I once saw a man in the ED who needed to see his primary doctor to renew his medications. He showed for a scheduled appointment, only to be told that he was fired because of too many ‘no shows’.
When I gently asked why he had missed appointments, he explained that he had one pair of boots (which his toes peeked out of and the heels flopped when he walked) , he had twenty miles to walk to get to the clinic, and when his mom answered the phone she often didn’t give him the message.
The social worker that brought him in for today’s presumed appointment added that he had traumatic brain injury. I contacted his doctor who was unaware that he had been refused care at the clinic and asked if the patient would see him in the morning. The following afternoon I saw him after a seizure. He had again been turned down by the clinic receptionist that morning.
I admitted him so that he could get the care he needed. These kinds of situations create moral distress.
What is Moral Distress?
Moral distress is characterized as producing frustration, anger, guilt, negative coping strategies, and even self-harm. It occurs when we recognize the appropriate action and are ineffective in making it happen. In this example, the patient’s primary doctor and I both knew what he needed and our efforts to remedy the situation were not effective.
Moral distress can also occur when you are acting in a way that is incongruent with your values. This was the most frequent complaint I heard from ICU doctors during the COVID Delta surge. They were asked to treat patients in futile situations repeatedly and this undermined their personal integrity.
Gaining Personal and Collective Agency
Personal agency is having the confidence and skills to accomplish purposeful acts. Collective agency occurs when a group of people have the sense that they can accomplish something together and the skills to make it happen intentionally. So, how does one attain personal and collective agency?
1.) Set realistic expectations.
It is very helpful to recognize what is in your control. Is the result you want within your personal control? Do you need to work with others to reach this goal or is this something you and your team cannot control. As an emergency physician I advocated for patients and often felt the system we contrived, made it cumbersome to care for patients.
For example, you can’t admit a patient to a unit that isn’t adequately staffed by nurses. You will need to transfer them. I have no power over staffing of the pysch unit and hospitalists cannot care for mentally ill patients on a medical unit with a pysch consult, largely because of nursing skills. I need to recognize that this is, at least in the moment, an issue that is out of my control.
2.) Have self-compassion.
It is okay not to be okay. When we are frustrated, angry, disappointed, unhappy we need to be aware of these emotions. This is the first step in self-compassion.
Sit with the emotion you are experiencing. Then normalize these emotions by recognizing the universality of them.
You are not alone in feeling this way when these situations arise. Some find the hardest part of self-compassion is to be kind to yourself.
Know what gives you solace and do that. What positive adaptive behavior can you engage in, that will improve your mood? Perhaps for you it is to get outdoors, go for a walk and silently ‘wish well’ those you pass along the way, remind yourself of the purpose of your work, or escape in a novel for 10 minutes.
Regulating your emotions without denying them is a delicate dance. You will find that you can be more effective when you are content.
3.) Know your values and be intentionally congruent with them.
Clarifying your values can be an enlightening exercise. When we act intentionally, aligned with our values; our sense of integrity comes through to others and this is respected. This is a direct antidote for moral distress. You may have to work out friction between your expectations and values.
Start by determining your sphere of influence and control and accept that. Don’t waste your energy on things you cannot control or influence, particularly in the moment.
4.) Skillfully advocate for yourself, your team, and your patients.
You will be able to influence your workplace more as you build relationships and communication skills. You can’t rely on your medical degree or academic degree alone to influence your workplace. Consider the sphere of your personal influence versus the sphere of the collective influence that your team may have. You may need to convince your team to join you in advocating for what you care about.
Your skills of holding conversations with equity of voice and diversity of perspectives will be key to coming up with robust solutions influenced by those the decision will affect. Learn the values of those you wish to influence and appeal to them. You will be relied upon for the evidence that supports your request. The heartfelt stories, that align with the values of those whom you wish to influence, may be more impactful than the evidence alone.
5.) Know and respect your boundaries.
This is especially difficult for those of us that want to do everything for everyone every time in a system that feels broken. You may have discovered during the pandemic that you cannot deliver optimal care if you yourself are not well. I hope that a silver-lining of the pandemic is that our tribe discovered that self-care is essential and that it is courageous to ask for help.
This will require setting boundaries and sticking to them whether at work, at home or in your community. These boundaries are most effective when you have clarified your values and align your boundaries with your values. You may decide to step-down from committees that don’t satisfy your values, or take the vacation that you are allowed.
Other examples of boundaries can include not spending every Saturday cleaning the house, allowing yourself time to tuck your kids into bed 4 nights a week, and reserving the right not to pick-up more than your fair share of working holidays.
“Boundaries are the distance at which I can love me and you simultaneously.”
— Prentis Hemphill
6.) Reflect on results and adjust appropriately.
One of the benefits of coaching that my clients often remark about is the dedicated time and opportunity to reflect with another. They otherwise run the treadmill unconsciously. Reflection will assist you in acting more effectively, and intentionally.
You may discover that a key stakeholder in a solution was left out and effectively blocked a solution, that had they been involved, they would have supported. The next time you attempt to impact your work environment you will be more inclusive.
By focusing on building personal and collective agency, you will have better control over work-life integration, a larger influence on decisions at work, and stronger communication towards building a cohesive, strong department. Together, these new skills will give you the confidence to act with intention and self-conviction.