Hospitals see rise in moral distress

“I knew I had to quit when my 15-year-old daughter would say, ‘Mom, don’t go to work and cry again.’ ”

That quote was just one data point in Francis Maza’s PhD thesis for his Doctor of Ministry at Toronto’s University of St. Michael’s College. Maza defended his thesis on “Moral Distress Among Nurse Managers in Long-Term Care Facilities” in August, when the Canadian Armed Forces’ report on what soldiers found in Ontario long-term care homes as they helped in the struggle with COVID-19 was dominating headlines.

Though the term has only been around since the 1980s, moral distress is something everybody who works in health care knows about — stress caused by conflict between what a health-care provider knows is right and what the health-care system can or will deliver. Doctors, nurses, personal support workers — everybody working in health care has experienced it, and COVID-19 has made it worse.

“Moral distress is that sense that you know the right thing to do, but for whatever reason it’s not allowing you to perform in a way that you believe is the right course of action,” explained Maza. 

“It’s something that happens in all health-care environments,” said Unity Health’s director of the Centre for Clinical Ethics Michael Szego.

Szego points to the stress nursing staff experience when they have to tell families that because of COVID-19 they can’t visit their critically ill loved ones.

“I had a manager in tears earlier because this is not what she wants to do, even though she recognizes it’s the right thing to do,” Szego said. “These are tough times not only for our patients and families, but also for our caregivers.”

Maza began his doctoral research in 2017, long before the global pandemic, but he recognizes that it’s landed right in the middle of a tidal wave of COVID-induced moral distress.

“My research kind of took a different light,” he told The Catholic Register. “Because of COVID-19, it became more real for so many people and now it seems like all we talk about is moral distress.”

Maza’s research is based on interviews with nurse managers in the Emmanuel Care system of 12 nursing homes in Saskatchewan, where he works as manager of mission, ethics and spirituality. Saskatoon Bishop Mark Hagemoen calls the research “insightful and prophetic.”

“The COVID-19 pandemic is a widespread experience that is exposing issues for pastoral care of people that have been developing for a long time,” Hagemoen said in an e-mail. “Francis Maza’s work helps us identify critical issues that Catholic institutions and communities need to thoughtfully address.”

From the bishop’s point of view, if COVID-19 has revealed that the health-care system is getting in the way of people following their conscience, then something needs to change.

“Who would have thought that suddenly the provision of high-quality care in Catholic health-care facilities would be the very places that now experience some of the most dramatic curtailments of community life and support, and have caused so much isolation and anxiety for elder residents?” Hagemoen said.

Though he studied nurse managers, Maza is sure that a gap between what conscience says should be done and what the health-care system says can be done isn’t just a management problem. Hourly-wage personal support workers experience moral distress too.

“It’s hard work and it doesn’t always pay well. As soon as people find another place, they go,” Maza observed. “The acute needs of the residents coming into long-term care is higher than before. So, in order to provide a good quality of care you need more people, you need trained people and you need to have the resources to handle them. And often we don’t.”

Too often health-care systems try to deal with moral distress by counselling self-care and running staff seminars on healthy work-life balance, but not addressing the source of the problem, said Maza.

“It wasn’t just about eating healthy and exercising. It was about the fact that somehow they have carried this with them,” he said. “That they have allowed themselves to be compromised by agreeing to a decision that they knew, either professionally or personally, was not right.”

At Unity Health, the Toronto Catholic hospital system that includes St. Michael’s, St. Joseph’s and Providence, they’ve recognized the extra moral distress of the COVID-19 era by instituting a “Code Lavender” to go along with more traditional emergency protocols such as Code Blue (cardiac or respiratory arrest) and Code Red (fire in the hospital). With an e-mail to a designated address, any employee or department can call a Code Lavender, which will bring together chaplains, ethicists, management and others to debrief and offer support to hospital staff experiencing moral distress. 

“The Code Lavender can be a prayer at a nursing station, or bringing (individually wrapped) treats to staff. It’s not meant to replace assistance supports in place for employees. It’s meant to be a compassionate approach to stress and care,” said Unity Health spokesperson Jennifer Stranges.

Maza recognizes that chocolates and kind words won’t make the problem go away.

“Is this a moral problem or a budgetary problem? I think it’s both,” he said. “Practically speaking, how many hours are you funding me, per resident, to provide care? If you keep giving me 3.8 (hours of hands-on care), well I can’t do anything with that. If you keep having four residents in one room, well that’s just a recipe for COVID to come and kill many people. So infrastructure has to change. Funding has to change and that has to be done at the system level for advocacy.”

Catholic health systems should be at the forefront of addressing moral distress, said Maza.

“I can say, based on who we say we are, we ought to do more about this,” he said.