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Moral Distress Intervention

Updated: Aug 30, 2023

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


1. Katz R. When our personal selves influence our professional work: an introduction to emotions and countertransference in end of life care. In: Katz RS, Johnson TA, eds. When Professionals Weep: Emotional and Countertransference Responses in End-of-Life Care. New York, NY: Routledge;

2006:3-12.

2. Shanafelt TD, Novotny P, Johnson ME, et al. The well-being and personal wellness promotion strategies of medical oncologists in the North Central Cancer Treatment Group. Oncology. 2005;68(1):23-32.

3. Vachon MLS, Sherwood C. Staff stress and burnout. In: Berger AM, Shuster JL, Von Roenn JH, eds. Principles and Practice of Palliative Care and Supportive Oncology. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007: 667-686.NY: Brunner-Routlege; 2002.

4. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001; 52:397-422.

5. Figley CR, ed. Compassion Fatigue: Coping With Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. New York, NY: Brunner/Mazel; 1995.

6. Rohan EA. An Exploration of Vicarious Traumatization: Effects of Repeated Exposure to Death and Dying on Oncology Social Workers, Physicians and Nurses [dissertation]. Boston, MA: Boston University; 2005.

7. Maslach C, Leiter MP. Early predictors of job burnout and engagement. J Appl Psychol. 2008;93(3):498-512.

8. Kuerer HM, Eberlein TJ, Pollock RE, et al. Career satisfaction, practice patterns and burnout among surgical oncologists: report on the quality of life of members of the Society of Surgical Oncology. Ann Surg Oncol. 2007;14(11):3043- 3053.

9.. Vachon MLS, et al. Oncology staff stress and related interventions. In: Holland JC, Breitbart WS, Jacobsen PB, eds. Psycho-Oncology. 2nd ed. New York, NY: Oxford University Press. In press.

10. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296(9):1071-1078.

11. Halbesleben JRB, Rathert C. Linking physician burnout and patient outcomes: exploring the dyadic relationship between physicians and patients. Health Care Manage Rev. 2008;33(1):29-39.

12. Vachon MLS. Staff stress in hospice/palliative care: a review. Palliat Med. 1995; 9(2):91-122.

13. Valent P. Diagnosis and treatment of helper stresses, traumas, and illnesses. In: Figley CR, ed. Treating Compassion Fatigue. New York, NY: Brunner- Routledge; 2002:17-37.

14. Maslach C. Job burnout: new directions in research and intervention. Curr Dir Psychol Sci. 2003;12(5):189-192. Psychol Res Pr. 1997;28(1):5-13.

15. Novack DH, Epstein RM, Paulsen RH. Toward creating physician-healers: fostering medical student’s self-awareness, personal growth, and well-being. Acad Med. 1999;74(5):516-520.

16. Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician: personal awareness and effective patient care. JAMA. 1997; 278(6):502-509.

17. Meier DE, Back AL, Morrison RS. The inner life of physicians and care of the seriously ill. JAMA. 2001;286(23):3007-3014.

18. Lazar SW, Kerr CE, Wasserman RH, et al. Meditation experience is associated with increased cortical thickness. Neuroreport. 2005;16(17):1893-1897.

19. Davidson RJ, Kabat-Zinn J, Schumacher J, et al. Alterations in brain and immune functioning produced by mindfulness meditation. Psychosom Med. 2003; 65(4):564-570.

20. Siegal DJ. The Mindful Brain: Reflection and Attunement in the Cultivation of Well-Being. New York, NY: Norton; 2007.

21. Rabinowitz S, Kushnir T, Ribak J. Preventing burnout: increasing professional self efficacy in primary care nurses in a Balint Group. AAOHN J. 1996;44(1): 28-32.

22. Kjeldmand D, Holmstrom I, Roenqvist U. Balint training makes GP’s thrive better in their job. Patient Educ Couns. 2004;55(2):230-235.

23. Epstein RM. Mindful practice. JAMA. 1999;289(9):833-839.

24. Kabat-Zinn J. Mindfulness-based interventions in context: past, present, and future. Clin Psychol Sci Proc. 2003;10(2):144-155

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