Moral distress in physicians: New study measures prevalence, offers interventions

Almost two in five physicians suffered moral distress in the two weeks leading up to their being asked about it by researchers. That was a markedly larger slice than the team observed in the general U.S. working population. 

Lead author Michael Tutty, PhD, MHA, of the American Medical Association and colleagues note that moral distress is distinct from burnout, but the two conditions often strike simultaneously and probably feed each other.

Where the symptoms of workplace burnout are well-known and thus readily recognizable—exhaustion, cynicism, irritability—signs of moral distress can go unnoticed by the stricken as well as their fellow workers. 

For that reason, Tutty and co-authors suggest, interventions are needed at both the organization and system level to address the underlying factors that contribute to moral distress as well as occupational burnout in the U.S. physician workforce.

JAMA Network Open published Tutty et al.’s study March 24. 

Moral distress defined and differentiated 

The American Medical Association has defined moral distress in medicine as the negative emotional response and psychological distress that occurs when clinicians know the ethically correct action to take but feel powerless to act on it due to internal or external constraints. 

The feeling arises from “a conflict between one’s deeply held values and institutional constraints,” AMA adds, “leading to a sense of compromised integrity.”

To gauge presence and severity of condition for the present study, the investigators analyzed survey responses using the Moral Distress Thermometer and the Maslach Burnout Inventory. 

The survey drew completed responses from around 5,700 physicians and 3,500 nonphysician workers.

Primary findings bring the problem into focus 

Moral Distress Thermometer scores may range from 0 to 10. Any score higher than four is considered high. 

Tutty and colleagues found the mean moral distress score for physicians was 3.29, with 2,243 (39.1% of physician respondents) reporting a high level of moral distress.  

They also noted that women physicians and physicians working more hours per week had higher odds of moral distress, while those who were older or married had lower odds.

Other findings of note: 

• Compared with internal medicine subspecialists, emergency medicine physicians and general internal medicine physicians were more likely to report high levels of moral distress. 
   
• Mean emotional exhaustion and depersonalization scores, as well as the proportion of physicians with burnout, were higher with each 1-point increase in moral distress score. 
   
• Some 1,068 of 3,477 physicians (30.7%) with a moral distress score less than 4 had burnout symptoms compared with 1,675 of 2,231 physicians (75.1%) with scores of 4 or more. 
   
• The prevalence of “intent to leave” and “intent to reduce work hours” indications was higher for each 1-point increase in moral distress score. For example, the authors explain, 619 of 3,404 physicians (18.2%) with low moral distress reported intent to leave within 24 months compared with 748 of 2,171 (34.5%) among those with high moral distress. 
   
• Compared with other U.S. workers, physicians had markedly higher odds of experiencing moral distress.

Preventing powerlessness 

In their discussion, the researchers underscore that, in the present study, moral distress was associated with numerous troubles in need of attention. 

These included higher levels of burnout, lower levels of professional fulfillment and increased odds of intent to quit work or cut hours. 

They cite prior research showing that moral distress can lead to feelings of anger, frustration, depression and guilt, “aligning with an overall sense of powerlessness within physicians.”

Recognizing the distinction between moral distress and burnout is “essential for developing targeted organizational interventions,” Tutty and co-authors comment. “While some interventions may address both moral distress and burnout, other interventions may target one more effectively than the other.”

Promoting a ‘thoughtful, professional response’  

Addressing structural barriers such as those created by employers, health systems or payers—especially those that prevent physicians from acting in accordance with their ethical values—may help mitigate moral distress and indirectly improve burnout, the researchers add. 

More: 

“Organizational efforts to reduce moral distress should prioritize open communication and systematic approaches that align patient care, especially around patient preferences and team consensus, helping to avoid care that is perceived as futile. … Encouraging the recognition and normalization of conflicting emotions supports self-awareness and promotes a thoughtful, professional response to challenging situations.” 

The study is posted in full for free.