Impact of moral distress on burn-out: a cross-sectional survey of front-line family physicians during the initial wave of the COVID-19 pandemic

Avital Sabrina Fischer; Reece Fenning; John Michael Robb; Allison Slater; Uyen Mai; Tien Lam; Jan Paolo De La Cruz; John Billimek; Johanna Shapiro; Tan Nguyen; Cynthia Haq

doi:10.1136/bmjopen-2024-089980

Impact of moral distress on burn-out: a cross-sectional survey of front-line family physicians during the initial wave of the COVID-19 pandemic

BMJ Open. 2025 Feb 11;15(2):e089980. doi: 10.1136/bmjopen-2024-089980.

Authors

Affiliations

¹ Psychiatry and Behavioral Sciences, Stanford Health Care, Stanford, California, USA avitalf@stanford.edu.
² Family Medicine, Sutter Health, Sacramento, California, USA.
³ School of Medicine, University of California Irvine, Irvine, California, USA.
⁴ Department of Public Health, University of California Irvine, Irvine, California, USA.
⁵ Health Policy Research Institute, University of California Irvine, Irvine, California, USA.
⁶ Department of Family Medicine, University of California Irvine, Irvine, California, USA.
⁷ Family Medicine, University of California Irvine School of Medicine, Irvine, California, USA.

Abstract

Objectives: Primary care clinicians are especially prone to burn-out. The primary objective of this study was to investigate factors contributing to burn-out and moral distress and their relationship among practising family physicians (FPs) in California early in the COVID-19 pandemic.

Design: Cross-sectional study, online survey evaluating burn-out, moral distress and associated factors.

Setting: California FPs between July and August 2020 practising in community health centres, hospital systems, private clinics and university systems were surveyed with a 22-item online questionnaire.

Participants: FPs practising in California were eligible. The final sample included 218 physicians.

Primary and secondary outcome measures: The primary independent variable was frequency of moral distress and the primary outcome variable was worsening burn-out. Moderator variables included gender and employer support.

Results: FPs experiencing higher burn-out and moral distress were more likely to report concerns regarding personal COVID-19 risk and lack of personal protective equipment. Practising self-care and personal wellness were associated with decreased moral distress. Female physicians were 3.86-fold more likely to report worsening burn-out compared with male physicians. Employer support was associated with a 59% reduced burn-out risk and 54% reduction in frequent moral distress. Frequent moral distress was associated with a 3.12- fold higher burn-out risk. Gender moderated the relationship between moral distress and burn-out. Moral distress was associated with a 3.55-fold increase in burn-out risk among females.

Conclusions: Female FPs experienced greater levels of moral distress and burn-out than male physicians. Moral distress was differentially associated with increased burn-out among female physicians. Employer support was a protective factor against moral distress and burn-out.

Keywords: Burnout; COVID-19; Health Workforce; Physicians.

MeSH terms

Adult
Burnout, Professional* / epidemiology
Burnout, Professional* / psychology
COVID-19* / epidemiology
COVID-19* / psychology
California / epidemiology
Cross-Sectional Studies
Ethical Dilemmas
Female
Humans
Male
Middle Aged
Morals*
Physicians, Family* / psychology
SARS-CoV-2
Sex Factors
Surveys and Questionnaires