June 24, 2024

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Understanding healthcare systems through stories of moral distress | Institute of Health Sciences Education

4 min read

From her recent publication in the British Journal of General Practice (BJGP) to her new appointment as Assistant Professor in the Institute of Health Sciences Education (IHSE) at McGill University, Monica Molinaro, PhD, has had a hectic Fall semester.

Since her arrival, she has been co-teaching Advanced Qualitative Research: Philosophical and Theoretical Foundations with Elizabeth Anne Kinsella, Director of the IHSE – a course that Prof. Molinaro herself took as a PhD candidate at Western University.

At the IHSE, she also continues her research into one of the most urgent issues in health sciences education – moral distress among healthcare providers.

Moral distress has been defined as when an individual knows the right thing to do, but institutional or other constraints – such as staffing shortages, increased workload and issues related to remuneration – make it almost impossible to pursue the right course of action.

Prof. Molinaro’s latest research focuses on the experience of moral distress among family physicians, specifically those who care for patients experiencing health needs related to social inequity (e.g. precarious housing, poverty, racism, substance use, or mental ill health).

The study found that family physicians experience moral distress when unable to offer crucial resources to improve the health of patients with complex social needs resulting from structural features of the Canadian health and social welfare system.

Prof. Molinaro also appeared on the BJGP Interviews podcast and the journal’s YouTube channel to discuss the findings – some of the first that shed light into moral distress experiences in family medicine.

“Research into moral distress is rife with potential for understanding our healthcare system, how that system is structured, how healthcare is delivered, and how we can ensure our healthcare providers do not experience moral distress as a result of structural deficits,” Prof. Molinaro says. “Ultimately, moral distress not only affects them, but it also affects how, or if, patients receive care.”

Moral distress rooted in structural issues

Prof. Molinaro first explored moral distress in her PhD thesis, which examined experiences of the phenomenon among pediatric oncology nurses. Looking back at her interviews with the nurses, she recalls that moral distress was reflected “in every single thing the nurses told me.”

Although those interviews took place as the COVID-19 pandemic hit, Prof. Molinaro notes the nurses’ experiences of moral distress were frequently, “rooted in historical, structural issues in relation to payment, staffing, workload, and the incongruency between the realities of practice versus their education.”

“With COVID, these historical issues became much worse,” she adds. “They were exacerbated by the pandemic, so healthcare providers were operating in a very urgent, stressful situation that broke open many cracks in the healthcare system.”

From there, Prof. Molinaro built upon her expertise, using narrative and other qualitative methodologies to examine experiences of moral distress in other healthcare contexts. She explored provision of morally and ethically complex health care during her research assistantship at Western University’s Centre for Education Research and Innovation (CERI) and in her Banting post-doctoral research fellowship at McMaster, where she now holds an appointment as a McMaster Education Research, Innovation and Theory (MERIT) Scholar.

Interest in moral distress has grown exponentially in recent years, but Prof. Molinaro cautions against conflating it with general stress or anxiety. She adds that scholarship that understands moral distress as a phenomenon related to structural issues – rather than difficulties that an individual experiences – can pose crucial questions about healthcare policy and health sciences education.

“Moral distress has been understood as an individual issue – the idea that people experience moral distress when they have bad coping skills, or are not resilient enough,” she explains. “That’s not okay, because we’re pushing responsibility for structural issues onto the individual. It’s up to those responsible for making these broader decisions with downstream effects like moral distress to make decisions that ultimately benefit our healthcare providers.”

“What benefits healthcare providers’ well-being and their conduciveness to staying in the profession is what benefits the people receiving care from them,” she adds.

Hopes to never stop learning

Prof. Molinaro is excited about what lies ahead at the IHSE. In the new year, she’ll be releasing a podcast: Narrative Remedies: Re-Scripting Care, which will share stories from the health care practitioners documented in her dissertation and act as a resource for health care researchers and clinicians, graduate students, and general audiences to hear about the inner workings and benefits of critical narrative research. She’ll also be writing up the results of another study examining moral distress experiences in family medicine and critical care during the COVID-19 pandemic.

About the IHSE, she says: “This is an environment that is so supportive and conducive to everyone’s success, in a way that I think is quite rare in many academic contexts. They aren’t just investing in me as an academic, they are investing in me as a person.”

“My hope is that I’m never going to stop learning in some way,” she adds. “Here, I feel reassured that learning will always be taking place for me, whether it’s methodologically, philosophically, theoretically or foundationally.”

Elizabeth Anne Kinsella, PhD, Director of the IHSE, says the Institute is thrilled to welcome Prof. Molinaro, adding that she “draws on a fresh set of conceptual and methodological perspectives to tackle some of the most pressing challenges facing healthcare practitioners, educators and healthcare systems.”

“Her research is already making an impact, gaining international attention, and helping us to think about how we can design education, structure practice, develop policy and create healthcare systems that better support health professions students and practitioners.”


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