Moral Distress in Healthcare Settings
Moral distress is the profound psychological and emotional suffering that occurs when healthcare workers are prevented—by internal or external constraints—from acting according to their deeply held moral and professional values, particularly when they cannot provide ethically appropriate care or feel complicit in moral wrongs. 1
Core Definition and Distinguishing Features
Moral distress represents the immediate discomfort experienced when constraints prevent morally appropriate action, while moral injury refers to the lasting psychological, emotional, and existential harm that results from unresolved moral distress. 1 This condition is fundamentally characterized by a sense of powerlessness that distinguishes it from other forms of occupational distress. 1
Key Distinction from Related Conditions
Burnout vs. Moral Distress: While related, moral injury incorporates existential and identity-based distress beyond the transdiagnostic symptoms of exhaustion and cynicism seen in burnout. 1 Burnout typically involves exhaustion, alienation, and decreased performance, whereas moral distress centers on value conflicts and ethical compromise. 2, 1
Moral Distress vs. Moral Injury: Moral distress is the acute experience of ethical constraint, while moral injury represents the chronic, lasting damage that can result when moral distress remains unaddressed. 1
Primary Causes in Healthcare
The most common triggers for moral distress include:
Resource limitations: Insufficient staffing, lack of personal protective equipment, medications, beds, and essential equipment that prevent adequate patient care. 1
Inappropriate workload and staffing ratios: Heavy workloads that compromise care quality and force clinicians to work beyond safe limits. 1
Triage decisions: Being forced to allocate scarce resources, especially problematic when bedside clinicians are inappropriately tasked with these decisions rather than dedicated triage teams. 1, 2
Inability to act ethically during crises: System-level constraints that prevent clinicians from following their professional and ethical standards. 1
Patient isolation from families: Particularly during critical illness or end-of-life care, as witnessed during COVID-19. 1
High-Risk Populations
Healthcare workers at elevated risk include:
- Less-experienced workers and staff in training 1
- Those with direct contact with severely affected patients, particularly in emergency departments and intensive care units 1
- Staff involuntarily deployed to unfamiliar or high-stress clinical areas 1
- Healthcare workers without strong social support at home 1
- Individuals with significant family and childcare needs 1
- Those with prior trauma exposure 1
Clinical Impact
The US Surgeon General in 2022 described healthcare worker burnout and moral distress as threats not only to the workforce but to public health, requiring "systems-oriented, organizational-level solutions" beyond individual resiliency efforts. 2 This condition can lead to deprofessionalization, decreased quality of care, lasting negative emotions, job dissatisfaction, and high levels of burnout and intentions to quit. 1, 3