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Moral Distress

Moral Distress and the Healthcare Assistant

Anne Marie Lee

Working in any area of healthcare we come across moral distress.   Some healthcare workers are better able to manage their moral distress than others.

What is moral distress?

“In 1984, Andrew Jameton defined “moral distress” as a phenomenon in which one knows the right action to take but is constrained from taking it. Moral distress is different from the classical ethical dilemma in which one recognizes that a problem exists, and that two or more ethically justifiable but mutually opposing actions can be taken. Often, in an ethical dilemma, there are significant downsides to each potential solution.”

Through research it has been discovered that moral distress can cause some healthcare workers to change career, it can also be the cause of burn out in staff.  It is a subject that has only recently been taken seriously and is still not generally recognised and catered for.

Moral distress is widely recognised in the nursing sector but may not be as well recognised in the case of healthcare assistants.

Examples of Moral Distress for healthcare assistants

You have been trained in manual handling.  A member of staff, senior to you, asks for help in moving a patient up in the bed.  Standing on either side of the patient she proposes catching the patient under the arms and hauling him up the bed.   You know this is an incorrect manoeuvre, but your colleague outranks you and you are reluctant to correct her.  You are aware of the damage this manoeuvre could do to the patient and you are also aware that this is common practice.  The moral dilemma here is: do you protect the patient from possible injury or protect yourself from the wrath and ridicule of your senior colleague? Would you express your concerns and to whom?  Would you continue to carry out this manoeuvre if you were not listened to?  This is the moral dilemma which may cause you distress.

The nursing home in which you work has a routine which you believe serves the staff over the residents.  Most of the residents spend the day sitting around a large room with little to do but watch TV.   The staff claim to have no time to carry out activities with the residents.  The residents are bored and in your opinion are deteriorating gradually from lack of physical exercise and mental stimulation.  When you try to entertain them, you are quickly given a task to do and told not to be wasting time. The moral dilemma here is to weigh the wrath of management against creating a pleasant atmosphere of activities and entertainment for the residents.  Do you put up with this situation; bring it up with senior staff or report to HIQA?  Failing a response that satisfies you do you seek employment elsewhere?

You are a healthcare assistant (HCA) working in a day care centre for people with dementia. The person who was responsible for cleaning the centre resigned and the manager decided that the HCAs could do the cleaning and save the salary of the cleaner.  Some of the HCAs resented this and one felt so strongly that when it was her turn to clean, she did a very poor job. As a result, the clients were likely to suffer e.g. they might pick up infections. You had been of the belief that an HCA carries out hands-on tasks with the care recipient while the cleaner does the domestic duties, cleaning, laundry etc. You didn’t train to be a cleaner.  Resentment is building up and the atmosphere is becoming very difficult to work in. What do you do?  Put up with it; refuse to clean; discuss with the manager or seek new employment.

Moral dilemmas occur in all disciplines of healthcare.  In Britain in the 1970’s there was major moral distress among healthcare workers when abortion was legalised.  Initially most clinics were sympathetic to those who had a moral or religious objection to working with people seeking abortion.  It was also the case that where one’s objections were dismissed many health professionals felt the need to resign rather than comply.  Since the Irish referendum this may be a moral distress facing us into the future.

Another moral dilemma can occur over medication administration.   While healthcare assistants have no national scope of practice they are bound by the policies and protocols of their workplace.  In the case of a person with dementia whom you are caring for in their own home. You know this person will not remember to take her medication.  She is also not capable of responding to suggestions and doesn’t know how to manage the blister pack even with assistance; nor does she know what to do with the tablets if they are handed to her.  You are only permitted to remind her to take her tablets!  If she doesn’t take her tablets her condition worsens, the registered Nurse can’t call in twice a day to give them to her and there is no one else available to do so. What do you do?  Apparently, this is quite a common problem.  Do you report to your line manager?  Do you refuse to help with medication administration and let the employer solve the problem?

You are caring for an extremely difficult patient in her own home.  She is your first call each day and you find yourself dreading coming to work in the mornings.  You are very stressed and it is beginning to affect your family life. One of your colleagues advises you to request a second healthcare assistant be appointed to share the task with you on a four-day/three-day plan.  You put in the request but your managers refuse.  You are very disappointed and frustrated but work on for another six weeks or so.  Then, backed by your colleagues you put in the request again.   Again, you are refused.  What do you do?  Continue working with this patient while your distress builds up.  Contact HIQA, find another healthcare position or change career altogether.  (The HCA in this situation moved out of healthcare entirely)

Outcomes from ignoring morale distress

Where moral distress exists the healthcare worker always suffers and the patient may be at risk too but not always.  Where the cause of the moral distress is not relieved the healthcare assistant can become numb and bad habits kick in. ‘It must be OK because this way of behaving is the norm in this workplace.’ This will in turn lead to poor standards of care.

In a lot of cases healthcare assistants will vote with their feet and leave the healthcare sector for less challenging roles.

 What can be done to alleviate morale distress?

Would a prescribed national standard of training on how to manage moral distress benefit healthcare assistants?

Should employers have a moral distress policy and procedure and an appropriate structure for dealing with issues raised by staff?

Healthcare assistants need to have a debate on the issue and raise the general level of literacy of moral distress in the sector.

What do I do if I believe I am suffering from morale distress?

Since moral distress is beginning to be recognised and since it can lead to burn out and staff retention problems in the sector, the individual healthcare assistant should talk to someone about their concerns.

  • Talk to your line manager or employer and explain why you believe the health or welfare of the care recipient is in danger
  • Talk to HIQA
  • Talk to a trusted friend in confidence
  • Contact us at the Alliance of Health Care Assistants in Ireland to arrange for someone to talk to you
  • Make arrangements to attend counselling.

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