Wendy Austin

Moral Distress and the Contemporary Plight of Health Professionals

Once a term used primarily by moral philosophers, “moral distress” is increasingly used by health professionals to name experiences of frustration and failure in fulfilling moral obligations inherent to their fiduciary relationship with the public. Although such challenges have always been present, as has discord regarding the right thing to do in particular situations, there is a radical change in the degree and intensity of moral distress being expressed. Has the plight of professionals in healthcare practice changed? “Plight” encompasses not only the act of pledging, but that of predicament and peril. The author claims that health professionals are increasingly put in peril by healthcare reform that undermines their efficacy and jeopardizes ethical engagement with those in their care. The re-engineering of healthcare to give precedence to corporate and commercial values and strategies of commodification, service rationing, streamlining, and measuring of “efficiency,” is literally demoralizing health professionals. Healthcare practice needs to be grounded in a capacity for compassion and empathy, as is evident in standards of practice and codes of ethics, and in the understanding of what it means to be a professional. Such grounding allows for humane response to the availability of unprecedented advances in biotechnological treatments, for genuine dialogue and the raising of difficult, necessary ethical questions, and for the mutual support of health professionals themselves. If healthcare environments are not understood as moral communities but rather as simulated marketplaces, then health professionals’ moral agency is diminished and their vulnerability to moral distress is exacerbated. Research in moral distress and relational ethics is used to support this claim.

An Overview of Moral Distress and the Paediatric Intensive Care Team

A summary of the existing literature related to moral distress (MD) and the paediatric intensive care unit (PICU) reveals a high-tech, high-pressure environment in which effective teamwork can be compromised by MD arising from different situations related to: consent for treatment, futile care, end-of-life decision making, formal decision-making structures, training and experience by discipline, individual values and attitudes, and power and authority issues. Attempts to resolve MD in PICUs have included the use of administrative tools such as shift worksheets, the implementation of continuing education, and encouragement to report. The literature does not yet show these approaches to be effective in the resolution of MD. The need to acknowledge MD among PICU teams is discussed and an argument made that, to facilitate understanding among team members, practice stories need to be shared.

From Interdisciplinary to Transdisciplinary Research: A Case Study

The specialization of contemporary academia necessitates the adoption of a multidisciplinary approach to study topics that cross multiple disciplines, including the area of medical ethics. However, the nature of multidisciplinary research is limited in some regards, further requiring some researchers to use interdisciplinary and transdisciplinary approaches. The authors present as a case study a research project in bioethics that began as an interdisciplinary study and which, through the research process, moved to being a transdisciplinary study in health ethics. They outline not only this transformation but also the strengths and difficulties of transdisciplinary research in the area of ethics.

A Re-Visioning of Boundaries in Professional Helping Relationships: Exploring Other Metaphors

There are many ethical issues arising for practitioners in what are termed the boundaries of professional helping relationships. In this article, the authors argue that the boundary metaphor is not sufficient for conceptualizing these ethical issues and propose that alternative metaphors be considered. The use of a different metaphor might allow practitioners to re-vision the relationship issues in a more realistic, richer, and holistic way. Those explored here include highway, bridge, and territory. For the authors, it is territory that seems to hold the greatest promise.

The incommensurability of nursing as a practice and the customer service model: an evolutionary threat to the discipline.

Corporate and commercial values are inducing some healthcare organizations to prescribe a customer service model that reframes the provision of nursing care. In this paper it is argued that such a model is incommensurable with nursing conceived as a moral practice and ultimately places nurses at risk. Based upon understanding from ongoing research on compassion fatigue, it is proposed that compassion fatigue as currently experienced by nurses may not arise predominantly from too great a demand for compassion, but rather from barriers to enacting compassionate care. These barriers are often systemic. The paradigm shift in which healthcare environments are viewed as marketplaces rather than moral communities has the potential to radically affect the evolution of nursing as a discipline.Corporate and commercial values are inducing some healthcare organizations to prescribe a customer service model that reframes the provision of nursing care. In this paper it is argued that such a model is incommensurable with nursing conceived as a moral practice and ultimately places nurses at risk. Based upon understanding from ongoing research on compassion fatigue, it is proposed that compassion fatigue as currently experienced by nurses may not arise predominantly from too great a demand for compassion, but rather from barriers to enacting compassionate care. These barriers are often systemic. The paradigm shift in which healthcare environments are viewed as marketplaces rather than moral communities has the potential to radically affect the evolution of nursing as a discipline.

Uncovering the Lived Experience of Well-Being:

The words well-being, health, and wellness are commonly used in an interchangeable manner by health care professionals and the lay public. We undertook a hermeneutic phenomenological study of well-being and discovered a soulful strength and a rhythmic flow to this lived experience. There is a letting go that is experienced as a tension and rhythmic interchange, as in breathing. Harmony and balance lie at its foundation. Well-being requires a personal drive to exist. It is not experienced through purposeful means; rather, it is experienced in a self-forgetful way, in the free space where life unfolds and where people come to see their worlds in different ways. The results of this research suggest the experience of well-being holds a significant place within nursing practice for clients and for nurses.

Unresolved pain in children: A relational ethics perspective

It is considered the right of children to have their pain managed effectively. Yet, despite extensive research findings, policy guidelines and practice standard recommendations for the optimal management of paediatric pain, clinical practices remain inadequate. Empirical evidence definitively shows that unrelieved pain in children has only harmful consequences, with no benefits. Contributing factors identified in this undermanaged pain include the significant role of nurses. Nursing attitudes and beliefs about children’s pain experiences, the relationships nurses share with children who are suffering, and knowledge deficits in pain management practices are all shown to impact unresolved pain in children. In this article, a relational ethics perspective is used to explore the need for nurses to engage in authentic relationships with children who are experiencing pain, and to use evidence-based practices to manage that pain in order for this indefensible suffering of children to end.

Community treatment orders: the ethical balancing act in community mental health.

Community treatment orders (CTOs) are legal mechanisms by which an individual with a mental illness and a history of non-compliance and potential for violence can be mandated (against their will) to undergo psychiatric treatment in an outpatient setting. Although CTOs are increasingly being adopted by governments as a means of protecting both mentally ill persons and society itself, their use continues to stimulate considerable debate. While there is some evidence of their potential benefits in promoting treatment compliance and reducing hospital stays, there is concern that they infringe on the mental health clients human rights and freedoms. Consideration of the ethical and practical implications of the use of CTOs must continue. In this paper, some of the most pressing issues are identified and discussed.

Contemporary healthcare practice and the risk of moral distress

Healthcare professionals are moral agents whose fiduciary relationship with the public is animated by responsibility and the promise to use knowledge and skills to aid those in their care. When their ability to keep this promise is constrained or compromised, moral distress can result. Moral distress in healthcare is defined and outlined. Constraints and factors that lead to moral distress are identified as are the means that individual professionals and organizations use to address it. A call is made for transformative change to overcome a culture of silence and to sustain a healthcare system that is morally habitable.

Engagement in contemporary practice: a relational ethics perspective

Os desafios e restricoes da interacao significativa com os pacientes sao discutidos do ponto de vista da etica relacional. Se a abertura para os outros e sua situacao e o inicio da etica, como argumentado por filosofos cujo trabalho informa a etica relacional, entao, no cuidado de saude, nos devemos lidar com esta abertura (ou sua ausencia) assim como vivida pelo individuo que e profissional da saude, dentro das necessidades imediatas e da complexidade de sua pratica. Se, como tem sido argumentada, a falta de compromisso e a origem da maleficencia nos sistemas de saude, enfrentar limites ao comprometimento das profissionais de saude se torna particularmente urgente.The challenges and constraints of meaningful engagement with patients are discussed from a standpoint of relational ethics. If openness to others and to their situation is the beginning of ethics, as is argued by philosophers whose work informs relational ethics, then in health care we must address that openness (or its lack) as it is lived by individual health professionals within the immediacy and complexity of their practice. If, as has been also argued, disengagement is the source of maleficence within healthcare systems, addressing constraints to engagement becomes particularly urgent.