Survey: Most clinicians who treat low-income COVID patients are morally distressed | By The Perfect Enemy

Constrained by a lack of sufficient resources and faced with difficult decisions amid COVID-19 surges in the first year of the pandemic, nearly 72% of US primary care, dental, and behavioral health clinicians working in safety-net clinics report experiencing mild to intense moral distress, finds a study published late last week in BMJ Open.

Led by University of North Carolina at Chapel Hill researchers, the study involved a 10-minute online survey of 2,073 frontline clinicians serving low-income patients in safety-net clinics in 20 states and participating in state and national education loan-repayment programs. The survey, fielded from Nov 24, 2020, to Feb 7, 2021, included the single-question Moral Distress Thermometer and one open-ended question.

Safety-net clinics care for patients—many of whom are racial minorities—who face barriers to receiving care in mainstream clinics. They include Federally Qualified Health Centers, Indian Health Service clinics, county health departments, and community mental health facilities.

The authors defined moral distress as psychological unease resulting from conflict between the things one does or witnesses and deeply held moral and ethical beliefs and expectations. They also noted that such distress is known to lead to burnout, compassion fatigue, disengagement from patients, poor-quality patient care, and job turnover among hospital nurses.

Of all respondents, 54.9% were aged 35 to 49 years, 72.9% were women, 60.2% had children at home, 81.0% were White, 9.8% were Hispanic, 7.2% were Asian, 6.8% were Black, and 5.0% were multiracial.

More than a quarter noted intense distress

A total of 71.6% of survey respondents said they experienced moral distress. In weighted results, 26.8% of those surveyed reported “distressing,” “intense,” or the “worst-possible” moral suffering, while 44.8% said they had “mild” or “uncomfortable” distress, and 28.4% reported no distress.

The most commonly reported types of distressing problems were having to limit care to only the sickest patients and not being able to provide optimal or needed care when protocols changed to minimize infection risk between patients and staff. In addition to rationing care, staff sometimes had to rely on virtual visits even when in-person visits would have been better for patients or when patients couldn’t access telehealth.

Other issues described included abuse of clinic staff, patient and staff suffering, fears of viral transmission, politicization of the pandemic, shortages of personal protective equipment, the perceived indifference or selfishness of people who didn’t follow public health guidance, and social and health disparities and injustices among patients and in the community. Specific examples included patients dying alone and COVID-19 outbreaks that spread through nursing homes.

Providers who reported patient and community inequities and abuse of staff were most likely to indicate high levels of moral distress. A nurse practitioner said she felt moral distress when witnessing how the pandemic “impacted families in our clinic and feeling powerless to make meaningful change,” while a doctor cited “diagnosing patients experiencing homelessness with COVID and not being able to provide them with a safe place to isolate/recover.” 

Thirty-one percent of clinicians said they themselves were responsible for their moral distress, while others named their clinic or organization (15%); government, politics, or society (14%); patients (3%); and clinic staff or administrators (3%).

Some respondents said they felt distressed when colleagues were infected or lost their jobs or when their employers didn’t seem to care about staff well-being. “All our manager and director seem to care about is making money and how many patients we see,” a dentist commented. “I was having to balance being exposed to so many patients then going home to my family and potentially exposing them.”

Recommendations for clinic managers

The researchers said they can’t be sure whether the moral distress measured during the pandemic was greater than in 2019 or earlier because no studies had addressed this issue in safety-net clinics.

“But most issues these clinicians reported caused moral distress during the pandemic related directly or indirectly to the pandemic, thus their moral distress had likely increased during the pandemic,” they wrote. “Their moral distress may have increased further since this late 2020/early 2021 survey, as vaccines have since become widely available but then shunned by many people, prolonging the pandemic and causing many needless deaths.”

The team recommended that clinic managers understand the impact of moral distress, create supportive work environments, develop ways for clinicians and staff to discuss their unease, address ongoing sources of stress, give clinicians psychological support and time away from work, and include staff in operational decisions during crises.

The safety-net setting of this study is important because it was previously unexplored in terms of clinician psychological pain and discomfort, lead author Donald Pathman, MD, MPH, said in a University of North Carolina Health Care news release.

“Moral distress is a concept developed to understand the consequences of disturbing situations nurses can experience in hospitals, but the concept of moral distress is likely just as useful in understanding a type of distress clinicians in all disciplines and work settings experience,” he said.

“Given the type of individual who chooses to provide healthcare 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.”

#Black, #Employers, #HealthCenters, #Hispanic, #MentalHealth, #PublicHealth, #Vaccines

---

Published on The Perfect Enemy at https://bit.ly/3TtxLty.