زندگی کردن با درگیری های معضلات اخلاقی و پریشانی اخلاقی در سیستم مراقبت های بهداشتی

During the last decade, the Swedish health care system has undergone fundamental changes. The changes have made health care more complex and ethics has increasingly become a required component of clinical practice. Considering this, it is not surprising that many health care professionals suffer from stress-related disorders. Stress due to ethical dilemmas is usually referred to as “moral distress”. The present article derives from Andrew Jameton's development of the concept of moral distress and presents the results of a study that, using focus group method, identifies situations of ethical dilemmas and moral distress among health care providers of different categories. The study includes both hospital clinics and pharmacies. The results show that all categories of staff interviewed express experiences of moral distress; prior research has mostly focused on moral distress experienced by nurses. Second, it was made clear that moral distress does not occur only as a consequence of institutional constraints preventing the health care giver from acting on his/her moral considerations, which is the traditional definition of moral distress. There are situations when the staff members do follow their moral decisions, but in doing so they clash with, e.g. legal regulations. In these cases too, moral distress occurs. Hitherto research on moral distress has focused on the individual health care provider and her subjective moral convictions. Our results show that the study of moral distress must focus more on the context of the ethical dilemmas. Finally, the conclusion of the study is that the work organization must provide better support resources and structures to decrease moral distress. The results point to the need for further education in ethics and a forum for discussing ethically troubling situations experienced in the daily care practice for both hospital and pharmacy staff.

During the last decade, the Swedish health care system has undergone fundamental changes. New evidence based medicine and health care quality certification programs have been implemented alongside the development of advanced biomedical techniques. Organizational reforms have been carried out in order to make health care more efficient, often including elements of competitive inducements between health care providers. A more educated population and changes in values have increased the consumer demand on health care services (Forsberg, 2001). The changes have made health care more complex and ethics1 has increasingly become a required component of clinical practice. Demands on first-line professionals, i.e. doctors, nurses and auxiliary nurses, to make decisions concerning priority-setting in their everyday work have resulted. Not only do they have to consider what is best for the present patient, but also consider the future patient's needs and questions of social economics. Despite the increasing demands for qualified ethical judgements the health care organization often lacks standardized policies for guidelines as well as systematic education in ethics and structures of ethical support for their staff members who are to carry out the decisions. Considering this, it is not surprising that many health care professionals suffer from stress-related disorders. Several studies have shown how fundamental changes in the health care organization have added new stressors to the medical profession. Arnetz (2001) has identified several stressors facing physicians as part of their medical practice. Most stressors identified are psychosocial in their origin, such as workload, unsatisfying tasks, lack of skill development and lack of clear work directives from the immediate supervisor. According to recent studies ethical dilemmas can also cause stress-related disorders among health care professionals (van der Arend & Remmers-van den Hurk, 1999; Raines, 2000; Corley, Elswick, Gorman, & Clor, 2001). Stress related to ethical dilemmas is usually referred to as “moral distress”. A well-established definition of moral distress is that it “occurs when one knows the right thing to do, but institutional or other constraints make it difficult to pursue the desired course of action” (Raines, 2000, p. 30). In this article, the results of an investigation concerning the views of health care professionals themselves on what kinds of situations involve ethical dilemmas are presented. Building on Andrew Jameton's definition of moral distress (Jameton (1984), Jameton (1992) and Jameton (1993)), an analysis of whether these ethical dilemmas could also be considered as creating moral distress among health care professionals of different categories is undertaken. Unlike previous studies on moral distress, which have often focused upon the work situation of the nurse, this study covers health care in a broad perspective and includes both hospital clinics and pharmacies. Background Stress related to ethical dilemmas, or moral distress, has been discussed particularly in relation to nurses. According to Raines (2000) the impact of ethical issues in nursing practice in the United States has increased tremendously during the last decade. Nurses in almost every practice setting spend increasing amounts of their time resolving ethical dilemmas, as well as experience more stress in dealing with ethical conflicts. The trend has continued despite efforts by health care institutions and professional organizations to standardize policies relating to ethical issues in health care. Job satisfaction instruments for doctors and nurses have often included items of moral value. For example, Berger, Seversen, and Chvatal (1991) measured the frequency of encountered ethical dilemmas among nurses and the degree to which they where disturbed by them. According to Corley (1995) no instrument had until then been developed specifically to measure levels of moral distress. To fill that gap, Corley et al. (2001) developed the moral distress scale (MDS) to measure moral distress as an element of job stress in nursing. When applying this, Corley and co-workers found that 69% of the nurses in their study sometimes had to compromise their values, due to hospital policy or standards, a physician's request or nursing administration requirements. They were also sometimes forced to act against principles, as ethical guidelines (and in some cases even legal requirements) were impossible to carry out because of organizational constraints, such as lack of resources or lack of power (Corley et al., 2001). Raines (2000) developed a model for stress related to ethical dilemmas: the ethics stress model. The model is an adoption of Wilkinson's (16) and Wilkinson's (1989) studies of moral distress and describes the relation between moral reasoning, coping style and the amount of stress experienced in ethical decision-making situations in nursing. Raines’ study shows that the most frequently experienced sources of moral distress for oncology nurses were pain management and cost containment issues (Raines, 2000). Wilkinson (1987/88) had earlier identified three major types of ethical issues causing moral distress among nurses, namely situations involving prolonging life, performing unnecessary tests, and the desire to tell the truth. Rodney (1988) found that critical care nurses experienced resentment, frustration, and sorrow when they were unable to act on their moral choices. Theoretical framework The present research derives from Jameton (1984), Jameton (1992) and Jameton (1993) concept of moral distress in nursing. A basic assumption is that health care professionals hold values in their work and strive to deal with ethical dilemmas when they arise in their work environment. The principle starting point is that moral distress could not be studied adequately without taking philosophical concerns, concerning the concept of moral distress, seriously. Moral distress is therefore studied from two angles: the moral/ethical perspective and the stress perspective. Jameton has studied moral distress primarily among nurses. He identifies moral distress as painful feelings that occur when because of institutional constraints the nurse cannot do what he/she perceives as morally correct and necessary. The distress is based on a perception of moral responsibility and relates to a perception of being individually responsible but restricted by circumstances. In nursing practice, Jameton (1984, p. 6) distinguishes between: • Moral uncertainty, arising when one is unsure whether there is an ethical dilemma or not, or, if one assumes there is, one is unsure what principles or values apply in the ethical conflict. • Moral dilemmas, arising when two or more principles or values conflict. More than one principle applies and there are good reasons to support mutually inconsistent courses of action. Although it seems terrible to give up either value, a loss is inescapable. • Moral distress, finally, occurring when one believes one knows an ethical dilemma is at stake and also the morally right thing to do, but institutional constraints make it impossible to pursue the desired course of action. Jameton thus separates the nurse's experience of moral distress from her experience of moral dilemmas, although the distress is built upon the identifying of a dilemma; it does not occur in cases of uncertainty. Wilkinson (1987/88, p. 16), building on Jameton, defines moral distress as “the psychological disequilibrium and negative feeling state experienced when a person makes a moral decision but does not follow through by performing the moral behaviour indicated by that decision”. The failure to follow through the decision is due to institutional constraints. In accord with Jameton, Wilkinson assumes that moral distress could not occur in a state of uncertainty; on the contrary, the distress is a consequence of a severe moral dilemma, when the rightness or not of different courses of actions has been evaluated. In an article from 1993 Jameton brings in yet another distinction, namely between initial and reactive distress: Initial distress involves the feelings of frustration, anger, and anxiety people experience when faced with institutional obstacles and conflict with others about values. Reactive distress is the distress that people feel when they do not act upon their initial distress (Jameton 1993, p. 544). Initial distress is caused by bureaucratic obstacles and/or disagreeable colleagues. According to studies performed by Jameton and Wilkinson, nurses express a variety of strategies for coping with these situations, such as trying to influence the physician, call in the head nurse, submit an incident report or discuss the problem with the medical head of the unit ( Jameton, 1993; Wilkinson, 1987/88). If these strategies are not successful the reactive distress results. Depression, nightmares, headaches and feelings of worthlessness characterize this form of distress. Some studies have indicated that chronic reactive distress contributes to burnout and the decision to leave nursing ( Jameton, 1993; Fowler, 1989). Following Jameton and Wilkinson the accepted definition of moral distress could be as follows: Traditional negative stress symptoms, such as feelings of frustration, anger and anxiety, which might lead to depressions, nightmares, headaches and feelings of worthlessness, that occur due to a conviction of what is ethically correct but institutional and structural constraints prevent the desired course of action. Given Jameton's and Wilkinson's definitions it is not surprising that studies of moral distress have usually been conducted on nurses. They are the ones assumed to be unable to act on their beliefs as they are not the highest in rank in the hospital organization and do not take the final decisions concerning patient care. This research measures moral distress among health care professionals in a broader perspective, including nurses, doctors, auxiliary nurses and pharmacy staff. The central questions are: What kind of situations do health care providers themselves consider involve ethical dilemmas? Do they experience stress in connection with these dilemmas? Is moral distress limited, as it has hitherto been defined, to situations where the health care giver knows what is ethically correct but is prevented from acting in that direction?