Moral distress among clinicians working in US safety net practices during the COVID-19 pandemic: a mixed methods study

OBJECTIVE

To explore the causes and levels of moral distress experienced by clinicians caring for the low-income patients of safety net practices in the USA during the COVID-19 pandemic.

DESIGN

Cross-sectional survey in late 2020, employing quantitative and qualitative analyses.

SETTING

Safety net practices in 20 US states.

PARTICIPANTS

2073 survey respondents (45.8% response rate) in primary care, dental and behavioural health disciplines working in safety net practices and participating in state and national education loan repayment programmes.

MEASURES

Ordinally scaled degree of moral distress experienced during the pandemic, and open-ended response descriptions of issues that caused most moral distress.

RESULTS

Weighted to reflect all surveyed clinicians, 28.4% reported no moral distress related to work during the pandemic, 44.8% reported 'mild' or 'uncomfortable' levels and 26.8% characterised their moral distress as 'distressing', 'intense' or 'worst possible'. The most frequently described types of morally distressing issues encountered were patients not being able to receive the best or needed care, and patients and staff risking infection in the office. Abuse of clinic staff, suffering of patients, suffering of staff and inequities for patients were also morally distressing, as were politics, inequities and injustices within the community. Clinicians who reported instances of inequities for patients and communities and the abuse of staff were more likely to report higher levels of moral distress.

CONCLUSIONS

During the pandemic's first 9 months, moral distress was common among these clinicians working in US safety net practices. But for only one-quarter was this significantly distressing. As reported for hospital-based clinicians during the pandemic, this study's clinicians in safety net practices were often morally distressed by being unable to provide optimal care to patients. New to the literature is clinicians' moral distress from witnessing inequities and other injustices for their patients and communities.

Experiences of Safety-Net Practice Clinicians Participating in the National Health Service Corps During the COVID-19 Pandemic

OBJECTIVES

The impact of the COVID-19 pandemic has been particularly harsh for low-income and racial and ethnic minority communities. It is not known how the pandemic has affected clinicians who provide care to these communities through safety-net practices, including clinicians participating in the National Health Service Corps (NHSC).

METHODS

In late 2020, we surveyed clinicians who were serving in the NHSC as of July 1, 2020, in 20 states. Clinicians reported on work and job changes and their current well-being, among other measures. Analyses adjusted for differences in subgroup response rates and clustering of clinicians within practices.

RESULTS

Of 4263 surveyed clinicians, 1890 (44.3%) responded. Work for most NHSC clinicians was affected by the pandemic, including 64.5% whose office visit numbers fell by half and 62.5% for whom most visits occurred virtually. Fewer experienced changes in their jobs; for example, only 14.9% had been furloughed. Three-quarters (76.6%) of these NHSC clinicians scored in at-risk levels for their well-being. Compared with primary care and behavioral health clinicians, dental clinicians much more often had been furloughed and had their practices close temporarily.

CONCLUSIONS

The pandemic has disrupted the work, jobs, and mental health of NHSC clinicians in ways similar to its reported effects on outpatient clinicians generally. Because clinicians' mental health worsens after a pandemic, which leads to patient disengagement and job turnover, national programs and policies should help safety-net practices build cultures that support and give greater priority to clinicians' work, job, and mental health needs now and before the next pandemic.

The epidemiologic transition in a frontier town--Manti, Utah: 1849-1977

Census reports and information in burial records of Manti, Utah from 1849 to July 1977 are examined in order to (1) document mortality trends and differentials by age, sex, cause-of-death, and seasonality as Manti passed from a frontier settlement to a rural agricultural community; and (2) ascertain whether the shifts in the cause-of-death structure follow those patterns outlined by Omran (1971, 1974, 1977) in his theory of the epidemiologic transition. Findings parallel patterns suggested by Omran. Major factors accounting for mortality reductions are (1) elimination of the population's dependence upon a contaminated water supply, and (2) adoption of medical advances as they became available.