Veterinarians and moral distress

Lori R. Kogan College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO

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 PhD
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Mark Rishniw Veterinary Information Network, Davis, CA

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 BVSc, MS, PhD, DACVIM

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Abstract

OBJECTIVE

Assess veterinarians’ reported levels of moral distress and professional well-being. Determine the predictive value of moral distress, controlling for demographic factors, on veterinarians’ levels of Professional Fulfillment, Work Exhaustion, Disengagement, and Burnout.

SAMPLE

Members of the Veterinary Information Network.

PROCEDURES

An electronic survey distributed via the Veterinary Information Network data collection portal.

RESULTS

A total of 1,919 veterinarians completed the survey. For both associates and owners, gender and age were significant predictors of moral distress with younger female veterinarians reporting higher levels of distress than older male veterinarians. For associates, age was a positive predictor and moral distress score was a negative predictor of Professional Fulfillment. Age was a negative predictor, and female gender and moral distress score were both positive predictors for Work Exhaustion. For Interpersonal Disengagement and Burnout, age was a negative predictor and moral distress score was a positive predictor. For owners, age was a positive predictor and moral distress score was a negative predictor for Professional Fulfillment. Age was a negative predictor, and female gender and moral distress score were both positive predictors of Work Exhaustion, Interpersonal Disengagement, and Burnout.

CLINICAL RELEVANCE

We found that, controlling for age and gender, higher levels of moral distress predicted lower levels of Professional Fulfillment and higher levels of Work Exhaustion, Interpersonal Disengagement, and Burnout. Given the prevalence of moral distress and its impact on mental health, it is imperative that the veterinary field provide training and education on how to recognize and navigate ethical conflicts.

Abstract

OBJECTIVE

Assess veterinarians’ reported levels of moral distress and professional well-being. Determine the predictive value of moral distress, controlling for demographic factors, on veterinarians’ levels of Professional Fulfillment, Work Exhaustion, Disengagement, and Burnout.

SAMPLE

Members of the Veterinary Information Network.

PROCEDURES

An electronic survey distributed via the Veterinary Information Network data collection portal.

RESULTS

A total of 1,919 veterinarians completed the survey. For both associates and owners, gender and age were significant predictors of moral distress with younger female veterinarians reporting higher levels of distress than older male veterinarians. For associates, age was a positive predictor and moral distress score was a negative predictor of Professional Fulfillment. Age was a negative predictor, and female gender and moral distress score were both positive predictors for Work Exhaustion. For Interpersonal Disengagement and Burnout, age was a negative predictor and moral distress score was a positive predictor. For owners, age was a positive predictor and moral distress score was a negative predictor for Professional Fulfillment. Age was a negative predictor, and female gender and moral distress score were both positive predictors of Work Exhaustion, Interpersonal Disengagement, and Burnout.

CLINICAL RELEVANCE

We found that, controlling for age and gender, higher levels of moral distress predicted lower levels of Professional Fulfillment and higher levels of Work Exhaustion, Interpersonal Disengagement, and Burnout. Given the prevalence of moral distress and its impact on mental health, it is imperative that the veterinary field provide training and education on how to recognize and navigate ethical conflicts.

Introduction

Veterinarians’ mental health has been an area of increased concern in recent years. Numerous studies from around the world suggest that veterinarians have higher rates of psychological distress including anxiety, depression, stress, burnout, and suicidal ideation than the general public.13 In the United Kingdom, for example, veterinarians were reported to experience high levels of anxiety, depression, and suicidal thoughts, and lower levels of positive mental well-being.4 Similarly, veterinarians in the United States were found to have a higher prevalence of serious psychological distress, depression, and suicidal ideation than the general population.5 Australian veterinarians share similar challenges, with reported higher rates of depression, stress, and burnout than the general population.3

Psychological distress among veterinarians can negative impact physical and mental health,6 personal and professional wellbeing, and patient care.7 Common sources of stress within the veterinary profession include challenging work schedules, financial issues (eg, debt load), client demands/expectations, and ethical dilemmas.8,9 Terms used to explain these mental health challenges like compassion fatigue, burn-out, and moral distress are often used interchangeably, yet they mean different things.10

Compassion fatigue is a negative consequence of repeated secondary exposure to the pain and suffering of others. It occurs when emotional and physical exhaustion cause a reduced ability to empathize or feel compassion for others.11 This lack of empathy can negatively impact relationships with patients, owners, and colleagues. While any veterinarian can experience compassion fatigue, risk factors include a history of traumatic experiences, duration of the experience(s), chronic exposure to death and euthanasia, and moral dilemmas.10,12

Left unchecked, compassion fatigue can lead to burnout, which is characterized by high levels of emotional exhaustion and depersonalization, and low levels of feelings related to personal accomplishment.13 Burnout is a state in which a person feels emotionally, physically and mentally exhausted leading to changes in sleeping, eating, and overall physical health.14 People who are burned out often feel emotionally exhausted, negative, helpless, dissatisfied, demotivated, and detached from others.10 Burnout has been linked to substance abuse, depression, suicidal ideation, an increase in medical errors, and decreased patient satisfaction.15,16

Researchers mention moral distress less frequently, yet it is just as important when discussing veterinarians’ psychological well-being. Moral distress can be defined as the powerlessness, anger, and guilt that health-care professionals experience when they are unable to practice medicine according to their own ethical standards.17,18 Moral distress is a serious problem for numerous health-related disciplines including veterinary medicine.1921

Moral distress encompasses 5 areas: complicity in wrongdoing, lack of voice, wrongdoing associated with professional values, repeated experiences, and 3 levels of root causes (patient, unit, system; Figure 1).22 The first component involves the belief that one is doing something ethically wrong, yet has little power to change the situation.22,23 This external pressure to act unethically is the defining concept of moral distress and distinguishes it from other situations that are emotionally distressing.

Figure 1
Figure 1

Moral distress within veterinary medicine.

Citation: Journal of the American Veterinary Medical Association 261, 5; 10.2460/javma.22.12.0598

The second component of moral distress revolves around a lack of power. This is when health-care providers feel they have relevant knowledge and experience, yet their voice is not heard or taken into account. To meet the definition of moral distress (components 3 and 4), these interactions must take place in a professional setting and occur repeatedly over time.24,25

Lastly, it is important to note that moral distress can occur at 3 different levels.26 Patient-level causes are those that involve a particular patient or client. Examples from our moral distress assessment include items such as “Have clients elect to euthanize because of financial constraints” and “Be required to work with abusive clients who are compromising quality of care.” Moral distress at the unit level involves colleagues and team members. Items from our assessment that pertain to the unit level include “Feel unsafe/bullied amongst my own colleagues” and “Work with team members who do not treat vulnerable or stigmatized clients with dignity and respect.” System-level causes are those that occur outside the unit or department. Examples in our assessment include “Experience compromised patient care due to lack of resources/equipment/cage capacity” and “Experience lack of administrative action or support for a problem that is compromising patient care.”

Veterinary professionals frequently encounter ethical dilemmas or situations when their own morals and ethical standards conflict with professional obligations or clients’ wishes.27 These dilemmas, which often center around end-of-life care and euthanasia compounded by economics and owners’ expectations, can cause moral distress. Because of the complex ethical structure and multiple professional obligations within veterinary medicine, many in the field consider moral distress an unavoidable part of veterinary practice.21 However, it has been found to be a contributing factor in clinician burnout,18,28 intention to leave one’s position,18,20 and psychological distress.21

Despite its impact on veterinary medicine, much remains unknown about moral distress, including how it might affect veterinarians’ psychological well-being. For this reason, we sought to assess the potential impact of veterinarians’ demographics on reported levels of moral distress and professional well-being using a survey-based approach. We also sought to determine the predictive value of moral distress, controlling for participants’ demographic factors, on their levels of professional fulfillment, work exhaustion, disengagement, and burnout.

Materials and Methods

An anonymous online survey was created in collaboration with Veterinary Information Network (VIN), an online veterinary community. A link to the survey was distributed via an email invitation to eligible VIN members (n = approx 43,000), and access was made available from September 21, 2022, through October 6, 2022. A follow-up message was sent 2 weeks after the initial invitation. Only data from respondents who stated they currently worked in clinical practice were included in the study. The study was categorized as exempt by Colorado State University’s Institutional Review Board. The survey was administered directly via the VIN data collection portal, and branching logic was used to display only relevant questions to each participant. The body of the survey consisted of the Stanford Professional Fulfillment Index (PFI), 2 modified versions of the Measure of Moral Distress for Healthcare Professionals (MMD-HP; 1 for associates and 1 for owners/partners), and additional Likert scale and multiple-choice items. The complete survey is available as Supplementary Appendix S1.

Moral Distress

Moral distress was measured with 2 modified versions of the MMD-HP. The Cronbach α for the MMD-HP has been reported to be α = 0.93.19 Because not all questions were felt to fit both owners/partners and associates, 2 modified versions of the MMD-HP were created, 1 for owners/partners and 1 for associates. These modified versions were completed with the guidance and feedback of veterinary and psychology colleagues. Similar to the MMD-HP, participants were asked to rate how often each item occurs in their practice on a Likert scale with 0 = never and 4 = very frequently. They were then asked how distressing each item is when or if it occurs with 0 = none and 4 = very distressing. The frequency score was multiplied by the distress score to create a composite score and these composite item scores were summed to create an overall moral distress score. Higher scores indicated higher levels of moral distress.

Our modified versions of the MMD-HP retained the 5 key components of moral distress.29 We addressed complicity in wrongdoing and lack of voice in the wording of several of the items (eg, be required to …, be unable to …). Professional values were represented in several items, (eg, “Have clients choose less desirable treatment paths because of financial constraints”). The repetitive nature of moral distress was accounted for by measuring the frequency of occurrence and the 3 levels of root causes were captured by the system-level items.

Stanford Professional Fulfillment Index

To measure feelings related to work, participants who reported having worked in the past 2 weeks were asked to complete the Stanford PFI. The PFI is a validated survey designed to measure feelings related to Professional Fulfillment, Work Exhaustion, Interpersonal Disengagement, and Burnout in physicians within the past 2 weeks.3032 The PFI is a 16-item survey with 3 scales: 2 scales that measure Burnout in terms of Work Exhaustion (4 questions) and Interpersonal Disengagement (6 questions); and 1 scale that measures Professional Fulfillment (6 questions). Response options are on a 5-point Likert scale (“not at all true” to “completely true”) for professional fulfillment items and “not at all” to “extremely” for Work Exhaustion and Interpersonal Disengagement items.

Items are scored 0 to 4 with each dimension treated as a continuous variable. Scale scores are calculated by averaging the item scores of all the items within the corresponding scale. Higher scores on the Professional Fulfillment scale are viewed more favorably while higher scores on the Work Exhaustion or Interpersonal Disengagement scales are less favorable. Burnout scores are determined from the average item score of all 10 Burnout items (Work Exhaustion and Interpersonal Disengagement). Cut-off scores greater than 1.33 on the Burnout scale and greater than 3.00 on the Professional Fulfillment scale have been identified.32

Reported test-retest reliability estimates are 0.82 for Professional Fulfillment (α = 0.91), 0.80 for Work Exhaustion (α = 0.86), 0.71 for Interpersonal Disengagement (α = 0.92), and 0.80 for overall Burnout (α = 0.92).32 Trockel32 reported a correlation between the PFI Work Exhaustion subscale score and MBI Emotional Exhaustion subscale score of 0.72; a correlation between PFI Interpersonal Disengagement score and MBI Cynicism subscale score of 0.59; and a correlation between the PFI Professional Fulfillment score and MBI Professional Efficacy subscale score of 0.46. Kogan33 found a correlation of MBI Work Exhaustion and PFI Emotional Exhaustion of 0.80, MBI cynicism and PFI Interpersonal Disengagement’s correlation to be 0.61, and the correlation of MBI Professional Efficacy and PFI Professional Fulfillment to be 0.60.

We also asked participants to report on their demographic factors (ie, gender, age, type of position (owner/partner or associate/employee), and type of practice (ie, clinical academia, emergency practice, first opinion practice [fixed or mobile], referral practice, shelter medicine).

Additional questions (only seen by those who reported working in the same practice for the last 2 years) included items related to changes they have seen in their practice over the last 2 years. We asked if the number of clients who can afford first (optimum/recommended) choice for managing their pets’ health had changed in the past 2 years and if this number has changed, how they feel about it (ie, extremely distressed, distressed, neutral/indifferent). They were also asked if their practice had changed prices for services in the past 2 years, and if so, how they feel about this change using a 5-point Likert scale (1 = extremely distressed to 5 = very positive). Free-text boxes were provided for participants to enter brief alternative answers when none of the listed options applied to them. A final question at the end of the survey allowed for free-text entry for any comments participants chose to make about how they feel about their job.

Descriptive statistics, χ2 tests, analysis of variance (ANOVA), and logistical regressions were performed with SPSS Statistics (version 28; IBM). Multiple linear regression was used to assess the predictive value of age and gender on moral distress for both associates and owners. Chi Square tests were used to test for differences between associates and owners for the questions pertaining to perceived changes in institution prices and clients’ ability to afford veterinary care. ANOVA was used to test for significant differences between associates and owners for each of the PFI scales. Lastly, a series of multiple linear regression analyses was conducted for associates and owners (excluding those in academia or shelter medicine because they are neither associates nor owners) to assess the predictive value of gender (limited to male or female), age (30 or younger, 31 to 40, 41 to 50, 51 to 60, 61 and older) and moral distress on Professional Fulfillment, Work Exhaustion, Interpersonal Disengagement, and Burnout. Statistical significance was set at P < .05.

Results

A total of 1919 responses were received, mostly from females (n = 1,546; 81%) from the United States (n = 1,586; 82.6%) between the ages of 41 to 60 (n = 1,058; 55%) working in a first opinion practice (n = 1,552; 81%). Of those who reported working in a first opinion practice, emergency medicine or referral practice, 1,079 (56%) were practice associates or employees, 208 (11%) were practice partners and 515 (27%) were practice sole owners (Table 1). For further analysis, practice partners and sole owners were combined into 1 group. Because the Stanford Professional Fulfillment Index asks people to report feelings related to work in the past 2 weeks, participants were asked if they had been working in the last 2 weeks; 1,779 (93%) reported yes and 140 (7%) reported no. Those who reported they had not worked in the last 2 weeks or worked in clinical academia or shelter medicine were excluded from analysis pertaining to associate or owner MMD-HP and PFI scales.

Table 1

Participant demographics (n = 1,919).

Variable N %
Country
 United States 1,586 83
 Canada 197 10
 Australia 58 3
 New Zealand 14 1
 United Kingdom 14 1
 Other 50 2
Gender
 Female 1,546 81
 Male 363 19
 Non-binary/third gender 4 < 1
 Other 1 < 1
 Prefer not to say 5 < 1
Job setting
 Clinical academia 61 3
 Emergency practice 162 8
 First-opinion practice (fixed and mobile) 1,552 81
 Referral practice 88 5
 Shelter medicine 56 3
Age
 30 or younger 108 6
 31 to 40 371 19
 41 to 50 475 25
 51 to 60 583 30
 61 and older 382 20
Position
 Practice associate 1,079 56
 Practice partner 208 11
 Practice sole owner 515 27
 Not applicable 117 6

Moral distress

The modified version of the MMD-HP for associates consisted of 24 items. For each item, the frequency of occurrence was multiplied by how distressing the event is if/when it occurs. If an event did not occur, it would therefore score a zero. These scores were summed to create an overall moral distress score. For associates, the range of scores was 0 to 352 (X = 83.59; SD = 51.14). The modified version of the MMD-HP for owners consisted of 21 items, with a range of scores between 0 to 208 (X = 51.58; SD = 31.49). The Cronbach α was 0.92 for the associate version and 0.87 for the owner version.

Multiple linear regression was used to assess the predictive value of age and gender on moral distress for both associates and owners. For associates, the multiple regression model was significant (F[5] = 12.43, P = .001, R2 = 0.04), with both gender and age significant predictors. Females had higher scores than males (females: X = 86.97, CI = 83.72 to 90.21; males: X = 69.76, CI = 62.60 to 76.92). Younger participants (50 and younger) reported higher levels of moral distress than those over 50 years of age (participants 50 years of age and younger: X = 83.27, CI = 78.63 to 87.91, participants 51 years of age and older: X = 68.93, CI = 64.22 to 73.65)

For owners, the multiple regression model was significant (F[5] = 8.62, P = .001, R2= 0.08), with both gender and age significant predictors. Females had higher scores than males (females: X = 64.28, CI = 55.16 to 73.40; males: X = 48.52, CI = 38.40 to 58.64). Younger participants (50 and younger) reported higher levels of moral distress than those over 50 years of age (participants 50 years of age and younger: X = 53.87, CI = 48.22 to 59.53, participants 51 years of age and older: X = 46.75, CI = 43.59 to 49.90).

Because financial constraints can impact moral distress, participants were asked questions about perceived changes in institution prices and clients’ ability to afford veterinary care. When asked if they felt that the number of clients who can afford the optimal/recommended choice for managing their pets’ health had changed in the last 2 years, the largest number of respondents said no (n = 643; 41%), followed by fewer can afford it (n = 509; 33%) and more can afford it (n = 309; 20%; 98, 6% reported they did not know). Those who reported that fewer clients could afford the recommended treatment for managing their pets’ health were asked how this makes them feel. Responses to this question ranged from neutral/indifferent (n = 82; 16%), to distressed (n = 346; 69%) and extremely distressed (n = 74; 15%). No significant differences were found between owners’ and associates’ responses (X2 = 3.77[2]; P = .15). When asked if prices had changed within the last 2 years, 22 (1%) reported they did not know, 1 participant noted a decrease in prices, 26 (2%) responded no change, 266 (17%) reported minimal increase, 723 (46%) reported somewhat of an increase, and 521 (33%) reported a substantial increase. When asked how they feel about the price changes, 82 (5%) reported very positive, 348 (23%) reported positive, 676 (44%) said reported neutral, 362 (24%) reported feeling distressed, and 64 (4%) reported feeling very distressed. Owners were more likely to report feeling positive (owners: n = 209, 32%; associates: 125, 16%) and associates were more likely to report feeling distressed (associates: n = 250, 31%; owners: 95, 15%; X2 = 126.54[4], P < .001).

Stanford Professional Fulfillment Index

The mean total scores for each of the PFI scales were calculated: Professional Fulfillment scale: X = 2.39 (SD = 0.86), Work Exhaustion scale: X = 2.02 (SD = 0.97); Interpersonal Disengagement scale: X = 1.30 (SD = 0.92). The total score for the 10 burnout questions (Work Exhaustion and Interpersonal Disengagement) was X = 1.59 (SD = 0.86). The Cronbach α were: Professional Fulfillment scale = 0.91, Work Exhaustion scale = 0.89, Interpersonal Disengagement scale= 0.90, and total Burnout score (combined scales of Work Exhaustion and Interpersonal Disengagement) = 0.93.

One-way analysis of variance was used to test for significant differences between associates and owners for each of these scales. Owners scored higher for Professional Fulfillment (F = 153.16; P < .001), and lower for Work Exhaustion (F = 71.56; P < .001), Interpersonal Disengagement (F = 19.85; P < .001), and Burnout (F = 44.05; P < .001).

Using the suggested burnout cut-off score of 1.33, 56.9% of the total population reported feeling burned out (associates = 62.6%; owners = 48.8%). Additionally, 70.2% of the total sample fell under the cutoff point of > 3.0 for Professional Fulfillment (associates = 80.4%; owners = 66.2%).

We performed a series of multiple linear regression analyses for associates and owners (excluding those in academia or shelter medicine because they are neither associates nor owners) to assess the predictive value of gender (limited to male or female), age (30 or younger, 31 to 40, 41 to 50, 51 to 60, 61 and older) and moral distress on Professional Fulfillment, Work Exhaustion, Interpersonal Disengagement, and Burnout. We assessed associates and owners separately because of the 2 different moral distress scales used.

Professional Fulfillment

Associates—We ran 4 multivariable linear regression analyses to examine the predictive ability of age, gender and moral distress score on Professional Fulfillment score, Work Exhaustion, Interpersonal Disengagement and Burnout among veterinary associates.

Age was a positive predictor and moral distress score was a negative predictor of the Professional Fulfillment score (F[6] = 58.41, P = .001, R2 = 0.22; Supplementary Table S1).

Age was a negative predictor, and female gender and moral distress score were both positive predictors of Work Exhaustion (F[6] = 84.69, P = .001, R2 = 0.29; Supplementary Table S2).

Age was a negative predictor, and moral distress score was a positive predictor of Interpersonal Disengagement (F[6] = 70.91, P = .001, R2 = 0.26; Supplementary Table S3).

Finally, age was a negative predictor, and moral distress score was a positive predictor of Burnout (F[6] = 96.44, P = .001, R2 = 0.32; Supplementary Table S4).

Owners—We ran 4 multivariable linear regression analyses to examine the predictive ability of age, gender and moral distress score on Professional Fulfillment score, Work Exhaustion, Interpersonal Disengagement and Burnout among veterinary owners.

Age was a positive predictor and moral distress score was a negative predictor of the Professional Fulfillment score (F[6] = 23.16, P = .001, R2 = 0.23; Supplementary Table S5).

Age was a negative predictor, and female gender and moral distress score were both positive predictors of Work Exhaustion (F[6] = 28.52, P = .001, R2 = 0.26; Supplementary Table S6).

Age was a negative predictor, and female gender and moral distress score were both positive predictors of Interpersonal Disengagement (F[6] = 26.00, P = .001, R2 = 0.25; Supplementary Table S7).

Finally, age was a negative predictor, and female gender and moral distress score were both positive predictors of Burnout (F[6] = 33.25, P = .001, R2 = 0.29; Supplementary Table S8).

Discussion

Veterinarians in our study reported low levels of Professional Fulfillment and high levels of Work Exhaustion, Interpersonal Disengagement, and Burnout. These scores are comparable to those found in previous studies of veterinary technicians and physicians.32,33 Differences, however, were found between associates and owners with associates reporting higher levels of Work Exhaustion, Interpersonal Disengagement, and Burnout and lower levels of Professional Fulfillment than owners. Regardless of position, however, approximately half of participants fell under the cut-off point for Professional Fulfillment and above the cut-off for Burnout.

When we assessed moral distress, we found that both gender and age predicted levels of moral distress. For both associates and owners, younger females reported higher levels of moral distress then older males. Furthermore, we found that, controlling for age and gender, higher levels of moral distress predicted lower levels of Professional Fulfillment and higher levels of Work Exhaustion, Interpersonal Disengagement, and Burnout. These results mirror those in human medicine studies where moral distress has been noted to be a significant predictor of burnout.3436

For both associates and owners, age was a predictor for Work Exhaustion, Interpersonal Disengagement, and Burnout whereby younger veterinarians reported higher levels than their older colleagues. For associates, gender was also a predictor for Work Exhaustion but not Professional Fulfillment, Interpersonal Disengagement, or Burnout. Conversely, among owners, we found gender to be a predictor for Work Exhaustion, Interpersonal Disengagement, and Burnout.

While the prevalence of psychological distress among veterinarians has been reported in numerous studies,1,3,5,37,38 several studies, including ours, have identified that female veterinarians are at a higher risk than male veterinarians.1,7,8,39 For example, Best et al1 found 38% of female veterinarians report feeling burned out compared to 33% of males and Fritschi38 found that female Australian veterinarians are more likely to report feeling distressed, anxious and depressed when compared to their male colleagues. In the US, Nett et al5 found that female veterinarians report higher levels of psychological distress, including previous depressive episodes and suicidal ideation than males. Furthermore, in many studies conducted around the globe (eg, Australia,40 United Kingdom,4 and United States5), age appears to be a significant factor, with younger veterinarians at higher risk of psychological distress than older veterinarians.

While the veterinary profession has begun to address the importance of mental health with resources pertaining to burnout, compassion fatigue and resilience becoming more common, less attention has been given to moral distress and its potential impact on psychological well-being. Results of our study suggest that moral distress plays an important role in veterinarians’ mental health. These findings are similar to those found in both human and veterinary medicine, namely that moral distress can lead to feelings of burnout and negatively impact practitioners’ mental health.21,3436

The very nature of veterinary medicine, with its professional obligations to the patient, the owner, other veterinary professionals, and society, creates an environment rife with ethical challenges.9,41 Conflict between these obligations and the veterinarian’s own moral standards can cause feelings of powerlessness and a belief they are doing something ethically wrong.9,42,43 Challenges in choosing behaviors consistent with their morals can come from all 3 levels associated with moral distress: patient, unit, and system. Because of these commonplace, innate challenges, many veterinarians feel moral distress is an unavoidable part of veterinary practice.21

Common areas for moral distress among veterinarians revolve around euthanasia,44,45 limited owner finances, or when owners wish to continue treatment despite a poor prognosis or prolonged animal suffering.9 These morality-related stressors have been found to be associated with psychological distress and anxiety.21,46 In our study, we found that approximately one-third of respondents noted that fewer clients (compared to 2 years ago), could afford the recommended treatment for managing their pets’ health, with 84% of these veterinarians reporting this change as distressing. When participants were asked if prices had changed within the last 2 years, 80% reported yes, prices had increased more than a minimal amount. When asked how they felt about this price increase, a larger percentage of associates voiced feeling distressed (28%) than owners (17%). Because financial limitations of owners can negatively impact veterinarians’ ability to practice animal care consistent with their ethics and standards, these financial aspects of practice, especially for associates, must be considered. Offering ways to improve access to care as well as permission to offer a spectrum of care are 2 ways that hospitals can mitigate the negative impact of owners’ financial limitations on animal medical care.47,48

Given the prevalence of moral distress and its impact on mental health, it is imperative that the veterinary field provide training and education on how to recognize and navigate ethical conflicts. Even with the growing emphasis on mental health, there appears to be little recognition of the significant negative impact that repeated ethical conflicts can have on veterinarians’ mental health. One study of accredited US veterinary schools found that only 60% of reporting schools indicated they have an ethics course49; we suggest that this type of course be a requirement in all veterinary curricula. In addition, we suggest the implementation of ethics committees that can be used to facilitate discussion about ethically challenging scenarios as well as support students, faculty and staff who encounter ethical challenges. Beyond graduation, continuing education addressing this topic is needed to help practitioners navigate these situations in healthy ways. Just because ethical and moral challenges may be an innate part of veterinary medicine does not mean that we cannot help practitioners learn better ways of coping.

Recognizing and acknowledging ethical conflicts are important first steps in reducing moral distress. Next steps include helping empower veterinary professionals to voice their concerns and providing them a safe, supportive community in which to discuss these inevitable challenges.50 Changes must occur at all levels: individual units, entire hospitals, and more encompassing systemic levels. For example, the relatively new practice of incorporating social workers into veterinary hospitals could reduce some of the emotional burden and moral distress of veterinarians. Training in how to offer a spectrum of care may help empower veterinarians and the creation of an ethics committee may give them a safe place to discuss challenging situations and obtain mentorship and guidance.

Limitations to this study are those inherent in an on-line survey. Our sample consisted of a small percentage of VIN members, so caution is suggested when generalizing to other veterinarians. Another limitation, given the small number of responses from all those eligible, is response bias. It is possible that individuals who feel strongly about moral distress might have been more likely to respond to the survey.

In summary, moral distress appears to negatively impact veterinarians’ mental health. It is no longer acceptable to merely say that these ethical challenges are simply part of veterinary medicine. To continue making advances in supporting veterinarians’ mental health, we must be proactive in training veterinary students and professionals in ways to recognize and mitigate the potential harm that can be caused by moral distress.

Supplementary Materials

Supplementary materials are posted online at the journal website: avmajournals.avma.org

Acknowledgments

The authors declare that there were no conflicts of interest.

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