Moral distress, moral equilibrium and the moral equilibrium framework: health professionals' well-being in the face of daily challenges to moral values and integrity
AuthorOng, Caroline Gaik-Gim
AffiliationMelbourne School of Population and Global Health
Document TypePhD thesis
Access StatusOpen Access
© 2020 Caroline Gaik-Gim Ong
The impact of moral distress on health professionals, patient care, healthcare teams, organisations and the healthcare sector itself, is at this time significant and increasing. Most research into moral distress has focussed on nurses in acute care settings, and largely in the United States. This combined ethnographic and interpretive phenomenological research investigated gaps in the moral distress literature including the experiences of health professionals’ moral distress (1) in the Australian context, (2) in a multidisciplinary specialist palliative care team, and (3) in a community setting. My research began with the question: “how do community specialist palliative care health professionals experience and respond to moral distress?” This study makes three significant contributions to the contemporary exploration of moral distress. The first is the concept of moral equilibrium-disequilibrium that offers a new way of understanding and responding to moral challenges in palliative care. This new concept emerged from the iterative analysis of the experiences of participants in this setting. Moral disequilibrium results when health professionals, faced with challenges to their values and moral integrity, are unable to adapt to maintain their moral integrity. Moral disequilibrium is part of the everyday experience of being a health professional, and like all experiences will vary from person to person and in intensity, from mild (e.g. moral discomfort) to severe (e.g. moral distress, moral injury). The moral equilibrium-disequilibrium concept provides a positive perspective to moral challenges, and also considers the psychological, spiritual and physical well-being of health professionals. The concept is of practical value to clinicians as it names the dynamic involved in their experiences without the associations of varied current definitions of moral distress. If moral disequilibrium can be identified and addressed early, it may mitigate the progression into further disequilibrium. The second significant contribution is the development of the novel Moral Equilibrium Framework (MEF). The framework comprises three dynamic phases: identification of moral disequilibrium and the moral values involved; its resolution in attaining a “good enough” moral equilibrium; and the evolution phase of growth in moral understanding including the building of moral resilience. Whilst the framework was derived from the experiences of health professionals who were part of this study, I argue that its phases and processes are consistent with various recommendations in the moral distress literature, adding to its strength. The moral distress literature also emphasised the importance of organisational responsibilities in mitigating moral distress. Similarly, whilst the MEF focusses on individual and team processes, its use does not negate the organisation’s role in helping to minimise moral disequilibrium. The third important finding of this research is that the team as an entity can experience moral disequilibrium. This is in contrast to previous studies that name moral distress as individual experiences occurring within the team. This revelation of team moral disequilibrium highlights the importance of being attentive to and addressing the state of moral disequilibrium not only at the individual level but also at the team level. In answer to my research question, I conclude that experiencing daily moral challenges, community specialist palliative care health professionals often choose to respond in ways that help to regain a “good enough” moral equilibrium, both as individuals and members of a team. The thesis will be of interest to health professionals who experience daily moral challenges in an ever growing, stress-filled environment of caring for patients, and who seek to find ways of regaining and sustaining “good enough” moral equilibrium and integrity.
Keywordsmoral distress; moral equilibrium; specialist palliative care; health professionals; moral equilibrium framework; community; moral challenges; moral integrity; moral values; well-being
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