Systematic scoping review on moral distress among physicians

BACKGROUND

Concepts of moral distress (MD) among physicians have evolved and extend beyond the notion of psychological distress caused by being in a situation in which one is constrained from acting on what one knows to be right. With many accounts involving complex personal, professional, legal, ethical and moral issues, we propose a review of current understanding of MD among physicians.

METHODS

A systematic evidence-based approach guided systematic scoping review is proposed to map the current concepts of MD among physicians published in PubMed, Embase, PsycINFO, Web of Science, SCOPUS, ERIC and Google Scholar databases. Concurrent and independent thematic and direct content analysis (split approach) was conducted on included articles to enhance the reliability and transparency of the process. The themes and categories identified were combined using the jigsaw perspective to create domains that form the framework of the discussion that follows.

RESULTS

A total of 30 156 abstracts were identified, 2473 full-text articles were reviewed and 128 articles were included. The five domains identified were as follows: (1) current concepts, (2) risk factors, (3) impact, (4) tools and (5) interventions.

CONCLUSIONS

Initial reviews suggest that MD involves conflicts within a physician's personal beliefs, values and principles (personal constructs) caused by personal, ethical, moral, contextual, professional and sociocultural factors. How these experiences are processed and reflected on and then integrated into the physician's personal constructs impacts their self-concepts of personhood and identity and can result in MD. The ring theory of personhood facilitates an appreciation of how new experiences create dissonance and resonance within personal constructs. These insights allow the forwarding of a new broader concept of MD and a personalised approach to assessing and treating MD. While further studies are required to test these findings, they offer a personalised means of supporting a physician's MD and preventing burn-out.

Moral distress in oncology nurses: A qualitative study

PURPOSE

Oncology nursing is a special field of practice containing many factors that cause moral distress. The purpose of this study was to explore the sources of moral distress in oncology nurses.

METHODS

This qualitative phenomenological study was conducted with 14 oncology nurses. The mean interview duration was 30 min. Data were analyzed using qualitative inductive content analysis according to the methods of Corbin and Strauss.

RESULTS

Four main themes were identified in the study. The first theme, related to the failure of quality of care, includes the failure to provide holistic care and competence problems (not feeling competent in oncology practice). The second theme includes biomedical ethical issues commonly observed in the field of oncology. The third theme includes treatment and care practices, consisting of futile treatments, lack of regulation for 'do not resuscitate' orders and decisions to limit life-prolonging treatment, limited informational authority of nurses, and problems related to educational practices on the patient. The final theme includes problems arising from the health care system and institution's management and the need for regulation to support ethical decisions.

CONCLUSION

Oncology nurses face ethical problems in providing the quality and continuity of care they desire. It is difficult to manage the problems, especially in the end-of-life period. In order to reduce and eliminate these difficulties, it is recommended to make administrative, institutional, legislative, and systemic arrangements.

Navigating Cognitive Dissonance: A Qualitative Content Analysis Exploring Medical Students' Experiences of Moral Distress in the Emergency Department

BACKGROUND

As undergraduate medical students are acculturated into clinical practice, they develop a set of refined professional values that impact their decision making. We aimed to use students' reflective narratives on ethical dilemmas to identify how students experience moral distress while working in the emergency department (ED) to better understand how to support them in the development of their own agency to act ethically.

METHODS

Students rotating in our emergency medicine clerkship are required to submit an essay describing an ethical dilemma they encountered. We selected a random sample of these reflective pieces from the 2015 and 2016 academic years and used an exploratory qualitative thematic analytic approach to identify frequently recurring themes. This process was continued until thematic sufficiency was reached.

RESULTS

Two-hundred essays were coded, and seven unique themes were identified. The moral distress students described in reflective writing narratives stemmed from patient-provider discord, uncertainty, and social injustices. In each case, students were expressing the cognitive dissonance they experienced as they began to reconcile the difference between their perceptions of optimal patient care and the actual care delivered to the patient.

CONCLUSION

Understanding medical students' cognitive dissonance in the ED will help educators support their students as they negotiate the differences between preferences and principles while being acculturated into clinical practice. Future work should develop specific interventions to promote educator understanding of learners' moral distress and to develop novel models of support for learners.

Medical Students' Experiences of Moral Distress in End-of-Life Care

Background: Moral distress is a frequent phenomenon in end-of-life care. It occurs when one knows the morally correct response to an ethically challenging situation, but cannot act because of internal or external constraints. Medical students-having a perceived low level in the hospital hierarchy-may be particularly vulnerable to moral distress. Objective: To assess the frequency and intensity of medical students' moral distress occurring in end-of-life care. Design: We developed a questionnaire describing 10 potentially morally distressing scenarios in end-of-life care. Setting: The questionnaire was distributed to all fourth-year students of a German medical school. Measurements: We asked students (1) if they had ever witnessed the described scenarios and (2) to rate the extent (numeric rating scale 0-4) of moral distress for each situation. Results: Of 340 students, 217 (64%) completed the survey. On average, students had experienced 2.51 morally distressing situations (standard deviation = ±2.23). The majority of students (N = 163, 75%) had experienced at least one morally distressing situation. Providing futile care with the basic intention to make money was the item with the highest levels of experienced distress (2.88 ± 1.05), witnessed by 54 (25%) participants. Twenty-five students (12%) reported that they had thought about dropping out of medical school or choosing a nonclinical specialty because of moral distress. Conclusions: Medical students experience moral distress regularly and most frequently in scenarios of futile care. This may be an underestimated factor for medical school attrition. Interventions should identify the sources of moral distress and empower students to address their moral concerns.

Healthcare professionals’ moral distress in adult palliative care: a systematic review

Objectives

Palliative care providers may be exposed to numerous detrimental psychological and existential challenges. Ethical issues in the healthcare arena are subject to continual debate, being fuelled with ongoing medical, technological and legal advancements. This work aims to systematically review studies addressing the moral distress experienced by healthcare professionals who provide adult palliative care.

Methods

A literature search was performed on PubMed, Scopus, Web of Science and PsycINFO databases, searching for the terms ‘moral distress’ AND ‘palliative care’. The review process has followed the international PRISMA statement guidelines.

Results

The initial search identified 248 papers and 10 of them were considered eligible. Four main areas were identified: (1) personal factors, (2) patients and caregivers, (3) colleagues and superiors and (4) environment and organisation. Managing emotions of self and others, witnessing sufferance and disability, caring for highly demanding patients and caregivers, as well as poor communication were identified as distressing. Moreover, the relationship with colleagues and superiors, and organisational constraints often led to actions which contravened personal values invoking moral distress. The authors also summarised some supportive and preventive recommendations including self-empowerment, communication improvement, management of emotions and specific educational programmes for palliative care providers. A holistic model of moral distress in adult palliative care (integrating emotional, cognitive, behavioural and organisational factors) was also proposed.

Conclusions

Cognisance of risk and protective factors associated with the moral distress phenomenon may help reframe palliative healthcare systems, enabling effective and tailored actions that safeguard the well-being of providers, and consequently enhance patient care.