Financial incentives and moral distress in Australian audiologists and audiometrists

Introduction

Financial incentives are commonly implemented by employers as a way of motivating employees to improve their performance and productivity in line with organizational goals. Lupton, Rowe, and Whittle ¹ theorize that the implementation of such schemes create a means for employers to alter employees’ behavior so that these align with the interests of the organization. Financial incentive schemes thus risk “crowding out” the desire of employees to perform their job solely for the public good. ² In healthcare settings, financial incentives can lead to a conflict of interest as the employee will potentially choose to recommend a path linked with personal reward over what may be in the best interests of their client. ³ When public service motivations of employees in the healthcare setting become crowded out, this harms the ability of the organization to provide a high-quality service. ⁴

In Australia, the professionals that manage hearing aid dispensing are audiologists and audiometrists. Audiologists hold a 2-year postgraduate qualification and audiometrists a vocational training award. ⁵ The federal government offers subsidized hearing devices to a subsection of the population—people younger than 26 years of age, pension concession holders, veterans, First Nations peoples, and those with complex health needs. ⁵ Clients presenting with hearing loss are presented with the option of choosing a “free” fully subsidized device or a premium device that attracts an additional fee. Therefore, the potential exists for the client to contribute financially toward their hearing devices, either partially, or fully if not eligible for government support.

Financial incentive schemes have been used by employers in the industry as a way of encouraging audiologists and audiometrists to boost premium device sales.^6,7 The audiologist or audiometrist receives a commission for every premium device sale. Unsurprisingly, both professions have received a considerable amount of criticism and media attention for placing sales over client needs. ⁶ The Australian Competition and Consumer Commission (ACCC) conducted an inquiry into these concerns, releasing a report in 2017 identifying the perspectives and concerns of both consumers and clinicians regarding issues surrounding hearing device sales. ⁶ The report stated that the profession's sales-driven environment was highly likely to encourage unethical conduct. ⁶ Consumers surveyed for the report claimed that professionals were more interested in the sale of hearing devices than they were in providing independent healthcare advice.^6,8 From the professionals’ perspective, they reported feeling pressured to meet the sales targets enforced by their employers. Audiologists and audiometrists felt that the failure to meet expected targets could lead to potential employment termination. ⁶

Simpson et al. ⁹ found that audiologists who worked in hearing aid sales experienced a poorer ethical climate than those who worked in pediatric or diagnostic settings, with participants reporting stress, discomfort, frustration, worry, and anger. ⁹ Participants reported qualitatively that financial incentives were a factor contributing to “moral distress”—an emotional state arising from a situation when a person feels that the ethically correct action to take is different from what they are tasked with doing.^9,10

While early research exploring moral distress largely centered on the profession of nursing, ¹¹ recent evidence shows moral distress as a widespread phenomenon across several health-related professions, including audiology.^9,12 Several negative consequences have been associated with moral distress, including physical exhaustion, feelings of sadness, anxiety, and depression, ¹³ job disatisfaction, and poorer quality of client care.^11,14,15

The impact of moral distress on the health of professionals and their capacity to provide quality healthcare is, therefore, a cause for concern and further examination into the impact of commission-based sales on moral distress is warranted. In response to the ACCC report, Audiology Australia (AuDA), the self-regulated professional member association of audiologists released a position statement and revised its code of conduct discouraging the use of commission in hearing devices sales. ¹⁶ However, given that approximately 70% of Australian audiologists are employed in private audiological practices, ⁹ their ability to influence their employment conditions is limited. Such circumstances can lead to moral distress given the practitioners’ desire for ethical practice is compromised by organizational constraints and/or directives to increase revenue.

The authors were curious if the practice of commission-based schemes was still prevalent in the profession following the ACCC enquiry and what the impact of these schemes was on professionals’ ethical wellbeing. Given the presence of commission-based sales in audiology and hearing aid dispensary settings, it gives reason to question if the profession is particularly susceptible to the crowding-out effect, which proposes that the intrinsic factors of audiologists to provide good quality care has the potential to be disregarded if financial incentives are offered to them by their employers. ² The present study, therefore, aimed to examine whether financial incentives (i.e. commission-based sales of hearing devices) in audiology were associated with a greater degree of moral distress.

Methods

Incentives

After completing the MDT, participants were asked to complete four questions specific to financial and nonfinancial incentives within their clinical practice—see Table 1. If the participant answered “yes” to questions 1 and 2, additional questions opened up for participants to provide further detail to their response. Only results from the closed-ended questions are reported in this paper.

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Table 1.

Questions asked of participants in the survey.

Question	Response type
1. a. In your role, do you have targets or key performance indicators for the number of hearing devices you sell?	Yes/No
b. If yes, please tell us more	Text
c. If yes, are there any consequences for not meeting targets?	Text
2. a. In your role, do you receive financial incentives for selling hearing devices?	Yes/No
b. If yes, what is the best description of these incentives?	Text
3. Is the company you work for associated with a single hearing aid provider?	Yes/No
4. In your role, do you receive any of the following: • Discounts on equipment • Sponsored educational events • Branded gifts, for example, pens, pencils, and notepads • Travel • Meals • Other	Tick all that apply

Results

Sociodemographic information

A total of 65 participants, 34 audiologists, and 31 audiometrists participated in the study with sociodemographic information shown in Table 2. Most participants were female (n = 42, 65%) and employed in a full-time capacity (n = 48, 74%). 37% of participants were aged under 35 years of age, 22% aged 35–44 years of age, and 42% aged above 45 years. Just under half of the participants were mid-career with 6–15 years of experience (n = 30, 46%), with 28% of participants with over 15 years of experience, and 26% with under 6 years of experience.

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Table 2.

Participant sociodemographic information.

Variable	Sample
	N	%
Qualifications
Audiologist	34	52%
Audiometrist	31	48%
Gender
Female	42	65%
Male	23	35%
Prefer not to say	0	0%
Age
<35	24	37%
35–44	14	22%
45+	27	42%
Years of experience
<6 years	17	26%
6–15 years	30	46%
15+ years	18	28%
Employment type
Full time	48	74%
Part time	17	26%
Total	65

Incentives and moral distress

A total of 58 participants completed the incentives section of the survey—see Table 3. Regarding device sales targets, 67% (n = 39) of participants reported being required to meet sales targets while 33% (n = 19) did not. A chi-square test of association was performed to examine the relationship between sales targets and MDT scores. The relationship between these two variables was significant x² (2, N = 58) = 14.42, p = .001, indicating that professionals required to meet sales targets were also more likely to report a higher intensity of moral distress.

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Table 3.

Types of financial incentives received by participants.

	n	%
Sales targets
Yes	39	67%
No	19	33%
Total	58	100%
Financial incentives
Yes	41	71%
No	17	29%
Total	58	100%
Type of financial incentive (could select more than one)
Bonus per device sale	17	29%
Bonus per salary period	12	21%
Bonus per year	3	5%
Shares in business	12	21%
Total	58
Affiliated with only one hearing device manufacturer
Yes	20	34%
No	38	66%
Total	58	100%
Gifts and other benefits (could select more than one)
Sponsored professional development	26	54%
Branded gifts from device manufacturers	21	44%
Discounts on equipment and hearing devices	16	33%
Paid travel	12	25%
Paid meals	11	23%
Subsidy of professional body fees	5	10%
Total	48

Twenty-nine participants (43%) stated that they faced consequences for not meeting targets in their place of work, with three participants (4%) unsure, 13 (19%) reported no direct consequences, and 23 (34%) did not respond to the question. For participants who responded, the most common consequence reported by 16 participants was “contact from management”. This was followed by “performance management” reported by 15 participants. Five participants reported “no bonus payments”, three participants reported “risk of job loss” and one participant reported “naming and shaming in front of colleagues.”

Seventy-two percent of 58 participants reported receiving financial incentives—see Table 3 for type and distribution of financial incentives. A chi-square test of association examining the relationship between financial incentives and MDT scores was significant χ² (2, n = 58) = 9.58, p = .008 indicating that participants receiving financial incentives were more likely to report a higher intensity of moral distress. Among the 58 participants who responded, “bonus per device sale” was the most common incentive received (n = 17, 29%), followed by “bonus per salary period” and shares in the business (n = 12, 21%). A small number of participants reported receiving an annual financial bonus (n = 3, 5%).

A total of 48 participants responded to the question on whether they received other gifts and/or benefits from their employer with participants able to select all those that applied. The most common response among participants was receiving access to sponsored professional development (n = 26), followed by branded gifts from manufacturers (e.g. pens, notepads, etc.) (n = 21), discounts on equipment, and hearing devices (n = 16). Gifts and benefits reported by a smaller number of participants included travel (n = 12), meals (n = 11), and subsidy on professional body membership fees (n = 1)—see Table 3. For gift and benefit incentives, no statistically significant relationship was found between receiving gifts or benefits and MDT scores.

Discussion

This study found a significant association with the presence of sales targets, financial incentives, and an increased perception of moral distress among audiologists and audiometrists. This is an important finding given the consequences of moral distress on the quality of clinical decision making, care of patients, and job satisfaction.^11,15

In the current study, the mean MDT score of the total sample was 1.75 (SD = 2.49) with approximately one-quarter of participants reporting uncomfortable to intense levels of moral distress. These scores are slightly lower than the MDT mean of 2.9 (SD = 2.5) found by Wocial and Weaver ¹⁷ when validating the use of the MDT in nurses. Although a quarter of the sample may appear modest, this is a significant proportion of the workforce. Increased levels of moral distress have been associated with burnout, compassion fatigue, errors in patient care, patient suffering, and withdrawing or distancing from patients.^11,13,15,17 Research suggests that even months or years after a morally distressing situation ends, distressing thoughts and feelings may still linger. In cases where moral distress is ongoing, health professionals have been shown to resign or leave the profession altogether.^11,19

The findings of the current study support the qualitative interviews undertaken by Simpson et al. ⁹ in which respondents described the conflict of interest inherent in “selling” hearing devices as a major cause of moral distress. Although financial incentives have been discouraged, this study found that the practice continues with just under 70% of participants reporting the requirement to meet sales targets, and just under half of the sample reporting negative consequences for failing to meet targets.

Lupton, Rowe, and Whittle ¹ write how the promise of financial reward can influence an individual's behavior and result in a disregard toward their underlying intrinsic intentions. Although audiologists themselves have been shown to value patient-centered care^12,20,21, these values cannot be transferred into clinical practice if the clinician is placed in a situation of moral distress. In past research, participants have viewed audiologists as inherently untrustworthy due to the commercial arrangements often influencing their choices when it came to hearing devices. ²² As much as the ideals of patient-centered care align with audiologists’ aims and values, these ideals cannot be implemented when clinician behavior is regulated by organizational goals and requirements. This study's finding of a significant link between monetary incentives and moral distress highlights the negative impact of the current rewards system implemented in many hearing device clinics.

Putting pressure on employees to sell more hearing aids has been justified as a “necessary evil” due to the financial pressures of business to stay viable. ⁹ These adopted practices of competition, free market, and organizational structures celebrating entrepreneurship place the burden on audiologists and audiometrists to perform (i.e. meet sales targets) to grow the company's market share and profits. Certainly, the privatization of healthcare continues to grow at a rapid rate through increased demand from the affluent population, reduction in government subsidies, and profit logic of insurance companies into profit-seeking corporations. Access to hearing healthcare becomes a product and is no longer regarded as a collective or human right.

While audiologists have recognized the structural effects associated with privatization, these are viewed as an individual, rather than a collective responsibility.^9,14 Professionals have reported everyday workarounds to minimize the discomfort of being placed in a conflict of interest—these included a denial by some participants that sales targets influenced their behavior.^9,14 As Ng et al. ¹⁴ notes being able “to speak up or resist systemic ethical concerns requires a sense of agency that perhaps is ambitious for any one or small group of audiologists” (p. 583). Clinicians need support to uphold their professional values and without adequate government or professional body regulation in the hearing health industry, the effects of market forces (i.e. sales targets, organizational constraints, unethical conduct, and unqualified practice), are most likely to continue to influence the ways in which people with hearing loss are managed.

Conclusions

The push for sales in the hearing device industry negatively was found to impact the professionals’ experience with the results of this study finding a strong correlation between the industry's implementation of financial incentives and moral distress. If the needs of the client are to take priority in the industry, there needs to be a realignment of the profession's focus. Increased regulation of commission-based sales in hearing healthcare would greatly assist in renewing faith in the profession by the public.