Moral Distress: A Roadblock to Doing the Right Thing

Beth Warning, MS, MLS(ASCP)^CM, AHI(AMT), ASCLS Board of Directors

Moral distress is common in many health professions. It is well documented in nursing and among physicians and can be identified in nearly every healthcare profession. The fact that we can apply it to laboratory professionals doesn’t make us unique. Moral distress is the emotional discomfort that occurs when you are in a position where you know you should act, but there are roadblocks preventing action. Often, these are institutional situations that block the individual from doing what is just, and the individual feels powerless in their position. There are two stages of moral distress that can be experienced. The first stage occurs at the time of the situation or problem; the second stage occurs later or lingers as a type of moral residue.

For nurses and physicians, common reasons for moral distress include inadequate communication between providers, colleagues, and patients; inappropriate use of resources; giving false hope to patients and families; and risk of legal action from patients or families.

“Moral distress affects not just our patients, but our colleagues and coworkers, and most importantly our own personal wellness.”

What could be examples of moral distress that we may experience in our profession?

1. Workforce shortage. While this is not a new event, the pinch is on, and this has to be at the top of the list of causes of moral distress in the laboratory. This feeling of helplessness may occur when we are going above and beyond, but can only pick up so many hours, or volunteer for limited shifts. Also, we may become frustrated as we want to continue to do what is right but may not have the staffing to be better, such as bringing on new tests or new analyzers.
2. Working with staff inadequately trained to provide the required care. This goes hand-in-hand with the staffing shortage, where in the laboratory we are seeing cross-trained individuals and the hiring of individuals who do not carry a similar degree or credential. While we can train staff to work in the positions, the lack of depth of knowledge (or “the why” the test is being performed, or why the result doesn’t make sense) may increase emotional strain on the laboratory staff. We may be limited in the scope of practice that can be provided within a department, on a specific shift, or at a specific satellite location. Additionally, moral distress can occur due to constantly training new individuals or students, where we may see a decrease in our own productivity associated with training and teaching.
3. Lack of professional visibility. Again, this is a recurrent theme where laboratory professionals may feel undervalued among healthcare professionals. For this, it is important to rally behind the movement for our identification as a unified profession (a nurse is a nurse and is always recognized as a nurse, but which acronym of letters in the laboratory profession do you identify with?).
4. Workplace bullying. This is a toxic situation which leads to personal moral distress. You may dread coming in to work, which then exacerbates the staffing shortage. You know that doing the right thing would include leaving or removing yourself from the situation, but there are numerous other factors, such as finances and family, which need to be considered.
5. Discrimination. This can encompass a variety of factors that lead to moral distress, and could also reflect lack of visibility, having a limited voice, the feeling of being undervalued, or even harassment and bullying, where again there are roadblocks or fear of retaliation preventing action.
6. Hospital policies. While we would love to think that the pandemic is in the past, the repercussions continue, whether it is continuing supply chain issues, ongoing testing and validation, the re-implementation of masking, or visitor restrictions.

For us, the aftermath of moral distress can present as fatigue, anger, depression, and professional burnout. Other health related issues include physical effects such as headaches, heart palpitations, neck pain, and diarrhea. Sound familiar? The same conditions associated with moral distress are associated with burnout and lead to the conflict of wanting to do good, but unable to act. This can continue as indifference on the job, or even avoidance.

How can we relate our feelings of moral distress back to our professional code of ethics (see ASCLS Professional Code of Ethics), specifically, to our duty to the patient? We may think we are being ethical in our actions, by placing our patients’ welfare above our own, going the extra mile, showing grit and determination, showing up every day, attempting to comply with safe, efficient, timely and patient centered care. But in truth, what we need to do is to step back and make our personal health a priority. In trying to do the right thing, we can detract from our being the best laboratory professional we can be, where our patients may experience delays in care or diagnosis, or even, heaven forbid, an increase in the number of lab-related errors or mistakes, due to our physical and mental imbalance. Moral distress affects not just our patients, but our colleagues and coworkers, and most importantly our own personal wellness.

In searching for ways to deal with moral distress, the first step is recognition. It is important to recognize and educate yourself on what may be the root cause of your moral distress. Within the organization, communication is vital in allowing the dialogue to be voiced, as well as to be heard, through open discussion of shared concerns or experiences. If the situation is not voiced or stated, the problem may go unnoticed. Provide self-care by seeking assistance, through counseling or talking over the issue, through meditation, relaxation, or exercise as a means to refocus. Stay connected with friends, identify hobbies or downtime activities. Get healthy through diet or exercise—even a 10-minute walk outside can change your focus or energy level.

In terms of this ethics lesson, let’s begin by showing respect and beneficence not just to our patients, but to ourselves.

Beth Warning is Associate Professor at the University of Cincinnati in Cincinnati, Ohio.