Dealing with difficult choices: a qualitative study of experiences and consequences of moral challenges among disaster healthcare responders.

BACKGROUND: Disasters are chaotic events with healthcare needs that overwhelm available capacities. Disaster healthcare responders must make difficult and swift choices, e.g., regarding who and what to prioritize. Responders dealing with such challenging choices are exposed to moral stress that might develop into moral distress and affect their wellbeing. We aimed to explore how deployed international disaster healthcare responders perceive, manage and are affected by moral challenges. 

METHODS: Focus groups discussions were conducted with 12 participants which were Swedish nurses and physicians with international disaster healthcare experience from three agencies. The transcribed discussions were analyzed using content analysis. 

RESULTS: We identified five interlinked themes on what influenced perceptions of moral challenges; and how these challenges were managed and affected responders' wellbeing during and after the response. The themes were: "type of difficult situation", "managing difficult situations", "tools and support", "engagement as a protective factor", and "work environment stressors as a risk factor. Moral challenges were described as inevitable and predominant when working in disaster settings. The responders felt that their wellbeing was negatively affected depending on the type and length of their stay and further; severity, repetitiveness of encounters, and duration of the morally challenging situations. Responders had to be creative and constructive in resolving and finding their own support in such situations, as formal support was often either lacking or not considered appropriate. 

CONCLUSION: The participating disaster healthcare responders were self-taught to cope with both moral challenges and moral distress. We found that the difficult experiences also had perceived positive effects such as personal and professional growth and a changed worldview, although at a personal cost. Support considered useful was foremost collegial support, while psychosocial support after deployment was considered useful provided that this person had knowledge of the working conditions and/or similar experiences. Our findings may be used to inform organizations' support structures for responders before, during and after deployment.