Hope does not lie in a way out but in a way through ~ Robert Frost
It has been well established that health care professionals (HCP’s) caring for seriously ill/dying patients and their families are frequently exposed to distressing emotional situations and profound suffering leading to burnout and attrition 3,5. The persistent exposure to patient tragedy and death can increase the daily work strain experience leading to a sense of overwhelming grief which can lead to moral distress 4 . Moral distress is defined as when an individual recognizes one’s own moral responsibility in a situation, evaluates a course of action and identifies the correct decision but is not able to pursue said course of action 5,6 . Moral distress concepts have been studied since the mid 1980’s when philosopher Dr. Andrew Jametown first described the bedside nurses experience with feelings of “ powerlessness”, especially in the setting of institutional and systemic barriers complicated by a lack of recognition 6. Moral distress involves a threat to one’s moral integrity, the sense of wholeness and self-worth that comes from having clearly defined values that are congruent with one’s perceptions and actions 1-6.
The most common causes of moral distress include the following 6,11,12:
1. Continuing life support when not in the patient’s best interest
2. Initiating lifesaving action that merely prolongs dying
3. Inappropriate use of resources (justice/stewardship)
4. Inadequate staffing or inadequately trained staff
5. Inadequate communication about end-of-life
6. Providing false hope to patients and families
There has been considerable research into the epidemiology of burnout and moral distress sequala in critical and palliative care medicine 7,8. Unfortunately, highly motivated HCP’s with intense investment in their profession are at greater risk for the development of burnout 7-9. The compulsive triad of doubt, guilt and an exaggerated sense of responsibility can have an enormous impact on HCP’s professional, personal and family lives. Diminished awareness of one’s physical and emotional needs leads to a self-destructive pattern of over work or worse apathy 9. The most common signs and symptoms related to burnout based on Maslach et al and Vachon indicate 10,12 :
1. Physical and emotional exhaustion
2. Detachment and cynicism
3. Irritability and hypervigilance
4. Professional and personal boundary violations
5. High job turnover
6. Absenteeism, staff conflict, attrition and error
Evidence pointing to the medical benefits of medication and mindfulness training has been widely documented and continues to increase in quality and quantity 23 . The stated goal of mindfulness according to the University of Massachusetts Center for Mindfulness founder Dr. Jon Kabat-Zinn is to “maintain fluid awareness in a moment by moment experiential process that helps to disengage from strong attachments to beliefs, thoughts or emotions in a way that generates greater sense of emotional balance and well-being” 24. This simple yet radical assertion holds the potential for wide-reaching therapeutic benefit for many current HCP’s especially in terms of moral distress and burnout.
The goal of our mindfulness intervention for HCP’s is to create a moral distress tool kit that is founded in mindfulness and self-awareness development 14,15,24 . Self-awareness involves both a combination of self-knowledge and development of dual-awareness, a stance that permits the HCP to simultaneously attend to and monitor the needs of the patient, the work environment and his or her own subjective experience 14.
When functioning with less self-awareness HCP are more likely to lose perspective, experience more stress in interaction with their work environment, experience empathy as a liability and have a greater likelihood of compassion, fatigue and moral distress. HCP’s that practice mindfulness and self-awareness have been shown to experience greater job engagement with less stress in interactions with their work environment, experience empathy as a mutually healing connection with their patients and derive compassion satisfaction and vicarious post-traumatic growth 15,21,24 . This connection has been linked to staff retention, improved patient care and satisfaction 16,21,23 .
References
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2006:3-12.
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