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Moral Distress Experienced by Psychology Trainees in Multidisciplinary Team Settings
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Moral Distress Experienced by Psychology Trainees in Multidisciplinary Team Settings

Kayleigh Hale, M.A.

 

While attending a multidisciplinary team meeting, a psychology trainee overhears members referring to a medical inpatient with mental health symptoms as a “stupid,” “nasty, nasty man.” The trainee feels distressed, hesitant, and unsure of how to respond, perhaps knowing the “right” thing to do, but not acting accordingly.

 

Increasingly integrated into primary care models, psychology trainees are represented within multidisciplinary teams. The benefits of these collaborations include optimizing patient outcome through a holistic approach and facilitating contributions from multiple professions (Fouad et al., 2009). However, such environments may simultaneously cause trainees to be exposed to certain types of strain, resulting in what has been termed moral distress, as was depicted in the previous scenario.

 

The Manifestation of Moral Distress in Multidisciplinary Contexts

Moral distress has been defined as being “caused by situations in which the ethically appropriate course of action is known but cannot be taken” (Elpern, Covert, & Kleinpell, 2005), as the “experience of cognitive-emotional dissonance that arises when one feels compelled to act contrary to one’s moral requirements” (Berger, 2014), and as a reaction that arises when moral responsibility is not consciously acted on (Austin, Rankel, Kagan, Bergum, & Lemermeyer, 2005b). Such experiences may occur more frequently in multidisciplinary environments, in which professionals from varied backgrounds often present with equally varied personalities, attitudes, and communication styles. Moreover, the setting is often ripe with political, social, and personal matters, which result in conflict and power struggles (Austin et al., 2005b). Much of the literature on moral distress focuses on that experienced by nurses (Austin, Lemermeyer, Goldberg, Bergum, & Johnson, 2005a) and medical students.

 

Navigating these dynamics may be particularly challenging for trainees, potentially increasing the risk of moral distress. For example, trainees may spend significant time and energy deliberating the temporary nature of the traineeship position, their lack of knowledge of the team’s process, their place in the team’s hierarchy, and their role. Trainees may also fear alienation (Austin et al., 2005b) or retaliation. Ultimately, while the benefits of team-based practice are clear, the paths of responding ethically to conflictual issues may be comparatively murky, resulting in moral distress.

 

Sample Scenarios Eliciting Moral Distress

The primary focus of multidisciplinary team meetings is to create a forum for discussing patient care (Bokhour, 2006). However, meetings may digress into apparent “venting” about patients, particularly those experienced as especially challenging. While ideally a safe place in which to express concerns via a genuine dialogue, this behavior may result in trainee moral distress if not managed ethically.

 

Consider the following scenarios:

 

A medical patient with comorbid conversion disorder presents with new physiological symptoms. Members of the team roll their eyes, present as clearly irritated, and immediately consider the patient’s symptoms as somatization. When the patient appears to experience a seizure during a psychotherapy session, the treating trainee immediately facilitates a transfer for acute medical attention. When the team learns of this incident, certain members become agitated, quickly refer to the episode as a “pseudoseizure,” and imply that the trainee acted beyond his/her scope.

 

During a hospice team meeting, certain members discuss a patient with dementia in an infantilizing manner. They describe the patient as “cute” and laugh while referencing a tendency for the patient to refer to the treating physician as “dolphin” rather than “doctor.” The trainee is relatively new to the team and feels as though he/she has not yet established status within the group. Wondering whether to suggest that the patient’s phonemic errors relate to the etiology of dementia, remind members to honor the patient’s dignity, or remain silent, the trainee is stymied.

 

A trainee notices that team members are particularly judgmental, angry, and even hostile when a patient with cancer and HIV expresses hesitance to inform their partner of their HIV+ status. The patient is referred to as “selfish,” and it is suggested that the patient’s partner will “find out once [the patient] dies!”

 

Potential Response Options, Ethical Considerations, and Competency Guidelines

Clinicians may act contrary to their moral requirements as a result of internal constraints/failures or external constraints/barriers (Austin et al., 2005b). Regardless of precipitant, there are a number of ways in which psychology trainees might navigate challenging situations. The aim is not to eliminate moral distress, it is not to become morally blunted. Developing an awareness of moral distress may facilitate authentic communication and an enhanced understanding of ethical practice (Austin et al., 2005b).

 

Trainees responding to challenging scenarios may hope to combine maintaining patient-centered care, taking a stand, and protecting themselves while considering timing and familiarizing oneself with the group’s cultural context. Options are to remain silent, take a stance, act anonymously, seek support from colleagues, exit (Austin et al., 2005b), discuss the strain with a supervisor, seek consultation, and/or engage in internal reflection.

 

The APA Ethics Code (American Psychological Association, 2010) and competency benchmarks document influence how one responds (Fouad et al., 2009). Referring to the APA Ethics Code represents a primary, critical step in thoughtful ethical problem solving. General Principles A and E, in addition to Standard 3, are especially relevant. Principle A, Beneficence and Nonmaleficence, indicates that psychologists “take care to do no harm,” and “seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons.” It is important for psychology trainees to take steps to avoid or minimize harm. General Principle E, Respect for People’s Rights and Dignity, states psychologists respect patients’ dignity, worth, and self-determination. In addition, referring to 3.09 Cooperation with Other Professionals, the trainee should attempt to maintain interprofessional cooperation, effective collaboration, and appropriate behavior, especially when discussing patient care.

 

According to the competency benchmarks document, trainees are expected to demonstrate essential components as evidenced by specific behavioral anchors (Fouad et al., 2009). Components within the domains of interpersonal relationships, professionalism, ethical and legal standards and policy, and interdisciplinary systems are most germane to this discussion. To be classified as competent, trainees must exhibit and maintain effective and professional relationships with team members, including respectful/collegial interactions and effective negotiations of conflict/complexities (Fouad et al., 2009). Thus, trainees should select a response option that most effectively manages the situation while also protecting the interprofessional relationship.

 

For ethical legal standards and policy, trainees must demonstrate an awareness of the “obligation to confront peers and or organizations regarding ethical problems or issues and to deal proactively with conflict when addressing professional behavior with others.” This supports the decision to take a stance, and discuss the issue with a supervisor to understand the differing ethical guidelines at play in a multidisciplinary setting. However, there may also be circumstances in which leaving is the sole option (Austin et al., 2005b).

 

Competency benchmarks pertaining to interdisciplinary systems suggest that trainees demonstrate an ability to “deal effectively with disagreements about diagnosis or treatment goals” while exhibiting “respectful and productive relationships with individuals from other professions.” This further emphasizes the need for trainees to balance respect with action when considering their next steps.

 

It is strongly recommended that psychology trainees foster an awareness of moral distress experienced in multidisciplinary contexts, relevant applications of the ethics code, competency guidelines, and supervisor support. Ultimately, this can occur with patients’ well-being held at the forefront.

 

LACPA member Kayleigh Hale, M.A., is a doctoral student at Pepperdine University and LACPA Ethics Committee Student Representative. Ms. Hale’s professional interests include ethics, clinical neuropsychology, and serving the Veteran patient population.

 

 

References are available on request from the LACPA office, lacpa1@gmail.com.

 

 

 

 

 

 

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