By Richard Rudolph
It is a calling to serve patients who suffer with behavioral health issues. The staff who work in this field understand the special issues of these patients and the most helpful interventions for this population. But oftentimes, constraints within the healthcare system make it hard to achieve what is most helpful for patients.
To gain a deeper appreciation for this topic, I interviewed 10 staff members at Mercy Health Clermont Hospital’s Behavioral Health Institute about the moral distress that they experience. This is a state-of-the-art facility offering both inpatient and outpatient care using a recovery-based model at a regional hospital in southwest Ohio. The group interviewed included psychiatrists, therapists, nurses, technicians, and managers who represent the staff on this unit. As a chaplain, I work closely with this group of caregivers to provide support to their patients.
These staff members were asked to describe situations in which they or their co-workers experienced moral distress. Our working definition of moral distress was a distressing situation for a care provider caused by the internal conflict of wanting to do the appropriate, ethical action, but being prevented from doing what they believed was in the best interest of the patient.
A problem for many of those interviewed is treating newly admitted patients who have both acute medical and psychiatric illnesses. These cases present a real challenge in the hospital. In triaging the patient, it is often unclear if the best initial placement is on a medical unit or the behavioral health unit. The behavioral health unit does not offer the advanced medical technologies, and the staff does not have the same comfort level in addressing complex medical needs. However, the behavior of these patients may be so aggressive that it is unsafe for them to be treated on a medical unit. The behavioral health staff experiences moral distress when they believe the patients’ medical needs are not being adequately addressed in the behavioral health unit.
Another cause of moral distress is when it is clear a patient ready for discharge probably will not receive quality ongoing mental health care. The overburdened community systems have backlogs that may extend for months before patients can be treated. Also, some patients lack basic independent living skills, financial resources, and support systems, which may render them homeless. All too often, a crisis occurs in which the individual becomes a danger to themselves or others. So they are readmitted to the hospital via the emergency department. Clinicians feel frustrated and helpless that the system perpetuates this revolving-door cycle and there is little that they can do.
Some patients could take care of themselves in the community but are not committed to making the necessary changes in their lives to stay healthy. Because they are noncompliant with medications and follow-up treatment, they regress and frequently are readmitted. It is a challenge to treat these patients with compassion when they are not committed to their own recovery. Staffers question how they can stretch themselves to care for those with the highest acuity and still maintain compassion for the noncompliant “frequent flyers.”
Another situation that causes moral distress is when patients are admitted with significant eating disorders and other addictions. A general behavioral health unit like ours is not equipped to offer the specific treatment programs required to treat these patients with the best possible outcomes. Our unit engages in multistate searches for placement, often to no avail. So the clinicians do their best to treat the patient while knowing they would be better served elsewhere.
Several months ago, an outpatient took his life at home over a weekend. This caused great distress among the clinicians who had just seen him the previous Friday. When a suicide occurs, clinicians are troubled and ask themselves, “Is there something that I missed that might have prevented this?” and “What more could I have done?” Shock, guilt, anger, fear, and other feelings were present. The staff requested my support for themselves and for the outpatients who had bonded with this patient. Though it is always heart-wrenching, the clinicians who have experienced this before are often better able to put this into perspective. One psychiatrist said, “Severe depression may be a terminal illness.” Even with the best treatments for depression, some patients will take their lives.
The staff was asked what they find helpful in managing their stresses. Several people mentioned sharing one’s feelings with supportive colleagues. “Having even one person I can trust” appears to be key. Some staff members see a professional counselor or therapist. For some, nurturing their spirituality through prayer and other means helps them to find a higher purpose and meaning in their work. This helps to provide peace and sustained motivation. Everyone has his or her own unique ways of recharging and refreshing. Whatever the approach, good self-care (i.e., sleep, nutrition, exercise, family and social life, spirituality) should be a priority.
As a chaplain, I found that exploring the moral distresses of these staff members has given me a greater awareness of the stressors they experience and the importance of providing them spiritual and emotional support. I am grateful to each for their openness to share about the challenges they face and the impact on them and their colleagues.
Richard Rudolph, BCC, is a hospital chaplain at Mercy Health Clermont and Anderson Hospitals in Cincinnati, Ohio.