Coping with Moral Distress in Primary Care Medicine: How Doctors Use Moral Boundary Management Approaches

Abstract

Background: A growing body of literature shows moral distress is increasingly prevalent across healthcare professions, including primary care medicine (Čartolovni et al., 2021; Dean et al., 2019, 2024; Molinaro et al., 2023; Rabin et al., 2023; Talbot & Dean, 2018). Our research uses qualitative methods to develop a grounded theoretical understanding of how primary care doctors experience and cope with moral distress in their daily work.

Method: The data for our theorisation come from a cross-national research project that initially focused on meaningful and meaningless work among primary care doctors in three countries: New Zealand (NZ), the United States (US), and Sweden. We conducted semi-structured interviews with a total of 68 doctors (NZ=26; US=24; Sweden=18). Interviews lasted an average of one hour and were digitally recorded and transcribed. We have thus far thematically analysed interview data from all doctors in the US and NZ, following the template approach of King (2012); we will have finished analysing Swedish data by the time of next year’s conference. Preliminary results, therefore, are based on NZ and US data and may be updated based on themes in Swedish data.

Results: We found that moral distress was a common experience among primary care doctors in both NZ (known as general practitioners or GPs) and in the US (known as family physicians). Most commonly, moral distress was triggered by doctors’ powerlessness to overcome cost-related hurdles to patient care. Our initial analysis suggests doctors cope with moral distress through what we call “moral boundary management approaches,” whereby they (re)position their personal moral responsibilities in relation to their roles in the healthcare system. We identified three main approaches, as summarised. Moral self-differentiation: Doctors view themselves as moral actors in an immoral system and “prove” this by going above and beyond for patients. Our data suggest this often becomes unsustainable over long periods, leading to burnout. Moral dissociation: Doctors “morally zone out” when they cannot provide appropriate care due to cost constraints beyond their control, blaming the system rather than themselves. We found this strategy often develops over the course of longer careers, and due to the perceived futility of moral-self differentiation. Clinical moral dissociation combined with non-clinical moral self-investment: Doctors “morally dissociate” from their clinical roles (when unable to provide appropriate care) but simultaneously pursue moral imperatives in non-clinical roles as systemic change agents. We found that this approach was most common among doctors with established careers and a relatively high degree of control over their time, due to the absence of financial pressures.

Conclusion: Our research offers valuable insights into how doctors cope with moral distress at an individual level. However, it also emphasises that individual-level coping strategies are inherently related to a systemic context—for example, some doctors combine clinical moral dissociation with non-clinical work to address underlying issues. As such, our work demonstrates the importance of combining individual and systemic initiatives to address moral distress.