Experiences of moral distress among health care professionals in oncology and palliative care in Australia: a qualitative investigation

Abstract

Background: Cancer care involves challenging clinical problems requiring expertise of multiple disciplines and frequently necessitates nuanced decision-making. When decision-making and patterns of care conflict with the values of health care professionals (HCPs), moral distress may arise. Moral distress is defined as the unease resulting from the perceived violation of professional or personal values and ethical principles. It has been associated with increased burnout and lower workforce retention among HCPs. This study aimed to investigate moral distress among Australian oncology and palliative care HCPs to understand how, when, and why it is experienced. Method: We conducted a qualitative interview study, with an online survey to collect demographic, practice-related characteristics, and level of moral distress. Interviews were conducted with oncology and palliative care HCPs in Australia to explore participants' experiences of moral distress. Interviews were audio-recorded and transcribed. A thematic analysis was conducted using a framework analysis approach. Results: We interviewed 33 participants, who were predominantly female (78%) and nurses (42%) with 50% having 15 years or more experience in oncology/palliative care. Thematic analysis revealed one meta-theme, Power and Hierarchy, and four themes: (1) values and their conflicts; (2) moral distress and the system; (3) moral distress and interpersonal interactions; and (4) internalized moral distress. At the core of HCPs' experiences of moral distress were patient-centered and care-centered values and the imperative to not violate the oath to “Do No Harm.” Moral distress was perceived to be covert, primarily arising in response to day-to-day clinical dilemmas and resulted from interactions with other HCPs and structural factors. Moral distress appeared to be cumulative over time. Conclusion: Moral distress arises when there are conflicts between an individual's values and organizational culture, within teams, and within the HCPs themselves. Power and hierarchy within health care are critical elements contributing to moral distress where poor communication and limited recognition of differing views are present. There is a need for interventions facilitating open discussion of ethical concerns to reduce likelihood of moral distress and retain an experienced oncology and palliative workforce.