Physicians routinely face challenging situations and difficult decisions. In times of crisis – such as during a pandemic - this can lead to moral distress. In a podcast from the Canadian Medical Protective Association, hosts Drs. Yolanda Madarnas and Steven Bellemare explore the topic of moral distress with psychiatrist Dr. Caroline Gérin-Lajoie, executive vice-president of Physician Health and Wellness at the Canadian Medical Association.
Together, they dig into how to identify moral distress and discuss some coping strategies to improve your well-being.
tweetable: “As human beings, one of the ways we can cope through these difficult times is to look back and try to learn from what happened ― take those learnings to move forward and improve the health care system.” ― Dr. Caroline Gérin-Lajoie, EVP of Physician Health & Wellness, CMA
As physicians, the pandemic might force us to triage patients and make difficult decisions about who receives which level of care and under what circumstances. Caroline, what do you know about this issue and the effect it can have?
- We know the COVID-19 pandemic is causing ethically complex scenarios for physicians; that for example, situations where extreme resource limitations that affect patient care or the safety of health care providers. These can lead to moral distress.
- Moral distress is the sense of conflict or constraint that happens when we feel unable to fulfill what we believe is an ethically appropriate course of action.
- Some common elements include:
- A feeling of complicity or wrongdoing: when you believe you’re doing the wrong thing or that you have very little power to change a situation.
- Lack of voice: when you believe that you have insights or knowledge relevant to a situation, but you feel it’s not being heard or taken seriously.
tweetable: “It’s normal to experience moral distress in the context of a pandemic ― recognizing it is an important first step to be able to mitigate its impact.”
Can repeated or different situations of moral distress accumulate over time?
- Yes. These repeated situations leave a moral residue that can heighten someone’s level of moral distress in subsequent experiences ― even if the situation that caused moral distress has ended.
- If this moral residue doesn’t get resolved and remains high, its impact increases even more the next time we encounter a morally distressing situation ― that’s why dealing with it is so important.
tweetable: “We know that moral distress can be related to compassion fatigue, burnout and even depression. These are things that affect individuals, but it can have an impact at the organizational level ― through patient safety incidents, distancing from patients and decreased job satisfaction.”
How does someone recognize when they’re experiencing moral distress?
- Moral distress is not a mental health disorder in itself but needs to be managed well so it doesn’t lead to complications or issues with mental health.
- For some people, it can be managed easily, but for others, it can be completely debilitating.
- People experience moral distress in different ways ― symptoms can be:
- Physical: fatigue, headaches, difficulty sleeping, etc.
- Emotional: anger, fear, anxiety, etc.
- Behavioural: affecting our behaviour with loved ones and/or leading to addictive behaviours like drinking or taking drugs.
- Recognizing moral distress in yourself or your colleagues is an important step to begin managing it.
What can physicians do to reduce the impact of moral distress?
Although it’s impossible to eliminate situations in health care that cause moral distress, there are ways we can try to mitigate its impact at three different levels:
- The individual physician. Beyond the basics of proper sleep, nutrition and exercise, something you can do right now is connect:
- Open up communication with colleagues or peers you trust ― share your emotions and experiences (ex. at a team meeting).
- Check in with yourself and learn to treat yourself with empathy, compassion and forgiveness.
- If you need to, reach out to an ethicist working in your environment ― they can help work through some of these challenging situations when you encounter them.
- Realize you are not alone ― if you have a high level of distress or increasing difficulty functioning, you must reach out to your family physician, an employee assistance program (if you have one) or your provincial physician health program.
- The unit, team or department. This is a great opportunity for leaders to help recognize the impact of moral distress and try to build in processes to address it directly with staff:
- Build a feeling of cohesion and shared decision-making across the team ― some ways to do this are by hosting more team meetings or holding debrief meetings on a more regular basis, especially when these morally-charged situations occur.
- Make sure everyone feels supported ― encourage team members to support each other and reach out regularly, ensuring no one isolates themselves (ex. creating a buddy system).
- The organization or system: Organizations play a crucial role in recognizing and validating experiences that cause moral distress. More importantly, they can convey to health care providers that we’re in this together and that they have your back.
tweetable: “A buddy system is where you pick someone you trust and try to do regular check-ins with them. And interestingly, during COVID-19, this has been a really popular phenomenon within physician groups.”
What else can physician leaders do to help?
Some other effective strategies include:
- Being honest and transparent about the situation at hand ― for example, if there was a situation with resource constraints.
- Communicating in a clear and timely way ― provide clear guidance on changing policies and procedures.
- Accompany any process change with a plan to mitigate physician and health care provider moral distress – for example, creating triage teams to separate clinical and resource allocation decisions so they don’t have to feel alone making these difficult and emotional decisions.
- Organizations could create guides to help leaders provide support for their teams ― for example, with wellness supports and to encourage peer support.
- Create opportunities for people to access those supports and practice self-care.
- Post-crisis, we expect a rise in mental health issues and needs ― these supports, and resources should still be available to minimize the moral residue and improve everyone’s wellbeing.
Downloadable resource: CMA's COVID-19 and moral distress handout
tweetable: “We should be using the term “new normal” because we really can’t go back to how we were living in medicine prior to two months ago.”
This material is for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice. The opinions stated by the authors are made in a personal capacity and do not necessarily reflect those of the Canadian Medical Association and its subsidiaries including Joule. Feel passionate about this topic? Please connect with us at firstname.lastname@example.org.