Many studies have explored the experience of moral distress at the individual level, but for their article in the June 2021 issue of the Clinical Journal of Oncology Nursing, McCracken et al. looked at moral distress among oncology nurses at the team level. Their findings identified new institutional strategies to mitigate moral distress among healthcare providers.

Moral Distress in Health Care

The psychological distress that comes from facing a moral event, such as moral uncertainty or conflict, can build up over time and lead to burnout, compassion fatigue, staff turnover, and compromised care quality, McCracken et al. explained. All healthcare workers are at risk, including physicians, pharmacists, respiratory therapists, physical and occupational therapists, social workers, and administrators, but studies have shown that oncology nurses experience moderate to high levels of moral distress and may be at higher risk for it because of their frequent exposure to end of life, challenges with pain control, and conflicts about goals of care.

McCracken et al.’s qualitative, descriptive study used an interview format to elicit the oncology team perspective of moral distress, identify team-level barriers and facilitators to resolve morally distressing situations, and find strategies to support oncology team members. They conducted the interview among eight focus groups of three to five members of the cancer care team, with a total sample size of 32 participants. The focus groups represented nurses, nursing and medical assistants (nonlicensed personnel), physicians (residents, fellows, and attendings) and other providers (physician assistants or nurse practitioners), physical and occupational therapists, chaplains, social workers, case managers, respiratory therapists, and child life specialists.

The Team-Level Experience

McCracken et al. found six themes that emerged from the discussion responses.

• The meaning of oncology care: Working in oncology produces strong bonds, with both patients and families as well as the interprofessional team. Team members find those bonds both supportive and sacred.
• The rippling effects of cancer: Witnessing suffering, experiencing frequent patient losses without adequate time to grieve, and the emotional toll of being fully present for every patient and family affected team members individually and as a team.
• Decision-making barriers are central to the experience: Most of the team members’ moral distress evolved from goals-of-care conflicts, inadequate communication, false hope, difficulty moving from cure to comfort, and delayed decision-making that prolongs patient suffering.
• Other antecedents to moral distress: Process or institution-level factors also influenced team members’ distress, including delayed or missed palliative care and ethics consultations, the hierarchy of health care, the healthcare organization’s business agenda, and a culture where death is considered a failure.
• Consequences of moral distress: In addition to compassion fatigue and burnout, team members said it made them feel that they could not provide high-quality, patient- and family-centered care.
• Ways to mitigate moral distress and burnout in oncology: Strategies included working seamlessly as a team to improve; collaborating early and continually with palliative care specialists; aligning patient, family, and team goals with early and frequent family meetings; and supporting staff well-being through accessible organizational and unit-based resources.

Nurse Leaders and Institutions Can Support Interprofessional Teams

Common among both the individual responses and the six themes was the understanding that the interprofessional team is essential for optimal patient care and all team members rely on the others—not only to provide patient care, but also for moral support throughout the process.

The hierarchy of health care was a particularly strong thread for nurses, who said they felt powerless, ignored, and severely limited by their scope of practice when patients or families wanted to discuss aspects of their treatment. A palliative care specialist described frustration when their recommendations for care were ignored. Nurse leaders and institutional management should find opportunities to evaluate communication practices and role delineation across interprofessional teams, McCracken et al. concluded.

Collaborative practice models can help institutions develop a morale community, McCracken et al. said. Identifying tailored interventions to promote professional shared decision-making among oncology teams should be a focus for organizations and researchers alike.

Focus group participants also offered specific recommendations for resources, including leadership engagement in patient care concerns, greater use of the employee assistance program to support staff mental health, pet therapy, psychologists on the unit for staff, communication with providers, a specific healthcare team and family liaison role, and coworker-based support. Nurse leaders and institutional managers should assess for gaps in their mental health resource offerings.

“This study uncovered the interprofessional oncology team perspective on how to address moral distress in clinical practice and highlights the need for organizational investment in communication, team-based training, and psychosocial support for healthcare professionals,” McCracken et al. concluded. “Communication education and training for oncology teams that is guided by a model of interprofessional shared decision-making may lead to greater engagement among team members and improved outcomes for all involved.”

For more information about the study and the opportunity to earn 0.75 NCPD contact hours, free for ONS members, refer to the full article by McCracken et al