Healthcare professionals are inherently vulnerable to moral distress due to their frequent work with persons who are suffering or in crisis, in combination with the strong empathic orientation that underpins the very act of care giving [1
]. For some practitioners, morally distressing occurrences are perceived as just a part of their daily work. For others, the initial distress does not dissipate, but rather reactive distress sets in with lingering consequences [2
]. Moral distress occurs when a practitioner recognizes the right course of action but is unable to act ethically because of factors that are perceived to be beyond his/her control [2
]. For example, moral distress can result when a healthcare provider knows that a certain treatment will be more effective and less painful for a patient, but, because of resource limitations, they are required to use one that is less effective and causes more pain. Knowingly inflicting more pain, that is technically necessary over a number of episodes, is morally upsetting to people whose professional ethos centers on patient wellbeing and care. Moral distress is typically triggered and shaped by macro level structures that are usually beyond the health professionals’ purview [3
], and is associated with negative consequences for both individuals (job dissatisfaction, and progressive insensitivity to ethical patient care), and organizations (reduced quality of care, and increased staff turnover) [3
]. Unresolved moral distress, with accompanying feelings of depletion or powerlessness, can compromise healthcare providers’ ability to uphold their ethical standards and diminish the physical and emotional energy needed to fully address patients’ needs [3
]. This is a critical issue because, in addition to resulting individual health difficulties (such as emotional exhaustion, diminished moral sensitivity, and burnout [3
]), there is an increased threat to the safety and wellbeing of patients and co-workers [1
]. The literature reports a high incidence of nurses resigning from positions and even leaving the profession as a result of moral distress [5
]. Increased absenteeism and turnover gives rise to compromised patient care and poorer organizational outcomes due to loss of organizational knowledge, disrupted continuity of care, potential interruption in the implementation of evidence-based practices, and eventually lead to decreased consumer trust in the system. These worrisome consequences notwithstanding, there is evidence that resilience, or the ability to learn and grow from adversity, is effective in mitigating the detrimental effects of workplace stress and moral distress [6
]. For example, McAllister and McKinnon’s research review focused on nursing students, revealed that a number of qualities that foster resiliency (such as social support, problem solving, and communication skills) could be taught. They concluded that teaching resiliency—the ability to bounce back from negative events—was a critical skill that should be addressed in healthcare provider educational programs [7
Though moral distress is not unique to any one healthcare discipline, members of different professions may experience it for different reasons [5
]. While the moral distress experienced by Canadian occupational therapists has been examined [8
], no study was found that included participants from the Canadian prairies. According to Pauly et al., moral distress is specifically associated with difficulties navigating practice while upholding one’s professional values and responsibilities [11
]. Research with occupational therapists has indicated that ethical tensions tend to be related to: (a) resource and systemic constraints: e.g., insufficient economic resources to implement quality interventions and to inform practice, and working at a superficial level due to lack of time [12
]; (b) upholding ethical principles and values: e.g., being torn between a concern for clients’ priorities and those of their healthcare organization; and (c) interpersonal conflicts: e.g., perceptions that one’s clinical opinion is not respected, continually having to justify intervention decisions, or when one’s opinion frequently differs from the team’s resulting in tension between being client-centered and being perceived as delaying discharge [2
]. Moral distress can be experienced concurrently with, and/or lead to, burnout for which organizational risk factors include excessive workload, perceived powerlessness and lack of control over one’s work, inability to exercise professional autonomy, perceived inequity, and conflict between individual and organizational values [14
Encouragingly, some recent research also suggests that moral distress can become a catalyst for personal transformation and growth, and for positive action on the organization’s part [3
]. Aligning with this, resilience is described as the ability to “cope, learn, and grow from difficult experiences” [15
], to “healthfully adapt to challenges, stresses, adversity, or trauma” [3
], and to “maintain personal and professional wellbeing in the face of on-going work stress and adversity” [2
]. Moral resilience encompasses the ability to reframe stressful events as opportunities instead of viewing them as threats and to respond in healthy ways. More specifically, in the event of moral tensions, moral resilience represents “the capacity … to sustain or restore [one’s] integrity in response to moral complexity, confusion, distress, or setbacks” [3
]. Recognizing and measuring moral distress is a requisite first step in both mitigating it, and using it as a springboard for action by both practitioners and policy-makers that contributes to the cultivation of resilience.
As a component of a larger project to develop moral distress and resiliency web-based psychoeducational resources, we need to address the gap in research specific to occupational therapists and moral distress. This paper presents survey findings addressing the research question of the prevalence of moral distress, and levels of resilience, among occupational therapists in Alberta and Saskatchewan, Canada.
The mean MDS-R-OT [A] score of 68.08 (Table 3
) demonstrates that moral distress occurred among the occupational therapists included in this study. As this exact version of the MDS has not been used with other populations of healthcare providers, therefore, no direct comparisons can be made. However, Penny et al. used a very similar scale to measure moral distress in a national sample of American occupational therapists (N = 224), and reported a mean score of 50.63 [20
]. Perhaps more interestingly, and certainly most helpful in the development of the teaching module that was informed by this study, was the list of situations within the MDS-R-OT[A] scale for which respondents reported the highest levels of moral distress (Table 3
). These results provide an indication of the impact of specific workplace policies and culture on the moral distress of participants, and provide guidance in the selection and development of recommendations.
Especially concerning, however, were the responses relating to participants’ intentions to leave the organization. On the MDS-R-OT [A] 49% reported that they had considered leaving a position due to moral distress, 40% reported had actually left, and 24% reported currently considering leaving, compared to 20%, 25%, and 10% respectively in the Penny study [20
]. The results of this study suggest reason for concern regarding the moral distress experienced by occupational therapists practicing in these two Canadian provinces. Equally worrisome is their relatively low mean resilience score. By definition, moral distress is a relational experience that is shaped by the contexts in which it occurs. As such, attention to both individual and contextual characteristics and processes that enhance resilience in health care environments is warranted. Analysis of the participants’ answers to the open ended questions included in our survey, combined with an extensive review of the healthcare literature pertaining to moral distress, provided strategies that both individual healthcare providers, and the organizations in which they work, can put into place to enhance resilience.
Professional resilience enables occupational therapists, and indeed all healthcare practitioners, to persevere through difficult times by using challenges and adversity as catalysts for individual growth, and for positive action. Activities that assist healthcare professionals in cultivating resilience include: taking time for self-reflection, focusing on the purpose and meaning of one’s work, documenting one’s achievements, maintaining and improving one’s professional skills and competencies, and acting on one’s intuition and professional values rather than deferring to contextual pressures [7
]. The latter sometimes involves taking risks but is particularly useful in managing the uncontrollable parts of one’s job, and can help them move towards being energetic, engaged, and feeling efficacious [21
]. Indeed, taking initiative, asserting one’s professional role, and offering solutions to challenges can engender both personal and organizational growth. Finally, and perhaps most importantly, a strong professional identity has been shown to sustain and enhance resilience [22
]. For this reason, a list of concrete actions that individual occupational therapists can take to assist them in nurturing their professional identity was developed for inclusion in the educational module related to this project and is included here [24
] (See Table 4
Professional identity for occupational therapists, however, can be negatively influenced by the context in which they habitually work, for example, those dominated by biomedical models and, for therapists working in mental health, where psychological theories such as dialectical behavioral therapy or cognitive behavioral therapy [22
] predominate. In addition, program management structures and case management models of service, that often require health practitioners to work outside their professional domain, can cause professional isolation and blur professional roles, each of which can be challenging to professional identity [20
]. Frequently being in the minority on health teams, occupational therapists most often report to colleagues from other disciplines who may not understand their professional standards or share their practice perspective [22
]. In an examination of this scenario, Fortune concluded that when occupational therapists adopt roles dictated by managers and colleagues who have no knowledge of the occupational therapy treatment paradigm, it places them at risk of identity confusion [25
]. Evidence from studies in nursing has demonstrated the negative psychological effects of top down decision-making, limited autonomy, inter-professional antagonism, and professional invalidation, which are surely also relevant to occupational therapists and other healthcare disciplines [7
]. This invokes the responsibility that organizations have with regard to the implementation of policies and procedures that foster resilience-building environments.
Many of the avenues to individual resilience discussed in the previous section require a workplace culture that recognizes, supports, and promotes ethical professional practice, and implements resilience-building institutional policies and human resource management principles.
lists recommendations, categorized as they relate to the ways professional practice leaders, supervisors/managers, and employers/policy makers/government, respectively, which can contribute to the construction of resiliency promoting work environments. Of course, educators, accrediting bodies, professional and regulatory bodies, and researchers also have roles to play, but their discussion is beyond the scope of this paper. Persons interested in these are encouraged to visit the on-line educational module that was developed for occupational therapy students and practitioners upon completion of this study and placed in the public domain [24
This was a small descriptive study, and no definitive statistical conclusions can be drawn. There was an underrepresentation of males responding to the study, the snow-ball recruitment method may have introduced bias, and we cannot claim that a representative sample was achieved. Furthermore, there are possibly regional differences between the two provinces (both are agricultural and energy based economies) that would impact factors, such as regional healthcare budget, that in turn influence moral distress in the workplace. While the diverse sample demographics created some limitations it was also a potential advantage that the participants were from a range of ages and workplace situations so as to demonstrate proof of principle. These exploratory results support the notion that moral distress and resiliency education and strategy development for therapists and students in the occupational therapy workplace is important and that more research is warranted.
These findings suggest that moral distress exists for occupational therapists working in the Canadian prairie provinces of Alberta and Saskatchewan. The findings also suggest that there are certain morally distressing events and experiences that are more commonly encountered. These findings give some direction for educational and organizational interventions, but much remains unknown and larger studies are required.
A healthy workforce is pivotal to effective healthcare service delivery [26
]. However, as long as suffering, mortality, and social inequality remain components of the human condition healthcare providers are at risk of experiencing moral distress [5
]. Consequences of moral distress include damage to the psychological health of individuals, increased turnover within organizations with all the negative consequences that entails, and attrition within health professions, which present a possible risk to patients and co-workers. While individual occupational therapists, and all healthcare professionals, must take an active role in managing the inherent difficulties in their day-to-day practice, the role of management in fostering resiliency in current healthcare environments must also be addressed. The small study described in this paper informed the development of a web-based education module [24
] that describes moral distress and provides extensive information about the many ways in which individual healthcare professionals can cultivate their own resilience, as well as actions that healthcare organizations can take to promote workplace resilience.