Moral Distress in Healthcare and First Responders

 

Moral distress was first defined by Andrew Jameton in the 1980s. According to Jameton, “Moral distress arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.”

Moral distress was first recognized among nurses, and the majority of studies have focused on this population. It is important to note that moral distress is not solely a nursing problem. This is particularly prevalent in disaster response situations, where responders are exposed to unsafe environments, overwhelming workloads, and where existing ethical guidelines are not equipped to handle the complexity and pressure of a disaster, and do not adequately address the needs of first responders.

Some examples of first responders' experience that may cause moral distress.

• A Law Enforcement Officer (LEO) for reasons beyond their control, is not able to apprehend a dangerous criminal.
• A fire crew on a hose line might be instructed to evacuate before the primary search team has confirmed whether there are victims in the structure.
• A paramedic might be directed by a supervisor to provide treatment to a patient that goes against their belief on what is medically appropriate.
• An EMS provider who feels a sense of duty to respond and struggles with their moral responsibility to provide care, when a patient denies treatment or transport regardless of medical advice.

The central element in moral distress is the individual’s feeling of powerlessness and their inability to carry out what they believe is ethically right.

External constraints that contribute to moral distress include:

• Power imbalances between members of the healthcare or responder team
• Poor communication between team members
• Pressure to reduce costs
• Fear of legal action
• Lack of administrative support
• Policies that conflict with patient care needs 

Moral distress is a significant threat to an individual’s core values, leading to a sense of inner turmoil and damaging their moral integrity. Over time, this distress can accumulate and result in feelings of helplessness, shame, compromised ethical standards, and emotional pain. It can occur in two stages: “initial distress” at the time of the issue and “reactive distress” later on. Even after the reactive stress subsides, it may leave behind a lasting impact known as “moral residue,” which can have a negative cumulative effect on mental well-being. This psychological suffering can also manifest into physical symptoms and contribute to chronic illnesses. 

One of the main challenges in addressing moral distress is identifying it in the first place.

• New or worsening headaches, heart palpitations, & gastric upset
• Lingering anger
• Feelings of guilt or shame
• Withdrawal and depression

If you suspect you may be experiencing moral distress, it is important to identify, assess, and address it. The presence of moral distress is a sign that ethical challenges are not being addressed adequately. It's important for first responders to recognize when their work has begun to take a toll and seek support and professional help. It’s time to drop the stigma. Seeking help is not a sign of weakness, it's a necessary step towards healing and maintaining overall well-being.

*****

“If you believe change is possible, you want to change, and you are willing to do the work, you absolutely CAN get your life back.”

Get your copy of The Soldier's Guide to PTSD, The Soldier's Workbook, 

or Acknowledge & Heal, A Women's-Focused Guide to PTSD

Cumulative Trauma and First Responders

 

Cumulative Trauma is a term used to describe the psychological, emotional, and physical strain that comes from repeated exposure to traumatic events. For first responders, this can manifest in various ways, depending on the nature of their work. Law enforcement officers (LEOs), firefighters, and emergency medical service (EMS) all regularly face high-stress situations that most people can't even imagine.

First responders need to maintain emotional control in order to effectively help victims. This means that they may not always have the opportunity to fully process their own reactions and emotions during these traumatic events. Over time, this unresolved trauma can take its toll on the responder's mental well-being.

Unfortunately, this means the signs of cumulative trauma are often not acknowledged or addressed.

Indicators of Cumulative Trauma:

• Difficulty concentrating
• Frequent headaches
• Issues with sleep
• Irritability or anger concerns
• Social withdrawal
• Frequent anxious or depressed
• Relationship tension/problems reactions/thoughts
• Thoughts of self-harm
• Low motivation
• Alcohol/drug use problems
• Disciplinary problems at work

 Many first responders suffer in silence, believing that experiencing trauma is just part of the job. But as they progress through their careers, each traumatic event becomes like a heavy rock added to their mental load. And just like carrying a backpack full of rocks, eventually that heavy load becomes too much to bear.

How much can someone carry? The weight is different for each individual, as is how much each individual is capable of carrying.

This cumulative exposure to traumatic stress throughout the first responder’s career causes ongoing distress, often referred to as sub-threshold posttraumatic stress disorder (S-PTSD).

Sub-Threshold Posttraumatic Stress Disorder (S-PTSD) symptoms include irritability, sleep disruption, fatigue, anger, detachment, isolation, alcohol use increase, hypervigilance, startling, physical aches & pains, headaches and anxiety. Diminished quality of life can be ongoing and can contribute to a higher incidence of PTSD.

It's important for first responders to recognize when their work has begun to take a toll and seek support and professional help. It’s time to drop the stigma. Seeking help is not a sign of weakness, it's a necessary step towards healing and maintaining overall well-being. So please, take care of yourself, because you can’t save lives if yours is at risk. 

*****

“If you believe change is possible, you want to change, and you are willing to do the work, you absolutely CAN get your life back.”

Get your copy of The Soldier's Guide to PTSD, The Soldier's Workbook, 

or Acknowledge & Heal, A Women's-Focused Guide to PTSD

Compassion Fatigue and First Responders

 

Compassion Fatigue was a term coined to describe a set of negative psychological symptoms that caregivers experience in the course of their work while being exposed to direct traumatic events or through secondary trauma.

Within the context of first responders’ work, compassion fatigue is the stress resulting from exposure to traumatized individuals in the line of duty and the negative impact on the First responder’s mental and physical health.

It develops due to a combination of prolonged exposure to trauma or traumatized people and includes the inability to emotionally disengage from the suffering of others. The negative effects of providing care are aggravated by the severity of the trauma which the First responder is exposed to. The debilitating effects of Compassion fatigue include exhaustion, anger and irritability, negative coping behaviors including alcohol and drug abuse, become emotionally detached or numb, burnout, and an impaired ability to make decisions and care for patients and/or clients.

 

Let’s look at some of the risk factors which can be associated with Compassion Fatigue:

• A personal history of trauma
• Being overworked, overwhelmed, and/or underpaid
• Having limited professional experience and no training with Vicarious Trauma prevention
• Working with a high percentage of traumatized children
• Working under stressful conditions, with limited resources

 Compassion Fatigue is an erosive process. Dissociation, lack of concentration, as well as emotions like irritability and feelings of helplessness and hopelessness don't get left at work and also interfere with the individual's personal relationships. Over time, compassion fatigue—often exacerbated by stress within the organization and a lack of recognition from the community—can make first responders more susceptible to mental health issues, such as depression, burnout, and PTSD. The added pressure of public criticism and negative media coverage can further erode a First responder’s sense of support from the community and professional pride. This can further affect their overall ability to assist when encountering traumatic events in the line of duty.

• Between 40% and 85% of helping professionals develop Vicarious Trauma, Compassion Fatigue and/or high rates of traumatic symptoms.
• 86% of nurses had moderate to high levels of Compassion Fatigue.
• 15% of general practitioners turned to alcohol, prescription drugs, or both to help them “deal with work pressures.”
• 33% of Law Enforcement showed high levels of emotional exhaustion and reduced personal accomplishment. 56.1% scored high on the depersonalization scale.
• Only 15% of Law Enforcement professionals were willing to seek personal counseling as a result of Vicarious Trauma versus 59% of mental health professionals.
• Estimated prevalence rates of 11% for PTSD, 15% for depression, 15% for anxiety, and 27% for general psychological distress amongst ambulance personnel.

While not an exhaustive list, it definitely shows that those in the business of caring for others tend to be the most at risk.

Compassion fatigue is more likely to occur if first responders are unaware of or ignore warning signs and do not seek help from resources like supervisors, peer-support groups, or clinical practitioners. With that in mind, try to be aware of the following signs:

• Depression
• Frustration
• Feelings of uselessness
• Cynicism
• Feeling disconnected from others
• Worries you’re failing at your job
• Constantly feeling exhausted or tired
• Feeling the need to drink alcohol or do drugs

During a TED Talk in 2017, Patricia Smith, the founder of the Compassion Fatigue Awareness Project, had this to say:

“Caregivers are not good at asking for help. Asking for help is hard, no matter who you are. For nurses, doctors, teachers and more, the idea of leaving work can seem like an impossibility.

You may feel guilty or that you are abandoning your patients or students. But if you are struggling with drug or alcohol use, you need help too. Your clients, patients, and students will be happy for you.”

It's important for first responders to recognize when their work has begun to take a toll and seek support and professional help. It’s time to drop the stigma. Seeking help is not a sign of weakness, it's a necessary step towards healing and maintaining overall well-being.

*****

“If you believe change is possible, you want to change, and you are willing to do the work, you absolutely CAN get your life back.”

Get your copy of The Soldier's Guide to PTSD, The Soldier's Workbook, 

or Acknowledge & Heal, A Women's-Focused Guide to PTSD

Self-Medicating and Substance Use Disorders among First Responders

 

I’ve said it before in previous blogs, as well as in each of the books in the PTSD Recovery series, but it’s worth repeating:

Drug and alcohol abuse make a lot of sense in the context of PTSD. Criterion C of PTSD is avoidance, and drinking and drugging help us to avoid our feelings. Criterion D is all about changes in the way we think and feel, and alcohol and drugs can play a major role in this.

Now, self-medicating is a term used to describe individuals who turn to drugs or alcohol as a way to cope with overwhelming emotions and feelings that they are not ready or able to confront.

Alcohol, tobacco use, and excessive painkiller usage are common forms of self-medication.

According to the National Center for Injury Prevention and Control, CDC. Mental stress of the job can lead to substance and alcohol abuse as a way of coping with the stress.

Now let’s narrow the focus to first responders, who arguably have some of the highest stress jobs out there. It’s no surprise that they also show a higher rate of alcohol consumption when compared to the general population.

Chronic exposure to human suffering, tragic exposure to mangled bodies from an accident, the shrill cry of a mother screaming over her dying baby, being physically threatened while trying to save someone's life, having to deal with the gruesome reality of a drug overdose or suicide, going into a burning structure hoping to save those inside while knowing you are too late. Any one of those things could break the strongest person. But for first responders, this might be a single day's worth of emergency calls.

They’re trained for this, though, right?

Sure. But consider the constant pressure to remain composed during one crisis after another. We’ve mentioned cumulative trauma already and its effects. It’s common for first responders to develop co-occurring mental health and substance use disorders (SUDs). The long 24-hour shifts and traumatic calls lead countless first responders to develop mental health conditions such as acute stress disorder, depression, and post-traumatic stress disorder. Many individuals struggling with these issues turn to drugs and alcohol as a means of symptom relief. That’s Criterion D mentioned above.

While dealing with job stress is a factor, first responders may also turn to alcohol for other reasons. Sometimes, a cold beer (or a few) at the end of a tough day eases the tension. For others, maybe they need to take the edge off of their physical pain from injury or muscle strain and they grab their bottle of painkillers. No one likes to be in pain, whether mental or physical, so numbing it is one answer. And an easy habit to fall into.

Social drinking is also good for bonding with your peers. You’ve been through hell with your fellow first responders all day, and it would be a shame to miss some quality relaxation time with your pals once the shift ends. Problems related to substance abuse are easily hidden in a work culture where de-stressing with alcohol and comradery is normal.

The National Survey on Drug Use and Health revealed that up to 29% of firefighters engage in alcohol abuse, and as many as 10% of firefighters may be currently abusing prescription drugs.

Sometimes sleep or pain medication, while off-duty, is just the thing to help an aching first responder fall asleep after a crazy 24-hour day.

According to SAMHSA, 36% of EMS workers suffer from depression, 72% of EMTs suffer from sleep deprivation, and more than 20% of EMTs suffer from PTSD; all of which puts them at an increased risk of substance abuse.

Most people don't even realize they have an SUD until they try to cut down or face negative consequences from their self-medicating.

The good news is that substance use disorders are treatable. However, seeking help is often seen as a weakness in the first responder community, where being tough and resilient is essential.

It’s time to drop the stigma. When the work has begun to take a toll on mental and physical health, professional help is needed. That's the bottom line.

Seeking help is a necessary step towards healing. There are options available to use, and recovery is possible.

*****

“If you believe change is possible, you want to change, and you are willing to do the work, you absolutely CAN get your life back.”

Get your copy of The Soldier's Guide to PTSD, The Soldier's Workbook, 

or Acknowledge & Heal, A Women's-Focused Guide to PTSD