On the other hand, moral distress can also affect the wellbeing of health professionals, causing somatic symptoms such as palpitations, insomnia, nausea, fatigue, headaches, tearfulness and gastrointestinal upset.7 Evidence suggests that moral distress is significantly associated with burnout in critical care providers. The physical and psychological sequelae intertwine, resulting in poor job satisfaction, low workplace morale, and absenteeism.6Some studies found that moral distress is associated with poor staff retention, since health professionals may perceive themselves as moral agents who fail to fulfil their moral obligations, resulting in compromised professional integrity.8
Could we address moral distress?
Moral distress may be a communal experience to be interpreted in a broader context, rather than just as an individual experience. Institutional constraint is widely recognized as a contributing factor to moral distress. The implicit and explicit values of the organization affect the attitudes and behaviours of the health care providers in the clinical environment.6, 12-14 Recent literature noted that the socio-political healthcare context driven by government fiscal plan and policies that affect its structure and resources also play a role in shaping the ethical climate of healthcare organizations.3, 15
To mitigate moral distress, relevant interventions should be built into the systems and organizations with the goal of cultivating moral resilience among health professionals so that they could recognize the experience of moral distress and have the internal capacities to uphold their moral obligations.11-16 Following are some suggested ways for addressing moral distress:
Ethics education
The concept of moral distress should be introduced in both the pre-registration training curriculum for health professionals and continuing professional education in order to foster self-awareness towards moral distress. Monrouxe et al. (2017) underscore the importance of developing students’ moral decision-making skills when confronting with ethical dilemmas. Small clinician-led interactive sessions would enable them to understand the ethical complexities and develop confidence and skills in managing the situations.9 However, moral distress cannot be reduced simply through developing ethical competence. Health professionals with a heightened awareness of good healthcare are more susceptible to moral distress when they fail to act on the right course of action. Berger (2014) suggested that training on mediation and communication is also important for health professionals to improve their conflict management skills as well as patient-clinicians relationships.8
Organizational support
A wide range of interventions can be offered by the organization as structural empowerment so as to support health professionals in addressing moral distress. For example, multidisciplinary forums to encourage open discussion about ethical issues and operational constraints that have arisen in clinical care, mentoring for junior staff who may experience dissonance between what they have learnt and what they actually encounter in the clinical setting, regular structured debriefing sessions for ethically challenging situations in individual departments or units, and counselling services.3, 8, 15-17 Through open dialogue in these avenues, health professionals are encouraged to speak up, identify the contributing factors to moral distress and develop appropriate strategies in a collaborative approach. All these interventions indeed are supporting health professionals to co-create a culture of ethical practice. In addition to the aforementioned organizational measures, clinical ethics committees serve as a main resource for clinicians to seek for advice. The role of clinical ethics committees have emerged from formulating ethical guidelines to providing ethics consultation in various formats to support clinicians in clarifying their ethical concerns and moral obligations.17-18
Conclusion
Moral distress is a common phenomenon in day-to-day clinical practice across health care settings. It jeopardizes not only the wellbeing of health professionals, but also the quality and sustainability of health care services. Ethics education is imperative to deepen the moral sensitivity of health professionals. More importantly, the reciprocal influence between the ethical climate of the health care environment and health professionals underscores that there should be proactive interventions or changes in parallel at the organization level to construct a supportive culture for ethical practice.
References
- Jameton A. Nursing Practice: The ethical issues. Englewood Cliffs, NJ: Prenctice Hall, 1984.
- Jameton A. Dilemmas of moral distress: Moral responsibility and nursing practice. AWHONNS Clin Issues Perinat Women’s Health Nurs. 1993;4:542-551.
- Varcoe C, Pauly B, Webster G, Storch J. Moral distress: Tensions as springboards for action. HRC Forum. 2012;24:51-62.
- Austin W. Moral distress and the contemporary plight of health professionals. HEC Forum. 2012;24:27-38.
- Harmic AB, Borchers CT, Epstein EG. Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research. 2012;3:1-9.
- Whitehead PB, Herbertson RK, Hamric AB, Epstein EG, Fisher JM. Moral distress among healthcare professionals: Report of an institution-wide survey. J Nurs Scholars. 2015;47:117-125.
- Epstein EG, Hamric AB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics. 2009;20:330-342.
- Berger JT. Moral distress in medical education and training. J Gen Intern Med 2014;29:395-8.
- Monrouxe L, Shaw M, Rees C. Antecedents and consequences of medical students’ moral decision making during professionalism dilemmas. AMA J Ethics. 2017;19:568-77.
- Lutzen K, Kvist BE. Moral distress: A comparative analysis of theoretical understandings and inter-related concepts. HEC Forum. 2012;24:13-25.
- Chan HYL , Lai KF, Lau CK. Examining moral distress among nurses in Hong Kong. Presented in the C U Medical Education Conference. Hong Kong, 2017.
- Russell AC. Moral distress in neuroscience nursing: An evolutionary concept analysis. Am Asso Neurosci Nurs. 2012;44:15-24.
- Sporrong SK, Arnetz B, Hansson MG. Developing ethical competence in health care organizations. Nurs Ethics. 2007;14:825-837.
- Harmic AB, Baclhall LJ. Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. Crit Care Med. 2007;35:422-429.
- Musto LC, Rodney PA, Vanderheide R. Toward interventions to address moral distress: Navigating structure and agency. Nurs Ethics. 2015;22:91-102.
- Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and addressing moral distress and ethical climate. Dimen Crit Care Nurs. 2014;33:234-245.
- Rushton CH. Cultivating moral resilience: shifting the narrative from powerlessness to possibility. Am J Nurs. 2017;117:S11-5.
- Austin W. What Is the Role of Ethics Consultation in the Moral Habitability of Health Care Environments? AMA J Ethics. 2017;19:595-600.
- Annas G, Grodin M. Hospital ethics committees, consultants, and courts. AMA J Ethics. 2016;18:554-9.
醫療專業人員的道德困擾:問題與起因
年長病人晚期護理服務醫學倫理個案集
醫療專業人員的道德困擾:問題與起因
香港中文大學賽馬會老年學研究所陳裕麗副教授(禮任)撰寫
何為道德困擾?
道德困擾被定義為醫療專業人員的負面經歷,源於他們知道何為正確選擇,但礙於制度局限而無法付諸實行。1-2 這種困擾雖然可能與工作壓力和同情疲勞一同出現,但卻不能混為一談。3-4 道德困擾初期產生的負面情緒,會化為揮之不去的不安感,並隨時間而累積。2 未能徹底解決的道德困擾,可能會令醫療專業人員對倫理挑戰變得麻木。4
道德困擾的普及和來源
道德困擾的概念源於護理研究,但不斷有實證顯示,各類醫療專業人員,包括醫生、藥劑師、社會工作者和其他專職醫療人員都曾經歷道德困擾。6-7 研究亦發現,有關問題的影響範圍遍佈不同專業,如重症護理、外科護理、腫瘤護理和兒科護理,以及醫護環境下的急症護理、重症護理和長期護理。3-7 此外,道德困擾在醫科生和資歷較淺的員工之間也越見普遍。8-9
道德困擾主要源於醫護人員需要向患者提供無效醫療;或在明知道不符合患者最佳利益下仍然提供護理服務,並且目睹病人未能獲得良好照料。其他導致這種困擾的原因是醫護人手不足;與不稱職的同事合作;不適當地使用醫療資源;護理服務分割及缺乏團隊合作。6-10 2016年,一項本地調查研究了香港護士在急症醫院環境中的道德困擾程度。11 研究使用了修訂版道德困擾量表(MDS-R),透過21題描述不同道德挑戰情況的問卷,測量受訪者的道德困擾程度。5
如表一所示,得分最高的項目大部分與晚期護理服務有關。似乎當護士實際提供的晚期護理服務與理想的水平存在落差時,道德困擾便會出現。調查結果亦顯示,在腫瘤科、外科和急症護理等不同專科或部門工作的護士,道德困擾程度與重症監護病房護士相當。會持續惡化的慢性疾病越見普及和人口老化問題,揭示了各單位應更著重重症護理服務的需要。
表1. 分數最高的5個修訂版道德困擾量表項目*(N=447)
頻率分數最高的5個修訂版道德困擾量表項目 | 平均值±標準差 |
遵照家屬的意願為病人提供維持生命治療,即使我認為這並不符合病人的最佳利益。 | 5.61 ± 4.00 |
按照醫囑執行我認為非必要的測試和治療。 | 5.19 ± 4.05 |
提供各種維持生命的行動,即使我認為只會延長病人的死亡過程。 | 5.14 ± 3.88 |
照顧靠呼吸機維生的晚期嚴重病患者時,因為沒有人撤銷有關護理決定,而需要繼續照料他們。 | 4.39 ± 3.87 |
與未能勝任病人護理要求的護士或其他醫護人員合作。 | 4.20 ± 3.65 |
*使用5個等級的李克特量表,量度受訪者在提供護理時有多常遇到這些情況(頻率)以及在這些情況下受到的干擾程度(強度)。頻率範圍從 0(從不)到 4(非常頻繁),而強度從 0(沒有)到 4(很大程度)。每個項目的頻率分數和強度分數相乘。
道德困擾的影響
道德困擾顯然與醫療服務的成本、質素和可持續性有密切關聯。憤怒、焦躁和抑鬱都可能是受到道德困擾的情緒表現。這些情緒是源自照顧病人所帶來的情緒疲憊、挫敗感、內疚、羞愧、無力感,或是與病人的隔閡和對護理病人不聞不問有關。6-7
另一方面,道德困擾亦會影響醫療專業人員的健康,導致不同的身體症狀,如心悸、失眠、噁心、疲憊、頭痛、容易流淚和腸胃不適等。7 證據顯示,道德困擾與重症護理人員的身心疲憊息息相關。在生理和心理後遺症的交互影響下,導致護理人員欠缺工作滿足感,工作場所士氣低落,甚至曠工。6 一些研究發現,道德困擾會更容易令醫療專業人員流失,因為他們會認為自己擁有道德批判能力,卻沒履行應有的道德義務,欠缺專業操守。8
我們能解決道德困擾嗎?
道德困擾不僅是一種個人體驗,更可以從更宏觀角度來理解的共同體驗。制度局限被廣泛認同是導致道德困擾的成因之一。而醫療機構的隱性和顯性價值取向,會影響醫護人員在臨床環境的態度和行為。6, 12-14 最近期的文獻亦指出,政府的財政計劃,以及左右醫療結構和資源分配的政策,影響著醫療環境中的社會政治。而醫療環境裡的社會政治,具塑造醫療倫理氛圍的角色。3, 15 為了紓緩道德困擾,我們應在醫療系統和機構內推行不同的措施,培養醫療專業人員面對道德問題的能力,讓他們體驗何為道德困擾,以及擁有堅持道德義務的內在能力。11-16 以下是一些解決建議:
倫理教育
應引入道德困境的課題在醫療專業人員註冊前的培訓課程和持續專業進修課程中,以增強他們對道德困擾的自我意識。Monrouxe等人(2017)強調,在面對倫理困境時,培養學生的道德決策能力非常重要。以醫生帶領的小組互動環節,可令學生理解錯綜複雜的倫理抉擇,提升他們面對相關情境時的信心和能力。9 然而,僅靠提升應對倫理困難的能力,並不足以減低醫療道德困擾。對醫護水平要求較高的醫療專業人員,會因為未能在照顧病人時採取自認為正確的行動,而更容易出現道德困擾。Berger(2014)提出,調解和溝通訓練有助改善醫療專業人員處理衝突的能力,維持患者和醫生的良好關係。8
機構層面支援
醫療機構可以採用不同的措施,在機構層面上賦權醫療專業人員,幫助他們解決道德困擾,例如:舉辦跨專業範疇論壇,鼓勵醫護人員就臨床護理中的倫理問題和工作限制進行公開討論;輔導資歷較淺的員工,協助他們處理所學知識與現實臨床護理之間的矛盾;定期安排簡報會,分享個別部門或單位所遇到的倫理挑戰;以及提供諮詢服務。3, 8, 15-17 這些公開對話的途徑有助鼓勵醫療專業人員發表意見,找出造成道德困擾的因素,並且共同制定合適的解決策略。以上所有措施都協助醫療專業人員共創道德實踐文化。除上述措施外,臨床倫理委員會亦是臨牀醫護人員尋求諮詢的主要對象。委員會的負責範圍甚廣,除了制定倫理準則,還會提供各類倫理諮詢服務,幫助臨牀醫護人員釐清他們在道德方面的疑問和道德責任。18-19
結論
道德困擾是醫療機構日常運作中常見的現象。這種困擾不僅危害醫療專業人員的健康,更會令醫療護理服務質素下降,難以維持良好運作。倫理教育能令醫療專業人員對道德問題更為敏感。更重要的是,醫療環境的倫理氛圍與專業醫療人士息息相關,互相影響,故此機構亦應採取積極措施或主動作出改變,建立一種支援倫理實踐的文化。
引用文獻:
- Jameton A. Nursing Practice: The ethical issues. Englewood Cliffs, NJ: Prenctice Hall, 1984.
- Jameton A. Dilemmas of moral distress: Moral responsibility and nursing practice. AWHONNS Clin Issues Perinat Women’s Health Nurs. 1993;4:542-551.
- Varcoe C, Pauly B, Webster G, Storch J. Moral distress: Tensions as springboards for action. HRC Forum. 2012;24:51-62.
- Austin W. Moral distress and the contemporary plight of health professionals. HEC Forum. 2012;24:27-38.
- Harmic AB, Borchers CT, Epstein EG. Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research. 2012;3:1-9.
- Whitehead PB, Herbertson RK, Hamric AB, Epstein EG, Fisher JM. Moral distress among healthcare professionals: Report of an institution-wide survey. J Nurs Scholars. 2015;47:117-125.
- Epstein EG, Hamric AB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics. 2009;20:330-342.
- Berger JT. Moral distress in medical education and training. J Gen Intern Med 2014;29:395-8.
- Monrouxe L, Shaw M, Rees C. Antecedents and consequences of medical students’ moral decision making during professionalism dilemmas. AMA J Ethics. 2017;19:568-77.
- Lutzen K, Kvist BE. Moral distress: A comparative analysis of theoretical understandings and inter-related concepts. HEC Forum. 2012;24:13-25.
- Chan HYL , Lai KF, Lau CK. Examining moral distress among nurses in Hong Kong. Presented in the C U Medical Education Conference. Hong Kong, 2017.
- Russell AC. Moral distress in neuroscience nursing: An evolutionary concept analysis. Am Asso Neurosci Nurs. 2012;44:15-24.
- Sporrong SK, Arnetz B, Hansson MG. Developing ethical competence in health care organizations. Nurs Ethics. 2007;14:825-837.
- Harmic AB, Baclhall LJ. Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. Crit Care Med. 2007;35:422-429.
- Musto LC, Rodney PA, Vanderheide R. Toward interventions to address moral distress: Navigating structure and agency. Nurs Ethics. 2015;22:91-102.
- Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and addressing moral distress and ethical climate. Dimen Crit Care Nurs. 2014;33:234-245.
- Rushton CH. Cultivating moral resilience: shifting the narrative from powerlessness to possibility. Am J Nurs. 2017;117:S11-5.
- Austin W. What Is the Role of Ethics Consultation in the Moral Habitability of Health Care Environments? AMA J Ethics. 2017;19:595-600.
- Annas G, Grodin M. Hospital ethics committees, consultants, and courts. AMA J Ethics. 2016;18:554-9.
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題目: 簡介: |
「賽馬會安寧頌 – 安寧服務培訓及教育計劃」簡介 本片旨在提升病人及其家屬,和醫護專業人士對安寧議題的關注,探討死亡是什麼及如何準備死亡,並強調良好溝通對安寧服務的重要。此外,本片亦介紹香港中文大學賽馬會老年學研究所協助推行的「賽馬會安寧頌 – 安寧服務培訓及教育計劃」。 |
題目: 講者: 簡介: |
預設照顧計劃及預設醫療指示簡介 大埔醫院內科及老人科顧李舜華醫生 00:12 何時適合討論預設照顧計劃 |
More Details... More about Advance Care Planning |
題目: 講者: 簡介: |
病人如何打開晚期照顧的話題? 生死教育學會前主席謝健泉醫生 00:30 何時開始討論預設照顧計劃 |
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「吾該好死」刊物 |
晚晴照顧手冊 如果你有任何想法或意見,歡迎按此留言。 |
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「打開晚期照顧的話題 」小冊子 | 「賽馬會安寧頌─安寧服務培訓及教育計劃」小冊子 |
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JCECC Capacity Building and Education Programmes on End-of-Life Care
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Topic: Introduction: |
Introduction of JCECC: Capacity Building and Education Programmes on End-of-Life Care This video has an aim to arouse awareness about end-of-life issues amongst patients, patients’ families and healthcare professionals on what dying is, how to prepare for dying, and emphasises the importance of communication for better end-of-life care. It also introduces “JCECC: Capacity Building and Education Programmes on End-of-Life Care” by CUHK Jockey Club Institute of Ageing under Jockey Club End-of-life Community Care Project (JCECC). |
Topic: Speaker: Introduction: |
Introduction of Advance Care Planning & Advance Directive Dr Jenny Lee, Consultant, Department of Medicine & Geriatrics, Tai Po Hospital 00:12 When to discuss Advance Care Planning |
More Details... More about Advance Care Planning |
Topic: Speaker: Introduction: |
How could a patient start the end-of-life care conversation with health care staff? Dr Vincent Tse, Ex-Chairman, Society for Life & Death Education 00:30 When to start the Advance Care Planning conversation |
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Advance Care Planning Handbook If you have more thoughts and sharings on this handbook, please feel free to share your comments here. |
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Leaflet on "How to initiate End-of-Life care conversation" | Leaflet on "Capacity Building and Education Programmes on End-of-Life Care" |