Female Healthcare Workers Have Faced Heightened Moral Distress

New research shows that female healthcare providers were disproportionally affected by moral distress during the COVID-19 pandemic compared to their male counterparts. The authors concluded that female healthcare providers were more likely to experience a “double dose” of moral distress both at home and in the workplace.

Moral distress is a complex and challenging problem affecting healthcare providers more frequently during a crisis or disaster but also during circumstances such as end-of-life care or understaffing. It should be distinguished from the term “burnout,” which is often used to describe the effects of ongoing stress in the workplace, but the two conditions can overlap.

Moral distress occurs when someone is aware of the ethically correct action to take but is constrained by internal or external factors from taking it. It can include physical, emotional, and psychological symptoms, such as headaches, palpitations, gastric upset, anger, guilt, frustration, withdrawal, and depression.

In addition to these symptoms, when left unaddressed, moral distress can affect the quality of care patients receive and result in healthcare providers leaving the profession. I discuss the impact of moral distress, moral trauma, and moral injury on healthcare providers and the broader population during the COVID-19 pandemic in my book, COVID-Related Post Traumatic Stress Disorder (CV-PTSD): What It Is and What to Do About It.

The research was based in British Columbia, which had some of the highest COVID-19 case numbers (84,569 confirmed cases) in Canada during the first year of the pandemic. The researchers conducted 16 focus groups with 66 participants, 12 semi-structured interviews, and 10 key informant interviews with those in management positions in the health system and representatives of unions and professional organizations between December 2020 and March 202. Healthcare providers interviewed included workers from community health, long-term care, nurses, and midwives.

Pre-COVID-19, many of the women interviewed already worked in environments where external constraints related to the increasing privatization of healthcare restricted their ability to provide quality care. In 2019, the province had the lowest number of registered and licensed practical nurses working in direct care in Canada, leading to severe staffing shortages. There was also a significant gender wage gap of 15.8 percent in 2020, with a disproportionate number of women fulfilling lower-paid positions, such as care aids, and men dominating leadership positions.

Women in Canada also remain the primary care providers within households and families, doing 2 to 3 times more unpaid care work than men. The closures of schools and childcare centers and mandatory isolation periods have continued to impose heightened care burdens on women. A survey conducted in April 2021 found 71 percent of mothers were “at the breaking point” due to stress and anxiety.

Researchers investigated how participants responded to challenges related to moral events, which were categorized as constraints, conflicts, dilemmas, or uncertainties.

Moral constraints at work and home

Moral constraint is understood as the inability to carry out a preferred personal moral requirement due to external or internal constraints. Many participants spoke about how inadequate staffing and a lack of PPE led to moral constraints related to the quality of care. During the early stages of the pandemic, midwives couldn’t access PPE from the government supply, forcing them to source and reuse their own PPE.

All participants noted that, as women, they were primarily responsible for unpaid care in their families and that unpaid care work had increased dramatically due to COVID-19-related childcare, schooling, and service interruptions, as well as due to the needs of vulnerable family members. Many reported feeling guilty that they could not adequately support their children’s well-being and education during the pandemic.

Moral conflict at work and home

Frontlines female healthcare workers often felt decision-makers, including supervisors or managers, were too distanced from the realities of care work to understand the consequences of COVID-19 protocols. Many female healthcare workers reported that attempts to adapt their schedules and accommodate childcare duties faced resistance at work.

A moral dilemma at work and home

Women healthcare providers felt unable to provide an ethical standard of care while maintaining COVID-19 prevention protocols. Nurses were instructed to spend as little time as possible with patients to reduce transmission risk when patients needed increased emotional support because they were isolated from their families. With insufficient PPE in the workplace, they also felt they were putting their families at heightened risk.

Moral uncertainty at work

Constantly changing information about COVID-19, particularly early on, made it difficult for healthcare providers to know how to best protect their patients/residents. They linked uncertainty and lack of communication to distress.

While some sources of moral distress were entirely out of the control of healthcare providers, many also reported actions that they took to fight moral distress. Midwives collaborated with hospital managers and other HCPs to successfully advocate for access to government-supplied PPE, and workers in long-term care joined unions to advocate for improved staffing policies. Many also increased counseling sessions or began therapy during the pandemic. Unfortunately, midwives were the only healthcare providers who reported not having access to employer-provided mental health support or extended benefits. They were forced to pay out of pocket for mental healthcare, often racking up credit card debts and causing an additional source of stress.

However, our responses to this crisis must go beyond short-term mental health interventions to address the underlying constraints, many of which pre-date COVID-19 and are notably gendered, around working conditions and investments in the care economy. Such structural change will not only strengthen COVID-19 recovery efforts but will also better prepare health systems for future pandemics.


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