Quality in healthcare is not only a question of technical and scientific proficiency, but also of the professionals’ attitudes and their ability to identify and handle value conflicts. Research has shown that traditional work-environment factors such as lack of time to do a proper job and too heavy a workload, increase stress related conditions and reduce work satisfaction.1 2 Work conditions limit the professionals’ ability to act according to professional and ethical ideals. High ethical ideals constitute an important part of a professional self image,3 4 and being forced to work contrary to such ideals may reduce work satisfaction and increase the feeling of distress.

One definition of moral distress is “traditional negative stress symptoms that occur due to situations that involve ethical dimensions and where the healthcare provider feels she/he is not able to preserve all interests and values at stake”.5 This definition includes distress caused by conflicting ideals and by moral uncertainty, as well as external constraints which prevent the healthcare worker to act according to professional and ethical ideals. Examples of conflicting ethical principles are the principle of respect for patient autonomy and the principle of justice, or solidarity with the weak. In Norway the principle of patient autonomy has been formalised with The Patient Rights Act of 1999. At the same time consumerism has entered healthcare. Strengthened patient’s rights may give rise to moral distress if doctors feel pressured to choose an alternative with which they are not professionally comfortable or which may require seemingly unnecessary resources. If empowered patients lead to more futile interventions with marginal utility, it may threaten weaker patients with less ability to fight for their interests. After the US, Norway together with Switzerland rank highest among the Organisation for Economic Co-operation and Development countries on percentage of gross national product spent on healthcare, but still our healthcare workers need to prioritise and ration healthcare.6

The medical culture itself may also create ethical conflicts and moral distress. One example is the medical profession’s defensive attitude towards complaints and criticism.7 8 Few things in medicine are indisputable, and value issues which may generate conflicts should be debated openly. Hurst et al9 have found that doctors faced with ethical dilemmas tend to avoid conflict as a coping strategy. Fear of being categorised as incompetent or of losing professional authority are potential reasons for not giving feedback to colleagues on their unethical or unprofessional comportment, or for not reporting adverse advents.10 In a previous study we have shown that many Norwegian doctors report low tolerance for criticism of unprofessional and unethical conduct at their workplace.11 The study also demonstrated a positive correlation between working in a setting with high tolerance of appropriate critical feedback and collegial support for those who had been involved in serious iatrogenic patient injury. Thus, a culture which tolerates criticism is not necessarily a cold and hostile culture. A more intolerant culture in this respect may suppress the open and systematic discussion of ethical dilemmas both before an action is taken and retrospectively, when a controversial decision has been made. Doctors may refrain from taking difficult ethical cases to ethics consultation services because of fear of opposition, or even hostility, from colleagues.12 Lack of openness towards criticism and lack of willingness to discuss difficult matters clearly may attenuate support in ethical dilemmas, and may thus increase moral distress.

Moral distress has been described as an important source of stress and burnout among healthcare workers.5 13 14 Kälvemark et al5 used focus group interviews with nurses, doctors and pharmacists. However, most research on moral distress includes nurses only. The present study describes the kind of moral distress doctors experience, whether their work conditions are in accordance with their own moral standards, and to what extent they experience a work place with good strategies for the resolution of ethical dilemmas.

MATERIAL AND METHOD

Since 1992 The Norwegian Medical Association, organising more than 90% of all doctors practising in Norway, has sponsored its own research institute with the main objective to study the health and behaviour of doctors.15 An important part of this effort has been to follow a representative panel of approximately 1200 doctors with postal questionnaires from 1994. In 2000 a group of approximately 300 recent graduates was included in the panel.

Some of the themes have been how threats from patients may affect clinical decisions,16 work characteristics and morbidity as predictors of self-perceived health status,17 and difficult end-of-life decision.18

Specialist categories: There are 43 medical specialties and subspecialties in Norway, some with only 30–40 active members. Hence, with a sample of only 1500 it is necessary to collapse the specialties into larger entities with similar work conditions. In a number of studies we have used the following six categories: family medicine/general practice, laboratory medicine (including radiology, pathology and biochemistry), internal medicine (including neurology and oncology), surgical medicine (including anaesthesiology, obstetrics and gynaecology), psychiatry and community medicine/public health. Specialists in training are categorised according to their future specialty.

Questionnaire

In December 2004 a questionnaire was disseminated with questions on the following topics: job satisfaction, prioritisation dilemmas, the interpretation of new regulations on patients’ rights, use of internet for professional update and questions on continued medical education. Also, the following statements on tolerance of criticism and on different ethical dilemmas were presented:

Tolerance of criticism:

1. It is difficult to criticise my colleagues for their ethically unacceptable conduct

2. It is difficult to criticise my colleagues for their professionally unacceptable conduct

The responses were scored on a 4-point scale according to how well they described the respondent’s relationship with his or her present colleagues: a good description, a fair description, a poor description, and a wrong description. These statements were also presented to the same group of doctors in 2000.

Moral distress: Moral distress was explored by means of nine statements, some of which were taken, but modified, from Kälvemark5:

“Below you will find [nine] statements which deal with moral distress. To which extent do you find that these statements apply to your particular situation?

1. The patient who “cries loudest” gets more or quicker treatment

2. Patients must wait long for treatment

3. The care for patients suffers due to time constraints

4. Patients who should be hospitalised in other institutions take up place for others

5. A great deal of the working day is spent on administration and documentation

6. Patients are not treated adequately due to economical limitations

7. Treatment not likely to be effective, is given

8. Elderly patients are not prioritised

9. I must sometimes act against my conscience”

The following five response alternatives were given: not distressing at all, a little distressing, somewhat distressing, very distressing and don’t know.

Values and goals at the workplace: The following five statements were used to explore the doctors’ values and goals in their work organisation, and the doctors were asked to report how well the statements could be applied to their particular situation.

1. Ethical problems often arise at my workplace

2. At my workplace we have strategies to solve ethical problems

3. My own job values accord well with the values of my work organisation

4. I strongly identify with the goals of my organisation and the frames of my work organisation

5. I often feel that I compromise with my own values to cope with job demands

These five response alternatives were given: applies completely, applies mostly, does not apply very well, does not apply at all, and not applicable.

Statistical analyses

Responses are basically reported as fractions of doctors who chose the different response alternatives. Each of the three grouping variables gender (female and male), age (30–39, 40–49, 50–59, 60–69 and 70+) and specialty group (general practice, laboratory medicine, internal medicine, surgical disciplines, psychiatry and public health) was cross tabulated against each of the nine statements on moral distress and the five statements on values and goals, and χ² was used to test for possible statistically significant differences. In order to facilitate the interpretation of these rather extensive cross tables we have also indicated which cells that have the largest difference between observed and expected frequencies under the null hypothesis.

RESULTS

The number of respondents was 1005, a response rate of 67% (1005/1497). Table 1 shows that compared with the total Norwegian doctor workforce in 2004 our respondents are slightly older (females only), comprise slightly more senior and less junior doctors and more general practitioners.

Tolerance of criticism

In all, 57% of the doctors indicated that the statement “It is difficult to criticise my colleagues for their professionally unacceptable conduct” was a good or a fair description of their present work situation. Similarly, 51% said that the statement “It is difficult to criticise my colleagues for their ethically unacceptable conduct”, was a good or fair description. Age, gender and specialty did not influence the answers.

Moral distress

The responses to the nine statements on moral distress are shown in table 2. In all, 51% expressed moral distress by sometimes having to act against own conscience. Two-thirds (66%) said that they found it distressing that patients have to wait long for treatment and the same proportion that the care of patients suffers due to time constraints. Over half (55%) reported distress by having to spend too much time on documentation and administration and 45% found it very or somewhat distressing that the patient who “cries loudest” gets more or quicker treatment than others. The last three columns of the table indicate as to which statement and to what effect there were significant differences between groups.

Female doctors tended to be more stressed than male doctors. Older doctors got stressed by the low priority given to elderly patients, and younger doctors because of time constraints. Internal medicine specialists and surgeons (ie, doctors working in hospital settings) were particularly stressed by time constraints. Psychiatrists reported distress by slow circulation (inpatients who should be admitted to other institutions) and much administrative work.

General practitioners (GPs) more than other specialties reported distress related to patients with strong voices getting more or quicker treatment, to patients having to wait long for treatment and to elderly patients not being prioritised.

A substantial number of doctors and particularly those working in laboratory medicine, responded “do not know” to some of the statements on moral distress, but only 11 gave this response to all nine statements.

Values of the work organisation

Table 2 also reports the responses to the five statements about values and goals at the workplace. In all, 22% agreed mostly or completely to the statement that they often had to compromise with their own values to cope with the demands on the workplace and 42% felt that ethical problems frequently occurred at work. However, 76% indicated that their own professional values and the values of the organisation were coherent. The table also indicates differences between groups with regard to the five value variables. Female doctors and younger doctors tended to experience ethical problems more often, as did surgeons, internists and psychiatrists. Public health specialists score particularly high on coherence between own values and those of the organisation, and surgeons seem to have the strongest identification with their work organisation.

DISCUSSION

Our study did not explore moral distress resulting from traditional ethical dilemmas such as confidentiality and end of life situations. Still, a large proportion of Norwegian doctors report distress, particularly to dilemmas related to lack of resources. The way we have posed our statements imply that the situations described may cause distress, which may influence the answers in a positive direction. However, the fact that more than half of the doctors agree to the statement “I must sometimes act against my conscience”, indicates strongly that such situations really occur. It is also noteworthy that 42% say that ethical problems frequently occur at work and at the same time that 46% report an absence of strategies to solve ethical problems. Even in Norway, with its high fraction of BNP allocated to health services, almost 40% of the doctors are distressed by the gap between objective needs and available resources. It is likely that this source of distress may be even more important in countries with smaller health budgets.

That between 2–15% of the doctors in our study answered “do not know” to the questions on moral distress may indicate that this type of distress is hardly acknowledged. The fact that this percentage is especially high among laboratory doctors is not surprising, as these doctors have fewer patient encounters. Saarni et al19 found that laboratory doctors faced fewer ethically problematic decisions. However, this does not necessarily mean that laboratory work is devoid of ethical dilemmas.

GPs see the same patients more regularly and more over time compared with their hospital colleagues. Most GPs also see many old people. Therefore, it is not surprising that GPs more frequently report distress related to long waiting lists for specialist treatment and unsatisfactory services for older patients. GPs may also more directly experience that patients with strong voices get more and quicker treatment. That GPs more than their hospital colleagues report stress related to patient demands is in line with the recent study by Saarni19 where around 30% of Finnish GPs reported ethical problematic decisions related to patient demand.

The majority report their individual job values to accord well with the values of their work organisation. If an organisation’s values and goals are similar to those of its employees, higher satisfaction and lower levels of burnout are likely to occur.20

We have data on the two statements on tolerance of criticism among colleagues from the same doctors in 2000 and there is virtually no difference between the two points in time. During this period a new Health Personnel Act was passed where doctors and other health professionals now are obliged to report if they see something that may represent a threat to patients’ life or health. It is, in our opinion, troubling that every other doctor admits that it is difficult to criticise a colleague for professional and ethical misconduct. Legal requirements to report practice which may harm patients compete with strong traditions of criticism of a colleague being perceived as deceit and disloyalty.11 Thus, a moral dilemma for modern doctors is that ethically and legally necessary criticism may have a serious bearing on their own career and work conditions.8 21 This represents a great challenge for hospital administrators and educators.

Corley et al13 found that nurses experience heavy moral strain, among other things due to lack of time to attend to individual patients. Shortage of time was also a significant source of distress in Kälvemark’s study.5 Time constraints and lack of time to care for patients is experienced as distressing by many doctors in our study as well. It is not surprising that doctors in internal medicine with many old patients with complex problems experience moral distress due to lack of time. In a recent prioritisation study on older patients, lack of time was seen as the emotionally most distressing factor by doctors and nurses alike.22 As with in the present study, long waiting lists for treatment and diagnosis for older patients was a commonly described problem. In theory, old people’s healthcare is a field that has been prioritised in Norway for more than two decades, but more than ever a gap between needs and available resources is experienced.

It is worth noting that one in two doctors find it morally distressing that the stronger patients are prioritised at the expense of the weaker. Increased health consumerism and strengthened patient’s rights may have expanded this dilemma. Increased emphasise on the principle of patient autonomy may make it harder for doctors to act as gate keepers.23

Increased emphasis on administration and documentation was reported to represent distress for the doctors in this study. Documentation of medical practice is necessary for transparency, accountability and for quality improvement. When time has to be spent on administration and documentation, less time is left for direct patient care. Psychiatrists were among the doctors who reported distress related to this. Psychiatric patients constitute a weak patient group. Strengthened patient’s rights as well as better accountability and transparency are new demands that may create conflicts and give rise to moral distress.

Ethical dilemmas and moral distress are, and will always be, part of medicine. The question is how healthcare should be organised so doctors can better cope professionally with conflicting demands and values. How can ordinary rank and file health professionals get time and opportunity to discuss ethical dilemmas, uncertainty and moral disagreement?5 24 A comparative study in four European countries found that ethical dilemmas were frequently described by physicians, but very few had access to assistance for resolving these dilemmas.25 Today hospital ethics committees are established in many European countries, in Norway by every hospital trust. However, substantial work remains for these committees to be able to meet the needs of the healthcare workers, the patients and their relatives. Lack of openness to outsiders and conflict aversion among medical professionals may explain why few ethically problematic cases are deliberated in the ethics committees.26 The fundamental challenge for the medical community is to create a culture where discussion and handling of ethically and emotionally difficult issues is welcomed and encouraged.