Moral Distress, Organizational Climate, and the Risk of Burnout Among Physician Assistants in Oncology

PURPOSE:

Moral distress (MD) is the result of barriers or constraints that prevent providers from carrying out what they believe to be ethically appropriate care. This study was initiated to explore associations between MD, burnout, and the organizational climate (OC) for oncology physician assistants (PAs).

METHODS:

A national survey of oncology PAs was conducted to explore the associations between MD, OC, and burnout. The Nurse Practitioner-Primary Care OC Questionnaire was revised for oncology PAs to assess OC for PA practice. MD and burnout were assessed using the Measure of MD-Healthcare Professionals (MMD-HP) and the Maslach Burnout Inventory.

RESULTS:

One hundred forty-six oncology PAs are included in the analysis. PAs were mostly female (90%), White/Caucasian (84%), married/partnered (78%), and in medical oncology (73%), with mean age 41.0 years. The mean MMD-HP score for oncology PAs was 71.5 and there was no difference in MD scores on the basis of oncology subspecialty, practice setting, practice type, or hours worked per week. PAs currently considering leaving their position because of MD had significantly higher mean scores on the MMD-HP compared with those not considering leaving their position (108.2 v 64.8; P = .001). PAs with burnout also had significantly higher mean scores for MD compared with PAs without burnout (97.6 v 54.3; P < .001). A negative relationship between OC for PA practice and MD was only found for the PA-administration relations subscale, whereas all subscales were negatively associated with burnout.

CONCLUSION:

This study demonstrates that the risk of professional burnout increases significantly with increasing levels of MD. Additional research exploring the relationship between MD and burnout is needed.

INTRODUCTION

Professional burnout has significant implications for all members of the health care system and has received increased attention in the past several years.¹ Burnout has pushed the health care workforce to its limits and is an immediate threat to the delivery of quality care in all health care settings.² In oncology, there have been significant advances in research to help understand the drivers of burnout for the oncology team, and initiatives are underway to help mitigate the risks and consequences of professional burnout.^3-8 Despite the advances in our understanding of burnout among members of the oncology team, there remains a limited understanding of the impact of moral distress (MD) and its relationship to burnout.^9-12

MD is the result of barriers or constraints that prevent providers from carrying out what they believe to be ethically appropriate care. Barriers to carrying out what health care providers believe to be the right care can be related to patient-, team-, and institution-level constraints.¹³ The majority of research examining MD can be found in nursing literature. High levels of MD in nursing have been associated with poor perceptions of nurse-physician collaboration, lack of professional autonomy, lack of participation in care decisions, intention to leave the nursing position, and increased levels of burnout.¹⁴ Unfortunately, studies examining MD among members of the oncology team outside of the nursing profession have been limited.

We previously reported that oncology physician assistants (PAs) are at risk of burnout and those who were burned out had significantly lower perceptions of their work environment.¹⁵ In the oncology setting, PAs may also be at increased risk for MD because of challenges with caring for patients at the end of life or with limited treatments options, and because of the collaborative nature of PA practice and the team-based approach to patient care. Because PAs work under the supervision of physicians, they may experience situations where they perceive their authority to be compromised by the oncologist who has the final authority for major treatment planning. Additionally, the organizational climate (OC) for PA practice may affect the risk of MD.

Importantly, should PAs, as a result of MD or burnout, leave the profession? This could have significant implications with respect to workforce demands and the delivery of cancer care. In this study, we investigated the hypothesis that among oncology PAs, increasing levels of MD would be associated with higher rates of burnout, an association modified by the OC related to PA practice.

METHODS

Participants and Survey Administration

Oncology PAs were identified and contacted via e-mail using the membership database of the Association of Physician Assistants in Oncology. The study invitation was sent in October 2020 and included a description of the study and an electronic link to the online survey. Three reminder e-mail requests were sent to potential participants who had not completed the survey. Participants who completed the survey were offered a gift card of $10 in US dollars. This study was approved by the Fox Chase Cancer Center Institutional Review Board, and PAs provided informed consent before participation.

Survey Dimensions

General.

The survey included 88 items assessing personal and professional characteristics of participants (basic demographic information, subspecialty, area of clinical practice, practice setting, and hours worked): OC, burnout, and MD.

Burnout.

The Maslach Burnout Inventory (MBI) was used to assess burnout. The MBI is considered the gold standard for assessment of burnout in health care providers and has been used extensively in studies exploring the well-being of various professions that make up the oncology team.^16-21 The MBI consists of 22 items and examines the key dimensions related to burnout with three subscales: emotional exhaustion (EE), depersonalization (DP), and sense of personal accomplishment. Using established cut-scores, scores were classified into high, moderate, or low levels for each subscale.²² Burnout was defined in this study as the presence of high score on the EE subscale (≥ 27) and/or a high score on the DP subscale (≥ 10).^15,20,21,23

Organizational Climate

OC, as it relates to PA practice, was examined using the Nurse Practitioner-Primary Care OC Questionnaire. Face and content validity for the tool has been established in the primary care setting for nurse practitioners (NPs).^24-27 The only change to this tool was replacing NPs with Pas, which is not expected to affect the face or contact validity. The 29-item tool consists of four subscale factors: professional visibility (PV), PA-administration relations (PA-AR), PA-physician relations (PA-PR), and independent practice (ie, autonomy) and support (IPS). The PV subscale measures organizational and team understanding of the PA role, the PA-AR measures perceived relationships of PAs with administration, the PA-PR measures perceptions about PA and physician collaborative practice and teamwork, and the IPS measures perceptions of practice autonomy, scope of practice, and ancillary practice support. Participants indicate level of agreement with each item on a 4-point Likert scale. Increases in the subscale scores indicate better PA practice environments.

Moral Distress

The Measure of MD for Healthcare Professionals (MMD-HP) was used to measure MD. The MMD-HP assesses the currently understood causes of MD and demonstrates good reliability for measuring MD. It also predicts the intent to leave a position because of MD.²⁸ The tool consists of 27 situations that occur in clinical practice. The respondent indicates the frequency with which they have experienced each situation as well as the level of distress each situation caused. A composite item score for each clinical situation related to MD on the basis of the frequency and level of distress was calculated (range, 0-16). An overall composite score for MD was calculated by adding all of the composite item scores together. One missing item was allowed for the scoring of the MMD-HP using a weighted average of the completed 26 items (Cronbach's α for the MMD was very high, 0.91 [using the 27 items in those with complete data]), suggesting that the 26-item estimate is highly correlated with the 27-item estimate. Higher MMD-HP scores indicate higher levels of MD. Subscale scores were created by clustering items into three categories: patient-related (six items), team-related (13 items), or institutional-related (eight items).^28,29 Finally, the MMD-HP cohort was divided into tertiles (cutpoints) to create groups of high, medium, and low scores for MD, one third of the sample in each category.

Statistical Analysis

Descriptive statistics were used to describe the personal and professional characteristics of the participants. We compared MMD-HP subscales using a Kruskal-Wallis test. We examined the MMD-HP scores by participant characteristics, intention to leave current job, burnout status, and MBI subscales, and compared them using Kruskal-Wallis tests. We examined MD tertiles and intention to leave one's job using Fisher's exact test. OC subscales were compared by participant characteristics, MMD-HP tertiles, and burnout status using Kruskal-Wallis tests. We used multivariable logistic regression models to estimate odds ratios for burnout associated with MD and organizational context variables. We initially included only MD level as a predictor, and then included organizational context subscales separately in additional models. Interaction models to explore possible modifying effects of OC between MD and burnout were completed. We examined burnout with age, specialty, practice setting, and hours worked per week in separate regression models, considering P < .20 for inclusion in the multivariable model. Statistical analyses were performed using two-sided tests and type I error of 0.05, with SAS software, version 9.4 (SAS Institute, Cary, NC).

RESULTS

Of the 983 e-mail invitations that were sent, there were 177 participants who started the survey (18% response rate). Of these, 146 consented to participate, completed the MBI and the MMD-HP instruments, and have been included in the full analysis.

Participants in this study were mostly female (90%), White/Caucasian (84%), married/partnered (78%), and in the medical oncology subspecialty (73%).^15,30 Mean age of the participants was 41.0 years. Overall, participants reported an average of 13 years in clinical practice, with the majority of that time spent as an oncology PA (average of 10.6 years as an oncology PA). Most participants worked in the outpatient setting (70.5%) in an academic medical center (63.7%) and worked 41-50 hours per week (46.6%; Table 1).

TABLE 1.

Personal and Professional Characteristics Participants

Moral Distress

The mean MMD-HP score for participants was 71.5. The items with the highest mean scores that contributed to MD were (1) following family insistence to continue aggressive treatment despite believing it was not in the best interest of the patient, (2) providing aggressive care for someone most likely to die regardless of the treatment, and (3) witnessing providers giving false hope. When the individual items of the MMD-HP were clustered into subscales to explore the related root causes of MD, the average subscale score per respondent was highest for the patient-related items (mean, 3.7), followed by the system-related items (mean, 2.9) and lowest for the team-related items (mean, 2.0). The differences between the subscale scores were significantly different (P < .001; Fig 1).

FIG 1.

The box plot showing the distributions of the MD subscale scores. Higher scores indicate higher degrees of MD. The median subscale scores were highest for patient-related factors (median, 3.0) followed by system-related (median, 2.6) and team-related (median, 1.5). The difference in subscale scores was significant (P < .001 per Kruskal-Wallis test). MD, moral distress; MMD, measure of moral distress.

MD and Burnout

There was no difference in MD scores on the basis of oncology subspecialty, practice setting, practice type, or hours worked per week. As would be expected, participants currently considering leaving their position because of MD had significantly higher scores on the MMD-HP compared with those not considering this (108.2 v 64.8; P = .001; Table 2). Similarly, when looking at MD tertiles, a significantly higher percentage of participants in the high level of MD group considered leaving their position because of MD compared with the medium and low levels of MD groups (26% v 4%, respectively; P = .001). When we examined burnout, we found that 39.7% of participants overall had symptoms of professional burnout. High levels of EE were reported by 36.3% of participants, while high levels of DP were reported by 20.5% of participants and low levels of personal accomplishment were reported by 10.3%.

TABLE 2.

Measure of MD, Intent to Leave, and Burnout

Next, we examined the association between burnout and MD. Participants with burnout had significantly higher mean scores for MD compared with participants without symptoms of burnout (97.6 v 54.3; P < .001). Mean scores for MD significantly increased for each level of the EE and DP subscales (EE: low = 51.6, moderate = 62.1, high = 100.8, P < .001; and DP: low = 57.1, moderate = 74.9, high = 104.6; P < .001). Similarly, the rate of burnout was lowest (10.0%) for participants with low levels of MD, increased to 43.5% for participants with medium levels of MD, and burnout was highest at 66% for participants with high levels of MD (P < .01).

OC, Burnout, and MD

Overall mean scores were highest (more favorable) for PA-PR (3.41), followed by IPS (3.33), PV (3.00), and PA-AR (2.74). Differences in subscale scores were examined on the basis of specialty, practice setting, and practice type. The only significant difference in OC subscale scores occurred between the PV subscale on the basis of participant practice setting (inpatient [3.12] v outpatient [2.93] v flex between inpatient and outpatient [3.24]; P = .036).

When the association between levels of MD and OC was examined, the only significant difference detected occurred in the PA-AR subscale. As the level of MD increased, the mean subscale score significantly decreased (low = 2.96, medium = 2.66, high = 2.60; P = .003). There was no difference in mean scores for the other subscales when examined on the basis of level of MD. In contrast to MD, mean scores for all four of the OC subscales were significantly lower for participants with burnout versus without burnout: PV (2.80 v 3.13; P = .001), PA-AR (2.50 v 2.90; P < .001), PA-PR (3.27 v 3.50; P = .003), and IPS (3.13 v 3.46; P < .001; Fig 2).

FIG 2.

(A) Mean subscale scores for organizational climate for PA practice were computed and examined on the basis of differing levels of moral distress. The difference in the PA-AR subscale was significantly different (P = .003; Kruskal-Wallis test). Differences in the remaining subscales did not reach statistical significance. (B) Mean subscale scores for OC for PA Practice were computed and examined on the basis of the presence or absence of burnout. Significant differences in subscale scores were detected for PV (P = .001), PA-ARs (<.001), PA-PRs (P = .003), and IPS (P < .001). The Wilcoxon rank sum tests are reported. IPS, independent practice and support; MD, moral distress; OC, organizational climate; PA, physician assistants; PA-AR, PA-administration relations; PA-PR, PA-physician relations; PV, professional visibility.

Multivariable Analysis

In a logistic regression model, higher levels of MD were associated with increased odds of burnout. When compared with low levels of MD, the odds ratio for burnout at medium levels of MD was 6.92 (95% CI, 2.32 to 20.64) and increased to 17.47 (95% CI, 5.85 to 52.15) for high levels of MD (P < .001). In additional separate multivariable models, when adjusted for each OC subscale, the odds of burnout remained significantly associated with increasing levels of MD (Table 3). OC subscales did not modify the association of MD and burnout as none of the interaction terms for the OC subscales were significant for burnout or the individual MBI subscales. We also considered potential confounders including age, specialty, practice setting, and hours worked per week; hours worked per week was the only participant characteristic associated with burnout at the P < .20 level. With this additional variable in the multivariable model, the association of MD and burnout remained significant (results not shown).

TABLE 3.

Risk of Burnout Associated With Level of MD Adjusted for Organizational Climate

DISCUSSION

The current study demonstrates that MD may be an important aspect of addressing the overall well-being of oncology PAs. The risk of professional burnout significantly increases with increasing levels of MD. For oncology PAs with high levels of MD, the risk of professional burnout was 6.6 times greater compared with PAs with low levels of MD. The association between MD and burnout in the current study is consistent with findings from nursing literature that demonstrate a similar relationship.^31-33 Similarly, in a study among physicians, nurses, advanced practice providers, pharmacists, and social workers limited to the hematopoietic cell transplantation, MD was associated with an increased risk of burnout for all disciplines.¹⁰

There are also findings from the current study that have significant implications for the future oncology workforce. We found that because of MD, 29.5% of oncology PAs had left a position and 11.0% were currently considering leaving their job for this reason. As would be expected, there was a positive relationship between the intent of leaving a current position and the level of MD. A similar relationship was previously reported between intent to leave and burnout among hematology/oncology NPs.³⁴ Overall, 21.9% of participants in that study indicated an intent to leave the NP profession or the hematology/oncology specialty. However, the intent to leave increased to 43.5% for NPs with high levels of EE and was even higher for NPs with high levels of DP (55.6%). Prior studies have shown that provider turnover results in significant financial cost to the health care system because of recruitment expenses, lost revenue, and other direct costs.³⁵ In addition, turnover can negatively affect the quality and cost of care, and result in increased risks of burnout among the remaining team members.^35-37 Given the relationship between burnout, MD, and intent to leave, the current study clearly suggests that if MD and burnout are not addressed, there may be significant implications for the future workforce in oncology and the ability to meet the health care needs of patients living with cancer.

The root causes of MD were examined within three groups of related factors: patient, team, and system. We found that patient-related factors were associated with highest levels of MD for oncology PAs, followed by organizational-related and team-related factors. This suggests that a focus on PA and patient dynamics may have the greatest potential to reduce MD in oncology PAs. Prior interventions to address MD have predominantly focused on provider education on MD and debriefing opportunities after morally distressing events.³⁸ One approach to consider for mitigating the risk of MD in oncology PAs is to provide focused training on communication skills to further enhance this competency. A prior study of oncology PAs identified two communication skills in need of greater skill level development: communication at the end of life and managing unrealistic patient expectations.³⁹ Grief and sense of failure has shown to predict secondary traumatic stress and burnout in oncologists.⁴⁰ In addition, lower levels of traumatic stress and higher levels of compassion satisfaction among oncologists are associated with greater ability to directly and proactively communicate end-of-life discussions with patients.⁴¹ A successful mitigation strategy could combine the development of communications skills focused on end-of-life care and delivering bad news in addition to previously identified educational opportunities. Improvements in oncology PA/patient communication are likely to result in improved patient and caregiver experiences, improved shared decision making, and more consistent goal concordant care, which may reduce levels of MD experienced by the oncology PA.^42,43

The influence of OC on MD has been examined in nursing literature with negative associations identified with ethical climate, professional collaboration, and job characteristics.^33,44 In other words, MD is higher when the scores of ethical climate, professional collaboration, and job characteristics are lower. In the current study, we found that burnout was associated with low scores on all four factors related to the organizational context of PA practice. These findings are consistent with our previous work that identified an association between an increased risk of burnout and OC factors such as workload, control, reward, community, fairness, and values.¹⁵ In contrast to burnout, increases in MD were limited to negative perceptions of the administration-PA relationship. In addition, OC did not appear to influence the relationship between MD and burnout. It is notable in the hematopoietic cell transplantation study, that NPs and PAs had higher levels of MD compared with physicians but lower levels compared with nurses and social workers. In part, the differences in MD in that study were thought to reflect the greater decisional authority that oncologists possess. However, in our study, we did not find an association between practice autonomy and MD. The lack of association may be due to the team-based approach of oncology PAs and their high levels of satisfaction with collaborative practice.¹⁵

The lesser impact of the PA practice climate (system level influences) on MD also supports a focus on patient-centered aspects of clinical care and interventions aimed at the provider level to reduce levels of MD. Prior research has suggested that grief and a sense of failure in oncology plays a significant role in provider burnout, more so than the exposure to death and suffering of patients with cancer.⁴⁰ Strategies that aid oncology PAs in managing grief after a patient loss, increasing opportunities for them to reflect on their role in providing care, and helping to minimize their perception of failure may all help decrease MD and burnout. This could be accomplished through an educational ethics program that allows PAs to develop skills to recognize and address MD through cognitive, emotional, and behavioral strategies.⁴⁵

There are limitations of our study that are important to address such as the risk of response bias and small sample size. It would appear the risk of response bias for the study is low as participants in the current study have similar characteristics to oncology PAs included in the 2020 Statistical Profile of Certified Physician Assistants by Specialty and other studies of oncology PAs.^15,30 We do acknowledge that the sample size may not identify smaller associations and interactions between variables. Another limitation is the inability to detect cause and effect between MD and burnout. A longitudinal study to establish the causal relationship between MD and burnout would be an area of significant interest for future research. Finally, the impact that the COVID-19 pandemic had on the results of this study are unknown but may have contributed to increased levels of MD.

In conclusion, our findings significantly contribute to the understanding of PA well-being, underscore the complex relationship between MD and burnout, and highlight the need for greater attention on MD as a contributor to poor well-being of oncology PAs. Given the impact of MD and burnout on the health care system, the findings from this study may help organizational leaders identify strategies to reduce their incidence and in turn decrease PA turnover, reduce cost, and increase efficiency and quality of care. Further research studies that include all oncology team members are needed.

AUTHOR CONTRIBUTIONS

Conception and design: Eric D. Tetzlaff, Heather M. Hylton

Financial support: Eric D. Tetzlaff

Administrative support: Eric D. Tetzlaff

Provision of study materials or patients: Eric D. Tetzlaff

Collection and assembly of data: Eric D. Tetzlaff, Zachary Hasse

Data analysis and interpretation: Eric D. Tetzlaff, Karen J. Ruth, Zachary Hasse, Michael J. Hall

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Moral Distress, Organizational Climate, and the Risk of Burnout Among Physician Assistants in Oncology

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