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Always a burden? Healthcare providers’ perspectives on moral distress
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  • Published on:
    the value of, and obstacles to, reflective practice
    • Sebastian Kraemer, health staff group consultant (retired paediatric psychiatrist) Tavistock & Portman NHS Trust

    Moral distress is a good 'umbrella' term but it tends to invite diversionary philosophising when in truth we all know that work in intensive care puts enormous emotional pressures on staff. These can be attended to but as the paper shows, cannot be eradicated. Health care is not a mechanical process. As one of the subjects in this study said "if we removed moral distress we would be like robots" (F443).

    In my response to an earlier paper on this theme by the same authors I discussed the benefits and limitations of facilitated discussions. One of the most striking comments from a neonatal intensive care nurse in one such meeting was "if you don't talk about it you don't know it's bad" which perfectly captures our essential ambivalence about looking at troubling experiences in any depth. We are after all practitioners, and the tradition of 'getting on with it' - with occasional intelligent and practical thoughts on process - is the prevailing culture in most health services. Yet after almost 40 years as a psychiatrist in paediatric settings I know that there is a hunger for less systematic, but no less disciplined, attention to the daily experience of health work. This short paper 'stop running and start thinking' (Kraemer 2019...

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    Conflict of Interest:
    None declared.
  • Published on:
    The value of accepting good with bad in moral distress: a response to Benjamin Hickox
    • Trisha M Prentice, Neonatologist The Royal Women's Hospital, Melbourne
    • Other Contributors:
      • Lynn Gillam, n/a
      • Peter G Davis, n/a
      • Annie Janvier, n/a

    We agree that conceptual clarity is of great value. Furthermore we acknowledge that some ‘distress’ experienced by our clinicians was not of a moral nature – such as the distress that results from tragic circumstances. We believe that in practice, distress and moral distress overlap. It can be difficult for clinicians to isolate the precise aetiology of their distress. We have furthermore acknowledged that these factors mean that the frequency of ‘moral distress’ may be overestimated in this study. However we are unclear why the ‘distress’ experienced by our clinicians is better labelled as ‘moral stress’. We maintain that conceptual clarity must be of clinical significance and be meaningful to those experiencing it. The clinicians participating were not uncomfortable with the idea that good things could arise from ‘distressing’ situations. It seems a disservice to the healthcare professionals in our study experiencing it to relabel it as ‘stress’ rather than ‘distress’ for the purpose of a less unsettling conclusion. We assume that Mr Hickox remains sceptical that moral distress, as strictly defined (that is, where a clinician feels anguish due to being constrained from acting in accordance with his/her moral judgement), may have some positive attributes. We will outline why we believe that in addition to decreasing moral distress and it’s negative consequences, we – and...

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    Conflict of Interest:
    None declared.
  • Published on:
    Moral distress is always a burden. Moral stress is not. The importance of a priori conceptual clarity.

    It is a deleterious proposition to declare benefits to moral distress. In their recent response, Epstein and Hurst (2017) eloquently articulated many reasons for this. A better approach may be to invoke the work of Hans Selye (1974) and the parallels drawn by Rambur, Vallett, Cohen, and Tarule (2010) in advocating for the potential benefits of moral stress; not moral distress. The authors of the present article effectively revealed clinicians' general misunderstanding and misapplication of the concept of moral distress. Indeed, the authors acknowledged this explicitly: "This study demonstrates the importance of asking what clinical providers mean by 'moral distress' and/or what researchers mean when investigating this phenomenon" (p. F4). The authors' conclusions about frequency of moral distress and "inevitability" of moral distress are based on clinician self-report; not on a generally accepted definition of moral distress. Likewise, the authors do not use a validated, reliable tool to quantify moral distress (such as the Moral Distress Thermometer, Wocial & Weaver, 2013). Much qualitative research has been done that has clarified the concept of moral distress; it is not simply whatever the clinician says it is. As ethicist Denise Dudzinski (2016) stated, "clinicians benefit by distinguishing between distress and moral distress" and "without mapping the ethical dimensions of distress, clinicians are left...

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    Conflict of Interest:
    None declared.