What’s Moral Distress Got to Do With It? How to Avoid Burnout and Optimize Patient Care

Burnout is a complex issue that is characterized by three key themes: emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment. The prevalence of burnout is estimated to be between 40-80%,¹ a figure that emphasizes the widespread impact of burnout on both individuals and the healthcare system as a whole. Early research on burnout focused solely on personality traits associated with physicians, such as perfectionism and ability to delay gratification. However, it is now widely recognized that burnout is not solely an individual challenge, but a systemic one. There is growing recognition in the medical community that it is imperative to consider the effect of system-level factors.

The Stanford Model of Professional Fulfillment² incorporates both personal and system-level factors in a diagram that consists of three outer elements: efficiency of practice, personal resilience, and the culture of wellness surrounding a core of professional fulfillment. Dr. Finkelstein's alternative model of burnout (Figure 1) refines these elements found in the Stanford model of burnout to define three main factors driving burnout: inevitable suffering, moral distress, and "extra junk".

The first factor is the intrinsic suffering and the process of vicarious traumatization linked to providing patient care. Strategies to manage the inevitable suffering associated with healthcare work include coaching, therapy, journaling, and mindfulness practices. However, it is crucial to be cautious of the ways in which society, particularly within a late capitalist context, may exploit the need for such interventions and prioritize profit over genuine support.

The second factor is "extra junk", referring to the increasing burden of administrative tasks and non-patient care activities including time spent on electronic medical records (EMRs) and patient portals, prior authorizations required by insurance companies, and financial pressures. In academic and research centers, teaching and research responsibilities include substantial administrative obligations such as lecture preparation time and manuscript writing that do not receive adequate compensation or institutional support. Efforts have been made to address the system-level factors contributing to burnout. Initiatives such as American Medical Association (AMA) practice modules, workflow efficiency improvements, risk management, and improvements in working conditions aim to alleviate the burdensome tasks and responsibilities faced by healthcare professionals. However, it is important to critically evaluate the effectiveness of these interventions and ensure that they do not inadvertently add to the workload or further stress healthcare professionals.

The third factor is moral distress experienced by healthcare professionals, which was originally explored in nursing literature,³ and is now understood to be a main driver of burnout. Moral distress occurs when healthcare professionals face external constraints that impede an individual's ability to pursue actions that are in accordance with their ethical values.⁴ One notable example is the tension between prioritizing patient health and financial considerations in low- and middle-income countries (LMICs), especially when the standard of care is not achieved due to lack of resources.⁵ The COVID pandemic has only hastened the development of moral distress among health workers due to additional resource constraints, safety policies that impair patient-centered care, and heightened risk to personal health.

The harmful effects of burnout have extended past individual health care professionals to impact the entire health care system as a whole.⁶ Burnout has exacerbated workforce shortages as physicians and healthcare workers have retired early or transitioned to non-clinical careers, a phenomenon accelerated by the COVID-19 pandemic. The result is lower quality healthcare at a higher cost and worsening population health outcomes; the urgent need to address burnout has now been formally recognized by the United States (US) Surgeon General.⁶ In a recent advisory, the US Surgeon General outlined a multifaceted approach that considers both individual and system-level interventions to address burnout. This advisory also acknowledges that burnout arises from moral distress and ethical dissonance in addition to well-known factors that include long work hours, EMRs and burdensome administrative tasks. Similarly, the literature now highlights the complex and multidimensional nature of burnout.³ We believe that addressing moral distress requires cultural changes and commitment at every level of the complex healthcare ecosystem as technical or surface-level changes alone are unlikely to be effective in a landscape of various stakeholders and competing interests.⁷

Fortunately, there is a growing understanding that healthcare professionals are inherently resilient individuals who have overcome significant and largely systemic challenges to reach their current positions. This starts with individuals who recognize signs of burnout in themselves and in their peers, maintain work-life balance, and continue to find moments of joy and personal fulfillment in their work. But as part of a comprehensive cultural shift, individuals should also advocate for justice and equity in society, not just within the realm of healthcare. This includes prioritizing diversity in the workforce, which contributes to healthcare worker retention as well as improved cultural competency and patient trust in the healthcare system.⁸ However, the burden of change should not be placed entirely on the individual, and addressing disparities should be a priority for leaders within the healthcare ecosystem. This includes implementing system-level changes such as creating humane sick and maternity leave policies for healthcare workers, reducing unnecessary administrative burdens, and creating a diverse health care workforce. There are numerous opportunities to improve systems within the field of academic medicine, and academic institutions should place greater value on mentorship activities, recognize the contributions of underrepresented groups, and support research in the field of burnout within medical education.⁹

Many organizations have recognized the need for executive leadership to direct system level changes, resulting in the creation of the chief wellness officer (CWO) role.¹⁰ The success and efficacy of CWOs is measured by specific metrics designed to track rates of burnout and professional fulfillment within the organization, and early reports suggest that CWOs play a pivotal role in addressing burnout in a systematic fashion.¹¹ Physicians can join advocacy groups such as the American Medical Association (AMA) to support efforts to protect physician rights¹² and improve their quality of life. The AMA offers multiple educational resources, including a toolkit on quality improvement and the Plan-Do-Study-Act (PDSA) framework for identifying opportunities for optimizing the clinic workflow and subsequently developing a plan to test and implement changes.¹³ This process can be applied at all levels, from an individual physician's workflow to streamlining system-wide processes.¹⁴ Recent research underscores the benefits of a team-based model¹⁵ in lightening the workload of primary care physicians, who, on average, face the daunting task of providing an unattainable 26.7 hours' worth of recommended preventive, chronic, and acute care daily. By adopting team-based care, this figure can be reduced to a significant but feasible 9.3 hours per day. In conclusion, addressing burnout in healthcare requires a comprehensive approach that considers both individual and system-level factors. System reforms, advocacy, and prioritizing justice and equity within the healthcare ecosystem are necessary steps towards alleviating burnout and creating a healthier, more sustainable work environment for healthcare professionals.

The authors declare no conflicts of interest.

This overview was not funded by a specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Concept and design: BH, CAF, LS, NFU, HML

Data acquisition: BH, CAF, LS, NFU, HML

Data analysis and interpretation: BH, CAF, LS, NFU, HML

Drafting of the manuscript: BH, CAF, LS, NFU, HML

Critical revision of the manuscript: BH, CAF, LS, NFU, HML

All authors (BH, CAF, LS, NFU, HML) approved the final version of the manuscript and agree to be accountable for all aspects of the work, in accordance with the International Committee of Medical Journal Editors criteria.

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