I had a patient who had once been a psychiatrist and left the field to return to general medicine. He was an active duty Service member who'd had multiple deployments. I remember thinking that he had become so burned out from working with Service members around behavioral health issues and combat that he had to leave that part of the profession altogether. But even then, I realized that "burned out" did not capture what I was seeing in him. It was something more than that. More than just becoming overwhelmed with the system to the point of needing to leave. It was more than what we think of as “compassion fatigue” as well. Back then, I didn’t have a term to describe why he left. But now I believe it is what the field is calling "moral distress" or, more specifically, the impact of moral distress, moral residue, and the crescendo effect.
The fields of medicine and nursing have been looking at moral distress for a few decades now. While there is much debate about the specific definition of "moral distress," there is agreement that it is something different than compassion fatigue, burnout, and even moral injury. The term seems to represent a state that all of us may experience under specific circumstances, regardless of whether a lasting disorder comes from it, similar to depression. As with any phenomenon, the struggle to define it adds to the complexities of how to address it.
The concepts of moral distress, moral residue, and the crescendo effect may become highly significant for behavioral health providers as the COVID-19 pandemic continues, and as we find ourselves treating more medical and medical support workers. Personally, simply having the conceptual vocabulary has helped me to understand and explain what is happening with some of my patients, both in the medical field and military combat arenas. While the following concepts are still being discussed and refined in the research world, it is important for us to know them and apply them to both what we know and will hopefully learn about helping our medical care colleagues.
There are a number of articles about moral distress in nursing, as well as references to moral residue and the crescendo effect. Below, I am referencing three that I found particularly helpful in understanding these concepts. Full references for these can be found at the end.
What is Moral Distress?
This was first defined by Andrew Jameton in 1984 and has since gone through a few modifications. A Green Paper published in February 2018 by David Batho and Camilla Pitton, cited below, thoroughly reviewed various definitions and case examples and identified key elements involved with this phenomenon. From their review, they propose the following, which I believe captures the essence of what most professionals are describing:
The cause of a morally compromising situation is not easily identified. Sometimes there may not be a clear way to identify the “right or wrong” actions in a situation. There may also not be a clear person or agency to blame for the restrictions causing the moral discord. Even when there is a definitive event, such as with COVID-19 and having more patients than medical capacity, caretakers are still left with having to face their own limitations and capabilities. “The unstable oscillation between seeing oneself as a passive victim, on the one hand, and seeing oneself as a perpetrator, on the other, is likely to generate painful feelings of paralysation…” (Batho, 2018, p. 20).
What are Moral Residue and the Crescendo Effect?
Jameton’s original description of moral distress included two parts: 1) the initial distress and 2) reactive distress. The initial distress period ends with the situation while reactive distress remains. Different researchers have expanded on this and redefined these ideas as moral distress and moral residue. Included are the Epstein and Hamric (2009) and then Epstein and Delgado (2010) articles cited below. They describe moral residue as follows:
It is this residual distress that can cause so much damage over time, especially when the person is repeatedly exposed to morally distressing events. Epstein and Hamric (2009) termed this the crescendo effect. While people do recover to some degree from these events, repeated exposure builds up over time. Their 2009 article provides the following visual model:
This illustration looks very similar to what behavioral health scientists call moral injury. While I agree that we are talking about similar things, this model seems to more clearly describe how it may not be just one event that leads to the injury. Instead, it can build up over time and should thus be referred to more collectively. This is something that I have definitely seen with combat Veterans. I have previously struggled with applying the concept of "a moral injury" because many Veterans could not identify any single situation. They instead described it as a collective experience. The above concepts have helped me better describe their situations. And, unfortunately, I believe it will help me better understand what we are and will be seeing with COVID-19 health care workers.
What to do?
Scanning current literature at this time does not reveal clear, evidence-based guidance for treating moral distress and residue separate from what we already know about working with moral injury. However, there have been suggestions that if we are able to intervene early on, we can help keep individuals from progressing. Below are tables from Epstein and Hamric (2009) with recommendations on how to help individuals facing moral distress:
Table 3, page 18
It may also be helpful to have a general understanding of the reactions we may see in people faced with moral distress. Batho and Pitton (2018) propose three general response descriptions people may experience.
Rebellion: This reaction can be seen when a person rejects the morally distressing situation while still holding on to the overall moral principle. In other words, they remove themselves from the immediate situation causing the distress.
The individual can:
Acquiescence: This reaction consists of the person accepting the situation while letting go of or loosening their conflicted moral principles. Two ways this can be seen include:
Rediscovery: While the above two options either reject or accept the situation, this option reflects a complicated combination of the two.
As providers supporting the COVID-19 frontline workers, it is important that we help and intervene where we can. But first, we need to understand the psychological toll that these frontline workers may experience as a result of accumulated exposures to morally compromising situations. Many of us will even read this and see ourselves among the descriptions. Buildup of distress over time must be acknowledged and understood so we can continue to move forward with finding the best ways to support our health care colleagues.
For more detailed information, please read the below articles. They are available in full-text format on the internet. I also encourage you to do a search for moral distress and the crescendo effect if you want to read more on these.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Debra Nofziger, Psy.D., is a Senior Military Internship Behavioral Health Psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Dr. Nofziger is currently located at the Brooke Army Medical Center, TX.
Batho, D., & Pitton, C. (2018, February). What is moral distress? Experiences and responses. (The Ethics of Powerlessness). The University of Essex. Retrieved from https://powerlessness.essex.ac.uk/wp-content/uploads/2018/02/MoralDistressGreenPaper1.pdf
Epstein, E., & Delgado, S. (2010). Understanding and addressing moral distress. The Online Journal of Issues in Nursing, 15(3). Manuscript 1. https://ojin.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/Courage-and-Distress/Understanding-Moral-Distress.html
Epstein, E., & Hamric, A. (2009). Moral distress, moral residue, and the crescendo effect. Journal of Clinical Ethics, 20(4), 330-342.