... Moral Distress in the time of COVID-19: Occupational Therapy Practitioners Experiences Breanna Beckmann, Drew Flynn, Jon Haller, Macy Pohl, Kelsey Smith, & Scott Webb December 7, 2022 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Brenda Howard, DHSc, OTR, FAOTA MORAL DISTRESS IN THE TIME OF COVID-19 1 A Research Project Entitled Moral Distress in the time of COVID-19: Occupational Therapy Practitioners Experiences Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Breanna Beckmann, Drew Flynn, Jon Haller, Macy Pohl, Kelsey Smith, & Scott Webb Approved by: st Research Advisor (1 Reader) 12/7/2022 Date Accepted on this date by the Chair of the School of Occupational Therapy: Kate E. DeCleene Huber, OTR, MS, OTD Chair, School of Occupational Therapy Date MORAL DISTRESS IN THE TIME OF COVID-19 2 Moral Distress in the time of COVID-19: Occupational Therapy Practitioners Experiences Dr. Brenda Howard, Breanna Beckmann, Drew Flynn, Jon Haller, Macy Pohl, Kelsey Smith, & Scott Webb University of Indianapolis School of Occupational Therapy OTD 2023: Research Application December 9, 2022 MORAL DISTRESS IN THE TIME OF COVID-19 3 Abstract Background. COVID-19 has impacted the healthcare system, including the occupational therapy profession. Occupational therapy practitioners have had to adapt to these unknown times to best treat their clients. The conditions of COVID-19 have caused moral distress in practitioners. Purpose. The purpose of this study was to explore moral distress within the lived experiences of OT practitioners during the time of COVID-19. Method. Investigators utilized a stratified-purposeful sample to select occupational therapists in a variety of settings. Investigators conducted a semi-structured interview to explore their experience with moral distress during the time of COVID-19. The data were analyzed using a hermeneutical phenomenological approach to generate themes regarding the experience of moral distress. Findings. Investigators were able to identify commonalities in various settings as the COVID19 Pandemic impacted occupational therapy practitioners. These commonalities helped the investigators determine that the themes of the study were COVID-19, moral distress (MD) in OT, experiences, stressors, OT practitioner role, uncharted waters, managing moral distress, effects, personal protective equipment (PPE), COVID impact on roles, encouragement, mental health, vaccine impact, employment complications, and therapeutic relationships. Discussion. This studys findings brought awareness to the experience of OT practitioners during the pandemic and explored implications for preparing OT practitioners for future occurrences of moral distress. Keywords: COVID-19; ethics; mental health; moral distress MORAL DISTRESS IN THE TIME OF COVID-19 4 Moral Distress in the time of COVID-19: Occupational Therapy Practitioners Experiences Starting in December of 2019, cases of COVID-19, an acute respiratory syndrome that changed the world everyone knew (Turale et al., 2020), began to emerge. The COVID-19 pandemic has impacted everyone daily. However, individuals in the healthcare field work under unique challenges and unprecedented circumstances as the pandemic continues to impact individuals globally. COVID-19 has presented ethical and moral challenges in the healthcare field related to a scarcity of personal protective equipment (PPE), rationing of essential supplies and equipment, and other moral and ethical problems related to COVID-19 specific procedures and policies (Turale et al., 2020). The pandemic has impacted healthcare professionals as many navigated internal and external factors of distress related to COVID-19. The pandemic has resulted in ever-changing shortages and policies regarding COVID-19 care and PPE (Cacchione, 2020). In addition, the COVID-19 pandemic has posed moral challenges that have impacted practitioner performance, client relations, and the implementation of treatment as a whole (Cacchione, 2020). Occupational therapy (OT) practitioners and healthcare professionals often encounter clients facing adversity, which requires the clinician to exhibit empathy, understanding, and the ability to adapt. These situations often place practitioners in ethical problems and, if not adequately addressed, can lead to moral distress (Rivard & Brown, 2019). Jameton first defined moral distress as 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). Morley, Bradbury-Jones, & Ives (2021) broadened the definition of moral distress, stating, Moral distress is the psychological distress that is causally related to a moral event (p.2). In addition to moral distress, the experience of moral injury has also been present during the COVID-19 pandemic. MORAL DISTRESS IN THE TIME OF COVID-19 5 Moral Injury has been defined as difficult decisions made, high mortality, futility of treatment, and moral/ethical problems during the pandemic (Roycroft et al., 2020, p. 312). Occupational therapy practitioners have experienced emotional and mental trauma resulting from moral distress (Penny et al., 2014). The experience of moral distress has led to practitioner burnout within OT practice, which has led to a lesser quality of care for clients (Penny et al., 2014). Moral distress also has significantly impacted the practitioners personal life, including causing physical and emotional illnesses (Fourie, 2015). Moral distress has led to damaged practitioner rapport, including relationships with the client and their caregivers (Penny et al., 2014). The impact of moral distress during the COVID-19 pandemic among OT practitioners has not yet been fully explored. The investigators sought to answer the question, What has been the experience of moral distress in OT practitioners since the onset of the COVID-19 pandemic? A secondary purpose included finding out how OT practitioners had been managing moral distress during this time. Lastly, investigators sought OT practitioners' recommendations for managing moral distress. Investigators used a hermeneutical phenomenological methodology (Creswell & Poth, 2018) to answer these questions. Background Moral Distress and Occupational Therapy Moral distress has existed in OT practice in multiple countries, including Australia (Hazelwood et al., 2019), Canada (Drolet & Dsormeaux-Moreau, 2016; Drolet, 2018; Kinsella et al., 2008; Rivard & Brown, 2019), the United Kingdom (Bushby et al., 2015; Murray et al., 2015), Sweden (Kassberg & Skar, 2008), and the United States of America (Bennet et al., 2019; Erler, 2017; Penny et al., 2016; Slater & Brandt, 2009; Smith-Gabai et al., 2008). The literature MORAL DISTRESS IN THE TIME OF COVID-19 6 reports issues contributing to moral distress in health professionals that include conflicting values, failure to speak up, witnessing questionable behavior, systemic constraints, and experiences during the COVID-19 Pandemic. Conflicting Values Conflicting values significantly contributed to moral distress and ethical tensions, as reported in several studies (Bennett et al., 2019; Hazelwood et al., 2019; Kinsella et al., 2008; Rivard & Brown, 2019). Kinsella et al. (2008) discussed the nature of ethical tension experienced as a result of Conflicting values between practitioners and clients, between practitioners from different disciplines, and even between students and therapists'' (p.179). Bennet et al. (2019) stated that healthcare workers reported feeling like their professional values were incongruent with their job requirements'' (p. 9). Durocher et al. (2016) reported on conflicting values of patient care and management structures, stating, Services are shifted away from the provision of good-quality patient care and the fulfillment of professional values, and more emphasis is placed on implementing cost-saving measures and administrating budgets and resources'' (p. 1). Failure to Speak Up Failure to speak up has also contributed to moral distress and ethical tension (Bushby et al., 2015). Often, team members made comments about clients to the OT practitioner, placing them in an uncomfortable situation. Many practitioners have felt torn as advocacy is a staple in practice, but also feel the need to maintain a professional relationship (Hazelwood et al., 2019). Occupational therapy students on their Level II fieldwork have often experienced the failure to speak up when they felt uncomfortable speaking up for clients due to their lack of knowledge and inferior position to their supervisor and team members (Kinsella et al., 2008). MORAL DISTRESS IN THE TIME OF COVID-19 7 Witnessing Questionable Behavior From Other Healthcare Practitioners Occupational therapy practitioners and OT students on their Level II fieldwork rotations witnessed suspicious behavior from other healthcare practitioners (Slater & Brandt, 2009; Bushby et al., 2015; Hazelwood et al., 2019; Kinsella et al., 2008). Noted examples include (a) disrespectful and unprofessional behaviors from healthcare professionals toward clients (Hazelwood et al., 2019; Kinsella et al., 2008), (b) inappropriate conversations about clients (Kinsella et al., 2008), (c) referring to clients in the non-person-first language (Kinsella et al., 2008), (d) failure to communicate with patients about their prognosis (Kinsella et al., 2008), and (e) breaches of confidentiality (Kinsella et al., 2008). Systemic constraints Durocher et al. (2016) noted, ...systemic constraints [are] a predominant source of daily ethical tensions faced by occupational therapists in a variety of practice settings (p.225). The authors broke down systemic constraints into four domains, including (a) certain policies or instructions, (b) ineffective process implementations that hindered the overall therapeutic patient experience, (c) restrictions concerning good funds and resources, or (d) the lack of services. Sources of systemic constraints have included excessive caseloads, delays in receiving items to treat patients, advocating for resources, scarcity in staff numbers, and inadequate time to treat the patient correctly (Durocher et al., 2016). All of the above prevented practitioners from providing quality care to patients, leading to moral distress for OT practitioners (Bushby et al., 2015). Resources for coping with moral distress have been limited. Recognizing moral distress in the workplace has been the first step leading to potential interventions (Slater & Brandt, 2009). According to Penny et al. (2014), occupational therapy managers should promote team communication, improve care continuity, and benefit the teams skills and care strategies to treat MORAL DISTRESS IN THE TIME OF COVID-19 8 its clients. Improving communication has started with education among the entire interprofessional team. Facilitating interdisciplinary research, creating a healthy work environment, and promoting ethical leadership have been recommended as interventions as well (Slater & Brandt, 2009). Erler (2017) has suggested that OT practitioners could engage in ethics rounds. These open discussions about ethical tensions, concerns, and issues offered a space for OT practitioners to engage in thought about ethical tensions and the impact it has had on their lives (Erler, 2017). Although these authors offered suggestions for combating moral distress, studies demonstrating the efficacy of interventions for moral distress have not been found in the literature. Coronavirus-19 The novel coronavirus (COVID-19) pandemic in the United States started in March of 2020 when various governments and associations put lockdowns and restrictions on the healthcare system. Many parts of the healthcare system had to shift their principles to help protect the general public, themselves, and their loved ones (Berlinger et al., 2020). During the COVID-19 pandemic, there was a shift from patient-centered ethics to a public health focus (Angelos, 2020; Berlinger et al., 2020). This shift has caused health care workers to experience distressing ethical problems when making decisions regarding patients (Civaner et al., 2017). Additionally, the mass spreading of COVID-19 caused a great deal of distress to the health care workers, and as Turale et al. (2020) stated at the beginning of the pandemic, there were increasing numbers of videos... circulating showing nurses in tears or anger, telling their stories (p. 166). Recent literature has explored issues of concern during COVID-19 for rehabilitation professionals. Some articles directly addressed the topic of moral distress (Cacchione, 2020). MORAL DISTRESS IN THE TIME OF COVID-19 9 Others addressed burnout (Kellish et al., 2021), and the occurrence of moral injury due to extenuating circumstances (Roycroft et al., 2020). During this time of uncertainty, many authors have explored the impact of changing guidelines (Ness et al., 2021) and the impact of personal protective equipment (Cacchione, 2020; Turtle et al., 2020). Conclusions included the need for increased organizational support to reduce the occurrence of ethical problems resulting in moral distress (Ditwiler et al., 2021). Investigators completed a virtual interview with Kimberly Erler, OT, PhD, who is a Clinical Ethicist at Massachusetts General Hospital. In this interview, Dr. Erler discussed the topic of moral distress among OT practitioners during COVID-19 at Massachusetts General Hospital (Kimberly Erler, personal communication, February 24, 2021). Dr. Erler reported that in open forum meetings, occupational therapists discussed health disparities, lack of PPE, uncertainty regarding unapproved methods of cleaning PPE that was meant for single-use, the fear of transmitting COVID-19 from patient to patient through improper PPE re-use, and the anguish of weighing commitments to keep ones own family safe against the commitment to care for hospital patients. This interview reinforced the need for further investigation of moral distress during COVID-19 and informed the interview content. Healthcare Team and COVID-19 COVID-19 has impacted hospitals and other healthcare settings worldwide. Across the world, health care settings had constructed makeshift hospitals and quarantine centers overnight (Kumar et. al., 2020, p. S53) to help reduce the spread of the virus and to manage the influx of incoming patients. The staff members in these settings (doctors, paramedical staff, nurses, security guards, etc.) had to learn new protocols about caring for patients and managing their work aligned with the CDCs COVID guidelines (Kumar et al., 2020, p. S54). Occupational MORAL DISTRESS IN THE TIME OF COVID-19 10 therapy practitioners nationwide adapted to different roles, including participating in proning patients with COVID-19. Franzosa et al. (2021) explored the impact of COVID-19 on HomeBased Primary Care (HBPC). When the pandemic began, HBPCs goal shifted to gathering information about COVID-19 and how to prepare practices serving older adults nationwide. COVID-19 has severely impacted skilled nursing facility settings (Bagchi et al., 2021). Compared to the general population, residents in a nursing home setting were at a higher risk for morbidity and mortality in association with COVID-19 (Bagchi et al., 2021). There was also a sense of fear and vulnerability from healthcare workers and patients due to a lack of personal protective equipment (PPE), preparation, and proper planning (Turale et al., 2020, p. 165). There were patients that were dying without anyone by their side, due to visitors and visiting times being limited, which led to health social workers having moral distress (John et al., 2020, p. 514). Alleviation of Moral Distress Prior to the onset of the COVID-19 pandemic, OT practitioners had already developed strategies to alleviate moral distress. These strategies were based on beliefs and prior experiences, but there has been a need for more research supporting interventions for moral distress (Slater & Brandt, 2009). Recommendations for alleviating moral distress have included (a) identifying any ethical issues, (b) documenting possible causes of moral distress, (c) talking with persons in power to support good ethical action, (d) establishing safe spaces for expression, (e) using ethical resources when making decisions, (f) instructing pupils on ethical issues and possible solutions, (g) communicating and working together to find answers, (h) donating time, money, and power to larger professional bodies to help change employers, and (i) implementing collaborative management that focuses on values (Drolet, 2018). Despite interventions to MORAL DISTRESS IN THE TIME OF COVID-19 11 alleviate moral distress, OT practitioners have continued to face difficult and sometimes very personal decisions that have contributed to moral distress (Slater & Brandt, 2009). Summary Moral distress has occurred in a variety of healthcare settings and has been reported in several countries. Moral distress has highly impacted the effectiveness of healthcare workers, including OT practitioners (Erler, 2017; Bushby et al., 2015; Imbulana et al., 2021). While the literature has identified the prevalence of moral distress during the COVID-19 pandemic (Cacchione, 2020), more research is needed to define the experience of moral distress in OT practice during the pandemic and to create evidence-based interventions for combating moral distress. The purpose of this study was to explore moral distress among OT practitioners during the time of COVID-19. Investigators addressed this purpose through a hermeneutical phenomenological approach (Creswell & Poth, 2018). Methods This study was approved by the University of Indianapolis Human Research Protections Program as Exempt from Institutional Review Board review (Study #01423). Recruitment Investigators used a stratified-purposive sample to recruit participants in the spring and summer of 2021. The inclusion criteria included OTs and OTAs who were actively practicing. The exclusion criteria included OTs and OTAs who work exclusively in academics, OT or OTA students, and persons who work in other professions besides occupational therapy. Investigators recruited OT practitioners in a variety of practice settings through direct contact, snowball sampling, and social media (see Appendix A). Investigators directed the potential participants to a Google form (see Appendix B). The google form included the Informed Consent Document MORAL DISTRESS IN THE TIME OF COVID-19 12 (ICD), with instructions that completing the form constitutes assent to participate in the study, and an option to download the ICD. The form also collected demographic information, including age, gender identification, race/ethnicity/cultural identification, years in practice, and the setting they practiced in during the COVID-19 pandemic. Lastly, investigators asked the participants if they could reach out to the participant after the data analysis to complete member checking and requested they leave an email address if in agreement. Instrumentation In this phenomenological study, the investigators developed semi-structured interview questions based on the moral distress issues found in the literature and the investigators interview with Dr. Kimberly Erler (personal communication, February 24, 2021). Content experts examined the questions to improve and enhance the validity of the interview questions. See Appendix C for the interview questions. Procedures After recruitment, investigators conducted recorded Zoom semi-structured interviews with each participant in August of 2021. The participants selected a color identifier in order to help protect their identity. They were asked to change their name to this color identifier in the Zoom rename feature and to turn off their camera. Using Zooms transcript creation feature, investigators transcribed the interviews and edited them for accuracy. Investigators then analyzed the data using Dedoose 9.0.17 (Dedoose, 2021). Finally, investigators emailed a de-identified member checking survey using Google Forms to participants on 2/14/2022, which remained open for two weeks. The member checking survey addressed the clarity and relevance of the extracted themes and their definitions. Investigators left write-in options for participants to add anything else they wished to share. MORAL DISTRESS IN THE TIME OF COVID-19 13 Data Analysis To analyze the data, investigators used a hermeneutical phenomenological approach in which they analyzed the texts of the interviews to describe and interpret the experiences of the participants (Creswell & Poth, 2018). Investigators went through a deep reading process, then reduced and coded the transcripts to extract themes. At least three members of the team completed code comparisons on each transcript in order to validate the coding process. Following code comparisons, all team members met and discussed themes until a consensus was reached. Investigators then discussed each theme to come to a consensus on theme definitions and theme mapping. After completion of member checking, investigators included qualitative comments from the member checking survey in the dataset. Findings Sample In exploring the question, What has been the experience of moral distress in OT practitioners since the onset of the COVID-19 pandemic? investigators conducted semistructured interviews. Researchers were able to gather the responses of 18 total participants. Participants were mostly female, mostly white, and came from eight different practice areas. All participants were occupational therapists. See Table 1 for demographic information. Table 1. Demographics (n=18). Item Category Total n(%) Male 1 (5.6) Female 17 (94.4) 25-34 7 (38.9) Gender Age Range MORAL DISTRESS IN THE TIME OF COVID-19 14 35-44 8 (44.4) 45-54 1 (5.6) 55+ 2 (11.1) Skilled Nursing Facility 4 (22.2) Acute Care/Intensive Care Unit 5 (27.8) Adult Home Health 1 (5.6) Early Intervention 1 (5.6) Mental Health 1 (5.6) Outpatient Pediatrics 1 (5.6) Outpatient Orthopedics 1 (5.6) Multiple Settings 4 (22.2) 0-5 8 (44.4) 6-10 3 (16.7) 11-20 6 (33.3) 21-30 1 (5.6) White/Caucasian 16 (89.9) Asian 1 (5.6) Black or African American 1 (5.6) Midwest 15 (83.3) West 3 (16.7) Setting Years in Practice Race Area of the Country MORAL DISTRESS IN THE TIME OF COVID-19 15 Experiences of Moral Distress During COVID-19 Participants reflected on the sudden and fundamental shifts that COVID-19 brought about in health care. COVID has changed health care and we just have to work through it and decide this may be a new normal for us (member checking comments). Another participant reported that COVID-19 started The year healthcare will never look the same again (member checking comments). COVID-19 changed even the fundamental makeup of the healthcare team: In the beginning, we had decided that we would do a COVID team. There would be one OT and one PT to see the patient, so if we got COVID we could then move it down the list. The policy was that if you were over 60, or if you had an autoimmune disorder, that would eliminate you from being on the team. Therefore, when you went down through our group of OTs here, it left me. I was the last straw, but I didn't have much of a choice (Teal, Lines [L.] 30-33). Moral Distress in OT The theme of moral distress in OT has been defined as, The psychological distress that is causally related to a moral event (Morley et al., 2021, p.2). Occupational therapy practitioners participating in this study did report that they experienced moral distress during the COVID-19 pandemic. One participant identified their moral distress during the time of COVID-19, stating: I think there's an element of PTSD from it. I think it's a big part of why I switched jobs, I didn't want to be a part of it anymore. It was awful, the things that we saw. I cried a lot. It was an extremely stressful time and I don't think that anybody was okay from it. I think that was the hardest part, there was never time to recover from it because as soon as the numbers went down from COVID, the hospital census started picking back up because they started opening things back up and started doing surgeries. We never had time to regroup and reflect on what happened. In a lot of ways I probably didn't manage it (Purple, L. 43-47). Researchers asked each participant, on a scale of 0-5, with 0 being no moral distress and 5 being extreme moral distress, how would you rate your intensity of moral distress from March 2020 until now? Seventeen of 18 participants reported that their moral distress at the beginning of the pandemic (March 2020) was rated a 4 or a 5. As the pandemic continued, practitioners MORAL DISTRESS IN THE TIME OF COVID-19 16 explained that their moral distress was still present; however, they rated their moral distress as an average of 3 out of 5 at the time of the interview. As an example of moral distress, one participant stated they had a fear of treating people in physically close proximity but having a moral obligation to care for them despite my personal fears for myself (member checking comments). This comment demonstrated how the participant wanted to provide due care but felt conflicted due to their own fears of becoming ill. Experiences of Moral Distress Investigators have defined experiences of moral distress as each participants individualized encounter with COVID-19 and the impact the pandemic has had on their lives. The experience of living with COVID has affected interaction with all staff, brought up lots of issues with trust of employers, government, and changed how OT treats (member checking comments). The participants expanded upon their experiences with patients with COVID-19 and its impact on them emotionally: Your patient would be doing good, their oxygens great, and then you sit them up on the side of the bed, and you would crash your patient down into the 40s. They would not recover and then the next day, you would come in and they would be dead,or they would die within the next 24/48 hours. So it was the moral distress that you felt [as if] you weren't improving their quality of life, you caused trauma to them. It wasn't something that you did, but in the beginning [youre thinking] that's not what we OTs do, our job is to make people improve their quality of life (Teal L. 44-48). Some felt as if these times were a matter of life or death, stating, The consequences of the action were a lot higher to me (Red, L. 70). Stressors Investigators defined stressors as an internal or external event, force, or condition that causes physical or emotional distress (American Psychological Association, n.d.). Examples of stressors include: transmitting COVID to loved ones or clients, PPE, and mental health, MORAL DISTRESS IN THE TIME OF COVID-19 17 providing suboptimal care, and getting exposed to COVID-19. In response to asking about their current levels of distress, one participant answered: It is a background low level of stress, not to mention the terror of getting sick and dying. Working in a hospital, where early on they shut down all of the outpatient [surgery]. Everything's canceled and there were no visitors and anybody who's not direct patientfacing is working remotely, so the hospital's kind of a ghost town for a while. In that respect, it was less stressful because there was less traffic going to work and I always got great parking spaces and it wasn't so crowded. There was always that fear of what happens if I get sick, and what happens if I bring it home. So, I think it's very different from any other kind of stress because any other kind of stress that I've experienced has been time-limited, and who knows when this is going to end, if ever (Violet L. 107-112). Occupational Therapy Practitioner Role Many participants reported experiences that impacted their OT practitioner role during the time of COVID-19. The theme is defined as the responsibilities and capacity of OT practitioners to perform tasks within and outside of the scope of practice during the COVID-19 pandemic. Specific examples include proning, temperature checking, toileting, housekeeping, and providing emotional support. During the interviews, several practitioners identified their changed roles due to COVID-19. One participant stated: I don't feel it has put me in a position where I'm operating outside of my scope of practice because I feel the beautiful thing about [OT] is it's so dynamic and it's so inclusive. There's so much that we can do within our scope, so I felt my ability to be an educator and a coach increased more for my patients (Pink, L. 64-67). Alternatively, participants had identified that during the time of COVID-19, they were either asked or assigned job responsibilities and tasks that went outside their OT practitioner role. One participant discussed: I felt my job was more like a CNA than a therapist. Even when they allowed us to start doing therapy again, I was frequently having to come into a patient's room [around] two in the afternoon and could tell that they hadn't been touched all day (Olive, L.82-85). Uncharted waters MORAL DISTRESS IN THE TIME OF COVID-19 18 Participants reported experiencing things they had never seen before within their practice setting. Uncharted waters is defined as a feeling of uncertainty due to a lack of familiarity with new experiences and protocols related to the COVID-19 pandemic. Uncharted waters reported by participants ranged from uncharted COVID-19 protocols and PPE to unknown patient plans, such as not wanting to go to a SNF during COVID-19. One participant discussed the uncharted waters they experienced: It was super stressful because one day everyone is wearing a mask, the next day, nobody wears a mask unless you were sick. Then, it would be only wearing a mask if you're working with COVID patients. Finally, it came back to everyone wearing masks and then our hospital rationing PPE at first (Lavender, L.45-50). Personal Protective Equipment (PPE) Many participants discussed the lack of appropriate PPE in their workplace. The personal protective equipment theme (PPE) is defined as the presence, or lack thereof, of individual safety protocols and gear, provided through the workplace. Participants expressed the fear of not being protected from COVID or spreading it to patients or family. This led to an increase in stress and anxiety. I feel there's been a lot of situations of moral distress with the COVID pandemic. The first one that comes to mind is PPE in the beginning. We were unfortunately in one of those facilities where we had one surgical mask for a couple of months, then we had a COVID outbreak. We were limited with gowns and gloves and everything at one point. So providing the appropriate care with the limited resources that we had (Blue 2, L. 1316). Another participant discussed the distress they felt when their employment did not require masks at the beginning of the pandemic, and how the potential impact of not wearing masks could affect their clients lives and families. Early last March of 2020, I would say that [PPE usage] was the hardest because we didn't know what was going on. When everything started, [when] the world started to shut down, our practice didn't [shut down]. We weren't wearing masks and I felt very conflicted with my moral duty and ethical duty, that I felt we shouldn't be open. We don't MORAL DISTRESS IN THE TIME OF COVID-19 19 know what's going on, we don't know what we're doing, and that was the first time I cried at work. And I cried in my boss's office, saying I don't know what you guys are thinking, but this is not okay. She pretty much told me nobody knows what we're doing so if you feel you can't be here that's up to you, but I'm not going to say we're not going to make that call as a company yet. So I had a lot of internal struggles of not knowing, am I gonna kill my patients inadvertently? Knowing I have something wrong with me or not understanding what the symptoms are and how it's transmitted. For about a week, [I thought] I should quit or step back because I did feel I had patients [who were] taking care of elderly family members, or they had cancer or knew people [who had cancer]. I felt guilty that I shouldn't be there. But then when things kind of came out and we started wearing masks I felt a lot safer, but I struggled the first couple of weeks (Blue, L. 8-18). Even though PPE was a protective measure that created a safer environment, there were still nuisances that came with it. The therapeutic relationship between therapist and client was hindered due to a lack of personability throughout the session from the lack of close contact and hidden facial expressions. In the hospital, I'd say the main stressor for me is that they do a fit test when you are at a place that does things properly. They did a fit test when I got hired, and unfortunately, I failed the two masks that they had available at the time, so I had to wear a big half respirator mask that looks like a gas mask. It feels like it's really hard for patients to hear me in it. I'll be yelling and they can't hear me. Then you also have the fans in the room to try and keep the air as clean as they can and that's added noise plus if they're on a high flow oxygen system, it is added noise. So it's really hard for them to hear me and that can be frustrating (Olive, L. 140-156). There were even instances where the use of PPE violated clients autonomy, which caused moral distress to the participant. Patients weren't allowed to have their clothes, so everybody was in gowns and everybody was wearing masks. It seemed more like a prison. They were wearing uniforms and you cant see people's faces. A lot of what I doespecially in psych when you're doing group therapy, it's a lot of nonverbal stuff and you can't see people's expressions, and they can't see my slight subtle changes and expressions. I was really glad when patients got their clothes back, when they realized it's probably not going to be passed on by surfaces or clothing. We had to wear [PPE] until the CDC changed its guidelines. Until then, we had to wear eye shields for every patient-facing encounter. If I was in my office, I didn't have to, but I did anytime I walked out of my office. I say it took about a month or two before I didn't automatically leave my officebecause if you didn't have your goggles on or eye shieldsI had to go back into my office and grab them, so it was that unconscious pushing-up-glasses thing every time I walked out of my office. It was a good long time before that stopped (Violet, L. 62-77). MORAL DISTRESS IN THE TIME OF COVID-19 20 Effects of Experiencing Moral Distress Effects of experiencing moral distress reported by participants ranged from burn-out to dealing with death and loss. The effects of COVID-19 for some were long-lasting and initiated job and setting changes. The effects of experiencing moral distress are defined as the psychological, emotional, and physical impact of the practitioners experiences due to COVID19 on their well-being and quality of life. These impacts included effects on a practitioner's roles, their occupational performance, and their sense of self. A few key sub-themes included COVID19 burnout, exhaustion, and intense emotions. During the time of COVID-19, OT practitioners discussed feeling burnout within their practice setting due to the increased stressors that came along with COVID-19. One participant discussed their experience with COVID-19 burn out stating: I have worked in acute care for five years. I loved inpatient acute care, I loved ICU, that was definitely a passion setting of mine. I really do think that COVID was part of the reason, probably a big part of the reason, why I got burnt out and felt I needed to leave. I certainly didn't see myself going nonclinical after five years of OT work, I thought I'd be doing this for a lot longer. But it was extremely difficult to be doing things outside of our scope. I never thought that I would have been in a situation where I'm part of a code, where I'm the second person, no one else can respond and it was too hard seeing people literally die in front of you and I couldn't do it anymore. I switched roles and I do think that COVID was a big part of why I did that, and I think we're seeing that a lot right now with the nursing profession. I don't think it's specific to OT. Now we're seeing a lot of people leave, because of the PTSD, but also the extreme burnout that came from what we went through (Purple, L. 123-130). Investigators found that participants identified increased exhaustion as an effect of experiencing moral distress during the time of COVID-19. One participant explained their experience with exhaustion, stating Id come home exhausted and tearful and unable to do other things outside of my work, and come home and crash (Olive, L.287-289). MORAL DISTRESS IN THE TIME OF COVID-19 21 Occupational therapy practitioners identified experiencing intense emotions as a result of experiencing moral distress during the time of COVID-19. Participants identified intense emotions due to the COVID-19 experience while providing direct patient care, stating: Seeing those people sick and then they're staring at you, while you're in these big suits and you can't have that contact to touch them, hand in hand, because you have to wear two layers of gloves. It was very trying and emotional (Red 2, L.37-40). COVID Impact on Life Roles Not only did COVID impact OT Practitioners worker roles, it also spilled over into life roles. The investigators defined COVID Impact on Life Roles as the change in personal roles caused by providing health care during COVID-19. Examples include changes to work-life balance, hesitancy to interact with family and friends, and extra precautions taken to keep loved ones safe. One of the participants detailed their experience in relation to being a caregiver for their grandmother: The consequences of it, if I bring COVID home to my family. Normally I am a caregiver for my grandmother, my mom and I [both are], and I avoided her at all costs. I still helped out with managing things behind the scenes and getting things my mom needed, but I didn't go within six feet of her so that was pretty hard for a while. Going from being around her all the time and then staying away from her (Red 2, L. 90-96). When the pandemic first broke out, one participant stated COVID affected her overall well-being. It was definitely impacting my sleep; it was impacting different health behaviors. I do like to go to the gym, and at that time I wasn't completing, or wasn't partaking in a lot of my normal hobbies, just trying to stay healthy myself (Blue, L. 5961)/ Vaccine impact The COVID-19 vaccine production and distribution had varying effects and implications among the U.S. population that were due to the political undertones that developed throughout the pandemic. The vaccine impact theme is defined as the varying implications that came with the vaccine distribution within the United States such as co-worker disputes, family impact, and MORAL DISTRESS IN THE TIME OF COVID-19 22 personal health. One participant detailed their experience regarding conversations with their peers about the COVID-19 vaccine: Recently I had a conversation with a group of outpatient OT, PT, and cardiac rehab nurses in which they asked me if I was planning to get vaccinated. I responded with, I was vaccinated in January, why? Then it occurred to me that I didnt think they had been vaccinated. So I said to them, Are none of you vaccinated when they responded with No, and we dont plan to be. The words Well you are all idiots actually came out of my mouth. After I gathered myself, because I was shocked those words had come out, I apologized for calling them idiots. I asked what their reasoning for not getting vaccinated was. They told me that there was not enough research on long-term effects. I asked them if any of them had worked with COVID positive patients and they stated no. I said to them Well I will say this to you, we dont know the long-term effects of the vaccine, but we also dont know the long-term effects of COVID either. I assume that if any of you had seen the patients I have seen over the past year or been with patients who are intubated and still struggling with O2 sats, you would get the vaccine too. They told me I was overreacting and that the long-term worries outweighed the short term concerns. At that point I had to walk away, but on my way out the door I said to them, I do know the short term concerns of COVID and that is death, so yes I think everyone should get vaccinated so that you dont ever have to hold the hands of dying patients, like I have. Following my breath out of the room, I went to see my next patient and at the end of the day I did have one of the PTs tell me she was going to get vaccinated and that I had helped her see what she hadnt seen because she hadnt worked in acute [care] or a SNF during this pandemic. So, I was glad at least I helped one person out of the group be protected, but I still struggled working with these people the next few weeks and not wanting to scream at them (Red, L. 197-208). Some participants described their experience with the vaccine as hopeful. One participant describes the overall morale of the hospital being better because of the impact of the vaccine: I said to look at the positives of, now we are vaccinated, we have more research, and even our doctors feel better about treating these patients. I think just that general feeling around the hospital has gotten better (Lavender, L. 43-45). Employment complications The COVID-19 pandemic created various employment complications. The employment complications theme is defined as the various effects felt by practitioners in the workplace; from their employers during the pandemic relating to their employment status (e.g., hours cut, no new work available, short staffing); from coworkers, colleagues, and clients with attitudes and MORAL DISTRESS IN THE TIME OF COVID-19 23 opinions differing from their own. Sometimes these employment complications led to people switching roles, positions, and practice areas. One participant discussed a situation where COVID-19 caused them to switch roles and learn a completely new setting: They were banning any traveling workers, and that was a huge upset for me. I found myself almost unemployed, except for a couple hours a week, at one assisted living facility. I had to completely learn something new, taking the opportunity to help with the Telehealth clinics. I also ended up later in the fall doing some more adjunct teaching than I had done prior (Cyan, L. 44-48) . Another participant witnessed of people putting themselves and others at risk for an increase in pay: I worked at a SNF in May 2020 as PRN. The full-time staff would get premium pay if they agreed to work on the red (COVID-positive) units, and they also got additional premium pay if they themselves had contracted COVID and returned to work. I had a few of the employees tell me that they purposely had exposed themselves to COVID in order to test positive, so that they could return to work at a higher rate. I also had multiple people tell me that they would work the red units without appropriate PPE for the higher pay rate. I found out later that a CNA for this company made around $10/hour however if they meet these 2 other criteria they could make $30/hour. In this same facility, it was nursing home appreciation week, so the administration had decided they would provide some happiness and fun through the games and prizes. However what I witnessed was in the middle of the red unit, the nurses would take off their masks and PPE to play these games. The game consisted of using a straw to suck up M&Ms and move them from point A to point B (think minute-to-win-it type games). When I mentioned that this didnt seem like a good idea in a red unit, with a virus transmitted through air, they told me it was okay because they all wanted to get sick to receive the premium pay (Red, L. 168175). Therapeutic relationships Occupational therapy practitioners are called to create meaningful relationships to build rapport with their clients. COVID-19 made it more challenging to create these meaningful connections due to the contact limitations and personal disconnect due to the PPE. The therapeutic relationships theme is defined as the interrelated bond created between OT practitioners, healthcare workers, and clients through their shared experiences during the MORAL DISTRESS IN THE TIME OF COVID-19 24 COVID-19 pandemic. One of the participants provided an example of building therapeutic relationships during the COVID-19 pandemic: Sometimes I would push the limits and stay in the rooms a little bit longer. The patients, you could tell they appreciated that. They would be a little happier when I came back the next time; they were more willing to work with me. It's showing them that we do care instead of them just being a number or treatment we're trying to check off (Red 2, L. 109111). Managing moral distress Many participants discussed how they have or have not been managing moral distress during COVID-19. Investigators defined Managing moral distress as various ways that OT practitioners handled moral distress related to their experiences throughout the COVID-19 pandemic. Some examples of how practitioners managed their moral distress included seeking professional help, talking with family members or co-workers, or working out. One participant identified how talking about their moral distressed helped them manage it: I tried to be very open and to discuss these things. Especially when we have our meetings, because I find that most of the time, people are probably dealing with the same struggles that you're dealing with, and they may not feel so comfortable expressing how they feel. That's one of the things I've tried to be a proponent about, not holding it in and sharing what I think and what I feel (Pink, L. 101-105). Encouragement During COVID-19, many of the participants experienced ways in which they engaged in positive emotional and physical support that may have been provided by their coworkers, families, or employers. Some practitioners places of work planned virtual events or brought in something to try and boost morale. Other practitioners would focus on their physical health by exercising, and some would try to spend time with their families. Encouragement also came in the form of seeing a COVID-19 patient get healthier. One participant describes this experience as she got to see a patient go from the ICU to the main floor, to be successful at home: MORAL DISTRESS IN THE TIME OF COVID-19 25 I had started proning and supining a patient. And then he got into the main floor instead of ICU and I got to treat them over there, which was really cool to watch him progress from where he was before. Then I was interviewing for a home health position, and I happened to get to go to his house. They were seeing him, and he was walking and doing fantastic so that was cool to see that full spectrum of care, ICU to the regular floor, to at home, and being successful. You don't get that opportunity very often, so that was pretty cool to see (Sky blue 110-114). Mental health COVID-19 didnt just affect the worlds physical health. Some participants struggled with mental health through their emotional experiences. Investigators defined mental health in the context of this study as emotional experiences brought on by COVID-19, and the actions and resources taken by practitioners to cope with them. There were many emotional experiences that were precipitated by COVID-19, and many of the participants took action and used resources to help cope with those experiences. Several participants reported taking steps to advocate for mental health services during the time of COVID-19 as a result of realizing they need to make mental health a priority. I think there needs to be more resources available, and I do think that was the OT in me coming out a little bit, trying to coordinate something with the resources available in the community for the rest of the team, because I feel there wasn't a whole lot of conversation happening about what was going on. So I definitely think there's more opportunity for support and resource groups, as well as regular conversations. Maybe that's [providing] even more resources, as far as coping mechanisms, and going back to the basics of how we handle our basic stress levels, what are things that we can do in the workplace. And there was probably a lot of opportunity for more support groups and guided conversations that weren't happening (Purple L. 80-85). What we have learned The COVID-19 pandemic brought about a myriad of emotions and consequences, but there were still a lot of valuable lessons learned throughout these dark times that the OT profession can adopt. While this pandemic has caused a lot of pain and turmoil, OT practice can benefit from the lessons learned in self-care and advocacy for oneself and their patients. The MORAL DISTRESS IN THE TIME OF COVID-19 26 theme, what we have learned is defined as interventions and strategies that can be taken away from the COVID-19 experience about managing moral distress in order to mitigate it in the future. Some examples include recognizing moral distress, seeking professional help and social support, the importance of interprofessional relationships, maintaining a healthy work-life balance, and transparency and advocacy for ones own mental health to coworkers, clients, family, and friends. One of the participants shared their experience in how they learned to advocate for themselves to preserve their mental health: I think what I learned the most from this is that it's okay to ask for help. As a team member, I pretty much did COVID from March, because we had the first patient until I got COVID in April and I was out for two weeks. I came back to the COVID team. And then until I finally hit my breaking point, probably in November, and that's when I told my boss I can't do this anymore. And it was okay, and the team was very supportive and was surprised that I lasted that long. So I think, for me, learning it's okay to ask for help and not be the therapist that can fix things (Teal, L. 112-116). One of the participants added the importance of retaining a work-life balance for the sake of the patient: The biggest thing that we should do, in any profession, is to remember that there still is a work-life balance, even if you're in the middle of a worldwide pandemic. You can't pour from an empty cupWhen you're in these situations, you're pressured to be a caregiver. You go into this field because we want to help people, we want to take care of others. But then you start to feel the pressure when it keeps coming and coming, and then they want more and more. I think the biggest thing is setting boundaries and saying it's okay if I take a day off here, or an afternoon off. I need to take some time for myself to recoup, and then come back and be better for the patient's sake. It's usually not their fault when we get over-stressed, and they still need our help, and they are very sick (Lavender, L. 118-125). Another practitioner stated how important it was to feel emotions and recommended asking for help when needed: To feel the emotions. To have my first [patient loss] stick with me. [I was] trying to push all that in and not address it. It was a big one, so allowing myself to feel the emotions and ask for help when I needed it would probably be the biggest piece of advice (Red 2 L. 101-104). MORAL DISTRESS IN THE TIME OF COVID-19 27 Similarly, after experiencing distress, one participant expressed the need for transparency between therapist and patient on their own mental health in an empathetic way: I would have been more honest with my patients, not to give them my problems, or not to make them feel bad. But not to be, Oh I'm fine, it's okay, I'm here for you, but being more real with patients and letting them know that I'm a real person. I'm not up here with a white coat looking down on you telling you what to do, but more so, This is hard, and I haven't seen my family in nine months or hugged my mom, and it is really hard. But these are the things I've done to help me be more honest with them from a personal standpoint, rather than saying Oh medically, can I tell you what to do? I don't know and I feel like I don't have all the answers, so I shouldn't say anything. [The client] told me I needed therapy, so I went to therapy, but doing it from a personal perspective and being okay with my patients knowing that sometimes life's hard and that's okay (Blue, L. 94-102). Another participant expressed the importance and need for occupational therapy during these unprecedented times: OT has so much to offer, because I call this the year of occupational disruption, even though it's lasted more than a year. Its been nothing but occupational disruption for everybody, and if you can find me somebody who hasn't had something majorly disruptive, I want to talk to them about where they're living or what they're doing, because everybody's been challenged to give up or amend or adjust a role. As a society I'm not sure we have a lot of support for what that is when it happens and no teaser is uniquely placed for that because we think about the role and not from a psychological standpoint, we also think about it from a troubleshooting [standpoint], or a task analysis or an environment person standpoint (Turquoise 2, L. 125-131). Stories of COVID Time Many of the questions investigators asked of participants prompted stories. These stories are best told in their entirety, as they provide the best description of the lived experiences of moral distress during COVID time. Table 2 provides a summary of these stories. Table 2. Stories of COVID time. MORAL DISTRESS IN THE TIME OF COVID-19 Participant Excerpt Purple We are part of peoples discomfort. The hardest thing that I saw was pretty specific to being in an ICU setting and it wasn't even necessarily specific to OT practice. We saw a lot of patients whose care was kind of happening against their wishes. Patients who might have come into the hospital were diagnosed with COVID and immediately got placed on a ventilator. Those vented patients that had a previously stated DNR or they had some kind of living will that said that that was against their wishes but in [our state], you can go against that really at any point in time. Families or other next of kin can always go against those wishes. And so, we'd be working with patients while they're on the ventilator, which was extremely uncomfortable. They are very sick, very anxious, and the entire time you are, in the back of your head, knowing that that is completely against their wishes and what they would have wanted. But yet you still have to follow doctor's orders and go in there and do an evaluation or do a treatment, and that was extremely distressing to know that you were part of people's discomfort or just furthering their misery, really. Turquoise Three days later they were gone. I definitely saw a lot of patients who were doing great one day, and then two days later, they were no longer on the floor that I was on, and they were down in the ICU. People who went from being fine to being on the docket for being prone and a couple of people who three days after I saw them for an initial evaluation had passed away, and it's like, what? The thing about working in a hospital that's a Trauma Level 1 is you see really bad situations. It's not the first people that I've had passed away before, but man it's tough when you have somebody who seems like they're doing pretty good and they're only needing a couple of liters of oxygen, and three days later they're gone how do you handle that? The best thing you can do is just kind of talk it out with the folks that know what's going on and just try to focus on what's important in your life and not take anything for granted. I think that's why I like that focus on my family and just talking to them and reaching out to them via phone or zoom and spending time with my husband and my son was like a huge, huge help for me to balance some of that. 28 MORAL DISTRESS IN THE TIME OF COVID-19 Participant Excerpt Teal My breaking point. I think my breaking point was, I had a couple, they celebrated their 90th birthday party and the daughter decided that they needed to celebrate it, so she had a party for them, and half their guests wore masks, and the other half didn't. They sat with me, and they said, we've been really good, and we haven't gone out at all, until my daughter decided to have this party for us. And then they both ended up with COVID. We wheeled them in a room together and they held their hands and they died four minutes apart. And I had them both [as patients]. That was my endpoint because the daughter had a lot of guilt and would call in and cry and to watch the two of them, because they've been married for 70 some years. So that was that. Aqua Missing concerning signs on telehealth. I have had a lot of concerns about abuse and things like that that are happening in the home. Like during the virtual stuff that maybe we aren't catching or not seeing, because we're not entering the home, we're just seeing the picture they want us to see and that to me has weighed on my mind. I think, because of virtual, maybe I wasn't as quick to call DCS, to have them check out the place as I should have maybe. I just recently made a phone call. And it had kind of been on my mind, for you know, a couple months leading up to it. But I mean, I had not seen any abuse, so I just had kind of seen a lack of adults. It was a teenage mom; there were just never any adults around. And Mom was just really struggling to keep up with the therapy sessions and the baby was really medically fragile and in and out of the hospital. Finally, when she no-showed and I thought we're going to lose contact with this family, I thought I better call DCS and see if they can get someone in there to support them. She'd been bouncing around from different homes to homes, not really having a stable home environment. 29 MORAL DISTRESS IN THE TIME OF COVID-19 Participant Excerpt Turquoise Questionable management decisions and risks to personal health. And this patient had initially come in and tested negative. They moved her off the COVID unit. This therapist and I went to see her. She was on a BIPAP; she wanted to drink water and the PT helped her take the mask off to get a sip of water. And then later that night, her O2 sats started tanking again so they tested her again. She tested positive later that night for COVID, so whether she had a false negative we don't know, but this PT ended up getting COVID and the only exposure that they could figure where she didn't have the appropriate PPE on was this patient who had been negative, because we were only wearing surgical masks. Somehow, I was fortunate enough not to get it, and this PT was out for two months because of her battle with COVID. She literally got hospitalized for a short while, and then she was home. When [she got back], they asked her to be part of the prone team and Im like, this therapist is still probably recovering from having been out from like August to October, almost November. Having had COVID, why are you pulling her into this terrible swing schedule and asking her to do this? So, I think the prone team thing, I don't think that they accounted for who was really the appropriate choices for that team. There were plenty of other therapists who could have been pulled sorry, that's kind of opening a whole can of worms of my frustration with that choice. They should have asked if there were people who were willing to do it. I think that that could have been more well organized. Red Risks due to PPE shortage. Well, that would be the skilled nursing facility. That was very early in the pandemic and, as I said, the skilled nursing facility was, out of the 70 patients in the skilled nursing facility, there were two that were not positive, so not quite 100 percent positive. Everyone else was positive, and we had one set of PPE. We had one gown, we had one mask, one face shield. [Reusing face shields is] fine, you reuse those clean ones all the time, but I have one gown and one mask for weeks. I was also expected to treat the two patients who were not positive. But I was in the same PPE that I was [wearing into] COVID-positive rooms and so that was definitely, obviously, I felt like it was a huge problem, because I was exposing them with the same protective gear. I did try to mitigate some of that in that I would treat those two patients first during the day if they were on my schedule, and then go to the positive wings or the positive floors. Definitely PPE in that situation led to increased moral distress. 30 MORAL DISTRESS IN THE TIME OF COVID-19 31 Data Comparisons Themes and settings Upon comparing themes to their occurrence in practice settings, researchers found that participants in all settings described commonalities in how COVID-19 impacted their roles and the challenges it presented. In addition to role impact, many of the participants reported that they were working outside of their scope of practice. Another similarity among all practice areas was the experience of intense emotions. Practitioners who practiced in multiple settings experienced intense emotions and feelings of confliction at a higher rate. Table 3 indicates themes that occurred at a higher rate and what practice setting the themes occurred in. Table 3. Theme occurrence by setting Acute Care/ICU Multiple settings Skilled Nursing Facility Total theme occurrence among all settings COVIDs Impact on one's Roles 7 12 6 37 Dealing with death and loss 7 6 1 18 Feeling conflicted 1 14 0 25 Intense emotions 0 13 3 41 PPE Impact 13 12 7 48 Scope of practice issues 3 8 5 24 MORAL DISTRESS IN THE TIME OF COVID-19 Stories during COVID time 5 15 32 1 27 One notable difference between practice settings was the use and need of Personal Protective Equipment (PPE) and dealing with death and loss. The ICU, acute care setting, and various skilled nursing facilities were greatly impacted by death and loss as their patients were more vulnerable. Many therapists from these settings dealt with issues concerning PPE. They needed PPE to safely do their job, but therapists often found themselves having to re-use. This impact appeared to not be as significant among the other outpatient settings (i.e., pediatrics and orthopedics) as they were able to perform telehealth services as an alternative therapy option. Themes and years in practice Investigators analyzed data according to the participants' years in practice. (Refer to Table 1, Demographics). Many similarities existed in the responses among age groups, as a majority of the participants said that COVID had a significant impact on their roles. Practitioners stated that they had dealt with feelings of discouragement and exhaustion while working during the pandemic. To help cope with those feelings, practitioners of all ages stated they sought out professional help, relied on co-workers and friends/family, and performed mental health selfcare. Some examples of mental health self-care tasks include yoga/meditation, going for walks/exercising, and taking time for oneself. Researchers found that years in practice did correlate to some differences in the OT practitioner's experiences. Occupational therapy practitioners who had practiced from 0 to 5 years responded more to feeling conflicted, feeling as if they were offering less than optimal care, experiencing scope of practice issues, and having more overall moral distress experiences MORAL DISTRESS IN THE TIME OF COVID-19 33 than OT practitioners who had practiced from 11 to 20 years. Occupational therapy practitioners who practiced from 21 to 30 years had voiced the least number of responses regarding COVID's impact on their roles, how they dealt with intense emotions, and overall moral distress experiences. Co-occurrence of codes Researchers reviewed co-occurrence of codes to further understand how COVID-19 had impacted the participants in similar ways. One co-occurrence of codes was between intense emotions and feeling conflicted. Investigators coded participants statements as bridging both of these themes in 15 instances, suggesting a meaningful correlation. When participants began feeling conflicted in their roles and responsibilities, it would often result in intense emotions that could transfer into their professional and personal lives. In the codes, transcripts showed COVID-19 itself caused participants to feel conflicted about whether they were doing the right thing for their patients and families. Treating COVID-positive patients caused OT practitioners to fear bringing the virus home to their families. In turn, the conflicted feeling caused intense emotions in which participants identified what was happening both at home and in the workplace among patients and co-workers. In one co-occurrence of intense emotions and feeling conflicted, a participant stated: The one thing that I didnt mention in the interview, and to be honest I didnt mention it because I had one of the many experiences of this the day before, and it was too close and on my mind In the SNFs and ICUs, there were times that patients would ask me, Am I going to be okay? and sometimes I could answer honestly and say yes, you have made great progress. However, sometimes I would grab their hand and say yes, knowing that more than likely they would not survive the next 48-72 hours. (Red, 177-180) Discussion This study aimed to identify the experience of moral distress among OT practitioners since the onset of the COVID-19 pandemic, find out how OT practitioners had been managing MORAL DISTRESS IN THE TIME OF COVID-19 34 moral distress, and seek OT practitioners' recommendations for managing moral distress through a qualitative phenomenological study interviewing OT practitioners. Investigators found that moral distress had a significant impact on OT practitioners. Occupational therapy practitioners were impacted the most by fear of spreading COVID-19 to family, friends, co-workers, loved ones, and other patients. These findings were the results that the investigators expected. In addition, investigators found that OT practitioners who worked in acute care, the ICU, or skilled nursing facilities dealt with moral distress with more intensity than those in other practice areas based on code counts. Practitioners in these settings were also more prone to experience moral distress stemming from dealing with death/loss and PPE. Even though the COVID-19 experience was a trying time for individuals who worked in the health field, the differences that the researchers found between OT practitioners' years in practice and their responses can be seen as positive. These responses show newly graduated practitioners that things get better as time goes on with more experience. Investigators also found unexpected findings grouped into four themes. The COVID-19 pandemic exposed OT practitioners to unusual roles and sometimes conflicting roles. Occupational therapists are constantly advocating for this OT due to a lack of knowledge about the profession in the general public. The emergency situation of the COVID-19 pandemic only further affirmed the importance and need for OTs to better articulate the OT domain. Occupational therapys scope of practice is distinctly broad but does have limits. Although it is important to help wherever needed in a time of great distress, it is also equally important to make sure that patients are not getting lesser care or are not getting unethically billed because therapists are practicing outside their scope of practice. Another important finding from the study was the overall magnitude of the effects of COVID-19 on moral distress. While everyone in the world felt the impact of COVID-19, the MORAL DISTRESS IN THE TIME OF COVID-19 35 participants in this study articulated the excruciatingly overpowering and complex morally distressing issues that they navigated during this time. COVID-19 magnified moral distress because of the volume and complexity of the ethical and moral issues practitioners addressed all at one time; and it contributed to burnout, exhaustion, and emotions that sometimes drove practitioners from the OT field. While these findings have been observed anecdotally in OT and other professions (Cacchione, 2020; Dirette, 2020), few studies have reported on the direct impact of moral distress on the health professions during COVID (Smallwood et al., 2021). The COVID-19 pandemic also exposed the need for more moral distress interventions that address trauma in OT practitioners, in hopes to prevent burnout. OT practitioners felt the stress of the pandemic in many ways, but they didnt have the appropriate help, leading to them feeling burnout symptoms. Other authors have noted burnout and intense emotions (Kellish et al., 2021), employment complications, impact on therapeutic relationships and impact on the practitioners life rules (Smallwood et al., 2021) during the pandemic. Many of the participants of this study mentioned some type of trauma that COVID-19 caused, but few participants had access to professional help that helped them deal with the trauma. More in-depth research would be beneficial for OT practitioners, so there is a better understanding of how trauma contributes to burnout. One of the participants mentioned the need and usefulness of transparency for ones own mental and physical health. This transparency stems from a need in mental health as OT practitioners need to be able to humanely express their mental health status and needs to their employers, patients, family, friends, and themselves. As a holistic profession, it is imperative that the practitioners mental health is taken seriously in order to prevent burnout and high turnover rates. As stated before, burnout can lead to a lesser quality of care for clients (Penny et al., 2014). MORAL DISTRESS IN THE TIME OF COVID-19 36 Transparency with a client can also build more rapport in the therapeutic relationship, as trust can be built through sharing ones own experiences in life. It is also important that interdisciplinary healthcare practitioners advocate and support each other. It was demonstrated in the interviews that moral and social support could relieve anxious feelings and decrease burnout by asking for help from coworkers. Investigators expected to hear about the participants working outside of their scope of practice, as previous literature had discussed when occupational therapy practitioners had to operate outside of their scope of practice (Howard et al., 2020). However, when participants shared their experiences, it was unexpected that many OT practitioners were significantly involved in the death process, a new and impactful experience for OT practitioners. Moral distress has evolved through the COVID-19 pandemic. Previously, practitioners were experiencing moral distress with reimbursement, overall quality of care, and documentation discrepancies (Slater & Brandt, 2016; Penny et al., 2014). Recent research has looked into the impact COVID-19 has had on rehabilitation professionals and their experiences with moral distress due to the pandemic. Finding a place for occupational therapy practitioners to contribute during the beginning of the pandemic caused uncertainty within the scope of practice. As the pandemic progressed, moral distress experiences changed as the care guidelines became more unclear (Greenberg et al., 2020). In comparison with past literature, this study uses interviews with occupational therapists to further identify areas which need improvement. The literature correlated with the finding that it was important to allow for processing time for OT practitioners during the height of the pandemic (Roycroft et al., 2020). Research has also highlighted the importance of managing mental health throughout the pandemic (Greenberg et al., 2020). This was also a common theme MORAL DISTRESS IN THE TIME OF COVID-19 37 during the interviews as mental health was not prioritized during the height of the pandemic. Many of the participants in this study explained that there were very few coping strategies in place to allow them to process the current events. Researchers were able to gather valuable information from current research as well as the finding of this study to better understand the severity and impact COVID-19 has had not only on the occupational therapy profession, but healthcare as a whole. Clinical Implications The COVID-19 pandemic exposed the need for more moral distress interventions that address trauma in OT practitioners, in hopes to prevent burnout (Imbulana et al., 2021; Morley, Field, et al., 2021). Many of the participants of this study mentioned some type of psychological trauma that COVID-19 caused, but few participants had access to professional help that helped them deal with the trauma. Further research is indicated to understand the phenomena of trauma, burnout, and successful interventions to combat them in the unique roles that OT practitioners and other rehabilitation professionals occupy. Specifically, research is needed to address mental health in practitioners. It is also important that the interdisciplinary healthcare practitioners advocate and support each other. Participants in this study expressed that moral and social support relieved anxious feelings. Further investigation into how to build a structure of support into healthcare teams is needed (Berlinger et al., 2020; Roycroft et al., 2020; Smallwood et al., 2021). On the macro level, organizations, government agencies, and global systems need to have disaster and crisis management systems and standards in place to avoid confusion and mismanagement of resources when disasters strike (Leider et al., 2017). Occupational therapy practitioners need to be a part of the teams making decisions about crisis management systems and standards (AOTA, 2017; Howard et al., 2020). MORAL DISTRESS IN THE TIME OF COVID-19 38 Recent research has explored the impact COVID-19 has had on rehabilitation professionals and their experiences with moral distress due to the pandemic (Greenberg et al., 2020; Roycroft et al., 2020; Smallwood et al., 2021). Occupational therapy educators should address professional well-being and resilience in entry-level education as well as at the postgraduate level (Popova et al., 2022). Recommendations have included allowing time for practitioners to process their experiences (Roycroft et al., 2020) and managing mental health throughout the pandemic (Greenberg et al., 2020). These recommendations matched what participants stated they found helpful in their experiences. OT practitioners need to be mindful of the mental and emotional toll that comes with the profession, especially during crises like the COVID-19 pandemic (Roycroft et al., 2020). Professional mental health services may help reduce and prevent burnout (Kellish et al., 2021; Smallwood et al., 2021). Maintaining work-life balance and personal wellness activities are also warranted (Morley, Field, et al., 2021). Practitioners can be aware of resources pre-emptively to reference during times of uncertainty. These might include the AOTA Code of Ethics (AOTA, 2020a), OT Practice Framework (AOTA, 2020b), state or local laws pertaining to OT licensure, laws, rules, or policies pertaining to the setting in which the OT practitioner works. The Code of Ethics provides guidance on values and ethical principles to keep in mind (AOTA, 2020a) when making decisions during difficult times. Keeping these documents and organizational policies nearby will provide the practitioner with resources for addressing legal and ethical issues when they arise. Further, policies and procedures for managing crises must be put into place on the organizational and systemic level, thereby preventing moral distress by having the systems in place to assist with clinical decision making when resources are scarce (Berlinger et al., 2020; MORAL DISTRESS IN THE TIME OF COVID-19 39 Popova et al., 2022; Rivard and Brown, 2019). Rehabilitation services managers can work to build a culture in which speaking up is encouraged, not devalued (Popova et al., 2022). Education has been one effective intervention in combating moral distress (Morley, Field, et al., 2020). Education in advance of experiencing ethical problems may help to reduce moral distress, though current evidence is weak (Imbulana et al., 2021). Educators can develop curricula that facilitate speaking up when ethical tensions arise (Kinsella et al., 2008). Educators can provide current and future OT practitioners with the skills to self-advocate when ethical issues arise (Kinsella et al., 2008). Research Implications Currently, few research studies have addressed moral distress during the COVID-19 pandemic in occupational therapy or any other health care profession (Smallwood et al., 2021). Further research is needed to examine the impact of moral distress on OT practitioners and rehabilitation professionals, particularly during the COVID-19 pandemic. Smallwood et al. (2021) addressed moral distress in frontline health workers in Australia. Future investigators could focus on the differences in experiences of moral distress among various practice settings or in various geographic locations with differing health care systems. Investigators could also explore whether there are differences in experiences of moral distress during COVID between the health care professions within a setting type, or between OTs and OTAs. Since no OTAs responded to recruitment for this present study, future studies could explore recruitment methods that target this population, such as posting on social media sites specifically geared toward OTAs. Most importantly, research is needed to determine effective intervention approaches to combat moral distress among OT practitioners and rehabilitation professionals (Imbulana et al., 2021; Morley, Field, et al., 2021; Popova et al., 2022) and address the moral distress experienced MORAL DISTRESS IN THE TIME OF COVID-19 40 during COVID-19. Applying models of moral distress interventions established in nursing (Morley, Field, et al., 2021) to other health professionals may be beneficial in future studies. Strengths and Limitations As with any study, this study had strengths and limitations. One strength was that the investigators triangulated findings with member checking, which allowed the participants to review the results and determine if the results were indicative of their responses. Another strength was investigators were able to recruit participants from various settings, including acute care, the ICU, and skilled nursing facilities, which allowed investigators to gather data that was representative of the occupational therapy field. Lastly, multiple investigators completed code comparison and theme extraction for strengthening validity of the findings. One limitation was that the study contained a small sample size. Investigators attempted to mitigate the small sample size by stratifying by settings and geographical location. Another limitation was that there was a lack of demographic variability among the studys participants. Specifically, out of the eighteen participants, only one was male and two were non-white. No occupational therapy assistants (OTAs) responded to the call for participants; therefore, the perspectives of OTAs are not represented in this study. This study focused solely on the experiences of moral distress of OT practitioners and did not capture the similarities and/or differences between OT practitioners experiences and those of other health care practitioners during the COVID-19 pandemic. Lastly, a limitation of the study was self-selection bias as the participants willingly chose to participate in the study. Participants might have opted into this study due to experiencing moral distress at a higher prevalence compared to the general OT practitioner population. MORAL DISTRESS IN THE TIME OF COVID-19 41 Conclusion Moral distress has been a common occurrence in OT practice, and the COVID-19 pandemic has heightened experiences of moral distress among OT practitioners. The purpose of this study was to explore moral distress among OT practitioners during the time of COVID-19. Investigators examined experiences of moral distress, the effects of moral distress, and ways OTs managed moral distress during the COVID-19 pandemic. Recommendations for practice included highlighting awareness of moral distress and advocating for mental health support for practitioners. Research recommendations included studies for moral distress interventions with OT practitioners and other health care providers. The findings of this study can support OT practitioners efforts to acknowledge the unusual levels of moral distress during the COVID-19 pandemic and alleviate moral distress in practice. MORAL DISTRESS IN THE TIME OF COVID-19 42 References American Occupational Therapy Association. (2017). AOTAs societal statement on disaster response and risk reduction. American Journal of Occupational Therapy, 71(Suppl. 2), 7112410060. https://doi.org/10.5014/ajot.2017.716S11 American Occupational Therapy Association. (2020a). AOTA 2020 occupational therapy code of ethics. 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MORAL DISTRESS IN THE TIME OF COVID-19 48 Turale, S., Meechamnan, C. & Kunaviktikul, W. (2020). Challenging times: Ethics, nursing and the COVID19 pandemic. International Nursing Review, 67(2), 164 167 .https://doiorg.ezproxy.uindy.edu/10.1111/inr.12598 MORAL DISTRESS IN THE TIME OF COVID-19 49 Appendix A: Recruitment Paragraph Research Study: Moral Distress in the time of COVID-19: Occupational Therapy Practitioners Experiences Are you an occupational therapy practitioner? Have you been affected by COVID-19? Are you or have you experienced moral distress? If you answered yes to these questions, WE WOULD LOVE FOR YOU TO SHARE YOUR STORY WITH US! You may be eligible to participate in an IRB-approved research project that is designed to analyze occupational therapy practitioners' experience with moral distress during COVID-19. You will be asked to participate in a one-hour interview, a demographic questionnaire, and a 30minute follow-up interview if you would like. Participation is entirely voluntary and you may stop participating at any time. Possible harm may include experiencing distress when recounting events of the past year. Benefits include: helping future occupational therapy practitioners and other health care practitioners realize the repercussions that COVID-19 has caused on the world and the healthcare field. The results could also help indicate more effective ways to cope with and improve moral distress. MORAL DISTRESS IN THE TIME OF COVID-19 Appendix B: Informed Consent Document Informed Consent Document ICD IRB 50 MORAL DISTRESS IN THE TIME OF COVID-19 51 Appendix C: Interview Questions Moral distress is defined by Andrew Jameton (1984) as a situation when someone knows the right thing to do but is prevented from doing it due to systematic constraints. In other words, someone may feel constrained from doing what they believe is right due to outside factors, for example, organizational policies and rules. What, if anything, has been your experience of moral distress during the COVID-19 pandemic in your role as an OT practitioner? Building off this, on a scale of 0-5, 0 being no moral distress and 5 being extreme moral distress how would you rate your intensity of moral distress from March 2020 until now? What leads you to this score? How has Personal Protective Equipment impacted your moral distress? In what ways, if any, has the COVID-19 pandemic caused you to do things outside of your scope of practice? How have you managed your moral distress during COVID-19? In what ways, if at all, has moral distress in the time of COVID-19 differed from moral distress prior to the pandemic? In what ways has it been the same? In what ways, if any, did your employer advertise resources and/or offer assistance to combat moral distress? In what ways, if any, have you sought resources or assistance for combating moral distress outside of work or on your own as a result of the COVID-19 pandemic? How has the moral distress you have experienced as an OT practitioner during COVID19 transferred into other roles in your life, if at all? MORAL DISTRESS IN THE TIME OF COVID-19 52 If your current self could go back and say something to your March 2020 self, what would it be? What, if anything, have we learned about managing moral distress during this time that the occupational therapy profession should keep (or change) for the future? ...