Background: Moral Distress (MD) is the result of barriers or constraints that prevent providers from carrying out what they believe to be ethically appropriate care and has been associated with burnout. Advances have been made in our understanding of burnout in the oncology (Onc) workforce but our understanding of MD remains limited. This study was initiated to explore associations between moral distress, burnout, and the organizational climate (OC) for Onc Physician Assistants (PAs). Methods: A national survey of onc PAs was conducted in 2020. MD and Burnout were assessed with the Maslach Burnout Inventory and the Measure of MD – Healthcare Professionals (MMD-HP). To assess OC, the Nurse Practitioner Primary Care OC Questionnaire (NP-PCOCQ) was revised for Onc PAs and assessed professional visibility (PV), administrative relations (AR), physician relations (PR), and professional autonomy and support (PAS). A robust Poisson regression model was used to estimate risk ratios (RR) for burnout associated with MD and OC variables. Results: Respondents who completed the survey included 146 Onc PAs that were mostly female (90%), White/Caucasian (84%), married/partnered (78%), and in medical Onc (73%). Mean MMD-HP score was 71.5 and burnout was reported by 39.7% of PAs. MMD-HP scores did not differ based on specialty, practice setting or practice type. PCOCQ subscale scores were lower for PAs with burnout vs. without burnout (p=0.003 to p < 0.001). Increasing levels of MD were associated with increased levels of emotional exhaustion (p<0.001), depersonalization (p<0.001) and a higher overall rate of burnout. For Low, Medium and High MMD, burnout rates were 10%, 44% and 66% respectively (p<0.001). Risk of burnout was associated with increasing levels of MD, which remained when adjusted for the PCOCQ subscales. An interaction model with the PCOCQ subscales and the association between burnout and MD was not significant. Conclusions: Higher levels of MD and unfavorable organizational climate are associated with Onc PA burnout. The relationship between MD and burnout does not appear to be moderated by organizational climate. Additional research is needed to identify potential moderators of the MD/Burnout relationship. Risk Ratio estimate for Burnout.

* Each subscale was included in a separate model ** p-value for MMD-HP variable (tertiles) from each model.