Moral distress among healthcare professionals: when the excessive workload becomes a mental health risk

“83% of healthcare professionals believe that the workload is the main factor in omitting care.” (Survey on omitted care, 2023)

This finding raises a burning question: what happens when working conditions prevent healthcare professionals from meeting the quality and ethical standards of their profession?

The answer can be summed up in two words: MORAL DISTRESS.

Compromised quality: when doing it right becomes impossible

In organization of work, the concept of compromised quality is often used to highlight a situation where working conditions do not allow employees to produce quality work, despite their will and their skills. Like moral distress, it’s a concept that refers to the frustration and suffering experienced when faced with obstacles that prevent one from performing one’s work properly, according to one’s quality standards. This phenomenon can exist in all settings.

Ethics: a shaky compass

Ethics are at the heart of healthcare professionals’ practice. They guide clinical decisions, dictate priorities and give profound meaning to every action taken. They are also based on the knowledge, attitudes and skills that enable them to identify ethical concerns inherent in their practice. For example:

• Carrying out an ethical analysis of possible actions
• Judging which actions are ethically superior (or the least problematic in situations where all possible options are ethically problematic)
• Drawing up an action plan
• Ensuring follow-up and continuous assessment

When organization of work contradicts these principles – for example when a healthcare professional must choose between two patients because of lack of time – this ethical compass is off course. It is in this gap between what we should do and what we can do that moral distress arises.

Moral distress occurs when one knows the right action to take or the right thing to do, but organizational obstacles and constraints prevent one from acting accordingly. It stems from the negative feelings and psychological imbalance experienced by individuals who find themselves in a situation where the actions they are required to perform do not align with their professional standards and their desire to provide quality care.

These situations generate psychological suffering for healthcare professionals, as they face them with an unsolvable dilemma: to respect their values or to obey organizational constraints.

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Consequences on mental health and the healthcare system

An aggravating factor is an element or condition that intensifies a problematic situation, a state of suffering or an already existing risk. The main aggravating factors for moral distress are:

• Excessive workload
• Lack of human or material resources
• Administrative decisions contrary to ethics
• Lack of support from colleagues or superiors
• Rigid organizational policies or policies that are disconnected from the reality in the field
• Unhealthy working environment
• Fear of reprisals or job loss if situations reported
• Fear of interpersonal conflicts
• Mismatch between personal values and imposed practices
• Potentially traumatic event (code silver, code orange, pandemic, disaster, etc.)

Too often, occupational health and safety policies focus on physical risks (injuries, falls, ergonomics) and neglect the organizational factors that affect mental health and may cause:

• Emotional detachment
• Feelings of guilt, powerlessness, failure
• Deterioration in the relationship between the healthcare professional and the patient
• Anxiety, frustration, anger

Moral distress may cause physical symptoms such as:

• Headaches
• Musculoskeletal disorders (TMS)
• Problems sleeping

In the most serious cases, moral distress can lead to:

• Depression
• Detachment
• Absenteeism
• Staff turnover
• Professional burnout
• Giving up the job, even the profession

In June 2025, the health and social services network had 94,048 Class 1 healthcare professionals (all unions combined). Among these, 15,716 were absent from work, while the manpower needs were evaluated at 26,117. That’s a difference of 41,833 workers.  (In French only)

By the same token, what about the care that is not provided? Or the workload of healthcare professionals who have to compensate for these absences and the need for additional staff?

Key issue in occupational health and safety

Since An Act to modernize the occupational health and safety regime (LMRSST) went into effect on October 6, 2021, An Act respecting occupational health and safety (OHS Act) has been clear:

“[Every] employer must take the necessary measures to protect the health and ensure the safety and physical and mental well-being of his worker. He must, in particular ensure that the organization of work and the working procedures and techniques do not adversely affect the safety or health of the worker.” (Section 51, subparagraph 3)

The employer is obliged to protect both the physical and mental health of his staff, and he must therefore take concrete actions to prevent moral distress, in the same way as psychosocial risks (PSR) in the care settings. These actions can be:

• Training staff in preventing PSRs
• Encouraging the expression of ethical and professional concerns through dialogue, committees, etc.
• Ensuring confidential psychological support through an employees assistance program
• Involving staff in the decisions that affect their work by organizing regular team meetings, for example
• Promoting a healthy and respectful working climate
• Acting on the real workload
• Recognizing and valuing the work accomplished
• Intervening quickly in the event of moral distress or signs of professional burnout

What can a healthcare professional do to minimize the risk of suffering from moral distress?

• Know how to recognize moral distress
• Inform her local union team of the situations that could lead to moral distress so that she is involved in the actions to be taken
• Focus on teamwork, which is an essential protective factor against occupational health and safety risks, including moral distress
• Refer to her Code of ethics which can support reflection and action by clarifying the boundaries of professional responsibility
• Express oneself and hold managers and employers accountable for moral distress, its causes and consequences

Mandatory overtime for a nurse: scenario

A nurse working an 8-hour day shift is forced to stay on for the evening shift due to a colleague’s absence. She is beginning to feel very tired and does not feel in full physical and mental control to cover another shift and provide safe care to patients.

Two sections of the Code of ethics of nurses contain contradictions as to the ethical obligations that apply in this situation.

Under Section 44, subparagraph 4, the nurse is responsible for ensuring continuity of care and treatment. In this respect, before leaving, she must ensure that continuity of care will be ensured for patients. This ethical obligation may be invoked by the employer.

1. According to Section 16, a nurse can refuse to perform a task if she is in a state, such as fatigue, which is likely to compromise the quality of the care and services. As such, a nurse has not only the right, but also the duty, to refuse MOT if she believes that she is in a state that may endanger patients.

The Ordre des infirmières et infirmiers du Québec (OIIQ) has set the following guidelines: (in French only)

“The nurse is the only person who can judge whether or not she is fit to practise. However, her assessment must be based on honesty and integrity. After assessing her ability to practise and the context in which she is being asked to work overtime, such as the complexity of care, the condition of clients, etc., the nurse may agree to remain at work. If she considers that she is unfit for work, she has a duty to abstain from working and refuse to work overtime. However, before ceasing to practise, she must:

• Inform her superior of her decision;
• Give her superior a reasonable amount of time to find a solution.”

This scenario clearly illustrates the issues associated with moral distress. Using the tools at her disposal, such as the Code of ethics or guidelines by the professional order, can enable a healthcare professional to better assert her rights in order to reduce her daily workload, which can become a source of stress and exhaustion.

In all cases, MOT should remain an exceptional and urgent measure. The employer cannot use it  to compensate for a foreseeable shortage of staff or to compel a nurse to work beyond her capabilities.

Codes of ethics

In conclusion: protecting mental health means protecting the quality of care

Moral distress is not an individual weakness, but rather a collective sign of alarm.

It is caused by political choices and poor management decisions which lead to dysfunction in the organization of work.

It endangers both the health of healthcare professionals and the quality of care provided to the population.

Recognizing it as an OHS issue is an essential step towards a more humane, more ethical and more sustainable healthcare system.

The Federation encourages its members to report situations that are unsafe for themselves or for their patients by completing their institution’s form for reporting a dangerous situation and the FIQ’s Safe Staffing Form. The latter enables healthcare professionals to report a situation involving risks for the safety and quality of care to their union. By documenting problem situations, we are giving ourselves the means to act collectively to upgrade care quality. Taking collective and union action to improve the quality of care is also a way of protecting oneself against the risks of suffering from moral distress.

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