Experience Of Moral Distress Research Articles

From moral distress to resilient ethical climate among general practitioners: Fostering awareness. A qualitative pilot study.

Moral distress in and ethical climate of health care institutions are highly intertwined subjects and have been linked to various quality of care indicators as well as job turnover intentions among health care professionals. Predominantly, both phenomena have been studied in intensive care, palliative and in-hospital settings. We aimed to explore the experience of moral distress by general practitioners (GPs), the role of ethical climate in GP moral distress and how ethical climate and moral distress can result in moral resilience in general practice. Between April and October 2021, we interviewed 13 doctors active in general practice in Flanders, Belgium, through semi-structured interviews. Data were processed and analysed using the Qualitative Analysis Guide of Leuven (QUAGOL). Most GPs had ample experience with morally distressing situations. Causes, determinants, and consequences do not differ significantly from other care settings. Moral distress can arise from conflicting views of good care, communication problems, and impending harm to third parties. We detected determinants of moral distress on micro-, meso- and macrolevels. GPs associate moral distress with job turnover and emotional, physical, existential, and quality of care effects. Several malleable factors can contribute to resilient ethical climates. This requires acquisition of vocabulary, skills, and knowledge. Moral distress and ethical climate are important emerging themes for GPs. This research identifies determinants and effects of moral distress and ethical climate in primary care and could help GPs leverage moral distress experiences into morally resilient primary care through multiple suggested strategies.

Nurturing moral community: A novel moral distress peer support navigator tool.

Moral distress is a pervasive phenomenon in healthcare for which there is no straightforward "solution." Rhetoric surrounding moral distress has shifted over time, with some scholars arguing that moral distress needs to be remedied, resolved, and eradicated, while others recognize that moral distress can have some positive value. The authors of this paper recognize that moral distress has value in its function as a warning sign, signaling the presence of an ethical issue related to patient care that requires deeper exploration, rather than evidencing identification of the "right" course of action. Once the experience of moral distress is identified, steps ought to be taken to clarify the moral issue, and, if possible and reasonable, the patient's values ought to be prioritized. This paper offers concrete actions steps, drawn from theory, which can be used in clinical practice to provide peer support or to facilitate self-reflection for morally distressed individuals. This approach empowers morally distressed individuals to explore ethical issues, identify concrete steps that can be taken, and mitigate feelings of powerlessness that are often associated with moral-constraint distress. The questions guide individuals and peers to reflect first on the micro-space and then more broadly on the institutional culture, facilitating meso- and macro-reflection and action.

Approved Mental Health Professionals’ Experiences of Moral Distress: ‘Who Are we For’?

Abstract In England and Wales, approved mental health professionals (AMHPs) undertake interviews with service users as part of wider Mental Health Act assessments. AMHPs act as the ultimate decision-maker in relation to statutory detentions. They have legal duties to consider the least restrictive outcomes for service users, including alternatives to hospital. Yet they are increasingly unable to act on this, resulting in conflicting pressures. This article draws on a qualitative research study incorporating ethnographic research and interviews with AMHPs. Evidence suggests that service restructures are creating different approaches to practice with contradictory priorities, for example, whether the work is values-driven and relational or whether approbation is attached to a ‘need for speed’. AMHPs are increasingly deliberating about what makes ‘proper’ or ‘good’ AMHP practice, asking ‘who are we for?’ and referring to their work as ‘political activity’. AMHPs’ sense-making and language are indicative of moral distress. Organisational politics may lead to the work being seen as a technical-rational endeavour, not a moral one, leading to dissonance. More broadly, AMHPs and service users are, together, bearing the brunt of austerity measures and there are increasing unmet needs. Overall, there is a need to establish an ideological, theoretical and political base for practice.

Moral distress in nurses in developing economies: an integrative literature review.

Moral distress has been extensively studied in developed economies; however, not much in terms of studies has been carried out in developing economies. To review the literature reporting the experience of moral distress in nurses in health care settings in developing economies. An integrative literataure review was used. Cumulative Index of Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online Cochrane and Psych INFO were searched to retrieve titles and abstracts of papers on the experience of moral distress in nurses in developing economies. Sixteen articles reporting the experience of moral distress in nurses in developing economies published between 1984 and March 2019 were used for the review. Analysis of the findings revealed seven themes, nurses' experience of moral distress, inadequate material and human resources, end-of-life challenges, cultural and religious beliefs as a source of moral distress, perceived inactions of medical and nursing staff, impact of moral distress on nurses in developing economies and coping strategies. There is paucity of empirical studies on moral distress in nurses in developing economies. More qualitative studies are needed in various cultural settings to enhance its understanding in nurses working in developing economies.

Reducing Moral Distress by Teaching Healthcare Providers the Concepts of Values Pluralism and Values Imposition.

AbstractThere is a clear need for interventions that reduce moral distress among healthcare providers (HCPs), given the high prevalence of moral distress and the far-ranging negative consequences it has for them. Healthcare ethics consultants are frequently called upon to manage moral distress, especially among nursing staff. Recently, researchers have both broadened the definition of moral distress and demarcated subcategories of the phenomenon with the intent of creating more targeted and effective interventions. One of the most frequently occurring subcategories of moral distress in this new taxonomy has been labeled "moral-constraint distress," though scholars have argued that not all constraints on HCPs' moral agency are inappropriate given the often-competing healthcare values of patients, families, and clinical staff. To attempt to reduce the instances of moral distress in cases in which the constraints on HCPs' moral agency are justified, we propose an intervention that focuses on shifting the HCPs' "frame of reference" on moral-constraint distress, teaching HCPs how to distinguish unjustified and justified constraints on their moral agency. The anchors of this blueprint for reducing moral-constraint distress are the philosophical concepts of "values pluralism" and "values imposition." The rationale for this intervention is that, in situations where the constraint on moral agency is justified but the experience of moral distress could nevertheless be severe, the emphasis needs to be on helping the HCP to "think differently" rather than "act differently."

Nurses' experiences of moral distress and how it affects daily work in surgical care-a qualitative study.

To describe nurses' and specialist nurses' experiences of moral distress and how it affects daily work in surgical care. A qualitative descriptive study design was used. A qualitative study with 12 interviews with nurses and specialist nurses working in surgical care. All interviews were conducted during October and November 2022 in two hospitals in southeastern Sweden. Data were analysed using conventional qualitative content analysis. Three categories and seven subcategories generated from the data analysis. The three categories generated from the analysis were Experiences that lead to moral distress, Perceived consequences of moral distress and Strategies in case of moral distress. The results show that a lack of personnel in combination with people with complex surgical needs is the main source of moral distress. Both high demands on nurses as individuals and the teamwork are factors that generate moral distress and can have severe consequences for the safety of patients, individual nurses and future care. The results show that moral distress is a problem for today's nurses and specialist nurses in surgical care. Action is necessary to prevent nurses from leaving surgical care. Prioritizing tasks is perceived as challenging for the profession, and moral distress can pose a patient safety risk. Surgical care departments should design support structures for nurses, give nurses an authentic voice to express ethical concerns and allow them to practice surgical nursing in a way that does not violate their core professional values. Healthcare organizations should take this seriously and work strategically to make the nursing profession more attractive. There was no patient or public contribution.

An Intersectional Analysis of Moral Distress and Intention to Leave Employment Among Long-Term Care Providers in British Columbia.

Objectives: In this study, we aimed to explore the relationship between intersectional inequities and moral distress among those working in Long-Term Care (LTC) in British Columbia, Canada. Methods: This was a cross-sectional and retrospective study. We assessed moral distress, of 1678 respondents, using a modified Moral Distress Scale, and an equivalent distress mitigation score, at the intersections of gender and racial/ethnic identity. Then, we explored which worker attributes were more predictive of intention to leave work. Results: We found notable difference in experiences of moral distress across intersecting identities, including high moral distress scores among Indigenous men and women, and white women. Significant differences in mitigation scores were also found by intersectional identities. Discussion: Moral distress was the most important predictor of intention to leave work. The differences across racial and gender identity groups suggest the need for tailored interventions to address moral distress among LTC providers.

Canadian respiratory therapists who considered leaving their clinical position experienced elevated moral distress and adverse psychological and functional outcomes during the COVID-19 pandemic.

Respiratory therapists (RTs) faced morally distressing situations throughout the COVID-19 pandemic, including working with limited resources and facilitating video calls for families of dying patients. Moral distress is associated with a host of adverse psychological and functional outcomes (e.g. depression, anxiety, symptoms of posttraumatic stress disorder [PTSD] and functional impairment) and consideration of position departure. The purpose of this study was to understand the impact of moral distress and its associated psychological and functional outcomes on consideration to leave a clinical position among Canadian RTs during the COVID-19 pandemic. Canadian RTs (N = 213) completed an online survey between February and June 2021. Basic demographic information (e.g. age, sex, gender) and psychometrically validated measures of moral distress, depression, anxiety, stress, PTSD, dissociation, functional impairment, resilience and adverse childhood experiences were collected. One in four RTs reported considering leaving their position. RTs considering leaving reported elevated levels of moral distress and adverse psychological and functional outcomes compared to RTs not considering leaving. Over half (54.5%) of those considering leaving scored above the cut-off for potential diagnosis of PTSD. Previous consideration to leave a position and having left a position in the past each significantly increased the odds of currently considering leaving, along with system-related moral distress and symptoms of PTSD, but the contribution of these latter factors was small. Canadian RTs considering leaving their position reported elevated levels of distress and adverse psychological and functional outcomes, yet these individual-level factors appear unlikely to be the primary factors underlying RTs' consideration to leave, because their effects were small. Further research is required to identify broader, organizational factors that may contribute to consideration of position departure among Canadian RTs.

The advocacy process in Canadian community health nursing: A collaborative ethnography.

To shed light on the process of advocacy in the context of community health nursing, through a methodology inspired by the epistemologies of the South. We conducted a collaborative ethnography in a community health centre in Canada. de Sousa Santos' epistemologies of the South, a typology of advocacy and main themes from historic research informed the methodology. Data were collected between 2016 and 2018 through 420 h of fieldwork observations and three group discussions, including a collective process to co-construct interpretations with participants. Twenty-one nurses participated in the study. Nurses had sufficient work flexibility to practice advocacy actions focused on individuals and groups. They also engaged in attempts at policy reform in the form of defending access to appropriate care and changing the mode of care organization. However, these were curbed by bureaucracy and administrative rules, resulting in the eventual dismissal of health promotion actions and experiences of moral distress. Despite the political climate of their work environment impeding social justice agendas, nurses' advocacy practices showed a persistence of moral values and ideals in coherence with the regional nursing legacy. Acting at the organizational level and involving field nurses in decision making are potential avenues for increasing policy advocacy efficacy. Examining contexts through another epistemic lens and methods of research drawing on history and anthropology has shed light on a process of advocacy. This research shows that organizations need to equip themselves with mechanisms to promote the sharing of realities between nurses, thereby building collective advocacy. The research adheres to the EQUATOR guidelines with SRQR and COREQ methods. No patient or public contribution.

Moral distress thermometer: Swedish translation, cultural adaptation and validation.

Moral distress is a problem and negative experience among health-care professionals. Various instruments have been developed to measure the level and underlying reasons for experienced moral distress. The moral distress thermometer (MDT) is a single-tool instrument to capture the level of moral distress experienced in real-time. The aim of this study was to translate the MDT and adapt it to the Swedish cultural context. The first part of this study concerns the translation of MDT to the Swedish context, and the second part the psychometric testing of the Swedish version. 89 healthcare professionals working at a hospital in northern Sweden participated. Convergent validity was tested between MDT and Measure of Moral Distress-Healthcare Professionals (MMD-HP), and construct validity was tested by comparing MDT scores among healthcare professionals. MDT was compared with responses to the final questions in MMD-HP. One-way ANOVA, Welch's ANOVA, Games-Howell post-hoc test and Pearson's correlation analysis were done. The study was approved by the Swedish Ethics Review Authority (dnr 2020-04120) in accordance with Helsinki Declaration. The translated Swedish version of MDT was described as relevant to capture the experience of moral distress. The mean value for MDT was 2.26, with a median of 2 and a mode value of 0. The result showed moderate correlations between the MDT and MMD-HP total scores. There was a significant difference when comparing MDT and healthcare professionals who had never considered leaving their present position with those who had left and those who had considered leaving but had not done so, with the latter assessing significantly higher moral distress. The MDT is an easily available instrument useful as an extension to MMD-HP to measure the real-time experience of moral distress among healthcare professionals in a Swedish context.

A survey of pediatric intensive care unit clinician experience with restricted family presence during COVID-19

PurposeLimiting family presence runs counter to the family-centred values of Canadian pediatric intensive care units (PICUs). This study explores how implementing and enforcing COVID-19-related restricted family presence (RFP) policies impacted PICU clinicians nationally.MethodsWe conducted a cross-sectional, online, self-administered survey of Canadian PICU clinicians to assess experience and opinions of restrictions, moral distress (Moral Distress Thermometer, range 0–10), and mental health impacts (Impact of Event Scale [IES], range 0–75 and attributable stress [five-point Likert scale]). For analysis, we used descriptive statistics, multivariate regression modelling, and a general inductive approach for free text.ResultsRepresenting 17/19 Canadian PICUs, 368 of 388 respondents (94%) experienced RFP policies and were predominantly female (333/368, 91%), English speaking (338/368, 92%), and nurses (240/368, 65%). The mean (standard deviation [SD]) reported moral distress score was 4.5 (2.4) and was associated with perceived differential impact on families. The mean (SD) total IES score was 29.7 (10.5), suggesting moderate traumatic stress with 56% (176/317) reporting increased/significantly increased stress from restrictions related to separating families, denying access, and concern for family impacts. Incongruence between RFP policies/practices and PICU values was perceived by 66% of respondents (217/330). Most respondents (235/330, 71%) felt their opinions were not valued when implementing policies. Though respondents perceived that restrictions were implemented for the benefit of clinicians (252/332, 76%) and to protect families (236/315, 75%), 57% (188/332) disagreed that their RFP experience was mainly positive.ConclusionPediatric intensive care unit-based RFP rules, largely designed and implemented without bedside clinician input, caused increased psychological burden for clinicians, characterized as moderate moral distress and trauma triggered by perceived impacts on families.

A qualitative study of school nurses' moral distress related to COVID-19.

To understand school nurses' perceptions and experiences of moral distress related to COVID-19 case management in the school systems. A descriptive qualitative study guided by Braun and Clarke's reflexive thematic analysis. Twelve school nurses practicing in Colorado from December 2021 to January 2022. Semi-structured interviews about school nurses' experiences of COVID-19. Investigators utilized an iterative reflexive thematic analysis process engaging the participants' and researchers' subjective experiences. Four themes were created: (1) keeping kids and the community safe, (2) caught in the middle of the "tug of war" between health and politics, (3) distress amid an ocean of COVID-19 uncertainty, and (4) visibility as a bright spot shining through the COVID-19 cloud. Two research questions examined school nurses' experiences of moral distress and their role and scope of practice that affected their relationships in the educational and public health systems. The results of this study confirm the important role of school nurses and interprofessional case management in school environments in the fight against infectious diseases and pandemics. Building stronger relationships between school nurses and public health is imperative for future collaborative and cohesive public health responses to pandemics.

Moral distress and positive experiences of ICU staff during the COVID-19 pandemic: lessons learned

BackgroundThe COVID-19 pandemic causes moral challenges and moral distress for healthcare professionals and, due to an increased work load, reduces time and opportunities for clinical ethics support services. Nevertheless, healthcare professionals could also identify essential elements to maintain or change in the future, as moral distress and moral challenges can indicate opportunities to strengthen moral resilience of healthcare professionals and organisations.This study describes 1) the experienced moral distress, challenges and ethical climate concerning end-of-life care of Intensive Care Unit staff during the first wave of the COVID-19 pandemic and 2) their positive experiences and lessons learned, which function as directions for future forms of ethics support.MethodsA cross-sectional survey combining quantitative and qualitative elements was sent to all healthcare professionals who worked at the Intensive Care Unit of the Amsterdam UMC - Location AMC during the first wave of the COVID-19 pandemic. The survey consisted of 36 items about moral distress (concerning quality of care and emotional stress), team cooperation, ethical climate and (ways of dealing with) end-of-life decisions, and two open questions about positive experiences and suggestions for work improvement.ResultsAll 178 respondents (response rate: 25–32%) showed signs of moral distress, and experienced moral dilemmas in end-of-life decisions, whereas they experienced a relatively positive ethical climate. Nurses scored significantly higher than physicians on most items. Positive experiences were mostly related to ‘team cooperation’, ‘team solidarity’ and ‘work ethic’. Lessons learned were mostly related to ‘quality of care’ and ‘professional qualities’.ConclusionsDespite the crisis, positive experiences related to ethical climate, team members and overall work ethic were reported by Intensive Care Unit staff and quality and organisation of care lessons were learned. Ethics support services can be tailored to reflect on morally challenging situations, restore moral resilience, create space for self-care and strengthen team spirit. This can improve healthcare professionals’ dealing of inherent moral challenges and moral distress in order to strengthen both individual and organisational moral resilience.Trial registrationThe trial was registered on The Netherlands Trial Register, number NL9177.

Turning Rage Into Action: Abortion Care and Residency Training in the United States.

Turning Rage Into Action: Abortion Care and Residency Training in the United States.

Impact of the COVID‐19 pandemic on moral distress of care home staff caring for people with dementia

AbstractBackgroundHealthcare providers caring for people living with dementia may experience moral distress when faced with an ethically challenging situation, such as an inability to provide care that is consistent with their values. The COVID‐19 pandemic both created new and exacerbated pre‐existing factors which contributed to the experience of moral distress amongst healthcare providers in LTCHs.MethodWe conducted an online survey to examine changes in mortal distress during the first wave of the pandemic, its contributing factors and correlates, and its impact on the well‐being of LTCH staff. A total of 227 health care providers from LTCHs across Ontario, Canada completed the online survey. Using a Bayesian approach, we examined the associations between moral distress and staff demographics and roles, and characteristics of the LTCH in which they worked.ResultMore than 80% of LTCH healthcare providers working with people with dementia reported an increase in moral distress since the start of the pandemic. They frequently experienced physical and emotional symptoms related to moral distress more than once a week, with the most common symptoms being physical exhaustion (55%) powerlessness (39%), sadness/anxiety (38%) frustration/anger (31%), and difficulty sleeping (33%). There was no difference in the severity of distress by age, sex, role, or years of experience. The most common situations associated with moral distress were lack of activities and family visits, insufficient staffing and high turnover, and having to follow policies and procedures that were perceived to harm residents with dementia. Respondents working in not‐for‐profit or municipal homes reported less sadness/anxiety and feelings of not wanting to go to work than those in for‐profit homes. Front‐line staff were more likely to report not wanting to work than those in management or administrative positions. In the survey’s free‐text responses, respondents elaborated on the emotional impact of the change in care delivery for LTCH residents.ConclusionMoral distress increased during the pandemic, negatively affecting the well‐being of healthcare providers in LTCHs, with preliminary evidence suggesting that individual and systemic factors may intensify this negative effect.

Psychometric testing of the Swedish version of the measure of moral distress for healthcare professionals (MMD-HP)

BackgroundMoral distress has been described as moral constraints and uncertainty connected with guilty feelings of being unable to give care in accordance with one’s values for good care. Various instruments to measure moral distress have been developed. The instrument measure of moral distress for healthcare professionals (MMD-HP) was developed to capture the experience and frequency of moral distress among various healthcare professionals. The MMD-HP has been translated and culturally adapted into the Swedish language and context; however, the translation has not been validated. Therefore, this study aimed to evaluate the validity and reliability of the Swedish version of the measure of moral distress for healthcare professionals (MMD-HP).MethodsEighty-nine staff from various professions at a hospital in northern Sweden participated in the study. A confirmatory factor analysis was performed to check for consistency with the original version of the MMD-HP. To evaluate internal consistency, Cronbach’s alpha was calculated for each domain and for the scale as a whole.ResultsThe scale as a whole showed a Cronbach’s alpha of 0.96, with a range between 0.84 and 0.90 between the different subscales. A confirmatory factor analysis based on the original four-factor structure showed good fit indices with a χ2/df of 0.67, CFI at 1.00, TLI at 1.02 and NFI at 0.97. RMSEA was at 0.00, and SRMR was at 0.08. A comparison of the total score between three equally large groups of years of experience at the present workplace showed no significant differences (F = 0.09, df = 2, p = 0.912).ConclusionsWe found that the Swedish version of the MMD-HP has shown validity and reliability for use in a Swedish context for measuring moral distress among health personnel.

Psychiatric nurses' experience of moral distress: Its relationship with empowerment and coping.

Research has shown that moral distress negatively impacts nurses, patients, and organizations; however, several scholars have argued that it can be an opportunity for positive outcomes. Thus, factors that may mitigate moral distress and catalyze positive change need to be explored. The purpose of this study was to explore the relationships among structural and psychological empowerment, psychiatric staff nurses' experience of moral distress, and strategies for coping with moral distress. A descriptive cross-sectional correlational study. A total of 180 registered nurses working in psychiatric hospitals in Japan participated. This study examined relationships among key variables using four questionnaires to assess structural and psychological empowerment, moral distress for psychiatric nurses, and coping strategies. Statistical analyses of correlations and multiple regressions were conducted. The study was approved by the institutional review board at the author's affiliated university. Psychiatric nurses perceived moderate levels of structural and psychological empowerment, and their experiences of moral distress were related to low staffing. Structural empowerment was negatively related to the frequency of moral distress but not the intensity. Contrary to expectations, psychological empowerment was not found to mitigate nurses' moral distress. Multivariate regression analyses revealed that the significant predictors of moral distress were the leaving issues unresolved coping style, the problem-solving coping style, and a lack of formal power, which explained 35% and 22% of the variance in the frequency and intensity of moral distress, respectively. In psychiatric hospitals in Japan, nurses experience moral distress that compromises the quality of care they provide. Therefore, formal support for nurses in voicing and investigating their moral concerns is required to bestow formal power by establishing a ward culture that includes shared governance.

Exploring experiences of moral injury and distress among health care workers during the Covid-19 pandemic.

Health care workers have been exposed to a variety of practical and emotional challenges because of the Covid-19 pandemic, leaving them vulnerable to experiencing moral injury and distress. However, there is currently sparse research which directly explores such experiences. This study aimed to explore and characterise the experiences and impacts of moral injury and distress among health care workers during the pandemic. Twenty semi-structured interviews were conducted with health care workers employed across both mental and physical health care services. Interviews were analysed from a critical realist perspective using thematic analysis. Three key themes were identified: attitudes towards moral injury, experiences of moral injury and consequences of moral injury. Participants appeared to identify with the idea of acting against their morals to varying extents based on their job roles. Participants experienced a range of potentially morally injurious and distressing events throughout the pandemic and many ultimately felt that they provided sub-standard levels of care due to extreme pressures on services. Detrimental impacts upon wellbeing were commonly reported, including high levels of emotional distress and feelings of guilt and shame. Some reported a loss of enthusiasm for their job and a desire to leave the profession entirely. Moral injury and distress presents a real concern for staff wellbeing and retention within the profession. During and beyond the Covid-19 pandemic, there is an urgent need for health care providers to implement wider strategies to target moral injury and distress, and support staff within health care settings.

Moral distress and ethical climate in pediatric oncology care impact healthcare professionals' intentions to leave.

To assess perceptions of ethical climate, experiences of moral distress, and intentions to leave among healthcare professionals in Nordic pediatric oncology care. A cross-sectional survey with registered nurses, physicians, and nursing assistants at 20 Nordic pediatric cancer centers. Data were collected by using translated versions of the Swedish Hospital Ethical Climate Survey-Shortened and the Swedish Moral Distress Scale-Revised. Descriptive analyses and non-parametric tests were used to describe, summarize, and compare data. According to 543 healthcare professionals (response rate 58%), the ethical climate in Nordic pediatric oncology care was positive. Inadequate staffing levels, poor continuity and lack of time were the most common causes of moral distress. Registered nurses experienced significantly higher levels of moral distress compared to physicians and nursing assistants. About 6% of the respondents considered leaving due to moral distress. Typically, they assessed the ethical climate as less positive and reported higher levels of moral distress than those who had no intention to leave. Organizational actions that ensure safe staffing levels and improve the continuity of care are needed to prevent moral distress and high staff turnover.

The paradox of the impact of the COVID-19 pandemic on massage therapists in Australia and Canada: The reporting of a qualitative strand of a mixed methods study

IntroductionIn both Australia and Canada, healthcare providers considered essential were allowed to operate during the COVID-19 pandemic. The impact of the global pandemic on professional identity included opportunities for role expansion, a focus on ethical principles and social accountability, and professional pride. These results were found only for those considered to be essential and do not likely resonate with those classified as non-essential, such as massage therapists, leaving a gap in understanding. Materials and methodsThis qualitative strand of a sequential explanatory mixed methods study used qualitative description. Individuals who expressed interest were purposefully selected, based on age, gender, type of practice, and experience with the four key phenomena of interest. Data collected through semi-structured interviews was analyzed using qualitative content analysis. Member checking enhanced the trustworthiness of the results. ResultsThirty-one (16 Australian and 15 Canadian) participants were interviewed. The main theme described was the pandemic paradox. At some point during the pandemic, most participants were labelled by government agencies as a non-essential service. However, participants reported feeling both essential and non-essential. Two subthemes were also described: factors contributing to creating the paradox and consequences of the paradox. ConclusionA number of pre-existing factors around professional identity, such as patient relationships combined with the conditions instituted to manage the COVID-19 pandemic included designating health care services as essential or non-essential, created the paradox experienced by respondents and the subsequent experience of moral distress. Further research into moral distress experienced by massage therapists is needed.