“Being prevented from providing good care: a conceptual analysis of moral stress among health care workers during the COVID-19 pandemic” | BMC Medical Ethics
In the content analysis, three interlinked themes were identified which corresponded to the main theme “Being prevented from providing good care”. The three themes were: (1) “Seeing, but being prevented to act; feeling insufficient/inadequate and constrained in the profession,” (2) “Someone or something hindered me; organizational structures as an obstacle,” and (3) “The pandemic hindered us; pandemic-related obstacles.” The main theme describes moral stress as consisting of various obstacles to the provision of good care to patients in need and to acting based on empathic ability within the professional role.
Theme 1 “Seeing, but being prevented to act; feeling insufficient/inadequate and constrained in the profession”
This theme involves three categories: (1) Not being taken seriously, (2) Feeling inadequate/insufficient, and (3) Acting outside one’s area of competence.
The first category, “Not being taken seriously,” consists of seven subcategories. It represents a frustration regarding being unable to address problems and not being heard, not being trusted in one’s professional judgment, not being valued, or not being heard by the manager/leader when highlighting problems. Further, observing inaction on the part of the employer or leadership even though a problem was obvious, and lacking any possibility to address political decisions.
I heard about/witnessed situations that were contrary to my moral opinion, situations that I did not have the opportunity and/or resources to influence.
[I] raised risks regarding safety/spreading of infection, but wasn’t listened to, and our manager was initially on vacation and really didn’t understand the seriousness of the risks that we were being exposed to.
The second category, “Feeling inadequate/insufficient,” consists of 43 subcategories and is the second most common source of moral stress seen in the responses. This category involves reports of doing everything you could, but it not being enough in various aspects – such as being hindered to give comfort and care to patients in need, witnessing increasing loneliness without being able to address it, having too little time to attend to patients and watching patients die even though you have done everything you can. Frustration was reported at being unable to be present for and give comfort to patients’ next of kin, and being unable to support one’s colleagues as needed. Moreover, there were reports of powerlessness among HCWs when contracting COVID-19 themselves, and powerlessness and a sense of inadequacy when non-COVID-19 patients were abandoned or given lower priority. It was reported as especially problematic when patients did not receive appropriate medical care and when there was a lack of opportunities for follow-up of patients.
Patients felt very lonely and isolated, the fact that we, as staff, could only partly alleviate patients’ stress and anxiety, that we were not enough.
Feeling powerless at the ICU when people became real people that others have longed for, when a postcard, a letter, or a picture was pasted by the patient’s side // and when the outlook was bad, that they didn’t have someone beside them and that the little letter or greeting from a child or a father/mother, the nearest [and] dearest sending a greeting // that broke your heart, these people were missed… When next of kin could only come to say a last goodbye when the outlook was bad, when you stood outside the ICU and instructed next of kin on how to dress for the last farewell….
The third category, “Acting outside of one’s area of competence,” represents 14 subcategories that relate to having lack of competence and knowledge in the professional role due to a new disease and transfer of HCWs to workplaces with a surge of patents during the pandemic. Moreover, the category covered challenges related to working with new staff who lacked the appropriate competence. Furthermore, being left alone with too many responsibilities, watching the care of patients deteriorate due to lack of competence and being thrown into new work roles without introduction or preparation were common descriptions of moral stress.
Felt morally wrong to work without having the right experience, but had to do my best.
Support for workers on the floor, pressured co-workers to work with inexperienced colleagues to a higher extent than I normally do.
Had to work with patients from other wards where I felt that my competence was not sufficient and that resulted in me experiencing that the care we provided became worse which created moral stress.
Theme 2 “Someone or something hindered me; organizational structures as an obstacle”
The second theme consists of three categories: (1) Decision-making, (2) Teamwork, and (3) Information and communication by organizational management.
The first category, “Decision-making,” consists of 26 subcategories that describe difficulties related to one’s own decision-making, incorrect decisions being made by others, lack of decision-making, and lack of decisions by leadership. Being forced to make decisions based on too little medical information, making decision in line with moral values, but against protocols, being unable to make decisions, seeing decisions that need to be made but lacking authority, and feeling alone in decision-making and responsibility were described as challenges. Moreover, moral stress was reported when being forced to follow erroneous medical prescriptions or doctors’ decisions which were against one’s moral values, and being forced to adhere to others’ decisions despite knowing that they would prove ineffective. Lack of information and improper guidelines were perceived as leading to incorrect decisions. A lack of support in decision-making and experiencing that management did not make overall decisions, forcing frontline HCWs to make difficult prioritizations, were also described as problematic. Also, it was experienced as morally stressful to feel a duty to support one’s employer in relation to external parties when one did not agree with the employer’s decisions. Further sources of moral stress included situations when a patient decided what HCWs should do, or when a patient was dissatisfied with care. There were also difficulties in determining what is right when making decisions regarding patients with psychiatric conditions and dementia. Feeling alone with decision-making was reported by those in a leadership role.
When I, in front of others, must stick to a position that I know will cause stress to those who will work based on that position, but at the same time we as an organization must observe regulations and guidelines.
I was trained in making decisions that go against my moral compass, and know that people probably died needlessly due to that.
Being forced to make decisions on uncertain grounds which could cost lives and affect my co-workers’ mental and physical health.
The second category, “Teamwork,” consists of 15 subcategories that reflect situations related to collaboration in the workplace. Participants reported situations such as lack of initiative from team members, lack of communication between professions, lack of coordination leading to waste of personal protective equipment (PPE), and frustration among colleagues which made collaboration difficult. Furthermore, there were several examples of situations that created tensions in the teamwork: colleagues who behaved poorly with patients, colleagues who increased risks when not triaging right, colleagues who did not do their job, colleagues not observing guidelines, colleagues not providing collegial support, colleagues becoming paralyzed which increased the workload, colleagues’ fear of the disease, and colleagues who refused to work with COVID-19 patients.
Situations regarding management’s role related to putting too much pressure on staff and a lack of initiative from managers/leaders. Those in a leadership/managerial role reported issues regarding pressuring staff too much or pressuring them to work with new colleagues – things that they would not usually do.
Rushing/hurrying and unresolved frustrations among other colleagues who should cooperate professionally.
Colleagues [staying] at home, [due to] fear of contracting the disease.
The third category, “Information and communication by organizational management,” consists of 33 subcategories related to inconsistency in guidelines, poor overall management, and lack of collaboration and coordination between instances. There were many reports regarding poor leadership such as the manager not thinking PPE was needed, the employer making decisions against regulations, getting mixed messages from management, a lack of competence among management leading to decisions based on feelings rather than on evidence, management not being visible in the workplace, a lack of decisions and lack of responsibility on the part of management, a lack of coordination between managers, and a lack of support and initiatives from management. Regarding the inconsistency of guidelines, the responses were centered around new directives and guidelines that could not be adopted locally, a lack of clear guidelines, a lack of time to gather new knowledge and new information, and a lack of tutorials.
The participants in managerial positions described challenges related to leading and not working close to patients, and to implementing new ways of working for the staff. They also mentioned difficulties regarding planning and gathering staff amid all the concerns related to the pandemic, and difficulties in evaluating if staff were following the new procedures. Morally stressful situations regarding a lack of coordination and collaboration centered around a lack of collaboration between the state, the county councils, and the municipalities, a lack of collaboration between different wards, and differing routines between different care instances.
That management did not make decisions on the direction, so that we on the floor had to make the difficult prioritizations.
Non-decisions, management has more or less avoided coming to the workplace altogether.
Management makes decisions that we on the ‘floor’ have to follow even though we know that they don’t work.
Theme 3 “The pandemic hindered us; pandemic-related obstacles”
The last theme consists of four categories: (1) Priority setting, (2) Lack of resources, (3) Infection prevention measures, and (4) Limitations regarding end-of-life care.
The first category, “Priority setting,” represents 10 subcategories. Issues were reported regarding balancing different needs against risks, balancing mental needs among psychiatric patients against infection prevention, difficulties in prioritizing some patients and abandoning others, and the decreased quality of care resulting from this prioritization. Frustrations related to too much administrative work were common. Reports regarding the managerial role were centered around challenges in dealing with the role and conflicts related to providing care without risking the health of staff. Further, managers reported difficulties in advocating the “next best care” due to a lack of resources.
The stress increased because you didn’t have time for all your patients because it was extremely time-consuming to care for COVID-19 patients [and] at the same time [care for] patients who were not isolated.
Prioritization of COVID-19 patients made patient safety low.
The second category, “Lack of resources,” consists of 34 subcategories regarding material resources, staff, and lack of time. Reports regarding a lack of materials or inadequacy of materials such as PPE, gloves, soap, and disinfectants were common – however, the patients still need to be cared for. There were also reports of a lack of medical equipment such as oxygen, ventilators, and equipment for sampling.
High needs combined with illness and stress among staff led to a lack of staff, which resulted in overtime hours, changes in schedules, and work placement – at times, even sick staff had to work. Furthermore, a lack of hospital beds due to a surge of patients led to some patients being prematurely discharged, being sent to other hospitals or care instances, or having to stay at home. It was common with responses regarding not having enough time to care for patients, beyond the most essential needs.
There were also responses that the situation during the peak of the pandemic was extraordinary and could be likened to war-time care. On the other hand, some participants mentioned that they found work meaningful during the pandemic, and that it was frustrating to return to a lack of resources when working under normal conditions.
Being two night staff for 20 residents of whom 12 died in COVID-19.
For me, COVID care was the most well-functioning health care I’ve ever been part of – experiencing a lot of stress (and anger) at getting back to // “the line of people waiting for care” at my regular job, where resources, support, etc., are lacking. Unusually obvious that there is a human value, a decision, behind how patients will fare and what it should be like to work with them.
The care then and there was morally right, but if we had lifted out ONE patient and cared for them now, the care we had then would be wrong. We had to engage in war-time care, not the usual critical care we are used to.
The third category, “Infection prevention and control measures,” consists of 45 subcategories and includes the most responses. It was common that the PPE felt like a barrier to giving comfort and sound care to patients. Further, it was reported as stressful to, as a HCW, be potentially contagious for patients. Those who worked with care of COVID-19 patients felt frustration at being unable to provide care to other patients due to the restrictions. Other respondents reported frustration at having to witness diminished social support and activity affecting patients’ wellbeing, as restrictions and isolation led to increased loneliness among patients, especially the elderly. Other common responses were challenges related to patients with positive COVID-19 not wanting to be isolated, forcibly isolating patients who did not understand why or protested, being unable to explain the reasons behind the restrictions to patients with conditions like dementia, and witnessing or being forced to give compulsory care to patients.
Visiting restrictions were another common source of moral stress, for instance being forced to serve as a guard and argue with next of kin not respecting restrictions, giving cancer diagnosis without next of kin being there, giving bad news over the phone, separating COVID-19-positive parents from their babies, partners not being allowed on the delivery ward, doctors not doing bedside assessments of patients, using only video calls for medical assessments, and avoiding certain treatment to patients due to the risk of virus transmission.
When everything that these people include in quality of life has to be cancelled for reasons that they do not understand or that can be explained concretely or demonstrated, leaving them almost socially isolated with only staff around.
Protective equipment was scarce and management consistently stated that visors were sufficient for patient care. Experienced a lot of moral stress when having to send staff into an environment that I myself didn’t consider safe.
The fourth category, “Limitations regarding end-of-life care,” represents 16 subcategories. Common responses included that palliative care was the only option for patients or that patients were wrongly classified as palliative and did not receive the right care. Further, there were many responses about unnecessary medical efforts being given to patients only for the sake of next of kin, doctors avoiding decisions on discontinuing life support measures, and feeling like they participated in prolonged suffering without having any means to influence. Witnessing loneliness during end-of-life care due to visiting restrictions was a common response, exemplified by turning down next of kin who wanted to meet their family members, talking to next of kin regarding end-of-life care and having to say that only a few of them could come to visit, and being unable to give comfort to next of kin. There were also responses related to frustrations regarding how dead patients were treated at the beginning of the pandemic.
During the pandemic // some doctors thought it was better to make patients palliative, but we would sedate them so they could tolerate the treatment they were receiving until next of kin came. Even though most patients we cared for were lying there screaming ‘I don’t want to live. Let me die!’ and ripped off [Non-invasive ventilation] masks or [High flow nasal cannula]. We as the nurses/nursing assistant team had to give patients a lot of sedation // wrestle them into bed and forcible hold masks in place. Just to let the next of kin see that we had done everything for their next of kin. Was this a dignified death for the patient? NO.
Suddenly, according to staff at the residential homes, they were giving morphine and midazolam injections to elderly people in so-called palliative care who had tested positive for COVID-19 but were not particularly ill and thus actually gave them active euthanasia. How hard can it be to provide oxygen in residential care? That they choose to more or less kill people instead. There were many times we were told that the patient in question had been very alert just a few days before….
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