The Australian healthcare system was struggling to meet the demands of its people prior to the COVID pandemic. As with many countries, its health system shifted into crisis when the pandemic hit. One significant contributing factor to the severity of the crisis is the worsening skilled workforce shortage, with moral distress and injury as considerable reasons for this shortage. Yet it could be a catalyst to re-examine the approach taken by a healthcare system that has failed. I posit that whilst the healthcare system evolved in siloes with increasing specialities, subspecialities and prominence of other disciplines, it is time to view the system as a dynamic integral whole, with communication as central.
Moral distress and moral injury.
The phenomenon of moral distress has been described variously as the psychological disequilibrium experienced when individuals are unable to act according to their moral judgements/values because of personal and external constraints.[1] This impacts on health professionals’ moral integrity, identity, and agency. When unresolved, the cumulative moral residue can decrease resilience to further moral challenges. This may negatively affect the individuals’ physical-psycho-social and spiritual well-being, resulting in burnout, mental illness, and cause some to leave their profession. Its impact is not just on individuals. Moral distress, residue, burnout, and mental illness can negatively affect social and professional relationships. A considerable number leaving the skilled workforce impacts those left behind, and in combination, can further significantly stress a healthcare system. Moral injury is a violation of the individual’s moral code, either by themselves personally or by others, or a “betrayal by a trusted person in a high-stakes situation.”[2] Its impact on the individual is considered greater than that of moral distress. Hence, an ailing workforce in number, skill and well-being is a good indicator of the state of a healthcare system.
Healthcare system pre-COVID.
Australia’s bi-system of universal and private healthcare was struggling pre-COVID. Hospitals were crying out for more funding with increasing demand from an aging population with more chronic diseases. Waiting lists for specialist outpatient care and procedures were lengthening. Access to emergency care was at tipping point. General practices (primary healthcare providers) were struggling financially with Medicare[3] rebates relatively stagnant for years. Rising costs of running practices, encouraged shorter consults to make ends meet.[4] The GP workforce was dwindling, especially in rural areas with reports of growing GP burnout and poor mental health.[5],[6] Mental healthcare was wonting with more and more people experiencing anxiety, depression, and other mental illness.
Patchwork attempts to address these struggles were often ineffective, took too long to come into effect or often added to the complexity of service provision and workplace stresses for health professionals. Funding was limited as federal and state governments continually sparred on who should be responsible for healthcare costs. Numerous cries for improvement came from hospitals, general practices and professional bodies. Barriers and ineffective complex systems were named, alongside the lack of communication between specialities, between hospital and community care. Solutions offered by various healthcare organisations and professional bodies were often siloed solutions and thus limited. Occasionally the government would contribute millions of dollars in building new hospitals or sections of hospitals, but the dysfunctional “operating system” remained the same. Clearly this siloed approach was ineffective, and at times worsened the situation.
Australian healthcare crisis—an integrated response.
When the COVID 19 pandemic arrived in Australia, the already struggling system went into crisis. Considerable daily ethical challenges and experiences of moral distress/injury became commonplace across all sectors, especially in healthcare. Reports of increasing work-related psycho-social-spiritual and physical stresses resulting from rapidly rising demand for complex care provision, coupled with the fear of being infected by COVID (self and family) and the possible outcomes, including death, was common. These resulted in a huge loss in skilled workforces.[7]
This crisis affirms the argument in moral distress literature that addressing moral distress must involve both systemic and individual change. Individual health professionals have capacity to address their moral distress and build moral resilience. However, these pale into insignificance against a system that appears to perpetuate the daily stresses health professionals face. These include workforce shortages, time-consuming, complex reporting systems and complicated processes limiting accessibility to other services. Other stresses named are poor communication across disciplines and services, and the omitting of certain practices and services because of a lack of funding. At times the healthcare system seems to rely on the goodness, altruism and generosity of staff to give more than is fair or just.
A new paradigm
As with moral distress, if change for the better is to occur, new approaches and perspectives that consider the integral whole of healthcare with all its complexities are needed. These include consideration for:
- the type of care (acute/chronic/emergency and general/specialist);
- where care is delivered (community/hospital/residential aged care/mental health/disability care);
- who is being cared for and expectations (whole patient care involving family and multicultural communities);
- the values of healthcare organisations in the provision of care and their ethical practices, including care of the environment;
- good, timely and clear communication,
- care of all staff, including collaboration in decision-making—listening and finding creative solutions together
- creating environments that encourage, sustain and nurture the living of values thus affirming staff’s moral integrity, identity and agency
and the list continues. Australian context has changed. Medicine, once general, has evolved significantly into siloed specialties and sub-specialties. Australia is now a multicultural nation with varying values and expectations that have changed over time. Where once understanding and knowledge were siloed, we now recognise that everything is connected and part of a whole. No longer can we treat the physical without considering the psychological, spiritual, social, and even financial aspect of a person’s life. No longer can we claim to provide good healthcare whilst contributing to poor health outcomes with the choices we make impacting negatively on the environment. A total shift in thinking is needed to address an increasingly complex, multicultural nation with its spectrum of moral values, beliefs, perspectives, and expectations.
Faith-based healthcare organisations can seize this opportunity, if they haven’t already, to be leaders in creatively changing the Australian healthcare system. They can strongly advocate for a system that can accommodate all values and beliefs, one that is just, equitable, cost-effective and serves the people for whom they were founded, and those who provide the service.
Conclusion
Putting new wine in old wines skins is unlikely to work. A new paradigm that embraces differences, involves all, sees the interconnectedness in all things and creatively finds solutions for the larger whole as well as for each member sounds simple, though not easy, is possible.
—
[1] There have been numerous definitions of moral distress—both broad and specific and it is beyond the intention and scope of this article to explore this. See: Burston, A. S., & Tuckett, A. G. (2012). Moral distress in nursing: Contributing factors, outcomes and interventions. Nursing Ethics, 20(3), 312–324. https://doi.org/10.1177/0969733012462049 and Morley, G., Bradbury-Jones, C., & Ives, J. (2021) Reasons to redefine moral distress. Bioethics, 35(1), 61-71. https://doi.org/10.1111/bioe.12783
[2]Williamson, V., Murphy, D., Phelps, A., Fornes, D., Greenberg (2021). Moral injury: the effect on mental health and implications for treatment. The Lancet Psychiatry, 8(6): 453-455. https://doi.org/10.1016/S2215-0366(21)00113-9
[3] Medicare is a national insurance scheme that provides free or subsidised healthcare for Australians
[4] https://www.abc.net.au/news/2019-05-22/medicare-changes-see-doctors-pulling-out-of-outer-metro-areas/11134250
[5] https://www.racgp.org.au/getmedia/bacc0983-cc7d-4810-b34a-25e12043a53e/Health-of-the-Nation-2019-report.pdf.aspx
[6] The contribution of moral disequilibrium, moral distress or injury was not elucidated in this survey of doctors and medical students. https://medicine.uq.edu.au/files/42088/Beyondblue%20Doctors%20Mental%20health.pdf
[7]https://www.apna.asn.au/about/media/one-in-four-primary-health-care-nurses-plans-to-quit ; https://online.vu.edu.au/blog/understanding-nursing-shortage-australia; Hill, Michella, Erin Smith, and Brennen Mills. 2021. “Willingness to Work amongst Australian Frontline Healthcare Workers during Australia’s First Wave of Covid-19 Community Transmission: Results of an Online Survey.” Disaster Medicine and Public Health Preparedness:1-7. doi: 10.1017/dmp.2021.288. https://doi.org/10.1017/dmp.2021.288; https://www.racgp.org.au/getmedia/bacc0983-cc7d-4810-b34a-25e12043a53e/Health-of-the-Nation-2019-report.pdf.aspx; https://www.abc.net.au/news/2022-09-26/amaq-union-survey-reveals-junior-doctors-fatigued-worried/101468680