Let’s Talk About Ethics: Addressing Ethical Tensions and Building Moral Resilience in the Occupational Therapy Profession

Clinician Well-Being

Burnout and attrition from unresolved moral distress have been pervasive across health care practice settings for years and are often the result of the ethically challenging situations health professionals face in day-to-day practice. Before the coronavirus disease 2019 (COVID-19) pandemic, the phenomenon of moral distress was gaining increased levels of attention because of the high levels of burnout, compassion fatigue, posttraumatic stress disorder (PTSD), emotional distress, and secondary trauma that resulted from experiences of moral distress (American Nurses Association, 2017; National Academy of Medicine, 2022; Rivard & Brown, 2019; Tinkham et al., 2021; World Health Organization, 2019). The COVID-19 pandemic exponentially increased rates of depression and PTSD, substance abuse, and experiences of moral distress for both health care professionals and society in general (Delgado et al., 2021; DePierro et al., 2020; Spilg et al., 2022). Health care workers, including occupational therapy practitioners, were, are, and continue to be faced with ethically challenging and morally complex situations, high-stress environments, and difficult decisions on a daily basis.

Throughout the COVID-19 pandemic, occupational therapy practitioners were forced to make difficult decisions that had many ethical implications. The process of making difficult decisions, especially in ethically challenging situations, can be extremely stressful for occupational therapy practitioners because it forces them to simultaneously balance adherence to employer and patients’ rights, patients’ wants and needs, and the law (Paul-Emile et al., 2016). Ethical decision-making is a vital component of professional reasoning and an essential tool for overcoming obstacles to mitigate the negative consequences of moral distress (Doherty, 2021). Occupational therapy practitioners need to be adequately trained in recognizing moral distress and making sound ethical decisions, especially in complex situations that may cause moral distress (AOTA, 2020).

Causes of Moral Distress for Occupational Therapy Practitioners

An overwhelming amount of research has found that external and institutional constraints are the leading causes of moral distress experienced by occupational therapy practitioners. Both nurses and occupational therapy practitioners have reported a stressful organizational and ethical climate in the workplace, power dynamics in the health care system, conflicting loyalties, miscommunications, a lack of autonomy, and ambiguous implementation of workplace policies as sources of ethical tension and moral distress (Foye et al., 2002; Gupta et al., 2012; Mukherjee et al., 2009; Pauly et al., 2012; Penny et al., 2019; Rushton, 2017; Zuzelo, 2007). Conflict between a person’s professional values and the demands of their employer—including unmanageable workload and unrealistic productivity demands, which lead to compromised treatment—have also been noted as ethical tensions causing moral distress and posing a threat to one’s professional integrity (Bushby et al., 2015).

The need for more time and space to reflect on and discuss ethically challenging situations experienced in day-to-day practice and health care coverage, including insufficient economic resources and constrained access to services, has also been reported as a large external source of ethical tension and cause of moral distress (Bushby et al., 2015; Gupta et al., 2012; Mukherjee et al., 2009; Pauly et al., 2012; Penny et al., 2014; Storch et al., 2009; Zuzelo, 2007). Ethical tensions regarding health care reimbursement are not a new phenomenon and have caused moral distress for rehabilitation professionals for at least the past 20 years (Bushby et al., 2015; Foye et al., 2002; Kirschner et al., 2001). Because many ethical tensions resulting in moral distress are due to external or institutional constraints, it is vital that administration and leadership are adequately prepared to acknowledge and address the issue.

The Occupational Therapy Profession’s Call to Action

Many occupational therapy practitioners and other health professionals who experience moral distress report that their employers do not provide adequate education about, or access to, potential resources and solutions for addressing practice-related moral distress and ethical dilemmas (Zuzelo, 2007). Administration and leadership have the essential roles of (1) providing support to and resources for employees faced with ethical tensions and (2) implementing strategies to help employees cope with moral distress and prevent burnout (Pauly et al., 2012; Reilly & Jurchak, 2017; Slater & Brandt, 2009; Zuzelo, 2007). Leaders, managers, and administrators must foster a culture of ethical reflection to enhance individual moral reasoning and provide opportunities for the development of moral resilience. They can do this by encouraging, demonstrating, and facilitating ethical decision-making and engaging staff in reflective, ethical discourse (Doherty & Peterson, 2022; Newton, 2013). Effective interventions, starting at the leadership level, that promote engagement in ethical reflection and address moral distress have been found to increase feelings of value and decrease levels of moral distress in health care providers. These interventions also led to increased feelings of empathy, affirmation, and empowerment, ultimately resulting in improved ethical practice both individually and unit wide (Doherty & Peterson, 2022; Gupta et al., 2012; Reilly & Jurchak, 2017).

Ethics resources, ethical supports, ethics discussions (or “rounds”), and continuing professional development on ethics and ethical dilemmas, in conjunction with the strategic development of coping strategies, have the potential to mitigate the negative effects of moral distress (Forozeiya et al., 2019; Pauly et al., 2012; Reilly & Jurchak, 2017; Zuzelo, 2007). In addition, interprofessional ethics workshops and unit-specific ethics rounds have been identified in the literature as ways to increase communication and trust within teams, improve job satisfaction, increase feelings of empowerment, and decrease moral distress (Forozeiya et al., 2019; Pauly et al., 2012; Reilly & Jurchak, 2017; Tinkham et al., 2021; Zuzelo, 2007). This supports the overwhelming need for ethics-based resources and continuing professional development opportunities that are aimed at decreasing moral distress and increasing practitioner well-being and that provide practical strategies for building moral resilience.

We have developed and piloted a continuing professional development curriculum in ethics that supports the notion that education and training in ethics have the potential to proactively prepare occupational therapy practitioners to navigate ethically challenging situations and build moral resilience. Participants in this professional development activity have reported that, after participating in one 90-min ethics session, they (1) had a deeper understanding of the relationship among moral distress, moral resilience, and clinician well-being; (2) felt better prepared to incorporate ethics language into everyday practice; (3) were able to recognize ethical tensions in their own practice; and (4) could identify ways to build moral resilience to improve clinician well-being (Doherty & Rotelle, 2022). These positive outcomes document the power of ethics education in cultivating moral resilience, expanding the knowledge, skills, and well-being of occupational therapy practitioners.

Moral Resilience: An Essential Practice Skill

Finding solutions to reduce moral distress and promote clinician well-being in a health care setting is multidimensional. External constraints and institutional barriers contributing to moral distress cannot easily be removed; however, the skills needed to cope with ethical tensions can be taught. The literature provides a multitude of strategies for promoting clinical well-being, especially while navigating a global pandemic (e.g., meditation, self-care, mindfulness, journaling, gratitude, rest; Hedderman et al., 2021; Klatt et al., 2020; National Academy of Medicine, 2023; Wiederman et al., 2020). Although these are all proven strategies, they do not fully eradicate the moral residue that accumulates over time should a clinician not have the skills or resources needed to cope with repeated experiences of moral distress in practice. Enhanced moral resilience, which is a multidimensional, teachable, and learnable skill that enables practitioners to thrive even when experiencing distress, can effectively and proactively negate the negative effects of moral distress in the workplace (Mealer et al., 2012; Rivard & Brown, 2019). Now more than ever it is essential to build moral resilience in the profession to mitigate moral suffering, preserve clinician well-being, and foster a practice culture that champions ethical practice and decision-making.

Given that many professionals find mnemonics helpful tools for reflection and action (Merideth, 2007), we have proposed the “Five Cs of Navigating Ethical Tensions and Building Moral Resilience.” The goal of the five Cs, which are grounded in the moral resiliency literature (American Nurses Association, 2017; Delgado et al., 2021; Rushton et al., 2017), is to provide a resource for promoting ethical practice and fostering moral resilience across communities of practice.

The following are the Five Cs of Navigating Ethical Tensions and Building Moral Resilience:

Start the Conversation: Ask your intra- and interprofessional colleagues, “Can we talk about the ethical implications of . . .?”

Conclusion

Developing a culture of ethical practice and moral resilience is necessary for occupational therapy practitioners because moral distress and burnout were, are, and will continue to be wide-reaching problems that affect all occupational therapy practitioners and transcend all practice areas. Moral distress is often caused by ethical tensions that result in feelings of inferiority, an undermining of practitioners’ values, and improper use of coping strategies (Rushton, 2006; Zuzelo, 2007). These situations can activate a stress response in the brain that, if not properly addressed, leads to long-term mental, physical, and emotional consequences (Rushton, 2017). It is evident that continuing professional development in ethics and ethics supports, and engaging in discussions that specifically address the moral dimensions of practice, can better prepare occupational therapy practitioners to confront the negative effects of moral distress (Pauly et al., 2012; Reilly & Jurchak, 2017; Zuzelo, 2007). These strategies are also documented in the literature as having the potential to foster moral resilience and cultivate the skills necessary to cope with ethical dilemmas related to occupational therapy practice (Doherty, 2021; Forozeiya et al., 2019; Mealer et al., 2012; Pauly et al., 2012; Reilly & Jurchak, 2017; Rivard & Brown, 2019; Zuzelo, 2007). Moral distress among occupational therapy practitioners must be addressed to prevent burnout, decrease health care costs, ensure quality patient care outcomes, and improve the overall well-being of individual occupational therapy practitioners and the profession as a whole.