Moral Distress Amid the Pediatric Behavioral Health Crisis: A Call to Action Free

Jamie was a 7-year-old girl with bright blue eyes and a winsome smile. Sarah, the admitting intern, carefully pulled up a chair beside Jamie, complimented her on her colorful shirt, and then asked, “Do you know why you are in the hospital today, Jamie?”

Jamie looked up, her blue eyes flickering as often happens when children try to recall their pets’ names or siblings’ ages. She then bashfully said, “I tried to kill myself with scissors.”

Her answer, so discordant with her innocent countenance, hardly caused Sarah to bat an eye. As Sarah asked Jamie and her mother more questions, she drew out a story of behavioral health issues against the backdrop of family discord, substance abuse, and sexual assault. Jamie was admitted to our hospitalist service while awaiting inpatient psychiatric placement, to be cared for by our pediatric residents and hospitalist attending. She would remain there for 4 days before a suitable facility was identified.

Unfortunately, stories such as Jamie’s are commonplace at my training institution and are reflective of a nationwide trend.¹  This is primarily due to the poor pediatric mental health infrastructure in states that cause children with psychiatric emergencies to be housed at local hospitals until bed spaces open at an available behavioral health facility.

It is no secret that the state of pediatric behavioral health in the United States can be described as a “crisis,” one that has intensified in the era of coronavirus disease 2019.²  The description of this crisis primarily (and rightfully) focuses on the morbid outcomes for patients who receive insufficient care. Yet an underemphasized aspect of this crisis is the consideration of the experience of pediatric trainees caring for these patients within systems of resource strain. For example, what impact does the above experience have on Sarah, a pediatric intern with no formal psychiatric training, who recurrently hears of and bears witness to stories of abuse, neglect, and severe mental illness? More than this, how does Sarah, or the residents caring for Jamie thereafter, square such moral strain with the lack of training and ability to offer robust intervention and hope for improvement?

The act of witnessing suffering without the opportunity for meaningful response is one form of moral injury, the process of “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”³  Persistent moral injury leads to the experience of moral distress, a “state of psychological suffering one may experience when acting in ways that run counter to one’s ethical or moral beliefs or commitment, particularly when one feels compelled to do so.”⁴ 

Moral distress has received increased attention in health care literature recently and is recognized as an increasing threat to the well-being of house staff who find themselves powerless to act in ways they deem clinically appropriate.⁵  Importantly, although many believe moral distress only occurs when one feels compelled to perform immoral acts, this term also applies when one is faced with morally taxing situations and is ill-equipped to respond meaningfully. The “bearing witness” element of the definition above describes the state of the team caring for Jamie in this instance when possible responses are constrained by institutional policies which fail to consider the experiences of moral agents in these positions.

Despite the increasing burden of the pediatric mental health crisis on academic medical centers, pediatric trainees continue to report low levels of competency and confidence in caring for this patient population because the significant strain on such medical centers outstrips behavioral health education.^6,7  This deficiency in training with morally challenging situations is one of the primary drivers of ethical distress in trainees, as is the perception that trainees lack agency in offering compelling responses to such situations.⁸  Residents seeking to care for behavioral health patients are thus vulnerable to moral distress both because of insufficient education in how to care for this population (including trauma-informed history taking and physical examination skills, deescalation techniques, and navigating the often complex family and social dynamics that frequently arise), as well as the belief that admitting and supervising these children offers little in the way of meaningful treatment of their presenting concerns.

This experience should not be confused with house staff caring for medically critically ill children; that is something residents expect during training, where they learn the appropriate therapeutic response to illness and, to varying degrees, maintain agency in being able to enact such responses. The possibility of moral distress and vicarious trauma is generally held in balance with the potential to provide meaningful therapy to medically ill patients and is an integral component of what it means to be a physician. Yet this is not true when house staff admit and care for patients with primary behavioral health concerns, admitted for temporary placement. In these cases, simply hearing traumatic stories without being trained or equipped to meaningfully help these patients places residents in a position they did not sign up for with the risk of long-term mental health sequelae themselves.⁹  This concern is heightened for residents in particular among other medical professionals, who often lack meaningful recourse when faced with instructions they deem inappropriate, injurious, or unfair, such recourse which may be available in varying forms for advanced practice practitioners or attending physicians higher up in the medical hierarchy.¹⁰ 

Although national efforts must be continued to improve pediatric behavioral health access, those in medical leadership should proactively work to improve conditions for house staff who incur moral distress while caring for this patient population, in the following ways.

First, recognition of this behavioral health crisis, and its effects on house staff, should be acknowledged and investigated at a national level, primarily in the form of enhanced research characterizing the scope of the problem. Simply quantifying the number of patients hospitalized for behavioral health issues is an important first step. More than this, attention should be paid to institutions like my own, where the realities of our state’s pediatric mental health infrastructure mean that the bulk of admitting and caring for these patients falls on pediatric house staff. Utilizing pediatric house staff to care for behavioral health patients is an ad hoc response to a systemic problem that could lead to burnout and attrition, fewer choosing to enter pediatrics as a specialty, or significant difficulties in effective residency recruiting at such institutions unless this problem is more thoroughly researched to allow for better care provided from those trained in the area of behavioral health.

Second, academic pediatric hospitals should allocate resources to meet this need within their institutions, both to improve patient care and protect trainees. Although institutions may be tempted to invest in enhancing care for other patient populations or in bolstering specific revenue-generating hospital units, neglecting the need for well-resourced care plans for behavioral health patients causes these patients and the residents caring for them to feel deprioritized. This may mean investing in additional hospital staff, including midlevel providers, to help assist in care, as has been done at my institution, or hiring nurses with specialty training in the area of behavioral health. This may also involve the implementation of dedicated psychiatric teams in pediatric emergency departments, which may improve the quality of care for patients and prevent unnecessary admissions.¹¹  Moreover, institutions should provide specialized training in behavioral health care both to improve patient care and to enhance residents’ self-efficacy. Although such changes may require a significant culture shift, failing to harness the expertise of specialty-trained providers or provide more training to residents may unduly place the bulk of clinical responsibility on underequipped pediatric house staff who have little recourse to advocate on their own behalf when work is unfairly placed on them.

Third, in situations in which institutions have sought to enact these measures yet house staff still account for most of this work, a robust program of mental health counseling should be offered to trainees to enhance resilience. In a similar way that therapists are often required to see counselors because of the trauma they witness professionally, administrations and program leadership could take the proactive move of requiring therapy sessions for residents to mitigate long-term mental health sequelae, what has been termed “moral residue” of these challenging experiences.⁶  Residency programs should help to actively arrange for this, rather than assuming residents will be able to arrange this in the midst of their schedules when such important self-health measures are too often foregone.

One of the primary reasons many are called to the field of pediatrics is the opportunity to advocate for, protect, and offer hope for healing to the vulnerable, like Jamie. Yet those in places of academic leadership, at both the national and institutional level, must also recognize their charge to protect trainees in the course of this work to ensure both their health and the health of the patients they serve.