ICU Staff Report Severe Moral Distress, But Resources Are Underused
There is growing awareness of the prevalence of moral distress in healthcare — and the costs in terms of burnout and staff turnover. However, solutions to this problem remain somewhat elusive. “Moral distress is probably not preventable,” acknowledges Lucia Wocial, PhD, FAAN, RN, HEC-C, senior clinical ethicist at the John J. Lynch, MD, Center for Ethics at MedStar Washington Hospital Center in Washington, DC.
Healthcare workers continue to face staffing shortages and lack of resources that make their jobs harder. “Doctors and nurses have moral distress when they don’t have the resources they need to be at their best,” Wocial notes.
Electronic health record administration also is contributing to moral distress and burnout.1,2 “Anyone who has seen a doctor recently or been in a hospital has probably noticed that the computer is a constant presence. In some ways, it’s become a barrier to building therapeutic relationships,” Wocial observes.
Missed opportunities for advance care planning before patients face serious illness is another factor. “It is more than talking with patients about their values and goals. It is about setting realistic expectations for what is possible,” Wocial explains.
Typically, healthcare providers do not communicate the limits of medicine. This can result in patients or families believing clinicians gave false hope. Simultaneously, the care team is distressed by families demanding inappropriate treatment. “Thus, the whole therapeutic partnership is endangered,” says Matthew Eddleman, MDiv, BCC, a chaplain at Norton Healthcare in Louisville, KY.
Eddleman and colleagues set out to determine the severity and contributing factors of moral distress in staff in a 36-bed ICU over eight weeks in 2021.3 Many staff members reported experiencing at least a moderate level of moral distress at any given time.
Researchers also asked ICU staff about resources to help with moral distress. The institution offered an emotional support hotline, virtual well-being seminars, access to chaplains, and employee resource groups. “The data clearly showed that the resources being offered were not being utilized,” Wocial says.
Chaplains were an exception, with 17.8% of staff using spiritual care to cope with moral distress. “Chaplains have long been present on the unit; have built relationships with many bedside staff; and were a familiar, readily available resource,” Eddleman explains.
Eddleman encourages chaplains to gain expertise in speaking to the ethical principles involved in morally distressing cases. Chaplains can do this by collaborating with ethicists, or by serving on ethics committees. “Doing so enables the chaplain to see the process of working through ethics cases, and hearing different perspectives, as well as adding their unique voice to the deliberations,” Eddleman offers.
This allows chaplains to speak empathetically to nursing staff, either one on one or in groups. Chaplains can examine a challenging clinical case from an ethical perspective. “Nurses can then go home at night knowing that although they provided care in a difficult situation, they did so with integrity. In a time when staff shortages abound, this is essential in retaining a healthy workforce,” Eddleman says.
Survey respondents indicated communication issues often were root causes of moral distress. Yet, the hospital-provided responses were designed to help staff cope with moral distress, not address the communication barriers that were causing the moral distress.
“The message from leadership to staff, then, seems to be that moral distress is an unfortunate byproduct of the job, something to cope with but nothing that can be constructively addressed,” Eddleman says.
Clinical ethicists can help counter this message by becoming involved in cases earlier. For example, the care providers can alert ethicists if a patient may soon experience a clinical decline and subsequent loss of autonomy. The ethicists can meet with the patient to identify a healthcare surrogate, and facilitate a meeting between the patient and care group. “This ensures that the patient’s medical preferences are communicated, and that the plan of care is congruent with their wishes,” Eddleman explains.
If ethicists are familiar faces in clinical areas, staff are more likely to ask for help with moral distress, according to Robin S. Cook, RN, MBA, former preventive ethics advisor at Veterans Health Administration. For example, an ethicist who spends a lot of time in surgical areas or the ICU can offer support for difficult patient care issues specific to those units.
“Unresolved ethical concerns not only cause individual moral distress, but can also change the staff relationships and clinical cohesiveness,” Cook warns.
1. Budd J. Burnout related to electronic health record use in primary care. J Prim Care Community Health 2023;14:21501319231166921.
2. Muhiyaddin R, Elfadl A, Mohamed E, et al. Electronic health records and physician burnout: A scoping review. Stud Health Technol Inform 2022;289:481-484.
3. Eddleman M, Montz K, Wocial LD. Moral distress in the ICU: Measuring, tracking, and responding to staff experiences. Nurse Lead 2023;21:e64-e72.
Unresolved ethical concerns not only cause individual moral distress, but can also change the staff relationships and clinical cohesiveness.
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