Annals of International Occupational Therapy

Original Research 

An Investigation of the Moral Distress Experienced by Occupational Therapy Practitioners

Neil H. Penny, EdD, OTR/L; Taylor M. Benjamin, MS, OTR/L; Chelsea R. Gonsalves, MS, OTR/L; Amber L. Gordon, MS, OTR/L; Erin N. Kinsley, MS, OTR/L; Samantha R. Markel, MS, OTR/L

Abstract

Background:

The phenomenon of moral distress has been widely researched in nursing but only recently in occupational therapy. The purpose of this study was to investigate moral distress as experienced by occupational therapy assistants and occupational therapists working in gerontic settings.

Methods:

The Moral Distress Scale-Revised Occupational Therapy (Adult Settings) (Penny, Bires, Bonn, Dockery, & Pettit, 2016) was mailed to a randomized selection of members of the American Occupational Therapy Association. The study population (n = 1,522) represented 20% of occupational therapy assistants (334 of 1,670) and 20% of occupational therapists (1,188 of 6,025) who indicated that they worked in a gerontic setting and resulted in 385 usable responses (25.3%).

Results:

Levels of moral distress and root causes were similar between levels of practitioner. Although most occupational therapy assistants worked with geriatric clients in nursing homes, only approximately half of the occupational therapists did. Negative correlations were found between moral distress scores and age of the practitioner, number of years in the current position, and number of years in the profession. In addition, half of all respondents (50.6%) indicated that they had left a position where they experienced high moral distress.

Conclusion:

The experience of moral distress for occupational therapy assistants and occupational therapists working in gerontic settings was remarkably similar, especially for those working in nursing homes. [Annals of International Occupational Therapy. 2019; 2(4):161–170.]

Abstract

Background:

The phenomenon of moral distress has been widely researched in nursing but only recently in occupational therapy. The purpose of this study was to investigate moral distress as experienced by occupational therapy assistants and occupational therapists working in gerontic settings.

Methods:

The Moral Distress Scale-Revised Occupational Therapy (Adult Settings) (Penny, Bires, Bonn, Dockery, & Pettit, 2016) was mailed to a randomized selection of members of the American Occupational Therapy Association. The study population (n = 1,522) represented 20% of occupational therapy assistants (334 of 1,670) and 20% of occupational therapists (1,188 of 6,025) who indicated that they worked in a gerontic setting and resulted in 385 usable responses (25.3%).

Results:

Levels of moral distress and root causes were similar between levels of practitioner. Although most occupational therapy assistants worked with geriatric clients in nursing homes, only approximately half of the occupational therapists did. Negative correlations were found between moral distress scores and age of the practitioner, number of years in the current position, and number of years in the profession. In addition, half of all respondents (50.6%) indicated that they had left a position where they experienced high moral distress.

Conclusion:

The experience of moral distress for occupational therapy assistants and occupational therapists working in gerontic settings was remarkably similar, especially for those working in nursing homes. [Annals of International Occupational Therapy. 2019; 2(4):161–170.]

Occupational therapy practitioners are called on to make many decisions that affect their client's treatment over the course of a workday, and some of these decisions are more difficult than others. If the decision of a practitioner, based on his or her best ethical and clinical judgment, is constrained by organizational expectations, the practitioner may experience a type of conflict called moral distress (Jameton, 1984). In occupational therapy, moral distress is defined as “the painful feelings and psychological disequilibrium that results from a moral conflict in which one knows the correct action to take, but constraints prevent implementation of the action” (Slater, 2016, p. 117). The following are examples of situations that may cause moral distress: organizational mandates for productivity override professional decision making for the amount of care provided, supervisors do not support the clinical decisions of practitioners for discharge, there are questions about client safety, and barriers to communication interfere with client care.

The concept of moral distress was first identified in the field of nursing. Systematic reviews of the research showed that moral distress affects the personal and professional lives of practitioners, leading to a sense of powerlessness, emotional exhaustion, detachment, thoughts of leaving the position, and concerns that moral distress is a threat to the quality of patient care (Hanna, 2004; Huffman & Rittenmeyer, 2012; McAndrew, Leske, & Schroeter, 2018; McCarthy & Gastmans, 2015; Oh & Gastmans, 2015; Prentice, Janvier, Gillam, & Davis, 2016; Sasso, Bagnasco, Bianchi, Bressan, & Carnevale, 2016; Schluter, Winch, Holzhauser, & Henderson, 2008).

Slater and Brandt (2009) were the first to raise awareness of moral distress in occupational therapy. Penny, Ewing, Hamid, Shutt, and Walter (2014) found “moderate” (p. 382) levels of moral distress among occupational therapists (OTs) working in gerontic or physical disability settings. Slater (2016) reported a “sharp increase in moral distress caused by excessive pressure to meet productivity standards, lack of administrative support, and excessive pressure to increase billable hours” (p. 118). Smith-Gabai, Kuzminski, and Eldridge (2018) found “minimal to moderate” (p. 25) levels of moral distress but no relationship between moral distress and productivity requirements for occupational therapy practitioners working in skilled nursing facilities. They also found no difference in the level of moral distress experienced by occupational therapy assistants (OTAs) and OTs. Other than the study by Smith-Gabai et al. (2018), there is a lack of research on moral distress among practitioners at different professional levels. For example, most participants in the nursing studies on moral distress were classified only as registered nurses. Occupational therapy has two distinct levels of practitioner, the OTA and the OT. Because moral distress occurs when constraints are placed on one's practice, the relationship between the OTA and the OT could be a source of moral distress for either practitioner. For example, the OTA might believe that the OT is limiting the services that the OTA provides, and the OT might believe that the OTA is not following through adequately on the OT's recommendations for services. Interventions to address moral distress must consider differences between OTAs and OTs in the experience and sources of moral distress. This study examined the experience of moral distress between OTAs and OTs working in gerontic settings.

Methods

Design

A quantitative mail survey design was used. Mail surveys can be used to reach a nationwide sample and generate acceptable response rates. The available evidence suggests that response rates for mail surveys are similar to or better than those for online or e-mail surveys (Friese, Crawford, O'Brien, & Lee, 2010; Hardigan, Popovici, & Carvajal, 2016; Hardigan, Succar, & Fleisher, 2012; Hoonakker & Carayon, 2009).

Participants

The participants for this study were randomly selected from the membership of the American Occupational Therapy Association according to the following criteria: 20% of OTAs (N = 1,670) and 20% of OTs (N = 6,025) working in gerontic settings. Working in a gerontic setting was determined by selection of gerontology as a primary or secondary special interest and/or employment in home care, private practice, community-based practice, a freestanding outpatient setting, a hospital (non-mental health), a rehabilitation hospital/center, a subacute facility/unit, or a skilled nursing or long-term care facility. The demographic questionnaire included questions that would allow further clarification of the work setting.

Survey packets were mailed to 1,522 occupational therapy practitioners; of these, 334 were OTAs and 1,188 were OTs. A total of 419 responses were received (response rate = 27.5%); however, 34 of these responses were not included in the analysis because the practitioner either had retired or was no longer practicing as a clinician in a gerontic setting. The study included a total of 385 participants (usable response rate = 25.3%); 66 were employed as OTAs (response rate = 19.8%) and 319 were employed as OTs (response rate = 26.9%). The demographic characteristics of the participants are shown in Tables 12. Most of the participants were female (93.8%), non-Hispanic (96.9%), and White (90.1%). Mean age was 44.55 years; respondents had been practicing occupational therapy for a mean of 15.14 years and had held their current job for a mean of 5.90 years. As a group, OTAs were older (M = 50.09) than OTs (M = 43.39) (t = 4.50, p < .001), but had been practicing occupational therapy for a shorter period (OTA M = 10.67, OT M = 16.07) (t = −3.93, p < .001). There was no statistically significant difference in how long the respondents had held their current job (OTA M = 5.30, OT M = 6.02) (t = 0.80, p = ns). Responses were received from all U.S. census regions, including the Midwest (26.8%), Northeast (24.9%), South (26.8%), and West (21.6%).

Demographic Characteristics of Participants: Categorical Variables (n = 385)

Table 1:

Demographic Characteristics of Participants: Categorical Variables (n = 385)

Demographic Characteristics of Participants: Continuous Variables (n = 385)

Table 2:

Demographic Characteristics of Participants: Continuous Variables (n = 385)

Most of the participants reported working in long-term care facilities, skilled nursing facilities, or nursing homes (51.9%), followed by acute care or inpatient hospital settings (15.1%), subacute and inpatient rehabilitation settings (11.9%), home care (11.2%), more than one setting (5.5%), and outpatient settings (4.4%). Most of the OTAs (77.3%) reported working in long-term care facilities, skilled nursing facilities, or nursing homes, whereas slightly fewer than half of OTs (46.7%) reported working in these settings. In terms of education, all but one OTA (98.5%) reported the associate's degree as their highest occupational therapy degree. Most of the OTs held a master's degree (51.4%), followed by a bachelor's degree (42.9%) and a doctoral degree (5.6%).

Instruments

The Moral Distress Scale-Revised Occupational Therapy (Adult Settings) (MDS-R-OT[A]) was used to measure the moral distress of occupational therapy practitioners (Penny et al., 2016). The MDS-R-OT(A) is a version of the Moral Distress Scale-Revised (MDS-R) created by Hamric, Borchers, and Epstein (2012). The MDS-R-OT(A) asks respondents to use two 5-point (0–4) Likert scales to rate how frequently a given situation occurs in their work setting and the level of disturbance they experience when it occurs. The score for each situation is calculated by multiplying the rating for frequency by the rating for disturbance. The MDS-R seeks to assess moral distress as a tangible experience rather than an abstract “what if” phenomenon. Thus, if a situation does not occur in the workplace (frequency = 0) or if the situation does not disturb the person (intensity = 0), the score for that situation is 0. If a respondent assigns the maximum rating for both frequency (4) and intensity (4), the score is 4 × 4 = 16. The scores for all situations are then added to obtain a moral distress score. The MDS-R-OT(A) includes 21 situations. In addition, respondents have the option to add and rate two situations that cause them moral distress, for a total of 23 situations. Therefore, scores on the MDS-R-OT(A) range from 0 to 368, with higher scores indicating greater moral distress.

Initial evidence to support the content validity of the MDS-R-OT(A) was provided by Penny et al. (2016), who found a scale content validity index of 81.8%. Further evidence to support the reliability and validity of the MDS-R-OT(A) was obtained in a pilot study where the MDS-R-OT(A) and the Hospital Ethical Climate Scale (Olson, 1998) were distributed to a randomized sample of 600 OTs working in gerontic or physical disability settings (response rate = 29.5%). To assess internal consistency reliability, Cronbach's alpha was calculated, and the result (α = .88) indicated good internal consistency (Charter, 2003; Cicchetti, 1994). Three hypotheses were tested to determine the construct validity of the MDS-R-OT(A). The first hypothesis was that there would be an indirect relationship between moral distress and the ethical climate of the organization. That is, less moral distress would be experienced in health care organizations that were perceived as more ethical. The results of Pearson's correlation (r(164) = −.59, p < .001) showed a statistically significant moderate indirect correlation. The second hypothesis was that therapists who were considering leaving their position due to moral distress would score higher on the MDS-R-OT(A) than those who were not considering leaving their position because of moral distress. A statistically significant difference was found (t(159) = 6.00, p < .001). The third hypothesis was that therapists with more years of experience in an organization would score lower on the MDS-R-OT(A). That is, if moral distress is associated with leaving a position, then therapists who remain (i.e., more years of experience in an organization) will report less moral distress. The results of Pearson's correlation (r(164) = −.19, p = .028, one-tailed), although weak, were statistically significant. The finding that all three hypotheses were confirmed in the expected directions provided supporting evidence of the validity of the MDS-R-OT(A).

Procedures

After approval was granted from the institutional review board at Alvernia University, survey packets were mailed to participants. The packets contained a cover letter, an anonymous survey informed consent form, a demographic questionnaire, the MDS-R-OT(A), and a stamped addressed return envelope.

Data Analysis

Data were collected during the first 3 months of 2016 and analyzed with IBM SPSS, version 24. Descriptive statistics were used to present the characteristics of the sample. Pearson's product-moment correlations were used to explore the relationship between continuous variables. Independent samples t tests, one-way analysis of variance (ANOVA), and factorial ANOVA were used to test differences between independent variables. Post hoc comparison tests used either the Tukey test of Honest Significant Difference or the Scheffé test if there were large differences in sample sizes. Levene's tests for the homogeneity of variance between groups were conducted and, when appropriate, adjustments were made to report the corrected test values.

Results

Before the data were analyzed to address the research questions, the reliability of the data was tested with Cronbach's alpha. An overall Cronbach's α of .91 was obtained, with α = .93 for OTAs and α = .91 for OTs. These values suggest that the data collected had excellent internal consistency (Charter, 2003; Cicchetti, 1994).

The mean MDS-R-OT(A) score for all participants was 85.03 ± 57.00. Scores ranged from 0 to 292; low scores indicate less moral distress, whereas high scores indicate more moral distress. The large standard deviation suggests that there was considerable variability in the level of moral distress experienced by participants. The mean MDS-R-OT(A) score for OTAs (M = 94.92, SD = 65.80) was somewhat higher than that for OTs (M = 82.98, SD = 54.90). However, an independent samples t test (two-tailed) showed that the difference was not statistically significant (t = 1.38, p = .172).

Table 3 shows the cross-tabulation for mean MDS-R-OT(A) scores by practice setting. As can be seen, OTAs and OTs work with geriatric clients in a variety of settings. Most of the OTAs reported working in nursing homes (77.3%), with only a small proportion working in other settings. The largest proportion of OTs also worked in nursing homes (46.7%); however, they also worked in other settings. As can be seen, the mean MDS-R-OT(A) score for OTAs working in nursing homes was almost identical to that for OTs, and an independent samples t test (two-tailed) showed that the difference was not statistically significant (t = 0.19, p = .846). The OTs working in nursing homes had a higher mean MDS-R-OT(A) score compared with OTs working in any other setting. One-way ANOVA showed that the difference was statistically significant (F(5, 313) = 7.15, p < .001). The Scheffé test showed that the difference was between OTs who worked in nursing homes and OTs who worked in home care. Because the number of OTAs who reported working in settings other than nursing homes was less than 10, the means are not presented and comparison of OTAs across settings was not possible.

Cross-Tabulation for Mean Moral Distress Score by Practice Setting (n = 385)

Table 3:

Cross-Tabulation for Mean Moral Distress Score by Practice Setting (n = 385)

Table 4 shows the cross-tabulation for mean MDS-R-OT(A) scores by type of organization. Those who reported working in for-profit organizations (M = 91.80, SD = 58.28) scored higher than those working in not-for-profit organizations (M = 74.69, SD = 54.84). An independent samples t test (two-tailed) showed that the difference was statistically significant (t = 2.83, p = .005). This difference was found for OTs (t = 3.28, p = .001), but not for OTAs (t = 0.91, p = ns).

Cross-Tabulation for Mean Moral Distress Score by Type of Organization (n = 372)

Table 4:

Cross-Tabulation for Mean Moral Distress Score by Type of Organization (n = 372)

To determine whether the level of moral distress varied by region, one-way ANOVA was conducted, and the findings were statistically significant (F(3, 381) = 4.57, p = .004). Overall, practitioners working in the West (M = 72.04, SD = 46.86) had the lowest moral distress scores. Those working in the Northeast (M = 77.36, SD = 55.24) and the Midwest (M = 87.71, SD = 54.78) were in the midrange, and those working in the South (M = 99.97, SD = 64.81) had the highest scores. A post hoc Tukey test showed the differences between those working in the South and those working in the West and the Northeast. To determine whether there were differences between region and level of practice, a 2 × 4 factorial ANOVA was conducted; the main and interaction effects approached statistical significance but were not statistically significant.

To determine whether moral distress was related to the amount of formal occupational therapy education, participants were asked about their highest occupational therapy degree. For OTAs, the required entry-level degree is an associate's degree. For OTs, formerly, the required entry-level degree was a bachelor's degree, but the requirement changed to a post-baccalaureate degree in 2007. After entering the profession, participants may or may not have gone on to earn a more advanced degree, for example, an advanced practice master's or doctoral degree in occupational therapy or an advanced degree in a different discipline. Table 5 shows the cross-tabulation for mean MDS-R-OT(A) scores by highest occupational therapy degree. For most of the OTAs (98.5%), the associate's degree was the highest occupational therapy degree, and for most of the OTs (51.4%), the master's degree was the highest occupational therapy degree. As can be seen, OTs who had a bachelor's degree reported less moral distress than those who had a master's degree or a doctoral degree. One-way ANOVA found that this difference was statistically significant (F(2, 316) = 3.25, p = .040). Post hoc comparison showed that the difference was between those with a bachelor's degree and those with a master's degree.

Cross-Tabulation for Mean Moral Distress Score by Highest Occupational Therapy Degree (n = 385)

Table 5:

Cross-Tabulation for Mean Moral Distress Score by Highest Occupational Therapy Degree (n = 385)

To determine whether there was a difference in the experience of moral distress between OTAs and OTs, the mean scores for each situation were calculated. The mean scores were then ranked from highest (first) to lowest (21st). A Spearman rank-order correlation (two-tailed) found a statistically significant correlation between the rankings (rs = .92, p < .001). That is, situations that received high scores from OTAs also received high scores from OTs and vice versa. Table 6 shows the rankings of the situations with the highest scores. For OTAs, the situations with the highest scores were 11, 20, 9, 12, 18, 7, and 3; and for OTS, the situations with the highest scores were 20, 11, 12, 9, 18, 3, and 7. Both OTAs and OTs found that situations where therapy services were limited because of insurance coverage (situation 11) or where the quality of care suffered because of a lack of follow-through (situation 20) caused the most moral distress. High scores were also assigned to situations where there was a high demand for billable units (situation 9) or where there was insufficient time allowed to treat and/or document on the number of expected clients (situation 12). Situations involving poor communication (situation 18), poor sensitivity shown by others (situation 7), and unrealistic administrative directives (situation 3) also ranked among the seven situations that caused the most moral distress.

Ranking of the Highest Scoring Situations on the Moral Distress Scale-Revised Occupational Therapy (Adult Settings) (n = 385)

Table 6:

Ranking of the Highest Scoring Situations on the Moral Distress Scale-Revised Occupational Therapy (Adult Settings) (n = 385)

To determine whether there was a relationship between continuous variables and scores on the MDS-R-OT(A), Pearson's correlations (two-tailed) were conducted. First, the relationship between age and MDS-R-OT(A) scores showed a weak, indirect, statistically significant relationship (all participants, r = −.17, p = .001; OTAs, r = −.10, p = ns; OTs, r = −.21, p < .001). That is, younger practitioners tended to experience somewhat more moral distress than older practitioners. Second, the relationship between the number of years of occupational therapy experience and MDS-R-OT(A) scores showed a weak, indirect, statistically significant relationship (all participants, r = −.23, p < .001, OTAs; r = −.05, p = ns; OTs, r = −.26, p < .001). That is, practitioners with fewer years in the profession tended to experience somewhat more moral distress than those with more years in the profession. The relationship between the number of years in the current position and MDS-R-OT(A) scores showed a weak, indirect, statistically significant relationship (all participants, r = −.15, p = .004; OTAs, r = −.17, p = ns; OTs, r = −.14, p = .012). That is, practitioners with fewer years working in their current position tended to experience somewhat more moral distress than those with more time in their current position. No relationships were found between MDS-R-OT(A) scores and the percentage of time spent providing direct client care (all participants, r = .01; OTAs, r = −.07; OTs, r = .01), the percentage of time spent providing indirect care (all participants, r = .04; OTAs, r = .10; OTs, r = .06), or the percentage of time spent on other duties (all participants, r = −.05; OTAs, r = −.00; OTs, r = −.06).

Finally, at the end of the MDS-R-OT(A), participants were asked two questions related to their experience of moral distress and employment. The first question asked the participants whether they were considering leaving their current position because of the moral distress they were experiencing; 23.6% replied yes (OTAs, 21.2%; OTs, 24.1%), and 76.1% replied no (OTAs, 78.8%; OTs, 75.4%). Participants who were considering leaving their position had significantly higher MDS-R-OT(A) scores (M = 138.32, SD = 61.61) than those who were not considering leaving their position (M = 68.70, SD = 44.01); t = 10.02, p < .001). The second question was asked in two parts. The first part asked whether respondents, in the past, had ever considered leaving a position because of moral distress; 58.4% replied yes (OTAs, 63.6%; OTs, 57.4%), 40.8% replied no (OTAs, 36.4%; OTs, 41.7%), and 0.8% did not answer (OTAs, 0.0%; OTs, 0.9%). The second part asked whether respondents who answered yes to the first part of this question eventually left that position; 86.7% replied yes (OTAs, 83.3%; OTs, 87.4%), and 13.3% replied no (OTAs, 16.7%; OTs, 12.6%). That is, of the 385 participants, 195 (35 OTAs and 160 OTs) indicated that they had left a position where they experienced high moral distress (50.6%).

Discussion

This study was conducted to explore the characteristics of moral distress experienced by occupational therapy practitioners working in gerontic settings. Most of the OTAs reported working in nursing homes, whereas only approximately half of the OTs worked in nursing homes. The level of moral distress experienced by OTAs was almost identical to that of OTs working in nursing homes. A comparison of moral distress by setting was not possible for OTAs because of the low OTA response rate. For OTs, those working in nursing homes experienced the most moral distress, followed by those working in rehabilitation and acute care inpatient settings, outpatient settings, and finally, home care settings. If moral distress is caused by organizational constraints, then this continuum makes sense. As services move away from institutional settings toward the home, the conditions that lead to moral distress would be expected to lessen.

Although there was a small difference in the levels of moral distress experienced by OTAs and OTs, the difference was not statistically significant; this finding was similar to that of Smith-Gabai et al. (2018). The situations that caused moral distress for OTAs and OTs were significantly correlated. That is, the experience of moral distress reported by OTAs and OTs was very similar. Because the OTA works under the supervision of the OT, this suggests that the professional relationship between the OTA and the OT was not a source or a contributor to moral distress for either type of practitioner. This is good news for the profession and suggests that educational programs are effectively instilling a common set of values, ethical principles, and standards of care during the educational experiences of OTAs and OTs. The situations that received the highest scores were similar to those identified in earlier studies and relate to constraints imposed by reimbursement, quality of care, productivity expectations, and directives from administration (Slater, 2016; Smith-Gabai et al., 2018).

As might be expected, practitioners employed by for-profit organizations reported more moral distress than those employed by not-for-profit organizations. However, this difference was found for OTs but not for OTAs. This finding may be related to the greater influence of business models and financial considerations in for-profit organizations compared with not-for-profit organizations.

Perhaps most concerning were the data on moral distress and employment. More than one in five respondents stated that they were considering leaving their current position because of the moral distress that they were experiencing. Also, those who were considering leaving their position reported greater moral distress than those who were not considering leaving. This finding was reported in other research (Hamric et al., 2012; Hamric & Blackhall, 2007; Penny et al., 2014). Even more concerning, half of the respondents indicated that they had left a position where they experienced high moral distress. This finding does not suggest that moral distress in itself led a practitioner to leave a position. Many factors go into the decision to leave a position. However, the finding that such a large proportion of respondents indicated that they had left a position where they experienced high moral distress should alert supervisors and managers to the importance of addressing moral distress to avoid job dissatisfaction and staff turnover.

The finding that practitioners who were younger, who had been in the profession for a shorter time, and who were in their current position for a shorter period tended to experience more moral distress makes sense. If moral distress is linked to leaving a position, then it is likely that practitioners tend to leave facilities where the conditions generate moral distress and that these same facilities would have job vacancies available to new practitioners. In addition, it can be anticipated that those with more years of practice in the profession either will have developed coping strategies or will be less sensitive to moral distress. In either case, it might be expected that those practitioners who continue to work in gerontic settings experience somewhat less moral distress.

Limitations and Future Research

The study had several limitations. First, the total response rate (27.5%) was relatively low compared with other studies (Friese et al., 2010, 30.5%; Hardigan et al., 2012, 26%; Hardigan et al., 2016, 21%; Hoonakker & Carayon, 2009, 37%). In addition, nothing is known about the experience of moral distress in those who did not respond. Second, the response rate for OTAs was considerably lower than that for OTs. The reason for this difference is not known. Did it arise from a difference in the prevalence of moral distress, an attitude toward research in general, or this research topic in particular? Another limitation of the study was the sampling strategy. Fewer than half of all current occupational therapy practitioners are members of the American Occupational Therapy Association; members of a professional association might be more concerned about issues such as moral distress than nonmembers because one of the functions of a professional association is to keep members informed about issues affecting practice. Lastly, the design of this study was descriptive, with the intent of providing a picture of a phenomenon rather than discovering the cause of the problem or determining how to address it. Further research is needed to identify the factors that led to the similarities and differences that were found. Longitudinal studies at specific sites or organizations are needed to address further questions, such as whether levels of moral distress fluctuate over time and what interventions have an effect on moral distress.

Implications for Practice

Occupational therapy practitioners work with geriatric clients is a variety of settings. The findings of this study have several implications for occupational therapy practice. First, OTAs and OTs experienced similar levels of moral distress. Second, OTAs and OTs showed a high degree of agreement as to the situations that caused moral distress. Third, beginning practitioners need to be aware that they are likely to experience greater moral distress than their more established colleagues. Fourth, educators need to prepare students for conflict in the workplace, including strategies to effectively address situations that are associated with moral distress. Finally, supervisors and managers need to be aware that high levels of moral distress are associated with consideration of leaving a position and should seek ways to reduce the experience of moral distress in the workforce.

Conclusion

The current findings suggest that the moral distress experienced by OTAs and OTs working in gerontic settings was similar and was almost identical for those working in nursing homes (OTA, M = 101.27; OT, M = 99.41). The finding that so many respondents (50.6%) reported that they had left a position where they experienced moral distress suggests an urgent need to address this issue. This study provides a reference point for educators, researchers, and managers as they prepare new practitioners for the realities of the workplace and investigate ways to reduce moral distress in practice settings.

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Demographic Characteristics of Participants: Categorical Variables (n = 385)

VariableAllOccupational therapy assistantOccupational therapist
n%n%n%
Gender
  Female36193.86090.930194.4
  Male246.269.1185.6
Ethnicity
  Hispanic/Latino71.823.051.6
  Non-Hispanic/Latino37396.96293.931197.6
  No answer51.323.030.9
Race
  American Indian or Alaska Native10.30010.3
  Black or African American102.623.082.5
  Asian184.700185.6
  White34790.16192.428689.7
  More than one/other51.311.541.2
  No answer41.023.020.6
Highest occupational therapy degree
  Associate's6516.96598.500
  Bachelor's13735.60013742.9
  Master's16542.911.516451.4
  Doctorate184.700185.6
U.S. Census region
  Midwest10326.81421.28927.9
  Northeast9624.91827.37824.5
  South10326.82334.78025.1
  West8321.61116.77222.6
Type of organization
  For-profit22558.45278.817354.2
  Not-for-profit14738.21319.713442.0
  No answer133.511.5123.8
Practice setting
  Nursing home, etc.20051.95177.314946.7
  Home care4311.257.63811.9
  Outpatient174.400175.3
  Rehabilitation4611.946.14213.2
  Acute care and inpatient hospital5815.146.15416.9
  More than one setting215.523.0196.0

Demographic Characteristics of Participants: Continuous Variables (n = 385)

VariableAllOccupational therapy assistantOccupational therapist
MSDMSDMSD
Age, years44.5512.7950.0910.5543.3912.93
Years practicing in occupational therapy15.1411.9310.679.6916.0712.15
Years in current position5.906.595.305.296.026.83

Cross-Tabulation for Mean Moral Distress Score by Practice Setting (n = 385)

VariableOccupational therapy assistantaOccupational therapist
nM (SD)95% CInM (SD)95% CI
All respondents6694.92 (65.80)[78.74, 111.09]31982.98 (54.90)[76.93, 89.03]
By practice setting
  Nursing home, etc.51101.27 (67.03)[82.41, 120.12]14999.41 (55.99)[90.35, 108.47]
  Home care53848.71 (36.25)[36.80, 60.62]
  Outpatient01762.76 (48.16)[38.00, 87.53]
  Rehabilitation44279.23 (52.86)[62.76, 95.70]
  Acute care inpatient45475.20 (52.83)[60.78, 89.62]
  More than one setting21971.21 (51.96)[46.30, 96.12]

Cross-Tabulation for Mean Moral Distress Score by Type of Organization (n = 372)

VariableFor-profitNot-for-profit
nM (SD)95% CInM (SD)95% CI
All respondents22591.80 (58.28)[84.15, 99.46]14774.69 (54.84)[65.76, 93.63]
Occupational therapy assistants5291.80 (67.27)[73.07, 110.53]13110.54 (61.45)[73.41, 147.67]
Occupational therapists17391.80 (55.51)[83.47, 100.13]13471.22 (53.13)[62.14, 80.29]

Cross-Tabulation for Mean Moral Distress Score by Highest Occupational Therapy Degree (n = 385)

Highest occupational therapy degreeOccupational therapy assistantaOccupational therapist
nM (SD)95% CInM (SD)95% CI
Associate's6592.58 (63.45)[76.85, 108.31]0
Bachelor's013774.09 (50.84)[65.51, 82.68]
Master's116489.21 (56.80)[80.45, 97.97]
Doctoral01893.94 (60.32)[63.95, 123.94]

Ranking of the Highest Scoring Situations on the Moral Distress Scale-Revised Occupational Therapy (Adult Settings) (n = 385)

Moral Distress Scale-Revised Occupational Therapy (Adult Settings) situationRanking
Occupational therapy assistantOccupational therapist
3. Be expected to follow unrealistic directives from administration that affect the quality of client care.76
7. Work with health care team members who demonstrate insensitivity towards clients, families, or staff.67
9. Be expected to obtain as many billable units as possible per client, regardless of their individual needs.34
11. Be unable to provide optimal therapy services to clients due to limited insurance coverage or insurance cutoffs.12
12. Be expected to treat and/or write documentation for more clients than time allows.43
18. Witness diminished quality of care due to poor team communication.55
20. Watch the quality of client care suffer due to lack of follow through with recommendations from therapy.21
Authors

Dr. Penny is Associate Professor, Ms. Benjamin is a student, Ms. Gonsalves is a student, Ms. Gordon is a student, Ms. Kinsley is a student, and Ms. Markel is a student, Occupational Therapy Department, Alvernia University, Reading, Pennsylvania.

The authors have no relevant financial relationships to disclose.

The authors acknowledge the support of Alvernia University while conducting this research project.

Address correspondence to Neil H. Penny, EdD, OTR/L, Associate Professor, Occupational Therapy Department, Alvernia University, 400 St. Bernardine St., Reading, PA 19607; e-mail: Neil.Penny@alvernia.edu.

Received: January 21, 2019
Accepted: April 22, 2019
Posted Online: July 03, 2019

10.3928/24761222-20190625-02

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