“The concept of moral distress was first developed in the 1980s by bioethicist Andrew Jameton (1984). Broadly, moral distress refers to painful feelings or psychological difficulties that occur due to awareness of the morally appropriate action to take but an inability to take that action because of internal (e.g., fear) or external (e. g., lack of time or resources) constraints (Corley et al., 2001; Jameton, 1984). Jameton (1993) later distinguished moral distress as having two forms: initial moral distress and reactive moral distress. Initial moral distress involves the emotional reaction (e.g., frustration, anger, and anxiety) that occurs when confronted with the conflict of wanting to do the right thing but facing obstacles to taking that action; reactive moral distress is the lingering distress that occurs afterward (Jameton, 1993) (pg.2)”
“The most broadly used instrument for measuring moral distress is the Moral Distress Scale (MDS)(pg2).”
He,A.S, Lizano, E.L.,& Stahlschmidt M. J. (2021) When doing the right thing feels wrong: Moral distress among child welfare caseworkers, Children and Youth Services Review, Volume 122, 105914, ISSN 0190-7409
https://doi.org/10.1016/j.childyouth.2020.105914. (When doing the right thing feels wrong: Moral distress among child welfare caseworkers (stockton.edu))
- Moral distress is identified among residential childcare workers in child welfare.
- Moral distress is a threat to worker and child well-being in residential settings.
- Trauma-informed care is indicated to mitigate moral distress among workers.
“Jameton (1977) coined the term moral distress within biomedical ethics discourse particular to nursing. It referred to the challenge nurses faced when their ethical or moral judgment differed from those who had the power to determine what care they could provide. For instance, when given orders by a physician in charge of a patient that a nurse believed to cause unnecessary pain, this unnecessary pain could be experienced by that nurse as an abuse of the patient. Nurses could thus be in the distressing position of being complicit in the abuse of their patients (Jameton, 2013). Moral distress included several elements: (1) the suffering of a person in their care; (2) delivering services that inadequately mitigated suffering, or perceiving they contributed to suffering by performing their professional duties; (3) delivering either inadequate or abusive care as a result of their lack of decision-making power. (pg.1)”
“Jaskela, Guichon, Page, and Mitchell (2018) described the causes and effects of moral distress and the supports considered effective by these social workers. Causes included: the poor judgment and subsequent behaviour of other health care professionals; unmanageably high caseloads; external agencies that caused hardship for their patients; internal rules of their own place of employment that put patients at risk; and, moral distress stemming from fear of reprisals for “pushing the rules” to get around the challenges listed here (p. 99). Effects included: exhaustion; difficulty sleeping; uncomfortable affect (e.g., anger, frustration, and sadness); self-doubt, withdrawal from friends, family, and helping relationships; intention to leave and turnover. Supports were identified as the promotion of their own physical and emotional well-being; workplace social support from knowledgeable insiders; optimism; experience; appropriate interpersonal boundaries and personal limit-setting. Recommendations included improving education about the potential for moral distress in social work settings and the need to prevent it by reducing workload demands and providing additional supports to professionals. (pg.1)” https://doi.org/10.7202/1051104ar
Brend, D.M. (2020) Residential childcare workers in child welfare and moral distress, Children and Youth Services Review, Volume 119, 105621, ISSN 0190-7409, https://doi.org/10.1016/j.childyouth.2020.105621
(https://www.sciencedirect.com/science/article/pii/S0190740920320442)
Alternatives to Seclusion and Restraint
Seclusion and restraint were once perceived as therapeutic practices in the treatment of people with mental and/or substance use disorders. Today, these methods are viewed as traumatizing practices and are only to be used as a last resort when less-restrictive measures have failed and safety is at severe risk.
Seclusion is defined as the involuntary, solitary confinement of an individual. Restraint refers to any method, physical or mechanical device, or material or equipment that immobilizes or reduces an individual’s ability to freely move his or her arms, legs, body, or head. A drug or medication also might be used to restrict behavior or freedom of movement.
Studies have shown that the use of seclusion and restraint can result in psychological harm, physical injuries, and death to both the people subjected to and the staff applying these techniques. Injury rates to staff in mental health settings that use seclusion and restraint have been found to be higher than injuries sustained by workers in high-risk industries. Restraints can be harmful and often re-traumatizing for people, especially those who have trauma histories. Beyond the physical risks of injury and death, it has been found that people who experience seclusion and restraint remain in care longer and are more likely to be readmitted for care.
SAMHSA's Continued Support
SAMHSA is committed to reducing and ultimately eliminating the use of seclusion and restraint practices in organizations and systems serving people with mental and/or substance use disorders. SAMHSA’s goal is to create coercion and violence-free treatment environments governed by a philosophy of recovery, resiliency, and wellness. Successful efforts have eliminated these practices in psychiatric hospitals, forensic psychiatric settings, therapeutic schools, residential treatment centers, and jails and criminal justice settings.
Trauma and Violence - What is Trauma and the Effects? | SAMHSA