October SOS

“Owning our story can be hard but not nearly as difficult as spending our lives running from embracing it. Embracing our vulnerabilities is risky but not nearly as dangerous as giving up on love and belonging and joy - the experiences that make us the most vulnerable. Only when we are brave enough to explore the darkness will we discover the infinite power of our light.”

~ Brene Brown

 As healthcare workers we are faced with moral dilemma almost daily.  Since the start of the pandemic the degree and amount of moral dilemma and potentially distress we face has been significantly amplified.

We are exposed to situations where our values, principles or moral commitments may not align with what actually happens in practice.  Some examples from the last year are the pain we feel not allowing families to be with their suffering loved ones, the frustration of having patients wait for hours to be seen as patient spaces are blocked due to isolation, the indignation we feel when people choose not to be vaccinated and then present for our care.  Why should we care when they seemingly don’t?

The pandemic is highlighting moral dilemmas we haven’t had to face before such as:

Limitations on individual choice for the public good (e.g. visitor restrictions and mandatory immunization)

Prioritizing population health needs over those of individual patients (e.g. delaying electives surgeries and triaging scarce critical care resources)

This can cause psychological, emotional, physical distress and suffering.  It’s a pervasive occupational hazard for health care workers.  And it can cause harm: sometimes from a single event but more often from the cumulative distress.  We face the potential of moral injury.  It’s hard.  And it’s normal and common to feel the distress.  But what must we do to prevent or heal from these injuries?  How do we embrace our vulnerabilities without being overcome by them?

It’s important to recognize that the feeling of moral distress is not always a sign of a fundamental ethical problem. Rather, it can be seen as an important signal of the health care provider’s deep sense of moral responsibility in a particular situation. 

This month we will be looking at our work through a moral lens. Intentionally looking for moral distress, naming internal conflicts and hopefully practicing some coping and debriefing techniques. We’ll be shining the light on the dark, difficult spaces in the hope of finding healing and power.

THE CHALLENGE

The challenge this month is to identify moral distress and to develop some tools to move through it.

Beginner level: Reflect on your work and name some situations that have caused moral distress and the emotions that may be triggered by these situations.

Intermediate: do a 4A’s exercise (Moral Distress: When doing the right thing feels impossible. Colleen R. Torgunrud, Clinical Ethicist, Alberta Health Services, July 2013 

• Ask - do I feel Distressed? Is the distress work related? What is the source of distress? the GOAL is to become aware moral distress is present

• Affirm - affirm your distress and make a commitment to take care of yourself. Validate your feeling and perceptions and affirm your professional responsibility to act

• Assess - Identify sources of your distress. 

  Under what circumstances do the signs and symptoms occur? 

  Triggers may be: 

  1. Certain patient care situations 

  2. Team or organization policies or practices 

  3. Lack of collaboration 

• Act - Develop a self-care plan 

  Identify appropriate sources of support 

  Investigate outside resources for guidance 

Advanced level: Use the debriefing tool below to work through a situation that caused moral distress that you encountered at work this month

Steps to Address Moral Distress:  A Debriefing Resource for Individuals or Groups 

This tool is adapted from the AE-SPA tool developed by Fraser Health Ethics Services, and the Moral Distress Map developed by Dudzinski (2016). 

In relation to the situation that you are concerned about, consider the following questions: 

Step 1: How are you feeling emotionally? What are the physical impacts?

Step 2: What action(s) do/did you feel prevented from doing? 

Step 3: What were the main barriers to action? Were they internal or external? 

Step 4: What are you doing now to cope with the situation? 

Step 5: What is important to you that you feel has been compromised? Why are these things important? 

Step 6: Are any of the important things that matter to you (e.g. values, obligations, responsibilities) in conflict?  - Name the important thing and what it conflicts with

Step 7: What is important to you that has not been compromised and that you have control over? 

Step 8: What actions can you take to reduce your symptoms of moral distress? 

Step 9: What actions can you take to address the source of the moral distress? 

Step 10: What resources or relationships will be necessary or helpful to follow through on these actions?  How will you access these?

Step 11: What is your plan of action? 

In facing moral distress we must have the courage to see both ourselves and others. Here’s Brene Brown to help us on the journey…