Dr James Cheong, Consultant at Medical Protection is a Family Physician in private practice and serves as a Clinical Sub-Lead in the Central North Primary Care Network in Singapore. He is a Fellow at the Ministry of Health Office for Healthcare Transformation (MOHT), where he contributes to national efforts in community mental health and primary care transformation.
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Healthcare practitioners should recognise moral distress both in themselves and in their colleagues and intervene early. Addressing and alleviating moral distress is a shared responsibility of both individuals and organisations. Although moral distress cannot be completely eliminated in healthcare, its impact can be mitigated. Doing so not only supports practitioners' well-being but also enhances patient care, improves outcomes, and reduces the likelihood of errors.
Moral distress, a term first introduced by Andrew Jameton in 19841, refers to the situation when healthcare practitioners recognise the ethically appropriate course of action but are prevented from acting by internal or external constraints, leading to negative emotional responses.2 It erodes their ethical integrity and commonly manifests as anger, frustration, negative self-image and a sense of disempowerment. Moral distress can occur in all clinical settings, especially in emergency, intensive, paediatric and palliative care.
Prolonged moral distress contributes to compassion fatigue and burnout and may precipitate mental health conditions such as depression.3 These consequences not only compromise the well-being of healthcare practitioners but also diminish the quality of care delivered, reduce patient satisfaction, and thereby increase medicolegal risk. Addressing moral distress is therefore essential both for healthcare practitioners and patients.4
Causes of moral distress
Moral distress can arise from both external and internal constraints.5
External constraints refer to factors such as limited time, insufficient resources (e.g., medications, equipment, or supplies), financial barriers, and competing workloads that hinder practitioners from delivering care in accordance with professional standards. These pressures can be amplified during healthcare crises, such as pandemics or natural disasters, where resource rationing may require prioritising some lives over others.
An unsupportive work environment, marked by poor collegiality, uncaring leadership, and insufficient organisational support, can leave practitioners feeling isolated and powerless, hindering their ability to act in the best interests of patients. Moral distress is further heightened when practitioners’ values conflict with those of their organisation, such as when cost-cutting or revenue-maximising priorities take precedence over quality of care, resulting in suboptimal patient outcomes.
Internal constraints relate to the characteristics of individual practitioners. Lack of confidence, self-doubt, inadequate knowledge, negative coping styles, and personality traits such as perfectionism, over-conscientiousness, and rigidness can trigger moral distress.
Addressing moral distress
Strategies to address moral distress need to involve both individual practitioners and healthcare organisations6. For the individual, adopting positive coping strategies is crucial. Aligning and reconciling one’s personal values, beliefs, and professional goals with those of the organisations, and with the practical realities of medical practice, can help reduce moral distress while strengthening a practitioner’s sense of agency and autonomy in care delivery. Where misalignment is profound and irreconcilable, practitioners may need the moral courage to step back or disengage from organisations whose ideals and practices conflict with their own.
A helpful tool to handle moral distress is the American Association of Critical Care Nurses’ 4 A’s framework7, which encompasses:
Ask: Asking questions to recognise the presence of distress.
Affirm: Acknowledge the distress, validate the feelings and make a commitment to act.
Assess: Identify sources of distress, the severity and readiness to act.
Act: Prepare, take action and maintain desired change.
At the organisational level, fostering a healthy ethical climate is key. Clear guidance on appropriate conduct, transparent processes for handling ethical issues, and open channels for communication and discussion all help practitioners manage and reduce moral distress. In addition, cultivating a caring and compassionate workplace culture strengthens resilience and equips practitioners to navigate ethical dilemmas more effectively.
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References
1. Jameton, Nursing Practice: The Ethical Issues.[1984] https://archive.org/details/nursingpracticee0000jame/page/n3/mode/2up
2. Kherbache, Mertens, and Denier, Moral distress in medicine: An ethical analysis. [2021] https://journals.sagepub.com/doi/10.1177/13591053211014586
3. Brune, Agerholm, Burström, Liljas, Experience of moral distress among doctors at emergency departments in Stockholm during the Covid-19 pandemic: A qualitative interview study. [2024] https://www.tandfonline.com/doi/full/10.1080/17482631.2023.2300151
4. Brune and Liljas, Communication barriers and perceptions of moral distress among doctors in emergency departments. [2023] https://pubmed.ncbi.nlm.nih.gov/38115277/
5. Kherbache, Mertens, and Denier, Moral distress in medicine: An ethical analysis. [2021] https://pubmed.ncbi.nlm.nih.gov/33938314/https://pubmed.ncbi.nlm.nih.gov/33938314/
6. Kherbache, Mertens, and Denier, Moral distress in medicine: An ethical analysis. (PDF). [2021] Kherbache_Mertens__Denier_2021_-_Moral_Distress_in_Medicine_-_JHP
7. Rushton, Defining and addressing moral distress: Tools for critical care nursing leaders. [2006] https://pubmed.ncbi.nlm.nih.gov/16767017/