“Survival Mode”: Experiences of moral distress in Canadian primary care professionals during and after the COVID-19 pandemic

Context: News and scholarly reports have highlighted that primary care professionals, including physicians, nurses, social workers, and administrators, are leaving comprehensive family medicine practice because of COVID-19 circumstances that may have fostered moral distress. “Moral distress” is the response of a person who is constrained from acting in ways they believe are right. The moral distress experienced by primary care professionals during the pandemic has not been discussed in the extensive literature on health system functioning during the pandemic.

Objective: This project explored the presence, nature, and effects of moral distress in Canadian primary healthcare professionals from two provinces during (March 2020-May 2023) and after the COVID-19 pandemic.

Study Design and Analysis: Following Merriam’s qualitative multiple case study approach, semi-structured interviews were conducted with primary care professionals in Ontario (n=14) and Alberta (n=11), in addition to casespecific document review.

Setting: Two group family medicine practices in Ontario and Alberta, Canada.

Population Studied: Primary healthcare professionals including family physicians, nurses, social workers, dieticians, and administrative staff working in the group practices during the pandemic.

Intervention/Instrument: Individual semi-structured interviews and review of pertinent case-relevant documents.

Outcome Measures: Participant descriptions of navigating and implementing COVID-19 induced changes to the healthcare system, which revealed moral distress.

Results: Twenty-five primary care professionals were recruited. Cross-case analysis identified similar concerns regarding delayed cancer screenings and a lack of specialist care, attempts to maintain continuity of care, and navigating conflict between patient needs with virtual care. In Alberta specifically, a significant concern was prioritizing provincial COVID-19 infection control over patient management.

Conclusions: Primary care professional descriptions of moral distress during the pandemic provides impetus for critically interrogating how family medicine was, and still is, structured to compensate for broader healthcare system constraints that are conducive to moral distress. Through measures such as the expansion of primary care professionals’ scope of practice, primary care attempted to compensate for restrictions on specialist care and limited entry into certain care environments due to provincial COVID-19 policy