Skip to main content
SpringerLink
Log in

The Experience of Moral Distress in an Academic Family Medicine Clinic

  • Published:
HEC Forum Aims and scope Submit manuscript

Abstract

Background and Objectives

Primary care providers (PCPs) report decreased job satisfaction and high levels of burnout, yet little is known about their experience of moral distress. The aim of this study was to gain insight into the experiences of PCPs regarding moral distress including causative factors and proposed mitigation strategies.

Methods

This qualitative pilot study used semi-structured interviews to identify causes of moral distress in PCPs in an academic family medicine department. Interviews were analyzed using conventional content analysis.

Results

Of 35 eligible participants, 12 completed the study (34% participation rate). Most were white, female, and had practiced for less than 10 years. Four PCPs had considered leaving their position due to moral distress. Participants identified five causes of moral distress: policies and procedures that conflict with patient needs, the unpredictable nature of primary care, need to “bend the rules,” lack of accountability, and lack of support staff. Six internal conflicts made resolving morally distressing situations difficult: perceived powerlessness, sense of responsibility, socialization to follow orders, emotional toll of the job, competing obligations, and fear of mistakes.

Conclusions

These findings matched themes in the current literature and identified an unbending infrastructure. This, coupled with the chaotic nature of primary care, resulted in frequent moral distress. Participants offered solutions to reduce and mitigate moral distress (also similar with current literature) and suggested moral distress and burnout are closely linked.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Data Availability

The data that support the findings of this study are available on reasonable request from the corresponding author DB. The data are not publicly available due to them containing information that could compromise research participant privacy/consent.

References

  • Association of American Medical Colleges. (2020). The complexities of physician supply and demand: Projections from 2018–2033. Washington, D.C.: Association of American Medical Colleges. 

    Google Scholar 

  • Abbo, E. D., Zhang, Q., Zelder, M., & Huang, E. S. (2008). The increasing number of clinical items addressed during the time of adult primary care visits. Journal of General Internal Medicine, 23(12), 2058–2065.

    Article  Google Scholar 

  • Agarwal, S., Pabo, E., Rozenblum, R., & Sherritt, K. M. (2020). Professional dissonance and burnout in primary care: A qualitative study. JAMA Internal Medicine, 180(3), 395–401.

    Article  Google Scholar 

  • Allen, R., Judkins-Cohn, T., DeVelasco, R., Forges, E., Lee, R., Clark, L., & Procunier, M. (2013). Moral distress among healthcare professionals at a health system. JONA’S Healthcare Law, Ethics and Regulation, 15(3), 111–118.

    Article  Google Scholar 

  • Aultman, J., & Wurzel, R. (2014). Recognizing and alleviating moral distress among obstetrics and gynecology residents. Journal of Graduate Medical Education, 6(3), 457–462.

    Article  Google Scholar 

  • Barina, R. (2014). Ethics outside of inpatient care: The need for alliances between clinical and organizational ethics. HEC Forum, 26(4), 309–323.

    Article  Google Scholar 

  • Brody, H. (1986). Ethics in primary care: Setting aside common misunderstandings. Primary Care, 13(2), 225–240.

    Article  Google Scholar 

  • Butz, A. M., Redman, B. K., Fry, S. T., & Kolodner, K. (1998). Ethical conflicts experienced by certified pediatric nurse practitioners in ambulatory settings. The Journal of Pediatric Health Care, 12(4), 183–190.

    Article  Google Scholar 

  • Ceci, C. (2004). Nursing, knowledge, and power: A case analysis. Social Science & Medicine, 59(9), 1879–1889.

    Article  Google Scholar 

  • Chambliss, D. (1996). Beyond caring: Hospitals, nurses, and the social organization of ethics. Chicago: University of Chicago Press.

    Book  Google Scholar 

  • Corley, M. (1995). Moral distress of critical care nurses. American Journal of Critical Care, 4(4), 280–285.

    Article  Google Scholar 

  • Corley, M., Elswick, R., Gorman, M., & Clor, T. (2001). Development of a moral distress scale. Journal of Advanced Nursing, 33(2), 250–256.

    Article  Google Scholar 

  • Corley, M., Minick, P., Elswick, R., & Jacobs, M. (2005). Nurse moral distress and ethical work environment. Nursing Ethics, 12(4), 381–390.

    Article  Google Scholar 

  • Dodek, P., Wong, H., Norena, M., Ayas, N., Reynolds, S., et al. (2016). Moral distress in intensive care unit professionals is associated with profession, age, and years of experience. Journal of Critical Care, 31(1), 178–182.

    Article  Google Scholar 

  • Epstein, E. G., & Hamric, A. B. (2009). Moral distress, moral residue, and the crescendo effect. Journal of Clinical Ethics, 20(4), 330–342.

    Article  Google Scholar 

  • Epstein, E. G., Whitehead, P. B., Prompahakul, C., Thacker, L. R., & Hamric, A. B. (2019). Enhancing understanding of moral distress: The measure of moral distress for healthcare professionals. AJOB Empirical Bioethics, 10(2), 113–124.

    Article  Google Scholar 

  • Epstein, E. G., Haizlip, J., Liaschenko, J., Zhao, D., Bennett, R., & Marshall, M. F. (2020). Moral distress, mattering, and secondary traumatic stress in provider burnout: A call for moral community. AACN Advanced Critical Care, 31(2), 146–157.

    Article  Google Scholar 

  • Fumis, R., Amarante, G., Nascimento, A., & Junior, J. (2017). Moral distress and its contribution to the development of burnout syndrome among critical care providers. Annals of Intensive Care, 7(1), 71.

    Article  Google Scholar 

  • Hamric, A., & Blackhall, L. (2007). Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress and ethical climate. Critical Care Medicine, 35(2), 422–429.

    Article  Google Scholar 

  • Hamric, A. B., Borchers, C., & Epstein, E. G. (2012). Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research, 3(2), 1–9.

    Article  Google Scholar 

  • Hamric, A. B., & Epstein, E. G. (2017). A health system-wide moral distress consultation service: Development and evaluation. HEC Forum, 29(2), 127–143.

    Article  Google Scholar 

  • Hsieh, H., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288.

    Article  Google Scholar 

  • Jameton, A. (1993). Dilemmas of moral distress: Moral responsibility and nursing practice. Awhonn’s Clinical Issues in Perinatal and Women’s Health Nursing, 4(4), 542–551.

    Google Scholar 

  • Kroth, P. J., Morioka-Douglas, N., Veres, S., Babbott, S., Poplau, S., Qeadan, F., et al. (2019). Association of electronic health record design and use factors with clinician stress and burnout. JAMA Network Open, 2(8), 199609.

    Article  Google Scholar 

  • Laabs, C. (2005). Moral problems and distress among nurse practitioners in primary care. The Journal of the American Association of Nurse Practitioners, 17(2), 76–83.

    Article  Google Scholar 

  • Laabs, C. A. (2007). Primary care nurse practitioners’ integrity when faced with moral conflict. Nursing Ethics, 14(6), 795–809.

    Article  Google Scholar 

  • Linzer, M., Konrad, T. R., Douglas, J., McMurray, J. E., Pathman, D. E., Williams, E. S., et al. (2000). Managed care, time pressure, and physician job satisfaction: Results from the Physician Worklife Study. The Journal of General Internal Medicine, 15(7), 441–450.

    Article  Google Scholar 

  • Linzer, M., Manwell, L. B., Mundt, M., Williams, E., Maguire, A., McMurray, J., & Plane, M. B. (2005). Organizational climate, stress, and error in primary care: The MEMO study. Advances in Patient Safety, 1, 65–77.

    Google Scholar 

  • Linzer, M., Manwell, L. B., Williams, E. S., Bobula, J. A., Brown, R. L., Varkey, A. B., et al. (2009). Working conditions in primary care: Physician reactions and care quality. Annals of Internal Medicine, 151(1), 28–36.

    Article  Google Scholar 

  • McDonald, K. M., Rodriguez, H. P., & Shortell, S. M. (2018). Organizational influences on time pressure stressors and potential patient consequences in primary care. Medical Care, 56(10), 822–830.

    Article  Google Scholar 

  • Meltzer, L.S., & Huckabay, L.M. (2004). Critical care nurses’ perceptions of futile care and its effect on burnout. American Journal of Critical Care, 13(3), 202–208.

    Article  Google Scholar 

  • Neumann, J. L., Mau, L. W., Virani, S., Denzen, E. M., Boyle, D. A., Boyle, N. J., Dabney, J., et al. (2018). Burnout, moral distress, work-life balance, and career satisfaction among hematopoietic cell transplantation professionals. Biology of Blood and Marrow Transplantation, 24(4), 849–860.

    Article  Google Scholar 

  • Pauly, B., Varcoe, C., Storch, J., & Newton, L. (2009). Registered nurses’ perceptions of moral distress and ethical climate. Nursing Ethics, 16(5), 561–573.

    Article  Google Scholar 

  • Peter, E., Lunardi, V. L., & Macfarlane, A. (2004). Nursing resistance as ethical action: Literature review. The Journal of Advanced Nursing, 46(4), 403–416.

    Article  Google Scholar 

  • Redman, B. K., & Fry, S. T. (2000). Nurses’ ethical conflicts: What is really about them? Nursing Ethics, 7(4), 360–366.

    Article  Google Scholar 

  • Schwenzer, K., & Wang, L. (2006). Assessing moral distress in respiratory care practitioners. Critical Care Medicine, 34(12), 2967–2973.

    Article  Google Scholar 

  • Shanafelt, T., Boone, S., Tan, L., Dyrbye, L., Sotile, W., Satele, D., et al. (2012). Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Archives of Internal Medicine, 172(18), 1377–1385.

    Article  Google Scholar 

  • Sinsky, C., Willard-Grace, R., Schutzbank, A., Sinsky, T., Margolius, D., & Bodenheimer, T. (2013). In search of joy in practice. Annals of Family Medicine, 11(3), 272–278.

    Article  Google Scholar 

  • Smith, H. L., & Churchill, L. R. (1986). Professional ethics and primary care medicine. Durham, N.C.: Duke University Press. 

    Google Scholar 

  • Trautmann, J., Epstein, E. G., Rovnyak, V., & Snyder, A. (2015). Relationships among moral distress, level of practice independence, and intent to leave of nurse practitioners in emergency departments. Advanced Emergency Nursing Journal, 37(2), 134–145.

    Article  Google Scholar 

  • Ulrich, C., Danis, M., Ratcliffe, S., Garrett-Mayer, E., Koziol, D., Soeken, K., & Grady, C. (2006). Ethical conflict in nurse practitioners and physician assistants in managed care. Nursing Research, 55(6), 391–401.

    Article  Google Scholar 

  • Ulrich, C., Zhou, Q., Hanlon, A., Danis, M., & Grady, C. (2014). The impact of ethics and work-related factors on nurse practitioners’ and physicians assistants’ views on quality of primary healthcare in the United States. Appl Nurs Res, 27(3), 152–156.

    Article  Google Scholar 

  • Westling, C., Walsh, T., & Nelson, W. (2017). Perceived ethics dilemmas among pioneer Accountable Care Organizations. Journal of Healthcare Management, 62(1), 18–27.

    Article  Google Scholar 

  • Whitehead, P., Herbertson, R., Hamric, A. B., Epstein, E. G., & Fisher, J. (2014). Moral distress among healthcare professionals: Report of an institution-wide survey. Journal of Nursing Scholarship, 47, 117.

    Article  Google Scholar 

Download references

Funding

None.

Author information

Authors and Affiliations

  1. Department of Student Health & Wellness, University of Virginia, PO Box 800760, Charlottesville, VA, 22908, USA

    Dawn Worsham Bourne

  2. University of Virginia School of Nursing, Charlottesville, VA, 22908, USA

    Elizabeth Epstein

Authors
  1. Dawn Worsham Bourne
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Elizabeth Epstein
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

DWB and EE have both contributed significantly to all aspects of this study/publication (study design, data collection/analysis/interpretation, drafting and revising the manuscript and final approval of this version).

Corresponding author

Correspondence to Dawn Worsham Bourne.

Ethics declarations

Conflict of interest

Bourne and Epstein have no disclosures.

Ethical Approval

This study was approved by the University of Virginia’s Social Behavioral Sciences Institutional Review Board (Protocol #2015–0235-00).

Consent to Participate

Informed consent was obtained from all participants prior to the study. Copies of documentation are available upon request from the corresponding author DB.

Consent for Publication

Participants were aware data may be published at the time informed consent was obtained.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bourne, D.W., Epstein, E. The Experience of Moral Distress in an Academic Family Medicine Clinic. HEC Forum 35, 37–54 (2023). https://doi.org/10.1007/s10730-021-09453-9

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10730-021-09453-9

Keywords

Search

Navigation