Occupational Therapy In Health Care, 28(4):382–393, 2014 C 2014 by Informa Healthcare USA, Inc. Available online at http://informahealthcare.com/othc DOI: 10.3109/07380577.2014.933380
ARTICLE
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
An Investigation of Moral Distress Experienced by Occupational Therapists Neil H. Penny, Timothy L. Ewing, Rachel C. Hamid, Kimberly A. Shutt, & Amy S. Walter Occupational Therapy Department, Alvernia University, Reading, PA, USA
ABSTRACT. This study used a quantitative survey design to investigate the existence of moral distress among occupational therapists. The Moral Distress Scale-Revised (MDS-R-OHPA) was distributed to a random sample of 600 members of the American Occupational Therapy Association (AOTA). The results of this explorative study found that occupational therapists reported moderate levels of moral distress with occupational therapists working in geriatric settings reporting higher levels of moral distress than occupational therapists who work in physical disability settings, although the difference was not statistically significant. However, occupational therapists who were considering leaving their current position reported the highest levels of moral distress. These initial findings are discussed as well as the need for further research. KEYWORDS.
Job stress, moral, moral distress, occupational therapy
INTRODUCTION Ethical and moral problems are a growing concern in health care (Ulrich, Hamric, & Grady, 2010), but little is known about the issue of moral distress in the field of occupational therapy. In early studies, moral distress was defined as a phenomenon where “one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (Jameton, 1984, p. 6). Jameton was a philosopher and when he wrote this definition, moral distress was not his main focus. He was interested in how nurses approached and solved ethical problems. Jameton sought to differentiate between what he considered were three distinct types of moral problems experienced by nurses: moral dilemmas, moral uncertainty, and moral distress. He viewed moral distress as a strictly cognitive problem and left it to later researchers to investigate the affective components of the phenomenon. Address correspondence to: Neil H. Penny, EdD. OTR/L, Chair, Occupational Therapy Department, Alvernia University, 400 St. Bernardine Street, Reading, PA 19607, USA (E-mail: [email protected]) At the time of the study Timothy Ewing, Rachel Hamid, Kimberly Shutt and Amy Walter were graduate students enrolled in the Occupational Therapy program at Alvernia University, Reading, PA. (Received 2 June 2014; accepted 7 June 2014)
382
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
Moral Distress
383
Moral distress has been researched extensively in the field of nursing. Corley (2002), proposed a theory of moral distress using eight moral constructs that impact nurses: moral commitment, moral sensitivity, moral autonomy, moral sense making, moral judgment, moral conflict, moral competency, and moral certainty. Hanna (2004) conducted a review of 36 nursing studies of moral distress and postulated that moral distress is made up of four interrelated components (1) anguish or interior suffering, (2) an inability to meet professional role expectations, (3) issues around truth telling (whistle blowing, withholding information from patients, and documenting to meet organizational requirements), and (4) professional insights about futile care. Repenshek (2009) suggested that the most common cause of moral distress occurs when there is a conflict between the practitioners’ knowledge of, and values about, health care and values of the patient and their family. Recently, Hamric, Borchers, and Epstein (2012) described moral distress as having three possible causes (1) problematic clinical situations, (2) internal constraints such as feelings of powerlessness, and (3) external constraints such as inadequate resources. The most current definition of moral distress describes it as “the experience of being seriously compromised as a moral agent in practicing in accordance with accepted professional values and standards. It is a relational experience shaped by multiple contexts, including the socio-political and cultural context of the workplace environment” (Varcoe, Pauly, Webster, & Storch, 2012, p. 59). This definition moves the focus away from the health practitioner as not acting as a moral agent and focuses instead on the context of the experience. There is growing concern that moral distress can negatively impact clinical practice and, in some cases, patient outcomes (Zuzelo, 2007). According to Schluter, Winch, Holzhauser, and Henderson (2008), moral distress is characterized by “painful feelings and associated emotional and mental anguish as a result of being conscious of a morally appropriate action, which, despite every effort, cannot be performed owing to organizational or other obstacles” (p. 306). They found that the educational level of nurses, the amount of support received from peers, and the ethical climate of the workplace influenced the level of moral distress experienced. Schluter et al. (2008) found that moral distress had a negative impact on the physical and mental wellbeing of nurses, nurses’ provision of care, job satisfaction, and staff turnover, and manifested as headaches, neck pain, muscle aches, diarrhea, as well as feelings of anger, guilt, powerlessness, and frustration. Other effects include depression, loss of self-worth, disengagement from family and friends, and not wanting to return to work. Patient care was also affected as the nurses became withdrawn from their patients and their interactions decreased. Job satisfaction was decreased, which resulted in nurse turnover; nurses either changed jobs or left nursing altogether (Schluter et al., 2008). VonDras, Flittner, Malcore, and Pouliot (2009) found a significant relationship between psychological stress and pressure to take short cuts in the delivery of care. Lawrence (2011) found there was a direct negative relationship between moral distress and the work engagement of nurses. Work engagement is characterized by high levels of energy, mental resilience, investment of effort, persistence in difficult times, fully concentrating on work, enthusiasm, and pride; all of which decrease as moral distress increases. Others (Wiegand & Funk, 2012) found that the negative consequences of moral distress included frustration or anger, helplessness, suffering, distress,
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
384
Penny et al.
disappointment, sadness or depression, and physical as well as psychological exhaustion. Corley is credited with developing the first instrument to measure moral distress, the Moral Distress Scale (MDS) (Corley, Elswick, Gorman, & Clor, 2001). Although, shown to be reliable and valid, with its focus on situations experienced by critical care nurses, this instrument has limited usefulness in other clinical settings or for other health care providers. To further the study of moral distress, Hamric and Blackhall (2007) modified the MDS by reducing the number of items from 38 to 19 and from a single seven point Likert scale to two Likert scales for each item (i.e., one for the frequency (0 to 4) and one for intensity (0 to 4)). Using this shortened version of Corley’s MDS, Hamric and Blackhall conducted a pilot study with 168 nurses and 29 physicians who worked at two Intensive Care Units (ICUs) in Virginia. The results showed that ICU nurses reported higher levels of moral distress than physicians. In a follow-up study, Hamric et al. (2012) created the 21 item Moral Distress Scale Revised (MDS-R) with three parallel versions for nurses, physicians and other health care providers. They then tested the psychometric properties of these instruments with 37 physicians and 169 nurses working at an academic medical center in Virginia. Once again, this new MDS-R revealed that physicians had significantly lower levels of moral distress than nurses (Hamric et al., 2012). McCarthy and Deady (2008) suggest that by limiting research to the profession of nursing, the insidious and pervasive problems caused by moral distress remain hidden. Other health care professions (e.g., pharmacy, physical therapy, psychologists and respiratory care) are just beginning to explore the experience of moral distress in their professions (Austin, Rankel, Kagan, Bergum, & Lemermeyer, 2005; Carpenter, 2010; Schwenzer & Wang, 2006; Sporrong, Hoglund, & Arnetz, 2006). Moral distress has been poorly studied in occupational therapy and usually in terms of ethical concerns rather than moral distress. While creating the Occupational Therapy Dilemma Test, Hansen (1984), interviewed occupational therapists (n = 22) from a variety of practice settings and found four common sources of ethical concerns: the choice of treatment, inappropriate referrals, insufficient time or resources to provide treatment, and conflicts concerning appropriate goals (as cited in Foye, Kirschner, Brady-Wagner, Stocking, & Siegler, 2002). Foye et al. (2002) investigated the ethical concerns identified by occupational therapists (n = 38) working in an urban rehabilitation hospital. The three most frequently identified ethical concerns included: reimbursement pressures (43%), conflicts around goal setting (21%), and patient/family refusal of treatment team recommendations (11%). Slater and Brandt (2009) surveyed a non-random selection of American Occupational Therapy Association (AOTA) members (n = 100) to identify the causes of moral distress. They found that more than half of the respondents answered commonly or occasionally to items, such as reimbursement constraints (70%), conflict with organizational policies (70%), excessive pressure to meet productivity standards (61%), lack of administration support (59%), questionable or unrealistic clinical decisions by others (57%), patients who decline treatment (57%), decision making regarding patient discharge (55%), excessive pressure to increase billable hours (54%), and compromised care due to pressure to decrease costs (53%). (p. 14). External constraints were the major cause of moral distress for occupational therapists. Slater and Brandt (2009) suggest six strategies to
Moral Distress
385
address moral distress. However, for any of these strategies to be effective, a deeper understanding of moral distress as it pertains to occupational therapists is needed. Thus, the purpose of this study was to determine if moral distress would be reported in a national sample of professional level occupational therapists and, if it exists, is moral distress more prevalent in one practice area compared to another? METHODOLOGY
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
Study Design The study used a descriptive quantitative survey design. The dependent variable was the level of moral distress experienced by occupational therapists as measured by the MDS-R, and the independent variable was the practice area (geriatric or physical disabilities). An important confounding variable was non-response bias (Forsyth & Kviz, 2006). Those who do not experience moral distress may not find the topic sufficiently interesting to take the time to complete and return the questionnaires. This may cause the data collected to be over represented by those who do experience moral distress, increasing the likelihood of committing a Type I error. Measurement Tools The Moral Distress Scale-Revised, Other Healthcare Provider (Adult) (MDS-ROHPA) (Hamric et al., 2012) was used to measure moral distress, and a brief questionnaire created by the researchers was used to collect demographic information about the respondents. The MDS-R-OHPA is a paper-and-pencil version of the MSD-R specifically designed to measure the moral distress experienced by health care disciplines other than nurses working in adult settings. Twenty-one situations that occur in clinical practice are described, and the respondents were asked to rate the frequency in which they have experienced the situation and the level of disturbance the situation caused or would cause if it did occur. Two open items are provided for respondents to add, if they choose, their own personal experiences of moral distress. The MDS-R concludes with two questions regarding leaving or contemplating leaving a job due to moral distress (Hamric et al., 2012). The level of moral distress is calculated by taking the level of disturbance score for each of the 21 situations and multiplying it by the corresponding frequency score. According to Hamric et al. (2012), items that are checked as never experienced or are not seen as distressing do not contribute to an individual’s overall level of moral distress score. Each individual item score can range from 0 to 16. To obtain the overall composite moral distress score, the twenty-one scores are added together. The final score ranges from 0 to 336, with a possible upper score of 368 if the respondent adds his or her personal experience items (Hamric et al., 2012). Low total scores represent low moral distress, whereas high total scores represent high moral distress. Hamric et al. (2012) report an overall Cronbach alpha for the MDS-R of .88. The Cronbach alpha for the data in this study was found to be .93. Cronbach alpha values that are close to .90 indicate high consistency among the scale items (Kielhofner, 2006). Hamric et al. (2012) report a content validity of 88% for the inter-rater agreement for the primary and secondary root causes of moral distress.
386
Penny et al.
Construct validity was tested against four hypotheses that were all statistically significant in the expected directions: ethical climate (r = -.40, p < .001), physicians had lower moral distress than nurses (t = −5.79, p < .001), clinicians who were considering leaving their position had significantly higher scores (F = 48.39, p < .001) and nurses with more experience had higher moral distress (r = .22, p = .005) (Hamric et al., 2012).
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
Participants The mailing address of 600 occupational therapists was obtained from AOTA’s membership list rental service. Randomization was achieved by an Nth selection of every 12th record from the 3,639 occupational therapists who checked geriatrics as their primary special interest and an Nth selection of every 17th record from the 5,192 occupational therapists who checked physical disabilities as their primary special interest. These two practice areas were chosen based upon research showing the impact of reimbursement systems on the services provided in these settings (Brayford et al., 2002; DeJong, Horn, Smout, & Ryser, 2005; Hutt et al., 2001; Kennedy, Maddock, Sporrer, & Greene 2002; Zinn et al., 2003). A total of 231 responses were received, of these seven were partially completed questionnaires. The resulting sample consisted of 224 respondents (response rate = 37.3%). The majority of the respondents were female (91.5%), white (92.0%), employed full time (72.8%) and held either a bachelor’s (41.5%) or master’s (53.1%) degree. The average age was 41.21 (SD = 13.04) years of age with a mean of 14.67 (SD = 12.36) years of experience. Respondents were almost equally distributed from across the four regions recognized by the AOTA (Midwest n = 61, Northeast n = 50, South n = 59 and West n = 54) χ 2 (3) = 1.32, p = .724. In terms of practice areas, 100 (44.6%) respondents reported working in a geriatric setting, 81 (36.2%) reported working in a physical disability setting and 43 (19.2%) reported working in more than one type of setting. Procedures After permission to use the MDS-R-OHPA was received from the instrument developer and the Institutional Review Board (IRB) approved the study, questionnaire packets were mailed. The mailings included a cover letter describing the study, a consent form, the demographic questionnaire, the MDS-R-OHPA, and a stamped addressed return envelope. Data was collected during the first months of 2013. RESULTS The mean MSD-R-OHPA score for all respondents was 50.63 with a standard deviation of 33.58. Scores ranged from a low of 0 to a high of 181. The median score was 44.00 and the distribution of the scores had a positive skew. A one-way ANOVA test found that there was not a statistically significant difference between occupational therapists who reported working in a physical disability setting (n = 81, M = 44.84, SD = 29.94, Mdn = 36.00), in a geriatric setting (n = 100, M = 53.92, SD = 35.14, Mdn = 48.00) or those who reported working in more than one type of setting (n = 43, M = 53.88, SD = 35.59, Mdn = 55.00), F(2, 221) = 1.90, p = .152.
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
Moral Distress
387
To investigate if there were a difference in moral distress between occupational therapists who identified themselves as only working in a physical disability setting or a geriatric settings, an independent sample t-test (two-tailed) was conducted; the result approached but did not show a statistical difference t(179) = −1.85, p = .067. No difference was found between MDS-R-OHPA mean scores by occupational therapy degree held (bachelor, n = 93, M = 46.38, SD = 28.97, Mdn = 40.00; master, n = 100, M = 54.15, SD = 36.17, Mdn = 47.00; or doctorate, n = 10, M = 54.10, SD = 40.67, Mdn = 54.00) F(2, 219) = 1.45, p = .237. To investigate if there were a difference between occupational therapists holding either a bachelor or master degree an independent sample t-test was conducted. No difference in mean scores was found t(210) = 1.69, p = .092. In addition, no difference was found between those who reported that their education included formal occupational therapy course work to learn how to resolve moral questions (n = 125, M = 50.94, SD = 32.29, Mdn = 44.00) compared to those who stated they did not receive formal occupational therapy education to learn how to resolve moral questions (n = 94, M = 49.38, SD = 34.76, Mdn = 43.00), t(219) = 0.35, p = .731. Lastly, a 2 × 2 ANOVA found no interaction effect for practice area (physical disabilities or geriatrics) and formal moral education to learn how to resolve moral questions (yes or no) F(1, 173) = 0.94, p = .334. Pearson product correlation coefficient tests between MDS-R-OHPA scores and continuous demographic variables found no statistically significant relationships (age: r = -.065, p = .334 and years of practicing: r = −.046, p = .491). Additional Findings Table 1 shows the situations within the MDS-R-OHPA that were most and least frequently reported as causing moral distress; these comprise situations that were scored as eight or higher. To address the issue of whether moral distress leads to staff turnover, there are two questions. The first asks if the respondent has ever left or considered leaving a job in the past due to moral distress. Occupational Therapists who had considered leaving but did not scored higher (n = 45, M = 70.67, SD = 32.88, Mdn = 60.00) than either those who had left a position due to moral distress (n = 57, M = 53.98, SD = 31.00, Mdn = 48.00) or those who never considered leaving a position due to moral distress (n = 113, M = 43.63, SD = 31.89, Mdn = 33.00). A one-way ANOVA found that these differences were statistically significant F(2, 212) = 11.73, p < .001. The Bonferroni post hoc tests indicated the difference was between all groups except those who had left a position and these who never considered leaving. The second question asks if the respondent is currently considering leaving his or her position. Occupational therapists who were considering leaving their current position scored significantly higher (n = 24, M = 83.17, SD = 37.86, Mdn = 79.50) than those who were not considering leaving their current position (n = 190, M = 48.03, SD = 30.83, Mdn = 41.00), t(212) = 5.12, p < .001. DISCUSSION With an overall mean score on the MDS-R-OHPA of 50.63, this study suggests that moral distress does occur among occupational therapists, confirming those
388
Penny et al.
TABLE 1. Situations Reported to Cause Moral Distress (Item Score of 8 or Higher) (n = 224)
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
MDS-R-OPHA Item Most frequently reported: Situation 18: Witness diminished patient care quality due to poor team communication Situation 1: Provide less than optimal care due to pressures from administrators or insurers to reduce costs Situation 20: Watch patient care suffer because of lack of provider continuity Situation 17: Work with nurses or other healthcare providers who are not as competent as the patient care requires Situation 21: Work with levels of nurse or other care provider staffing that I consider unsafe Situation 10: Be required to care for patients I don’t feel qualified to care for Least frequently reported: Situation 7: Continue to participate in care for a hopelessly ill person who is being sustained on a ventilator, when no one will make a decision to withdraw support. Situation 16: Follow the family’s wishes for the patient’s care when I do not agree with them, but do so because of fears of a lawsuit. Situation 12: Participate in care that does not relieve the patient’s suffering because the physician fears that increasing the dose of pain medication will cause death. Situation 13: Follow the physician’s request not to discuss the patient’s prognosis with the patient or family. Situation 11: Witness medical students perform painful procedures on patients solely to increase their skill. Situation 14: Witness increasing doses of sedatives/opiates given to an unconscious patient that I believe could hasten the patient’s death.
n
%
85
37.9
71
31.6
66 65
29.4 29.0
39
17.5
24
10.7
9
4.0
9
4.0
8
3.5
4
1.8
3
1.3
3
1.3
presented by Slater and Brandt (2009). While there was a difference in the mean scores in physical disabilities and geriatrics practice areas, the difference was not sufficient to be statistically significant. Interestingly, the overall levels of moral distress reported by occupational therapists in this study were less than those found among ICU nurses and more similar to those reported by ICU physicians (Hamric & Blackhall, 2007; Hamric et al., 2012). Several factors might contribute to this finding. First, the contexts of the studies were different. In the Hamric studies, the physicians and nurses were working in ICUs, whereas the occupational therapists came from a national sample of AOTA members working in a variety of physical disability and geriatric settings. Physicians and nurses who work in ICUs face complex critical medical decisions on a daily basis which might contribute to higher levels of moral distress. Secondly, it might be anticipated that the nature of the work of each discipline would lead to different levels of moral distress. Nurses are required to follow the orders of physicians, a situation that might lead to greater moral conflict. In contrast, while occupational therapists work under a physician’s order, they have a high degree of autonomy and their work rarely involves life or death decisions. Since no statistically significant relationships were found with the total MDS-ROPHA scores in relation to occupational therapy degree, age, or years of practicing, higher levels of moral distress are probably not related to levels of occupational therapy education, maturity, or the amount of clinical experience. These findings contrast with those of Schluter et al. (2008) who found that nurses’ educational level
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
Moral Distress
389
influenced level of moral distress experienced and that recent graduates reported less moral distress than experienced nurses. According to Hamric et al. (2012), moral distress arises from three root causes; clinical situations, internal constraints and external constraints. For the occupational therapists in this study, external constraints were three of the top six causes of moral distress including the top two causes witness diminished patient care quality due to poor communication, provide less than optimal care due to pressures from administrators or insurers to reduce costs and work with levels of nurse or other care provider staffing that I consider unsafe. While, clinical situations accounted for the third and fourth most frequently reported causes of moral distress watch patient care suffer because of a lack of provider continuity and work with nurses or other healthcare providers who are not as competent as the patient care requires, and internal constraints accounted for only one be required to care for patients I don’t feel qualified to care for. Scenarios on the MDS-R- OPHA that caused the least moral distress illustrate the limitations of the instrument itself, which while modified, continues to emphasize situations more likely to be experienced by nurses rather than other health care professionals. For occupational therapists in this study, Jameton’s original formulation of moral distress as institutional constraints which prevents therapists from providing the care they believe is needed appeared to be the major cause of moral distress. These findings are consistent with those reported by Foye et al. (2002) and Slater and Brandt (2009). Not surprisingly in studies of nurses and physicians working in ICUs the most frequent causes of moral distress were clinical situations related to critical life care. However, diminished quality of patient care due to poor communication and seeing patients care suffer due to a lack of provider continuity were the fifth and sixth causes of moral distress found by Hamric et al. (2012) and working with the providers who were not as competent as needed was the fifth cause of moral distress found by Hamric & Blackhall (2007). Using the MDS distributed to hospital nurses, Corley et al. (2001) found working with unsafe levels of staffing to be the fourth highest rated cause of moral distress, and Zuzelo (2007) found working with nurses who were not competent as the second highest rated cause of moral distress. These findings suggest that there are both similarities and differences between health care professionals in the causes of moral distress. It is speculated that similarities arise from shared values concerning patient care and differences arise from professional roles and education. Further research will be needed to investigate these factors. Of the occupational therapists, almost half stated that in the past they had either left a position due to moral distress (26.5%) or that they had considered leaving a position due to moral distress but had not done so (20.9%). A small proportion of the occupational therapists (n = 24, 11.2%) stated they were presently considering leaving their position due to moral distress and the level of moral distress was the highest in this group (M = 83.17). The next highest level of moral distress was among those occupational therapists (n = 45, 20.9%) who had considered leaving a position due to moral distress but had not done so (M = 70.67). It is likely that there was an overlap between those who were currently considering leaving a job due to moral distress and those who had considered leaving a position in the past but did not. That these two groups reported the highest levels of moral distress
390
Penny et al.
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
is not surprising since they could be expected to be the most likely to return the questionnaires. That occupational therapists who had left a position due to moral distress continued to report higher levels compared to the occupational therapists that had never left a position due to moral distress, suggests that either these occupational therapists once again found themselves employed in settings where the causes of moral distress were prevalent, or that they had become sensitized to moral distress and were more likely to experience it again. The findings of this study were similar to those reported in the nursing literature (Corley et al., 2001; Hamric & Blackhall, 2007; Hamric et al., 2012) and suggest that high levels of moral distress are associated with an increased likelihood of leaving a position. Implications The findings that occupational therapist experience moral distress and may be at risk for its negative effects have implications for occupational therapy practice. Educators, students, new graduates, and clinicians need to be aware that they may encounter situations that could lead them to experience moral distress, and there is a need to develop coping strategies. While some studies have found that education in ethical problem solving leads to higher levels of moral reasoning (Geddes et al., 2009), other studies have failed to find such an improvement (Dieruf, 2004; Kanny 1996; Penny & You, 2011). Educators may use the information from this study to create programs that teach students strategies to address both the cognitive and affective challenges posed by ethical dilemmas. Bell and Breslin (2008) assert that it is the responsibility of health care leaders to address the challenge of moral distress. Occupational therapy managers will note that five of the top six scenarios found to cause moral distress fall within their scope of responsibility. Even if occupational therapy managers are unable to change the practices of third party payers, they can create processes to improve team communication, to improve continuity of care, and to insure that employees have the necessary skills to provide appropriate and safe services. That occupational therapists who experience moral distress are more likely to consider leaving their current position than occupational therapists who are not experiencing moral distress should alert occupational therapy managers to one potential source of employee turnover. To prevent moral distress, occupational therapy managers might consider implementing coping strategies, including those suggested by Slater and Brandt (2009) such as education, improved communication, organizational support for ethical decision making and by modeling ethical leadership. In terms of research, discovering the moral distress does occur among occupational therapists in two practice settings should lead to more detailed studies in these and other practice areas. However, in order to accurately measure the levels of moral distress experienced by occupational therapists, there is a need to develop an instrument made up of scenarios familiar to occupational therapists. Unsolicited comments provided by the respondents in this study suggest their concerns centered on the work environments, job satisfaction, a lack of staffing, billing issues specific to Medicare, productivity demands, and quality of patient care. In addition, there is a need to investigate the extent of moral distress across the continuum of occupational therapy practice settings and between occupational therapists
Moral Distress
391
and occupational therapy assistants. Finally, qualitative research would enrich an understanding of the moral distress experienced by occupational therapists.
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
Limitations The main limitation was the use of the MDS-R-OHPA which, contained scenarios more relevant to nurses than occupational therapists. Also as discussed earlier, the issue to non-response bias was not addressed. It is possible that the actual occurrence of moral distress is much lower than that reported in this study, reflected by the relatively low response rate (37.2%). Lastly, the large standard deviations in relation to the mean scores suggest a high degree of variability between respondents. This makes it more difficult to find any statistical differences that might exist and increases the possibility of committing a Type II error. CONCLUSION While moral distress has been studied extensively in nursing practice, this study addressed moral distress in a group of occupational therapist in the practice areas of geriatric and physical disabilities. Although, the levels of moral distress were lower than those found among ICU nurses and similar to those found among ICU physicians, this study appears to support the need to address the issue in occupational therapy. While a difference was found in the reported levels of moral distress between the two practice areas of physical disabilities and geriatrics, the difference was not statistically significant. In addition, although no significant relationship was found between moral distress and degree, age, or years of practicing, it was found that higher levels of moral distress were associated with leaving a position. Further research is needed to understand more fully the extent and nature of moral distress among occupational therapists. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. ABOUT THE AUTHOR Neil H. Penny, EdD. OTR/L. Chair, Occupational Therapy Department, Alvernia University, 400 St. Bernardine Street, Reading PA 19607, Phone: 610 796 8377. E-mail: [email protected]. Timothy L. Ewing, MSOT, OTR/L. Rachel C. Hamid, MSOT, OTR/L. Kimberly A. Shutt, MSOT, OTR/L. Amy S. Walter, MSOT. OTR/L. REFERENCES Austin W, Rankel M, Kagan L, Bergum V, & Lemermeyer G. (2005). To stay or to go, to speak or stay silent, to act or not to act: Moral distress as experienced by psychologists. Ethics & Behavior, 15(3), 197–212. doi: 10.1207/s15327019eb10503 1 Brayford S, Buscarini J, Dunbar C, Frank A, Nguyen P, & Fisher G. (2002). A pilot study of the delivery of occupational therapy in long term care settings under the Medicare Prospective Payment System. Occupational Therapy in Health Care, 16(2/3), 67–76.
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
392
Penny et al.
Bell J, & Breslin JM. (2008). Healthcare provider moral distress as a leadership challenge. JONA’S Healthcare Law, Ethics & Regulation, 10(4), 94–99. Carpenter C. (2010). Moral distress in physical therapy practice. Physiotherapy Theory and Practice, 26(2), 69–78. doi: 10.3109/09593980903387878 Corley MC. (2002). Nurses moral distress: A proposed theory and research agenda. Nursing Ethics, 9(6), 636–650. doi:10.1191/096733002ne5570a Corley MC, Elswick RK, Gorman M, & Clor T. (2001). Development and evaluation of a Moral Distress Scale. Journal of Advanced Nursing, 33(2), 250–256. doi: 10.1111/j.1365–2648.2001.01658.x10.1046/j.1365–2648.2001.01658.x DeJong G, Horn SD, Smout RJ, & Ryser DK. (2005). The early impact of the inpatient rehabilitation facility prospective payment system on stroke rehabilitation case mix, practice patterns, and outcomes. Archives of Physical Medicine & Rehabilitation, 86(12), S93–100. Dieruf K. (2004). Ethical decision-making by students in physical and occupational therapy. Journal of Allied Health, 33(1), 24–29. Forsyth K, & Kviz FJ. (2006). Survey research design. In G. Kielhofner (Ed.), Research in occupational therapy: Methods of inquiry for enhancing practice. (pp. 91–109). Philadelphia, PA: F. A. Davis Company. Foye SJ, Kirschner KL, Brady-Wagner LC, Stocking, C, & Siegler M. (2002). Ethical issues in rehabilitation: A qualitative analysis of dilemmas identified by occupational therapists. Topics in Stroke Rehabilitation, 9(3), 89–101. Geddes EL, Salvatori P, & Eva KW. (2009). Does moral judgment improve in occupational therapy and physiotherapy students over the course of their pre-licensure training? Learning in Health and Social Care, 8(2), 92–102. doi:10.11 11/j.1473–6861.2008.00205.x Hamric AB, & Blackhall LJ. (2007). Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. Critical Care Medicine, 35(2), 422–429. doi:10.1097/01.CCM.0000 254722.50608.2D Hamric AB, Borchers CT, & Epstein EG. (2012). Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research, 3(2), 1–9. doi: 10.1080/21507716.2011.652337 Hanna DR. (2004). Moral distress: The state of the science. Research and Theory Practice: An International Journal, 18(1), 73–93. Hutt E, Ecord M, Eilertsen TB, Frederickson E, Kowalsky JC, & Kramer AM. (2001). Prospective payment for nursing homes increased therapy provision without improving community discharge rates. Journal of the American Geriatrics Society, 49(8), 1071–1079. doi: 10.1046/j.1532–5415.2001.49211.x Jameton A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice Hall. Kanny EM. (1996). Occupational therapists’ ethical reasoning: Assessing student and practitioner responses to ethical dilemmas. Dissertation Abstracts International: Section B, 57(07), 4336. (UMI AAT9637968). Kennedy J, Maddock B, Sporrer B, & Greene D. (2002). Impact of medicare changes on occupational therapy in skilled nursing facilities: Pilot study. Physical & Occupational Therapy in Geriatrics, 21(2), 1–13. Kielhofner G. (2006). Developing and evaluating quantitative data collection instruments. In G. Kielhofner (Ed.), Research in occupational therapy: Methods of inquiry for enhancing practice (pp. 155–176). Philadelphia, PA: F. A. Davis Company. Lawrence LA. (2011). Work engagement, moral distress, education level, and critical reflective practice in intensive care nurses. Nursing Forum, 46(4), 256–268. doi:10.111 1/j.1744–6198.2011.00237.x McCarthy J, & Deady R. (2008). Moral distress reconsidered. Nursing Ethics, 15(2), 254–262. doi:10.1177/0969733007086023 Penny NH, & You D. (2011). Preparing occupational therapy students to make moral decisions. Occupational Therapy in Health Care, 25(2–3), 150–163. doi:10.3109 /07380577.2011.565544 Repenshek M. (2009). Moral distress: Inability to act or discomfort with moral subjectivity? Nursing Ethics, 16(6), 734–742. doi: 10.1177/0969733009342138
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
Moral Distress
393
Schluter J, Winch S, Holzhauser K, & Henderson A. (2008). Nurses’ moral sensitivity and hospital ethical climate: A literature review. Nursing Ethics, 15(3), 304–321. doi: 10.1177/0969733007088357 Schwenzer KJ, & Wang L. (2006). Assessing moral distress in respiratory care practitioners. Critical Care Medicine, 34(12), 2967–2973. doi: 10.1097/01.CCM.0000248879.19054.73 Slater D, & Brandt L. (2009). Combating moral distress. OT Practice, 14(2), 13–16, 18. Sporrong SK, Hoglund AT, & Arnetz B. (2006). Measuring moral distress in pharmacy and clinical practice. Nursing Ethics, 13(4), 416–427. doi: 10.1191/0969733006ne880oa Ulrich CM, Hamric AB, & Grady C. (2010). Moral distress: A growing problem in the health professions? Hastings Center Report, 40(1), 20–22. Varcoe C, Pauly B, Webster G, & Storch J. (2012). Moral distress: Tensions as springboards for action. HEC Forum, 24, 51–52. doi: 10.1007/s10730–012–9180–2 VonDras DD, Flittner D, Malcore SA, & Pouliot G. (2009). Workplace stress and ethical challenges experienced by nursing staff in a nursing home. Educational Gerontology, 35, 321–339. doi: 10.1080/03601270802605382 Wiegand DL, & Funk M. (2012). Consequences of clinical situations that cause critical care nurses to experience moral distress. Nursing Ethics, 19(4), 479–487. doi: 10.1177/09697 33011429342 Zinn JS, Mor V, Intrator O, Feng Z, Angelelli J, & Davis JA. (2003). The impact of the prospective payment system for skilled nursing facilities on therapy service provision: A transaction cost approach. Health Services Research, 38(6 Part I), 1467–1485. Zuzelo PR. (2007). Exploring the moral distress of registered nurses. Nursing Ethics, 14(3), 344–359. doi: 10.1177/096973300707587.
ARTICLE
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
An Investigation of Moral Distress Experienced by Occupational Therapists Neil H. Penny, Timothy L. Ewing, Rachel C. Hamid, Kimberly A. Shutt, & Amy S. Walter Occupational Therapy Department, Alvernia University, Reading, PA, USA
ABSTRACT. This study used a quantitative survey design to investigate the existence of moral distress among occupational therapists. The Moral Distress Scale-Revised (MDS-R-OHPA) was distributed to a random sample of 600 members of the American Occupational Therapy Association (AOTA). The results of this explorative study found that occupational therapists reported moderate levels of moral distress with occupational therapists working in geriatric settings reporting higher levels of moral distress than occupational therapists who work in physical disability settings, although the difference was not statistically significant. However, occupational therapists who were considering leaving their current position reported the highest levels of moral distress. These initial findings are discussed as well as the need for further research. KEYWORDS.
Job stress, moral, moral distress, occupational therapy
INTRODUCTION Ethical and moral problems are a growing concern in health care (Ulrich, Hamric, & Grady, 2010), but little is known about the issue of moral distress in the field of occupational therapy. In early studies, moral distress was defined as a phenomenon where “one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (Jameton, 1984, p. 6). Jameton was a philosopher and when he wrote this definition, moral distress was not his main focus. He was interested in how nurses approached and solved ethical problems. Jameton sought to differentiate between what he considered were three distinct types of moral problems experienced by nurses: moral dilemmas, moral uncertainty, and moral distress. He viewed moral distress as a strictly cognitive problem and left it to later researchers to investigate the affective components of the phenomenon. Address correspondence to: Neil H. Penny, EdD. OTR/L, Chair, Occupational Therapy Department, Alvernia University, 400 St. Bernardine Street, Reading, PA 19607, USA (E-mail: [email protected]) At the time of the study Timothy Ewing, Rachel Hamid, Kimberly Shutt and Amy Walter were graduate students enrolled in the Occupational Therapy program at Alvernia University, Reading, PA. (Received 2 June 2014; accepted 7 June 2014)
382
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
Moral Distress
383
Moral distress has been researched extensively in the field of nursing. Corley (2002), proposed a theory of moral distress using eight moral constructs that impact nurses: moral commitment, moral sensitivity, moral autonomy, moral sense making, moral judgment, moral conflict, moral competency, and moral certainty. Hanna (2004) conducted a review of 36 nursing studies of moral distress and postulated that moral distress is made up of four interrelated components (1) anguish or interior suffering, (2) an inability to meet professional role expectations, (3) issues around truth telling (whistle blowing, withholding information from patients, and documenting to meet organizational requirements), and (4) professional insights about futile care. Repenshek (2009) suggested that the most common cause of moral distress occurs when there is a conflict between the practitioners’ knowledge of, and values about, health care and values of the patient and their family. Recently, Hamric, Borchers, and Epstein (2012) described moral distress as having three possible causes (1) problematic clinical situations, (2) internal constraints such as feelings of powerlessness, and (3) external constraints such as inadequate resources. The most current definition of moral distress describes it as “the experience of being seriously compromised as a moral agent in practicing in accordance with accepted professional values and standards. It is a relational experience shaped by multiple contexts, including the socio-political and cultural context of the workplace environment” (Varcoe, Pauly, Webster, & Storch, 2012, p. 59). This definition moves the focus away from the health practitioner as not acting as a moral agent and focuses instead on the context of the experience. There is growing concern that moral distress can negatively impact clinical practice and, in some cases, patient outcomes (Zuzelo, 2007). According to Schluter, Winch, Holzhauser, and Henderson (2008), moral distress is characterized by “painful feelings and associated emotional and mental anguish as a result of being conscious of a morally appropriate action, which, despite every effort, cannot be performed owing to organizational or other obstacles” (p. 306). They found that the educational level of nurses, the amount of support received from peers, and the ethical climate of the workplace influenced the level of moral distress experienced. Schluter et al. (2008) found that moral distress had a negative impact on the physical and mental wellbeing of nurses, nurses’ provision of care, job satisfaction, and staff turnover, and manifested as headaches, neck pain, muscle aches, diarrhea, as well as feelings of anger, guilt, powerlessness, and frustration. Other effects include depression, loss of self-worth, disengagement from family and friends, and not wanting to return to work. Patient care was also affected as the nurses became withdrawn from their patients and their interactions decreased. Job satisfaction was decreased, which resulted in nurse turnover; nurses either changed jobs or left nursing altogether (Schluter et al., 2008). VonDras, Flittner, Malcore, and Pouliot (2009) found a significant relationship between psychological stress and pressure to take short cuts in the delivery of care. Lawrence (2011) found there was a direct negative relationship between moral distress and the work engagement of nurses. Work engagement is characterized by high levels of energy, mental resilience, investment of effort, persistence in difficult times, fully concentrating on work, enthusiasm, and pride; all of which decrease as moral distress increases. Others (Wiegand & Funk, 2012) found that the negative consequences of moral distress included frustration or anger, helplessness, suffering, distress,
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
384
Penny et al.
disappointment, sadness or depression, and physical as well as psychological exhaustion. Corley is credited with developing the first instrument to measure moral distress, the Moral Distress Scale (MDS) (Corley, Elswick, Gorman, & Clor, 2001). Although, shown to be reliable and valid, with its focus on situations experienced by critical care nurses, this instrument has limited usefulness in other clinical settings or for other health care providers. To further the study of moral distress, Hamric and Blackhall (2007) modified the MDS by reducing the number of items from 38 to 19 and from a single seven point Likert scale to two Likert scales for each item (i.e., one for the frequency (0 to 4) and one for intensity (0 to 4)). Using this shortened version of Corley’s MDS, Hamric and Blackhall conducted a pilot study with 168 nurses and 29 physicians who worked at two Intensive Care Units (ICUs) in Virginia. The results showed that ICU nurses reported higher levels of moral distress than physicians. In a follow-up study, Hamric et al. (2012) created the 21 item Moral Distress Scale Revised (MDS-R) with three parallel versions for nurses, physicians and other health care providers. They then tested the psychometric properties of these instruments with 37 physicians and 169 nurses working at an academic medical center in Virginia. Once again, this new MDS-R revealed that physicians had significantly lower levels of moral distress than nurses (Hamric et al., 2012). McCarthy and Deady (2008) suggest that by limiting research to the profession of nursing, the insidious and pervasive problems caused by moral distress remain hidden. Other health care professions (e.g., pharmacy, physical therapy, psychologists and respiratory care) are just beginning to explore the experience of moral distress in their professions (Austin, Rankel, Kagan, Bergum, & Lemermeyer, 2005; Carpenter, 2010; Schwenzer & Wang, 2006; Sporrong, Hoglund, & Arnetz, 2006). Moral distress has been poorly studied in occupational therapy and usually in terms of ethical concerns rather than moral distress. While creating the Occupational Therapy Dilemma Test, Hansen (1984), interviewed occupational therapists (n = 22) from a variety of practice settings and found four common sources of ethical concerns: the choice of treatment, inappropriate referrals, insufficient time or resources to provide treatment, and conflicts concerning appropriate goals (as cited in Foye, Kirschner, Brady-Wagner, Stocking, & Siegler, 2002). Foye et al. (2002) investigated the ethical concerns identified by occupational therapists (n = 38) working in an urban rehabilitation hospital. The three most frequently identified ethical concerns included: reimbursement pressures (43%), conflicts around goal setting (21%), and patient/family refusal of treatment team recommendations (11%). Slater and Brandt (2009) surveyed a non-random selection of American Occupational Therapy Association (AOTA) members (n = 100) to identify the causes of moral distress. They found that more than half of the respondents answered commonly or occasionally to items, such as reimbursement constraints (70%), conflict with organizational policies (70%), excessive pressure to meet productivity standards (61%), lack of administration support (59%), questionable or unrealistic clinical decisions by others (57%), patients who decline treatment (57%), decision making regarding patient discharge (55%), excessive pressure to increase billable hours (54%), and compromised care due to pressure to decrease costs (53%). (p. 14). External constraints were the major cause of moral distress for occupational therapists. Slater and Brandt (2009) suggest six strategies to
Moral Distress
385
address moral distress. However, for any of these strategies to be effective, a deeper understanding of moral distress as it pertains to occupational therapists is needed. Thus, the purpose of this study was to determine if moral distress would be reported in a national sample of professional level occupational therapists and, if it exists, is moral distress more prevalent in one practice area compared to another? METHODOLOGY
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
Study Design The study used a descriptive quantitative survey design. The dependent variable was the level of moral distress experienced by occupational therapists as measured by the MDS-R, and the independent variable was the practice area (geriatric or physical disabilities). An important confounding variable was non-response bias (Forsyth & Kviz, 2006). Those who do not experience moral distress may not find the topic sufficiently interesting to take the time to complete and return the questionnaires. This may cause the data collected to be over represented by those who do experience moral distress, increasing the likelihood of committing a Type I error. Measurement Tools The Moral Distress Scale-Revised, Other Healthcare Provider (Adult) (MDS-ROHPA) (Hamric et al., 2012) was used to measure moral distress, and a brief questionnaire created by the researchers was used to collect demographic information about the respondents. The MDS-R-OHPA is a paper-and-pencil version of the MSD-R specifically designed to measure the moral distress experienced by health care disciplines other than nurses working in adult settings. Twenty-one situations that occur in clinical practice are described, and the respondents were asked to rate the frequency in which they have experienced the situation and the level of disturbance the situation caused or would cause if it did occur. Two open items are provided for respondents to add, if they choose, their own personal experiences of moral distress. The MDS-R concludes with two questions regarding leaving or contemplating leaving a job due to moral distress (Hamric et al., 2012). The level of moral distress is calculated by taking the level of disturbance score for each of the 21 situations and multiplying it by the corresponding frequency score. According to Hamric et al. (2012), items that are checked as never experienced or are not seen as distressing do not contribute to an individual’s overall level of moral distress score. Each individual item score can range from 0 to 16. To obtain the overall composite moral distress score, the twenty-one scores are added together. The final score ranges from 0 to 336, with a possible upper score of 368 if the respondent adds his or her personal experience items (Hamric et al., 2012). Low total scores represent low moral distress, whereas high total scores represent high moral distress. Hamric et al. (2012) report an overall Cronbach alpha for the MDS-R of .88. The Cronbach alpha for the data in this study was found to be .93. Cronbach alpha values that are close to .90 indicate high consistency among the scale items (Kielhofner, 2006). Hamric et al. (2012) report a content validity of 88% for the inter-rater agreement for the primary and secondary root causes of moral distress.
386
Penny et al.
Construct validity was tested against four hypotheses that were all statistically significant in the expected directions: ethical climate (r = -.40, p < .001), physicians had lower moral distress than nurses (t = −5.79, p < .001), clinicians who were considering leaving their position had significantly higher scores (F = 48.39, p < .001) and nurses with more experience had higher moral distress (r = .22, p = .005) (Hamric et al., 2012).
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
Participants The mailing address of 600 occupational therapists was obtained from AOTA’s membership list rental service. Randomization was achieved by an Nth selection of every 12th record from the 3,639 occupational therapists who checked geriatrics as their primary special interest and an Nth selection of every 17th record from the 5,192 occupational therapists who checked physical disabilities as their primary special interest. These two practice areas were chosen based upon research showing the impact of reimbursement systems on the services provided in these settings (Brayford et al., 2002; DeJong, Horn, Smout, & Ryser, 2005; Hutt et al., 2001; Kennedy, Maddock, Sporrer, & Greene 2002; Zinn et al., 2003). A total of 231 responses were received, of these seven were partially completed questionnaires. The resulting sample consisted of 224 respondents (response rate = 37.3%). The majority of the respondents were female (91.5%), white (92.0%), employed full time (72.8%) and held either a bachelor’s (41.5%) or master’s (53.1%) degree. The average age was 41.21 (SD = 13.04) years of age with a mean of 14.67 (SD = 12.36) years of experience. Respondents were almost equally distributed from across the four regions recognized by the AOTA (Midwest n = 61, Northeast n = 50, South n = 59 and West n = 54) χ 2 (3) = 1.32, p = .724. In terms of practice areas, 100 (44.6%) respondents reported working in a geriatric setting, 81 (36.2%) reported working in a physical disability setting and 43 (19.2%) reported working in more than one type of setting. Procedures After permission to use the MDS-R-OHPA was received from the instrument developer and the Institutional Review Board (IRB) approved the study, questionnaire packets were mailed. The mailings included a cover letter describing the study, a consent form, the demographic questionnaire, the MDS-R-OHPA, and a stamped addressed return envelope. Data was collected during the first months of 2013. RESULTS The mean MSD-R-OHPA score for all respondents was 50.63 with a standard deviation of 33.58. Scores ranged from a low of 0 to a high of 181. The median score was 44.00 and the distribution of the scores had a positive skew. A one-way ANOVA test found that there was not a statistically significant difference between occupational therapists who reported working in a physical disability setting (n = 81, M = 44.84, SD = 29.94, Mdn = 36.00), in a geriatric setting (n = 100, M = 53.92, SD = 35.14, Mdn = 48.00) or those who reported working in more than one type of setting (n = 43, M = 53.88, SD = 35.59, Mdn = 55.00), F(2, 221) = 1.90, p = .152.
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
Moral Distress
387
To investigate if there were a difference in moral distress between occupational therapists who identified themselves as only working in a physical disability setting or a geriatric settings, an independent sample t-test (two-tailed) was conducted; the result approached but did not show a statistical difference t(179) = −1.85, p = .067. No difference was found between MDS-R-OHPA mean scores by occupational therapy degree held (bachelor, n = 93, M = 46.38, SD = 28.97, Mdn = 40.00; master, n = 100, M = 54.15, SD = 36.17, Mdn = 47.00; or doctorate, n = 10, M = 54.10, SD = 40.67, Mdn = 54.00) F(2, 219) = 1.45, p = .237. To investigate if there were a difference between occupational therapists holding either a bachelor or master degree an independent sample t-test was conducted. No difference in mean scores was found t(210) = 1.69, p = .092. In addition, no difference was found between those who reported that their education included formal occupational therapy course work to learn how to resolve moral questions (n = 125, M = 50.94, SD = 32.29, Mdn = 44.00) compared to those who stated they did not receive formal occupational therapy education to learn how to resolve moral questions (n = 94, M = 49.38, SD = 34.76, Mdn = 43.00), t(219) = 0.35, p = .731. Lastly, a 2 × 2 ANOVA found no interaction effect for practice area (physical disabilities or geriatrics) and formal moral education to learn how to resolve moral questions (yes or no) F(1, 173) = 0.94, p = .334. Pearson product correlation coefficient tests between MDS-R-OHPA scores and continuous demographic variables found no statistically significant relationships (age: r = -.065, p = .334 and years of practicing: r = −.046, p = .491). Additional Findings Table 1 shows the situations within the MDS-R-OHPA that were most and least frequently reported as causing moral distress; these comprise situations that were scored as eight or higher. To address the issue of whether moral distress leads to staff turnover, there are two questions. The first asks if the respondent has ever left or considered leaving a job in the past due to moral distress. Occupational Therapists who had considered leaving but did not scored higher (n = 45, M = 70.67, SD = 32.88, Mdn = 60.00) than either those who had left a position due to moral distress (n = 57, M = 53.98, SD = 31.00, Mdn = 48.00) or those who never considered leaving a position due to moral distress (n = 113, M = 43.63, SD = 31.89, Mdn = 33.00). A one-way ANOVA found that these differences were statistically significant F(2, 212) = 11.73, p < .001. The Bonferroni post hoc tests indicated the difference was between all groups except those who had left a position and these who never considered leaving. The second question asks if the respondent is currently considering leaving his or her position. Occupational therapists who were considering leaving their current position scored significantly higher (n = 24, M = 83.17, SD = 37.86, Mdn = 79.50) than those who were not considering leaving their current position (n = 190, M = 48.03, SD = 30.83, Mdn = 41.00), t(212) = 5.12, p < .001. DISCUSSION With an overall mean score on the MDS-R-OHPA of 50.63, this study suggests that moral distress does occur among occupational therapists, confirming those
388
Penny et al.
TABLE 1. Situations Reported to Cause Moral Distress (Item Score of 8 or Higher) (n = 224)
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
MDS-R-OPHA Item Most frequently reported: Situation 18: Witness diminished patient care quality due to poor team communication Situation 1: Provide less than optimal care due to pressures from administrators or insurers to reduce costs Situation 20: Watch patient care suffer because of lack of provider continuity Situation 17: Work with nurses or other healthcare providers who are not as competent as the patient care requires Situation 21: Work with levels of nurse or other care provider staffing that I consider unsafe Situation 10: Be required to care for patients I don’t feel qualified to care for Least frequently reported: Situation 7: Continue to participate in care for a hopelessly ill person who is being sustained on a ventilator, when no one will make a decision to withdraw support. Situation 16: Follow the family’s wishes for the patient’s care when I do not agree with them, but do so because of fears of a lawsuit. Situation 12: Participate in care that does not relieve the patient’s suffering because the physician fears that increasing the dose of pain medication will cause death. Situation 13: Follow the physician’s request not to discuss the patient’s prognosis with the patient or family. Situation 11: Witness medical students perform painful procedures on patients solely to increase their skill. Situation 14: Witness increasing doses of sedatives/opiates given to an unconscious patient that I believe could hasten the patient’s death.
n
%
85
37.9
71
31.6
66 65
29.4 29.0
39
17.5
24
10.7
9
4.0
9
4.0
8
3.5
4
1.8
3
1.3
3
1.3
presented by Slater and Brandt (2009). While there was a difference in the mean scores in physical disabilities and geriatrics practice areas, the difference was not sufficient to be statistically significant. Interestingly, the overall levels of moral distress reported by occupational therapists in this study were less than those found among ICU nurses and more similar to those reported by ICU physicians (Hamric & Blackhall, 2007; Hamric et al., 2012). Several factors might contribute to this finding. First, the contexts of the studies were different. In the Hamric studies, the physicians and nurses were working in ICUs, whereas the occupational therapists came from a national sample of AOTA members working in a variety of physical disability and geriatric settings. Physicians and nurses who work in ICUs face complex critical medical decisions on a daily basis which might contribute to higher levels of moral distress. Secondly, it might be anticipated that the nature of the work of each discipline would lead to different levels of moral distress. Nurses are required to follow the orders of physicians, a situation that might lead to greater moral conflict. In contrast, while occupational therapists work under a physician’s order, they have a high degree of autonomy and their work rarely involves life or death decisions. Since no statistically significant relationships were found with the total MDS-ROPHA scores in relation to occupational therapy degree, age, or years of practicing, higher levels of moral distress are probably not related to levels of occupational therapy education, maturity, or the amount of clinical experience. These findings contrast with those of Schluter et al. (2008) who found that nurses’ educational level
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
Moral Distress
389
influenced level of moral distress experienced and that recent graduates reported less moral distress than experienced nurses. According to Hamric et al. (2012), moral distress arises from three root causes; clinical situations, internal constraints and external constraints. For the occupational therapists in this study, external constraints were three of the top six causes of moral distress including the top two causes witness diminished patient care quality due to poor communication, provide less than optimal care due to pressures from administrators or insurers to reduce costs and work with levels of nurse or other care provider staffing that I consider unsafe. While, clinical situations accounted for the third and fourth most frequently reported causes of moral distress watch patient care suffer because of a lack of provider continuity and work with nurses or other healthcare providers who are not as competent as the patient care requires, and internal constraints accounted for only one be required to care for patients I don’t feel qualified to care for. Scenarios on the MDS-R- OPHA that caused the least moral distress illustrate the limitations of the instrument itself, which while modified, continues to emphasize situations more likely to be experienced by nurses rather than other health care professionals. For occupational therapists in this study, Jameton’s original formulation of moral distress as institutional constraints which prevents therapists from providing the care they believe is needed appeared to be the major cause of moral distress. These findings are consistent with those reported by Foye et al. (2002) and Slater and Brandt (2009). Not surprisingly in studies of nurses and physicians working in ICUs the most frequent causes of moral distress were clinical situations related to critical life care. However, diminished quality of patient care due to poor communication and seeing patients care suffer due to a lack of provider continuity were the fifth and sixth causes of moral distress found by Hamric et al. (2012) and working with the providers who were not as competent as needed was the fifth cause of moral distress found by Hamric & Blackhall (2007). Using the MDS distributed to hospital nurses, Corley et al. (2001) found working with unsafe levels of staffing to be the fourth highest rated cause of moral distress, and Zuzelo (2007) found working with nurses who were not competent as the second highest rated cause of moral distress. These findings suggest that there are both similarities and differences between health care professionals in the causes of moral distress. It is speculated that similarities arise from shared values concerning patient care and differences arise from professional roles and education. Further research will be needed to investigate these factors. Of the occupational therapists, almost half stated that in the past they had either left a position due to moral distress (26.5%) or that they had considered leaving a position due to moral distress but had not done so (20.9%). A small proportion of the occupational therapists (n = 24, 11.2%) stated they were presently considering leaving their position due to moral distress and the level of moral distress was the highest in this group (M = 83.17). The next highest level of moral distress was among those occupational therapists (n = 45, 20.9%) who had considered leaving a position due to moral distress but had not done so (M = 70.67). It is likely that there was an overlap between those who were currently considering leaving a job due to moral distress and those who had considered leaving a position in the past but did not. That these two groups reported the highest levels of moral distress
390
Penny et al.
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
is not surprising since they could be expected to be the most likely to return the questionnaires. That occupational therapists who had left a position due to moral distress continued to report higher levels compared to the occupational therapists that had never left a position due to moral distress, suggests that either these occupational therapists once again found themselves employed in settings where the causes of moral distress were prevalent, or that they had become sensitized to moral distress and were more likely to experience it again. The findings of this study were similar to those reported in the nursing literature (Corley et al., 2001; Hamric & Blackhall, 2007; Hamric et al., 2012) and suggest that high levels of moral distress are associated with an increased likelihood of leaving a position. Implications The findings that occupational therapist experience moral distress and may be at risk for its negative effects have implications for occupational therapy practice. Educators, students, new graduates, and clinicians need to be aware that they may encounter situations that could lead them to experience moral distress, and there is a need to develop coping strategies. While some studies have found that education in ethical problem solving leads to higher levels of moral reasoning (Geddes et al., 2009), other studies have failed to find such an improvement (Dieruf, 2004; Kanny 1996; Penny & You, 2011). Educators may use the information from this study to create programs that teach students strategies to address both the cognitive and affective challenges posed by ethical dilemmas. Bell and Breslin (2008) assert that it is the responsibility of health care leaders to address the challenge of moral distress. Occupational therapy managers will note that five of the top six scenarios found to cause moral distress fall within their scope of responsibility. Even if occupational therapy managers are unable to change the practices of third party payers, they can create processes to improve team communication, to improve continuity of care, and to insure that employees have the necessary skills to provide appropriate and safe services. That occupational therapists who experience moral distress are more likely to consider leaving their current position than occupational therapists who are not experiencing moral distress should alert occupational therapy managers to one potential source of employee turnover. To prevent moral distress, occupational therapy managers might consider implementing coping strategies, including those suggested by Slater and Brandt (2009) such as education, improved communication, organizational support for ethical decision making and by modeling ethical leadership. In terms of research, discovering the moral distress does occur among occupational therapists in two practice settings should lead to more detailed studies in these and other practice areas. However, in order to accurately measure the levels of moral distress experienced by occupational therapists, there is a need to develop an instrument made up of scenarios familiar to occupational therapists. Unsolicited comments provided by the respondents in this study suggest their concerns centered on the work environments, job satisfaction, a lack of staffing, billing issues specific to Medicare, productivity demands, and quality of patient care. In addition, there is a need to investigate the extent of moral distress across the continuum of occupational therapy practice settings and between occupational therapists
Moral Distress
391
and occupational therapy assistants. Finally, qualitative research would enrich an understanding of the moral distress experienced by occupational therapists.
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
Limitations The main limitation was the use of the MDS-R-OHPA which, contained scenarios more relevant to nurses than occupational therapists. Also as discussed earlier, the issue to non-response bias was not addressed. It is possible that the actual occurrence of moral distress is much lower than that reported in this study, reflected by the relatively low response rate (37.2%). Lastly, the large standard deviations in relation to the mean scores suggest a high degree of variability between respondents. This makes it more difficult to find any statistical differences that might exist and increases the possibility of committing a Type II error. CONCLUSION While moral distress has been studied extensively in nursing practice, this study addressed moral distress in a group of occupational therapist in the practice areas of geriatric and physical disabilities. Although, the levels of moral distress were lower than those found among ICU nurses and similar to those found among ICU physicians, this study appears to support the need to address the issue in occupational therapy. While a difference was found in the reported levels of moral distress between the two practice areas of physical disabilities and geriatrics, the difference was not statistically significant. In addition, although no significant relationship was found between moral distress and degree, age, or years of practicing, it was found that higher levels of moral distress were associated with leaving a position. Further research is needed to understand more fully the extent and nature of moral distress among occupational therapists. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. ABOUT THE AUTHOR Neil H. Penny, EdD. OTR/L. Chair, Occupational Therapy Department, Alvernia University, 400 St. Bernardine Street, Reading PA 19607, Phone: 610 796 8377. E-mail: [email protected]. Timothy L. Ewing, MSOT, OTR/L. Rachel C. Hamid, MSOT, OTR/L. Kimberly A. Shutt, MSOT, OTR/L. Amy S. Walter, MSOT. OTR/L. REFERENCES Austin W, Rankel M, Kagan L, Bergum V, & Lemermeyer G. (2005). To stay or to go, to speak or stay silent, to act or not to act: Moral distress as experienced by psychologists. Ethics & Behavior, 15(3), 197–212. doi: 10.1207/s15327019eb10503 1 Brayford S, Buscarini J, Dunbar C, Frank A, Nguyen P, & Fisher G. (2002). A pilot study of the delivery of occupational therapy in long term care settings under the Medicare Prospective Payment System. Occupational Therapy in Health Care, 16(2/3), 67–76.
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
392
Penny et al.
Bell J, & Breslin JM. (2008). Healthcare provider moral distress as a leadership challenge. JONA’S Healthcare Law, Ethics & Regulation, 10(4), 94–99. Carpenter C. (2010). Moral distress in physical therapy practice. Physiotherapy Theory and Practice, 26(2), 69–78. doi: 10.3109/09593980903387878 Corley MC. (2002). Nurses moral distress: A proposed theory and research agenda. Nursing Ethics, 9(6), 636–650. doi:10.1191/096733002ne5570a Corley MC, Elswick RK, Gorman M, & Clor T. (2001). Development and evaluation of a Moral Distress Scale. Journal of Advanced Nursing, 33(2), 250–256. doi: 10.1111/j.1365–2648.2001.01658.x10.1046/j.1365–2648.2001.01658.x DeJong G, Horn SD, Smout RJ, & Ryser DK. (2005). The early impact of the inpatient rehabilitation facility prospective payment system on stroke rehabilitation case mix, practice patterns, and outcomes. Archives of Physical Medicine & Rehabilitation, 86(12), S93–100. Dieruf K. (2004). Ethical decision-making by students in physical and occupational therapy. Journal of Allied Health, 33(1), 24–29. Forsyth K, & Kviz FJ. (2006). Survey research design. In G. Kielhofner (Ed.), Research in occupational therapy: Methods of inquiry for enhancing practice. (pp. 91–109). Philadelphia, PA: F. A. Davis Company. Foye SJ, Kirschner KL, Brady-Wagner LC, Stocking, C, & Siegler M. (2002). Ethical issues in rehabilitation: A qualitative analysis of dilemmas identified by occupational therapists. Topics in Stroke Rehabilitation, 9(3), 89–101. Geddes EL, Salvatori P, & Eva KW. (2009). Does moral judgment improve in occupational therapy and physiotherapy students over the course of their pre-licensure training? Learning in Health and Social Care, 8(2), 92–102. doi:10.11 11/j.1473–6861.2008.00205.x Hamric AB, & Blackhall LJ. (2007). Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. Critical Care Medicine, 35(2), 422–429. doi:10.1097/01.CCM.0000 254722.50608.2D Hamric AB, Borchers CT, & Epstein EG. (2012). Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research, 3(2), 1–9. doi: 10.1080/21507716.2011.652337 Hanna DR. (2004). Moral distress: The state of the science. Research and Theory Practice: An International Journal, 18(1), 73–93. Hutt E, Ecord M, Eilertsen TB, Frederickson E, Kowalsky JC, & Kramer AM. (2001). Prospective payment for nursing homes increased therapy provision without improving community discharge rates. Journal of the American Geriatrics Society, 49(8), 1071–1079. doi: 10.1046/j.1532–5415.2001.49211.x Jameton A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice Hall. Kanny EM. (1996). Occupational therapists’ ethical reasoning: Assessing student and practitioner responses to ethical dilemmas. Dissertation Abstracts International: Section B, 57(07), 4336. (UMI AAT9637968). Kennedy J, Maddock B, Sporrer B, & Greene D. (2002). Impact of medicare changes on occupational therapy in skilled nursing facilities: Pilot study. Physical & Occupational Therapy in Geriatrics, 21(2), 1–13. Kielhofner G. (2006). Developing and evaluating quantitative data collection instruments. In G. Kielhofner (Ed.), Research in occupational therapy: Methods of inquiry for enhancing practice (pp. 155–176). Philadelphia, PA: F. A. Davis Company. Lawrence LA. (2011). Work engagement, moral distress, education level, and critical reflective practice in intensive care nurses. Nursing Forum, 46(4), 256–268. doi:10.111 1/j.1744–6198.2011.00237.x McCarthy J, & Deady R. (2008). Moral distress reconsidered. Nursing Ethics, 15(2), 254–262. doi:10.1177/0969733007086023 Penny NH, & You D. (2011). Preparing occupational therapy students to make moral decisions. Occupational Therapy in Health Care, 25(2–3), 150–163. doi:10.3109 /07380577.2011.565544 Repenshek M. (2009). Moral distress: Inability to act or discomfort with moral subjectivity? Nursing Ethics, 16(6), 734–742. doi: 10.1177/0969733009342138
Occup Ther Health Downloaded from informahealthcare.com by Nyu Medical Center on 06/20/15 For personal use only.
Moral Distress
393
Schluter J, Winch S, Holzhauser K, & Henderson A. (2008). Nurses’ moral sensitivity and hospital ethical climate: A literature review. Nursing Ethics, 15(3), 304–321. doi: 10.1177/0969733007088357 Schwenzer KJ, & Wang L. (2006). Assessing moral distress in respiratory care practitioners. Critical Care Medicine, 34(12), 2967–2973. doi: 10.1097/01.CCM.0000248879.19054.73 Slater D, & Brandt L. (2009). Combating moral distress. OT Practice, 14(2), 13–16, 18. Sporrong SK, Hoglund AT, & Arnetz B. (2006). Measuring moral distress in pharmacy and clinical practice. Nursing Ethics, 13(4), 416–427. doi: 10.1191/0969733006ne880oa Ulrich CM, Hamric AB, & Grady C. (2010). Moral distress: A growing problem in the health professions? Hastings Center Report, 40(1), 20–22. Varcoe C, Pauly B, Webster G, & Storch J. (2012). Moral distress: Tensions as springboards for action. HEC Forum, 24, 51–52. doi: 10.1007/s10730–012–9180–2 VonDras DD, Flittner D, Malcore SA, & Pouliot G. (2009). Workplace stress and ethical challenges experienced by nursing staff in a nursing home. Educational Gerontology, 35, 321–339. doi: 10.1080/03601270802605382 Wiegand DL, & Funk M. (2012). Consequences of clinical situations that cause critical care nurses to experience moral distress. Nursing Ethics, 19(4), 479–487. doi: 10.1177/09697 33011429342 Zinn JS, Mor V, Intrator O, Feng Z, Angelelli J, & Davis JA. (2003). The impact of the prospective payment system for skilled nursing facilities on therapy service provision: A transaction cost approach. Health Services Research, 38(6 Part I), 1467–1485. Zuzelo PR. (2007). Exploring the moral distress of registered nurses. Nursing Ethics, 14(3), 344–359. doi: 10.1177/096973300707587.
