Moral distress common among providers in safety net clinics during pandemic

Key takeaways

• Overall, 71.6% of primary care, dental and behavioral health providers who were surveyed reported some level of moral distress.
• Providers said they often felt morally distressed because they were unable to provide optimal care to patients.
• Nearly 27% of providers said that distress was “intense” or at the “worst possible” levels.

In safety net clinics, most clinicians who were surveyed said they felt morally distressed during the COVID-19 pandemic due to difficult work situations, watching their patients struggle and limits on the care they could provide, data show.

“Most people receive their health care in office settings, and many clinicians working there experienced moral distress from how the pandemic limited the care they could provide to patients and from witnessing the pandemic’s effects on patients and coworkers,” Donald E. Pathman, MD, MPH, a professor in the department of family medicine at the University of North Carolina School of Medicine, said in a university press release.

Moral distress, which was defined by Pathman and colleagues as “the psychological unease or distress that occurs when one witnesses, does things or fails to do things that contradict deeply held moral and ethical beliefs and expectations,” can contribute to burnout, an ongoing issue in primary care.

Similar to clinicians who were based in hospitals during the pandemic, the providers in this study “were often morally distressed by being unable to provide optimal care to patients,” the researchers wrote. Although previous research has already demonstrated moral distress among providers, the researchers wrote that “clinicians' moral distress from witnessing inequities and other injustices for their patients and communities” is “new to the literature.”

To better understand the pandemic’s impact on clinicians, the researchers studied data from 2,073 primary care, behavioral health and dental providers who work in safety net clinics, providing care to “poor and often racial-ethnic minority patients who face barriers to receiving care” across the country. They published their analysis in BMJ Open.

The researchers found that about 72% of providers reported some level of moral distress. Though the number is high, Pathman said in the release that the findings are understandable.

“Given the type of individual who chooses to provide health care in low-income communities, it is not surprising that some would be morally distressed watching the pandemic worsen the health and lives of their patients because of their limited resources,” he said.

Nearly 27% of survey respondents reported distress that was “intense” or at the “worst possible” levels, 44.8% said they felt mild or uncomfortable levels of distress and 28.4% of the participants said they felt no moral distress. A common thread among those who were more likely to report higher levels of moral distress was witnessing abuse of staff and instances of inequities for patients and communities.

The most frequently reported morally distressing issues included risking infection in the office and being unable to provide patients with the best or needed care, according to Pathman and colleagues.

A second issue was clinic staff abuse. A dentist from Arizona wrote that “all our manager and director seem to care about is making money and how many patients we see,” adding that “I was having to balance being exposed to so many patients then going home to my family and potentially exposing them.”

Another issue was patient and staff suffering. One nurse practitioner in North Carolina said they felt “powerless make meaningful change,” and a licensed social worker in Oregon said they felt “helpless.”

Many providers also reported inequities among patients as a contributing factor to moral distress. A physician in California noted that they were diagnosing patients who were experiencing homelessness with COVID-19, but unable to “provide them with a safe place to isolate/recover.”

Politics was another recurring issue. A dentist from Nebraska wrote that “the politicization of science and mask wearing has been very upsetting as it has put my life and my family’s life at risk.” Compared with primary care physicians or behavioral health professionals, dental clinicians “more often reported issues related to risking infecting patients and clinic staff” (17% vs. 35.1%, respectively; P = 0.005), the researchers wrote.

Injustices within the community also led to moral distress among providers. Notably, when the participants described the issues that caused moral distress, they most often pointed the finger at themselves.

“In most cases, these were situations where clinicians felt they had not provided needed care or had provided suboptimal care to patients because of the exigencies of the pandemic or the requirements of their practices,” the researchers wrote.

The clinicians identified themselves as responsible in 31% of issues mentioned, followed by clinics or organizations at 15%, and government or society at 14%. Patients, the public and clinic staff or administrators were all identified in 3% of issues. There was no responsible party identified in about one-third of the issues.

“Many comments that did not identify a responsible party spoke of situations that were widely known to occur during the pandemic and have been frequently highlighted in the lay press, for example, ‘patient dying alone;’ ‘watching outbreaks unfold in nursing homes,’” Pathman and colleagues wrote.

To reduce moral distress, the researchers wrote that “managers of outpatient practices should understand what moral distress means for clinicians and its importance to them, create supportive work environments, create ways for clinicians and staff to learn and talk about moral distress and safely raise morally distressing issues, identify and address any ongoing sources of moral distress, and provide clinicians with needed psychological support and time away from work.”

“Clinicians should be involved in operational decisions made during challenging times — indeed, all times — so that decisions can be informed by their perspectives and clinicians can better understand the choices available to their practices and reasoning behind the decisions made that affect them, their colleagues and their patients,” they concluded.

References:

• Majority of clinicians in U.S. safety net practices report ‘moral distress’ during COVID-19 pandemic. https://news.unchealthcare.org/2022/08/majority-of-clinicians-in-u-s-safety-net-practices-report-moral-distress-during-covid-19-pandemic/. Published Aug. 26, 2022. Accessed Sept. 7, 2022.
• Pathman DE, et al. BMJ Open. 2022;doi:10.1136/bmjopen-2022-061369.