Moral Distress Among Oncology Social Workers

Background and Purpose: As the primary providers of mental health services to people receiving cancer treatment, oncology social workers (OSWs) are an integral part of comprehensive cancer care. In the process of providing supportive services within complex organizational health care systems, OSWs face challenging situations that may trigger moral distress (MD) -- a phenomenon that occurs “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.” Literature on MD among OSW remains sparse. The aims of the current study were to 1) examine the prevalence of MD and its domains of influence among OSWs and 2) identify demographic and work-related characteristics associated with MD.

Methods: Data were derived from a nationwide survey of the OSW workforce across a variety of cancer care settings, conducted August–September 2020 (during the COVID-19 pandemic). Demographic and work-related characteristics, including job title, work setting, and years of experience were obtained. MD was measured using the Measure of Moral Distress for Healthcare Professionals (MMD-HP). Measured by two five-point Likert scales, a total MD score and four subscale scores are derived as a function of (1) the frequency in which subjects observe 27 conditions across four distinct domains (i.e., organizational structure or system; patient/family experience; as perceived threats to team members; and among team interactions) and (2) psychological distress experienced from observing each condition. Tests of association and multivariate linear regression were conducted to achieve the study aims.

Results: 745 OSWs completed the survey. The three highest item mean scores for MD all related to the patient/family experience domain. For examples, the highest levels of MD were observed when OSWs “Follow the family’s insistence to continue aggressive treatment even though I believe it is not in the best interest of the patient” (5.89), and “Witness health care providers giving ‘false hope’ to a patient or family” (5.35). Higher levels of moral distress were associated with younger age, being a direct service provider, provision of inpatient cancer care, and more years in the profession.

Conclusions and Implications: OSWs in direct service positions were most likely to report MD as a function of their interactions with patients and families; those in clinical supervision/management positions were more likely to report MD in the health system/organizational domain. The seemingly counter-intuitive finding that MD decreases with age but increases with years in the profession suggests that younger OSWs may be limited in their ability to manage emotional responses to relatively fewer observations of MD when compared to older OSWs, whereas more experienced OSWs are perhaps more affected by an accumulation of observations over time. The highest levels of MD occurred amongst OSWs working in inpatient settings, suggesting that there may be distinct aspects of in-patient care that increase MD risks. Although our study specifically focused on cancer care, MD may be experienced in diverse health care settings. Findings serve as justification for on-going professional education, clinical supervision, and support throughout one’s career in health social work.