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Turk JK, Claymore E, Dawoodbhoy N, Steinauer JE. "I Went Into This Field to Empower Other People, and I Feel Like I Failed": Residents Experience Moral Distress Post- Dobbs. J Grad Med Educ 2024; 16:271-279. [PMID: 38882403 PMCID: PMC11173027 DOI: 10.4300/jgme-d-23-00582.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 01/09/2024] [Accepted: 03/20/2024] [Indexed: 06/18/2024] Open
Abstract
Background The 2022 Supreme Court ruling in Dobbs v Jackson Women's Health Organization nullified the constitutional right to abortion, which led to effective bans in at least 14 US states and placed obstetrics and gynecology (OB/GYN) residents in dilemmas where they may have to withhold care, potentially causing moral distress-a health care workforce phenomenon less understood among resident physicians. Objective To identify and explore moral distress experienced by OB/GYN residents due to care restrictions post-Dobbs. Methods In 2023, we invited OB/GYN residents, identified by their program directors, training in states with restricted abortion access, to participate in one-on-one, semi-structured interviews via Zoom about their experiences caring for patients post-Dobbs. We used thematic analysis to analyze interview data. Results Twenty-one residents described their experiences of moral distress due to restrictions. We report on 3 themes in their accounts related to moral distress (and 4 subthemes): (1) challenges to their physician identity (inability to do the job, internalized distress, and reconsidering career choices); (2) participating in care that exacerbates inequities (and erodes patient trust); and (3) determination to advocate for and provide abortion care in the future. Conclusions OB/GYN residents grappled with moral distress and identified challenges from abortion restrictions.
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Affiliation(s)
- Jema K Turk
- is Director of Evaluation, Ryan Residency Training Program, Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Emily Claymore
- is Assistant Director of Programs, Ryan Residency Training Program, Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Nafeesa Dawoodbhoy
- is Program Manager, Ryan Residency Training Program, Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA; and
| | - Jody E Steinauer
- is Director, Ryan Residency Training Program, Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
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Song X, Ding N, Jiang N, Zhang X, Li H, Wen D. Moral distress from professionalism dilemmas and its association with self-rated professionalism behaviors among Chinese residents. MEDICAL TEACHER 2024:1-10. [PMID: 38329725 DOI: 10.1080/0142159x.2024.2307486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 01/16/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVES Residents inevitably witness or participate in a diverse range of professionalism dilemmas. However, few studies have focused on residents' moral distress from professionalism dilemmas and its relationship with residents' professionalism. This study aimed to understand the moral distress that Chinese residents may face after exposure to professionalism dilemmas and to examine the associations between moral distress and residents' perceived fulfillment of professionalism behaviors. METHODS We conducted a cross-sectional survey of residents from four standardized residency training bases in Liaoning Province, China, using stratified cluster sampling. A checklist of professionalism dilemmas, the Moral Distress Scale, and the Behavior-based Medical Professionalism Inventory were used to assess residents' moral distress from professionalism dilemmas and their perceived fulfillment of professionalism behaviors. Descriptive statistics, non-parametric tests, multiple linear regressions, and binary logistic regressions were used to analyze the data. RESULTS A total of 647 (81.1%) residents effectively completed the survey. The proportion of residents suffering from moral distress ranged from 58.4 to 90.6% for different professionalism dilemmas. As the number of professionalism dilemmas associated with moral distress increased, residents reported lower fulfillment of professionalism behaviors (β < 0, p < 0.05). Compared with residents with no distress, residents suffering from distress reported lower fulfillment of professionalism behaviors (OR < 1, p < 0.05). Among residents suffering from distress, as the distress intensity increased, residents reported higher fulfillment of professionalism behaviors (OR > 1, p < 0.05). CONCLUSIONS Residents suffered a wide range of moral distress from professionalism dilemmas, and residents with moral distress reported lower fulfillment of professional behaviors. A responsive reporting system for residents and reflection on role modeling may help residents cope with the negative effects of moral distress and professionalism dilemmas.
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Affiliation(s)
- Xinzhi Song
- Institute for International Health Professions Education and Research, China Medical University, Shenyang, P. R. China
| | - Ning Ding
- Institute for International Health Professions Education and Research, China Medical University, Shenyang, P. R. China
| | - Nan Jiang
- Institute for International Health Professions Education and Research, China Medical University, Shenyang, P. R. China
| | - Xu Zhang
- Department of Public Service, The First Hospital of China Medical University, Shenyang, P. R. China
| | - Honghe Li
- Institute for International Health Professions Education and Research, China Medical University, Shenyang, P. R. China
| | - Deliang Wen
- Institute for International Health Professions Education and Research, China Medical University, Shenyang, P. R. China
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Hsieh HY, Lin CH, Huang R, Lin GC, Lin JY, Aldana C. Challenges for Medical Students in Applying Ethical Principles to Allocate Life-Saving Medical Devices During the COVID-19 Pandemic: Content Analysis. JMIR MEDICAL EDUCATION 2024; 10:e52711. [PMID: 38050366 PMCID: PMC10799279 DOI: 10.2196/52711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/18/2023] [Accepted: 12/03/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND The emergence of the COVID-19 pandemic has posed a significant ethical dilemma in the allocation of scarce, life-saving medical equipment to critically ill patients. It remains uncertain whether medical students are equipped to navigate this complex ethical process. OBJECTIVE This study aimed to assess the ability and confidence of medical students to apply principles of medical ethics in allocating critical medical devices through the scenario of virtual patients. METHODS The study recruited third- and fourth-year medical students during clinical rotation. We facilitated interactions between medical students and virtual patients experiencing respiratory failure due to COVID-19 infection. We assessed the students' ability to ethically allocate life-saving resources. Subsequently, we analyzed their written reports using thematic analysis to identify the ethical principles guiding their decision-making. RESULTS We enrolled a cohort of 67 out of 71 medical students with a mean age of 34 (SD 4.7) years, 60% (n=40) of whom were female students. The principle of justice was cited by 73% (n=49) of students while analyzing this scenario. A majority of them expressed hesitancy in determining which patient should receive life-saving resources, with 46% (n=31) citing the principle of nonmaleficence, 31% (n=21) advocating for a first-come-first-served approach, and 25% (n=17) emphasizing respect for patient autonomy as key influencers in their decisions. Notably, medical students exhibited a lack of confidence in making ethical decisions concerning the distribution of medical resources. A minority, comprising 12% (n=8), proposed the exploration of legal alternatives, while 4% (n=3) suggested medical guidelines and collective decision-making as potential substitutes for individual ethical choices to alleviate the stress associated with personal decision-making. CONCLUSIONS This study highlights the importance of improving ethical reasoning under time constraints using virtual platforms. More than 70% of medical students identified justice as the predominant principle in allocating limited medical resources to critically ill patients. However, they exhibited a lack of confidence in making ethical determinations and leaned toward principles such as nonmaleficence, patient autonomy, adherence to legal and medical standards, and collective decision-making to mitigate the pressure associated with such decisions.
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Affiliation(s)
- Hsing-Yen Hsieh
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Chyi-Her Lin
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Department of Pediatrics, E-Da Hospital, Kaohsiung, Taiwan
| | - Ruyi Huang
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Holistic Medicine, Department of Family and Community Medicine, E-Da Hospital, Kaohsiung, Taiwan
- Data Science Degree Program, National Taiwan University and Academia Sinica, Taipei, Taiwan
- Division of Family Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, and School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Guan-Chun Lin
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Jhen-Yu Lin
- Holistic Medicine, Department of Family and Community Medicine, E-Da Hospital, Kaohsiung, Taiwan
| | - Clydie Aldana
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
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Currie GP, Laing RB. Moral distress in healthcare professionals: Time to reflect. J R Coll Physicians Edinb 2023; 53:237-238. [PMID: 37997844 DOI: 10.1177/14782715231215409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023] Open
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Hamui-Sutton L, Paz-Rodriguez F, Sánchez-Guzmán A, Vives-Varela T, Corona T. Violence and Clinical Learning Environments in Medical Residencies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6754. [PMID: 37754613 PMCID: PMC10531318 DOI: 10.3390/ijerph20186754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 09/07/2023] [Accepted: 09/11/2023] [Indexed: 09/28/2023]
Abstract
INTRODUCTION The objective of this study was to describe and analyze residents' perceptions of characteristics on the expansive/restrictive continuum of their clinical learning environment. METHODS We conducted a quantitative, descriptive and cross-sectional study. A self-administered questionnaire was designed, programmed and applied to residents at the Faculty of Medicine of the National Autonomous University of Mexico. The instrument was structured in eight sections, and for this article, Section 3, which referred to clinical environments and violence was considered. The questionnaire had an 85% response rate, with 12,612 residents from 113 medical units and 78 specialties participating. The reliability and internal consistency measured with alpha omega obtained a value of ω 0.835 (CI; 0.828-0.843). RESULTS Unpleasant, competitive, tense and conflictive contexts were related to restrictive environments. Sexual orientation influenced the perception of intolerance in the clinical setting with respect to discriminatory comments, such that for gender minorities, the environment was experienced as exclusionary. First-year residents perceived environments as more aggressive, a perception that tended to decrease in later years of residency. DISCUSSION Abuses in power relations, rigid hierarchical positions and offensive clinical interactions may foster restrictive environments. In such settings, the reproduction of socio-culturally learned violence is feasible; however, asymmetrical relationships may be deconstructed and transformed.
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Affiliation(s)
- Liz Hamui-Sutton
- Division of Graduate Studies, Faculty of Medicine, National Autonomous University of Mexico, Unidad de Posgrado, Coyoacán, Mexico City 04510, Mexico or (L.H.-S.); (A.S.-G.); (T.C.)
| | - Francisco Paz-Rodriguez
- Laboratory of Clinical Neuropsychology, National Institute of Neurology and Neurosurgery, Av. Insurgentes Sur 3877, La Fama, Tlalpan, Mexico City 14269, Mexico
| | - Alejandra Sánchez-Guzmán
- Division of Graduate Studies, Faculty of Medicine, National Autonomous University of Mexico, Unidad de Posgrado, Coyoacán, Mexico City 04510, Mexico or (L.H.-S.); (A.S.-G.); (T.C.)
| | - Tania Vives-Varela
- Department of Research in Medical Education, Faculty of Medicine, National Autonomous University of Mexico, Av. Universidad 3000, Coyoacán, Mexico City 04510, Mexico;
| | - Teresa Corona
- Division of Graduate Studies, Faculty of Medicine, National Autonomous University of Mexico, Unidad de Posgrado, Coyoacán, Mexico City 04510, Mexico or (L.H.-S.); (A.S.-G.); (T.C.)
- Clinical Laboratory of Neurodegenerative Diseases, National Institute of Neurology and Neurosurgery, Av. Insurgentes Sur 3877, La Fama, Tlalpan, Mexico City 14269, Mexico
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Amick AE, Schrepel C, Bann M, Watsjold B, Jauregui J, Ilgen JS, Lu DW, Sebok-Syer SS. From Battles to Burnout: Investigating the Role of Interphysician Conflict in Physician Burnout. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:1076-1082. [PMID: 37043749 DOI: 10.1097/acm.0000000000005226] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
PURPOSE Despite the recognized importance of collaborative communication among physicians, conflict at transitions of care remains a pervasive issue. Recent work has underscored how poor communication can undermine patient safety and organizational efficiency, yet little is known about how interphysician conflict (I-PC) impacts the physicians forced to navigate these tensions. The goal of this study was to explore the social processes and interpersonal interactions surrounding I-PC and their impact, using conversations regarding admission between internal medicine (IM) and emergency medicine (EM) as a lens to explore I-PC in clinical practice. METHOD The authors used constructivist grounded theory to explore the interpersonal and social dynamics of I-PC. They used purposive sampling to recruit participants, including EM resident and attending physicians and IM attending physicians. The authors conducted hour-long, semistructured interviews between June and October 2020 using the Zoom video conferencing platform. Interviews were coded in 3 phases: initial line-by-line coding, focused coding, and recording. Constant comparative analysis was used to refine emerging codes, and the interview guide was iteratively updated. RESULTS The authors interviewed 18 residents and attending physicians about how engaging in I-PC led to both personal and professional harm. Specifically, physicians described how I-PC resulted in emotional distress, demoralization, diminished sense of professional attributes, and job dissatisfaction. Participants also described how emotional residue attached to past I-PC events primed the workplace for future conflict. CONCLUSIONS I-PC may represent a serious yet underrecognized source of harm, not only to patient safety but also to physician well-being. Participants described both the personal and professional consequences of I-PC, which align with the core tenets of burnout. Burnout is a well-established threat to the physician workforce, but unlike many other contributors to burnout, I-PC may be modifiable through improved education that equips physicians with the skills to navigate I-PC throughout their careers.
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Affiliation(s)
- Ashley E Amick
- A.E. Amick is assistant professor, Department of Emergency Medicine and Department of Internal Medicine, University of Washington, Seattle, Washington
| | - Caitlin Schrepel
- C. Schrepel is assistant professor, Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Maralyssa Bann
- M. Bann is assistant professor, Department of Medicine, University of Washington, Seattle, Washington
| | - Bjorn Watsjold
- B. Watsjold is assistant professor, Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Joshua Jauregui
- J. Jauregui is associate professor, Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Jonathan S Ilgen
- J.S. Ilgen is professor, Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Dave W Lu
- D.W. Lu is associate professor, Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Stefanie S Sebok-Syer
- S.S. Sebok-Syer is assistant professor, Department of Emergency Medicine, Stanford University, Stanford, California
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Shomalinasab E, Bagheri Z, Jahangirimehr A, Bahramnezhad F. The Nurses' Second Victim Syndrome and Moral Distress. Nurs Ethics 2023; 30:822-831. [PMID: 36988002 DOI: 10.1177/09697330221142079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND The increasing prevalence of moral distress in the stressful environment of the intensive care unit (ICU) provides grounds for nursing error and endangers patients' health, safety, and even life. One of the most important reasons for this distress is the treatment team's second victim syndrome (SVS), especially nurses, following errors in the treatment system. OBJECTIVES The present study aimed to determine the relationship between moral distress and SVS in ICUs. RESEARCH DESIGN This cross-sectional study involved a sample size of 96 ICU nurses working in hospitals affiliated with Tehran University of Medical Sciences, Iran, in the 2021-2022 period, who were selected via a simple random sampling method. Data were collected using the Demographic Questionnaire, the second victim experience and support tool (SVEST) and Moral Distress Scale-Revised (MDS-R). Descriptive statistics (percentage, frequency, mean, and SD) and analytical tests (Spearman correlation coefficient test, independent t-test, and ANOVA) were employed for data analysis. PARTICIPANTS AND RESEARCH CONTEXT This study used a sample size of 96 intensive care unit nurses working in hospitals affiliated to Tehran University of Medical Sciences selected by simple random sampling. ETHICAL CONSIDERATIONS The study obtained research ethics approval, and all participants were informed of the voluntary and anonymous nature of their participation. FINDINGS The results showed that 59.4% of nurses suffered a low level of moral distress, and 40.6% suffered from a moderate level of moral distress. The SVS score of 86.5% of the nurses was moderate. There was no significant and direct correlation between moral distress and SVS in nurses; however, there was a significant and inverse correlation between the moral distress intensity and SVS (p = 0.011). CONCLUSION Despite no significant correlation between moral distress and SVS, these variables were at moderate levels. Accordingly, it is suggested to provide a proper ground for expressing morally stressful situations, counseling and training strategies to deal with moral distress, creating support resources for those suffering from SVS, and implementing empowerment programs.
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Affiliation(s)
- Esmat Shomalinasab
- Department of Critical Care Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | | | | | - Fatemeh Bahramnezhad
- School of Nursing and Midwifery, Nursing and Midwifery Care Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Chieco D, Poitevien P. "We've Got Your Back:" The Role for Faculty in Easing Moral Distress for Residents. Pediatrics 2023:191243. [PMID: 37153968 DOI: 10.1542/peds.2023-061372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 05/10/2023] Open
Affiliation(s)
- Deanna Chieco
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Patricia Poitevien
- Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Moral Orientation, Moral Decision-Making, and Moral Distress Among Critical Care Physicians: A Qualitative Study. Crit Care Explor 2023; 5:e0879. [PMID: 36895887 PMCID: PMC9990831 DOI: 10.1097/cce.0000000000000879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Moral distress is common among critical care physicians and can impact negatively healthcare individuals and institutions. Better understanding inter-individual variability in moral distress is needed to inform future wellness interventions. OBJECTIVES To explore when and how critical care physicians experience moral distress in the workplace and its consequences, how physicians' professional interactions with colleagues affected their perceived level of moral distress, and in which circumstances professional rewards were experienced and mitigated moral distress. DESIGN Interview-based qualitative study using inductive thematic analysis. SETTING AND PARTICIPANTS Twenty critical care physicians practicing in Canadian ICUs who expressed interest in participating in a semi-structured interview after completion of a national, cross-sectional survey of moral distress in ICU physicians. RESULTS Study participants described different ways to perceive and resolve morally challenging clinical situations, which were grouped into four clinical moral orientations: virtuous, resigned, deferring, and empathic. Moral orientations resulted from unique combinations of strength of personal moral beliefs and perceived power over moral clinical decision-making, which led to different rationales for moral decision-making. Study findings illustrate how sociocultural, legal, and clinical contexts influenced individual physicians' moral orientation and how moral orientation altered perceived moral distress and moral satisfaction. The degree of dissonance between individual moral orientations within care team determined, in part, the quantity of "negative judgments" and/or "social support" that physicians obtained from their colleagues. The levels of moral distress, moral satisfaction, social judgment, and social support ultimately affected the type and severity of the negative consequences experienced by ICU physicians. CONCLUSIONS AND RELEVANCE An expanded understanding of moral orientations provides an additional tool to address the problem of moral distress in the critical care setting. Diversity in moral orientations may explain, in part, the variability in moral distress levels among clinicians and likely contributes to interpersonal conflicts in the ICU setting. Additional investigations on different moral orientations in various clinical environments are much needed to inform the design of effective systemic and institutional interventions that address healthcare professionals' moral distress and mitigate its negative consequences.
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Mengesha B, Zite N, Steinauer J. Implications of the Dobbs Decision for Medical Education: Inadequate Training and Moral Distress. JAMA 2022; 328:1697-1698. [PMID: 36318119 DOI: 10.1001/jama.2022.19544] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This Viewpoint discusses how states’ restrictions on abortion will affect medical students’ training in providing reproductive health care and also create moral distress by being forced to provide care that may harm patients.
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Affiliation(s)
- Biftu Mengesha
- Innovating Education in Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | - Nikki Zite
- Department of Obstetrics and Gynecology, University of Tennessee Medical Center, Knoxville
| | - Jody Steinauer
- Kenneth J. Ryan Residency Training Program in Abortion and Family Planning, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
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Liu LX, Goldszmidt M, Calvert S, Burm S, Torti J, Cristancho S, Sukhera J. From distress to detachment: exploring how providing care for stigmatized patients influences the moral development of medical trainees. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2022; 27:1003-1019. [PMID: 35643994 PMCID: PMC9148414 DOI: 10.1007/s10459-022-10125-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 05/08/2022] [Indexed: 06/15/2023]
Abstract
In acute hospital settings, medical trainees are often confronted with moral challenges and negative emotions when caring for complex and structurally vulnerable patients. These challenges may influence the long term moral development of medical trainees and have significant implications for future clinical practice. Despite the importance of moral development to medical education, the topic is still relatively under-explored. To gain a deeper understanding of moral development in trainees, we conducted a qualitative exploration of how caring for a stigmatized population influences their moral development. Data were collected from 48 medical trainees, including observational field notes, supplemental interviews, and medical documentation from inpatient units of two urban teaching hospitals in a Canadian context. Utilizing a practice-based approach which draws on constructivist grounded theory, we conducted constant comparative coding and analysis. We found that caring for stigmatized populations appeared to trigger frustration in medical trainees, which often perpetuated feelings of futility as well as avoidance behaviours. Additionally, hospital policies, the physical learning environment, variability in supervisory practices, and perceptions of judgment and mistrust all negatively influenced moral development and contributed to apathy and moral detachment which has implications for the future. Recognizing the dynamic and uncertain nature of care for stigmatized patients, and addressing the influence of structural and material factors provide an opportunity to support moral experiences within clinical training, and to improve inequities.
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Affiliation(s)
- Lisa X Liu
- Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Mark Goldszmidt
- Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Sara Calvert
- Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Sarah Burm
- Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Jacqueline Torti
- Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Sayra Cristancho
- Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Javeed Sukhera
- Chair/Chief of Psychiatry, Hartford Hospital and the Institute of Living, 200 Retreat Avenue Terry Building, Hartford, CT, 06106, USA.
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Beck J, Falco CN, O'Hara KL, Bassett HK, Randall CL, Cruz S, Hanson JL, Dean W, Senturia K. The Norms and Corporatization of Medicine Influence Physician Moral Distress in the United States. TEACHING AND LEARNING IN MEDICINE 2022:1-11. [PMID: 35466844 DOI: 10.1080/10401334.2022.2056740] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 03/02/2022] [Indexed: 06/14/2023]
Abstract
PhenomenonMoral distress, which occurs when someone's moral integrity is seriously compromised because they feel unable to act in accordance with their core values and obligations, is an increasingly important concern for physicians. Due in part to limited understanding of the root causes of moral distress, little is known about which approaches are most beneficial for mitigating physicians' distress. Our objective was to describe system-level factors in United States (U.S.) healthcare that contribute to moral distress among pediatric hospitalist attendings and pediatric residents.ApproachIn this qualitative study, we conducted one-on-one semi-structured interviews with pediatric hospitalist attendings and pediatric residents from 4 university-affiliated, freestanding children's hospitals in the U.S. between August 2019 and February 2020. Data were coded with an iteratively developed codebook, categorized into themes, and then synthesized.FindingsWe interviewed 22 hospitalists and 18 residents. Participants described in detail how the culture of medicine created a context that cultivated moral distress. Norms of medical education and the practice of medicine created conflicts between residents' strong sense of professional responsibility to serve the best interests of their patients and the expectations of a hierarchical system of decision-making. The corporatization of the U.S. healthcare system created administrative and financial pressures that conflicted with the moral responsibility felt by both residents and hospitalists to provide the care that their patients and families needed.InsightsThese findings highlight the critical role of systemic sources of moral distress. These findings suggest that system-level interventions must supplement existing interventions that target individual health care providers. Preventing and managing moral distress will require a broad approach that addresses systemic drivers, such as the corporatization of medicine, which are entrenched in the culture of medicine.
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Affiliation(s)
- Jimmy Beck
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Carla N Falco
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Kimberly L O'Hara
- Department of Pediatrics, University of Colorado School of Medicine, CO, USA
| | - Hannah K Bassett
- Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Cameron L Randall
- Department of Oral Health Sciences, University of Washington School of Dentistry, Seattle, Washington, USA
| | - Stephanie Cruz
- Department of Oral Health Sciences, University of Washington School of Dentistry, Seattle, Washington, USA
| | - Janice L Hanson
- Department of Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, MO, USA
| | - Wendy Dean
- Moral Injury of Healthcare LLC, Carlisle, PA, USA
| | - Kirsten Senturia
- Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA
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Hunter R, Willis K, Smallwood N. The workplace and psychosocial experiences of Australian junior doctors during the COVID-19 pandemic. Intern Med J 2022; 52:745-754. [PMID: 35189019 PMCID: PMC9111491 DOI: 10.1111/imj.15720] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/07/2022] [Accepted: 02/11/2022] [Indexed: 11/29/2022]
Abstract
Background Junior doctors experience high levels of psychological distress and emotional exhaustion. The current Coronavirus disease 2019 (COVID‐19) pandemic has resulted in significant changes to healthcare globally, with quantitative studies demonstrating increased fatigue, depression and burnout in junior doctors. However, there has been limited qualitative research to examine junior doctors' experiences, challenges and beliefs regarding management of future crises. Aims To investigate the workplace and psychosocial experiences of Australian junior doctors working during the second wave of the COVID‐19 pandemic. Methods Australian healthcare workers were invited to participate in a nationwide, voluntary, anonymous, single time point, online survey between 27 August and 23 October 2020. A qualitative descriptive study of responses to four free‐text questions from 621 junior doctors was undertaken, with responses analysed using inductive content analysis. Results Participants were predominantly female (73.2%), aged 31–40 years (48.0%) and most frequently reported working in medical specialties (48.4%), emergency medicine (21.7%) or intensive care medicine (11.4%). Most (51.9%) participants had 0–5 years of clinical experience since medical graduation. Junior doctors described experiences related to four key themes: a hierarchical, difficult workplace culture; challenging working conditions; disrupted training and career trajectories; and broader psychosocial impacts. The COVID‐19 pandemic exacerbated longstanding, workplace issues and stressors for junior doctors and highlighted the threat that crises pose to medical workforce retention. There is an urgent need for authentic, positive workplace cultural interventions to engage, validate and empower junior doctors. Conclusions Challenging workplace cultures and conditions, which have worsened during the COVID‐19 pandemic, are associated with poor psychological well‐being in junior doctors. There exists a need for long‐term, widespread improvements in workplace culture and working conditions to ensure junior doctors' well‐being, facilitate workforce retention and enhance the safety and quality of patient care in Australia.
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Affiliation(s)
- Roseanna Hunter
- Department of Medicine, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, Victoria, 3065, Australia
| | - Karen Willis
- Public Health, College of Health and Biomedicine, Victoria University, Footscray Park, Melbourne, Victoria, 3011, Australia.,Division of Critical Care and Investigative Services, Royal Melbourne Hospital, Grattan Street Parkville, Victoria, 3050, Australia
| | - Natasha Smallwood
- Department of Respiratory Medicin, The Alfred Hospital, 55 Commercial Road, Prahran, Victoria, 3004, Australia.,Department of Allergy, Immunology and Respiratory Medicine, Central Clinical School, The Alfred Hospital, Monash University, Melbourne, Victoria, 3004, Australia
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14
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Bradshaw A, Dunleavy L, Garner I, Preston N, Bajwah S, Cripps R, Fraser LK, Maddocks M, Hocaoglu M, Murtagh FE, Oluyase AO, Sleeman KE, Higginson IJ, Walshe C. Experiences of staff providing specialist palliative care during COVID-19: a multiple qualitative case study. J R Soc Med 2022; 115:220-230. [PMID: 35133216 PMCID: PMC9158238 DOI: 10.1177/01410768221077366] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To explore the experiences of, and impact on, staff working in palliative care during the COVID-19 pandemic. Design Qualitative multiple case study using semi-structured interviews between November 2020 and April 2021 as part of the CovPall study. Data were analysed using thematic framework analysis. Setting Organisations providing specialist palliative services in any setting. Participants Staff working in specialist palliative care, purposefully sampled by the criteria of role, care setting and COVID-19 experience. Main outcome measures Experiences of working in palliative care during the COVID-19 pandemic. Results Five cases and 24 participants were recruited (n = 12 nurses, 4 clinical managers, 4 doctors, 2 senior managers, 1 healthcare assistant, 1 allied healthcare professional). Central themes demonstrate how infection control constraints prohibited and diluted participants’ ability to provide care that reflected their core values, resulting in experiences of moral distress. Despite organisational, team and individual support strategies, continually managing these constraints led to a ‘crescendo effect’ in which the impacts of moral distress accumulated over time, sometimes leading to burnout. Solidarity with colleagues and making a valued contribution provided ‘moral comfort’ for some. Conclusions This study provides a unique insight into why and how healthcare staff have experienced moral distress during the pandemic, and how organisations have responded. Despite their experience of dealing with death and dying, the mental health and well-being of palliative care staff was affected by the pandemic. Organisational, structural and policy changes are urgently required to mitigate and manage these impacts.
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Affiliation(s)
- Andy Bradshaw
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, SE5 9PJ, UK
| | - Lesley Dunleavy
- International Observatory on End of Life Care, Lancaster University, LA1 4AT, UK
| | - Ian Garner
- International Observatory on End of Life Care, Lancaster University, LA1 4AT, UK
| | - Nancy Preston
- International Observatory on End of Life Care, Lancaster University, LA1 4AT, UK
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, SE5 9PJ, UK
| | - Rachel Cripps
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, SE5 9PJ, UK
| | - Lorna K Fraser
- Martin House Research Centre, Department of Health Sciences, University of York, YO10 5DD, UK
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, SE5 9PJ, UK
| | - Mevhibe Hocaoglu
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, SE5 9PJ, UK
| | - Fliss Em Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, HU6 7RX, UK
| | - Adejoke O Oluyase
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, SE5 9PJ, UK
| | - Katherine E Sleeman
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, SE5 9PJ, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, SE5 9PJ, UK
| | - Catherine Walshe
- International Observatory on End of Life Care, Lancaster University, LA1 4AT, UK
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15
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Smid AMC, de Jong S, Inberg PH, Sinclair S, von Keyserlingk MA, Weary DM, Barkema HW. Western Canadian dairy farmers' perspectives on the provision of outdoor access for dairy cows and on the perceptions of other stakeholders. J Dairy Sci 2022; 105:4461-4473. [DOI: 10.3168/jds.2021-21237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 01/07/2022] [Indexed: 11/19/2022]
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16
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Experience of General Practice Residents Caring for Dependent Elderly during the First COVID-19 Lockdown-A Qualitative Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312281. [PMID: 34886006 PMCID: PMC8657085 DOI: 10.3390/ijerph182312281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/18/2021] [Accepted: 11/19/2021] [Indexed: 12/02/2022]
Abstract
Background: Understanding the experiences of general practice (GP) residents caring for dependent elderly people during the first lockdown as part of the countries COVID-19 pandemic strategy. The aim was to explore themes that could explain the gap between the missions and values at the heart of GP practice during this period of strict isolation. Method: Qualitative study using an iterative approach. Semi-structured interviews were conducted with 13 GP residents using a pre-established interview guide. Audio recordings were transcribed verbatim. Data were analyzed according to a coding grid, developed using Nvivo software (NVivo Qualitative Data Analysis Software; QSR International Pty Ltd. Version Release 1.5.1 (940) 2021), to identify emerging themes. Results: Three themes emerged from this qualitative research: cognitive dissonance, psychosocial risks, and fear. General practice residents have lived in the paradox between care and deprivation of liberty of dependent elderly people. Conclusion: The results suggest that the GP residents experienced a form of work-related suffering in this situation of deprivation of liberty of dependent elderly people. The present research serves as a pilot study to explore how GP residents experienced their care of locked-up dependent elderly people.
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17
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Hofmann B. The role of philosophy and ethics at the edges of medicine. Philos Ethics Humanit Med 2021; 16:14. [PMID: 34742309 PMCID: PMC8572077 DOI: 10.1186/s13010-021-00114-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 10/12/2021] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND The edge metaphor is ubiquitous in describing the present situation in the world, and nowhere is this as clearly visible as in medicine. "The edge of medicine" has become the title of books, scholarly articles, media headlines, and lecture series and seems to be imbued with hype, hope, and aversion. In order better to understand what is at stake at "the edge of medicine" this article addresses three questions: What does "the edge of medicine" mean in contemporary debates on modern medicine? What are the challenges "on the edge of medicine" (in these various meanings of "on the edge")? How can philosophy and ethics contribute with addressing these challenges? METHODS Literature searches in PubMed and Google Scholar are used to identify uses of the phrase "the edge of medicine" while conventional content analysis is used to analyze meanings of and challenges with "the edge of medicine." These results are then investigated with respect to how philosophy and ethics can address the identified challenges. RESULTS The literature reveals that "the edge of medicine" has many meanings, such as: Border; Margin (of life); Frontier; Forefront; Fringes; Plunge (abyss); Brink (verge); Conflict; and Balancing. In general, the various meanings address four basic challenges: setting limits, keeping control, make meaning, and handling conflicts or aporias. The analysis of each of the meanings of "the edge of medicine" identifies a wide range of important and urgent tasks for the humanities in general, and for philosophy and ethics in particular: 1) clarifying concepts; 2) clarifying assumptions and premises of arguments, methods, advice, and decisions; 3) elaborate new concepts and new theories; 4) conceptualize and handle uncertainty, moral regret, and residue; 5) reveal "the emperor's new clothes;" 6) identify trends and reflect on their implications; 7) demarcation; and 8) reflecting on goodness in medicine. CONCLUSION The phrase "the edge of medicine" expresses a wide range of challenges for modern health care. Together with other disciplines philosophy and ethics can and should make crucial contributions at "the edge of medicine," which is where the future of human beings and societies is created and formed.
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Affiliation(s)
- Bjørn Hofmann
- Department of Health Sciences, The Norwegian University Science and Technology, Gjøvik, PO Box 1, N-2802, Gjøvik, Norway.
- Centre for Medical Ethics at the University of Oslo, Oslo, Norway.
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18
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How Attendings Can Help Residents Navigate Moral Distress: A Qualitative Study. Acad Pediatr 2021; 21:1458-1466. [PMID: 34146721 DOI: 10.1016/j.acap.2021.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 05/26/2021] [Accepted: 06/07/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To explore how pediatric hospitalist attendings can recognize, prevent, and mitigate moral distress among pediatric residents. METHODS We conducted a qualitative study, utilizing a deductive approach, from August 2019 to February 2020 at 4 university-affiliated, freestanding children's hospitals in the United States using semistructured, one-on-one interviews with pediatric residents and pediatric hospitalist attendings. All transcripts were coded by pairs of research team members. Using constant comparative analysis, codes were categorized into themes and subsequently grouped into domains. We then conceptualized the relationships between the domains. RESULTS We interviewed 40 physicians (18 residents, 22 attendings) and identified specific strategies for attendings to help residents navigate moral distress, which were categorized into 4 proactive and 4 responsive themes. The proactive themes included strategies employed before morally distressing events to minimize impact: ensuring attendings' awareness of residency factors influencing residents' moral distress; knowing available support resources; creating a learning environment that lays the foundation for mitigating distress; and recognizing moral distress in residents. The responsive themes included strategies that help mitigate the impact of morally distressing situations after they occur: partnering with the senior resident to develop a team-specific plan; consideration of who will participate in, the timing of, and content of the debrief. CONCLUSIONS We present multiple strategies that attendings can implement to learn to recognize, prevent, and mitigate moral distress among residents. Our findings highlight the need for both proactive and reactive strategies and offer a possible roadmap for attending physicians to help their residents navigate moral distress.
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19
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Herschkopf MD. Moral Distress or Countertransference? Addressing Emotional Reactions of Psychiatry Trainees. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2021; 45:476-480. [PMID: 33825172 DOI: 10.1007/s40596-021-01443-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 03/22/2021] [Indexed: 06/12/2023]
Affiliation(s)
- Marta D Herschkopf
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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20
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Sukhera J, Kulkarni C, Taylor T. Structural distress: experiences of moral distress related to structural stigma during the COVID-19 pandemic. PERSPECTIVES ON MEDICAL EDUCATION 2021; 10:222-229. [PMID: 33914288 PMCID: PMC8082743 DOI: 10.1007/s40037-021-00663-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/17/2021] [Accepted: 03/30/2021] [Indexed: 05/14/2023]
Abstract
INTRODUCTION The COVID-19 pandemic has taken a significant toll on the health of structurally vulnerable patient populations as well as healthcare workers. The concepts of structural stigma and moral distress are important and interrelated, yet rarely explored or researched in medical education. Structural stigma refers to how discrimination towards certain groups is enacted through policy and practice. Moral distress describes the tension and conflict that health workers experience when they are unable to fulfil their duties due to circumstances outside of their control. In this study, the authors explored how resident physicians perceive moral distress in relation to structural stigma. An improved understanding of such experiences may provide insights into how to prepare future physicians to improve health equity. METHODS Utilizing constructivist grounded theory methodology, 22 participants from across Canada including 17 resident physicians from diverse specialties and 5 faculty members were recruited for semi-structured interviews from April-June 2020. Data were analyzed using constant comparative analysis. RESULTS Results describe a distinctive form of moral distress called structural distress, which centers upon the experience of powerlessness leading resident physicians to go above and beyond the call of duty, potentially worsening their psychological well-being. Faculty play a buffering role in mitigating the impact of structural distress by role modeling vulnerability and involving residents in policy decisions. CONCLUSION These findings provide unique insights into teaching and learning about the care of structurally vulnerable populations and faculty's role related to resident advocacy and decision-making. The concept of structural distress may provide the foundation for future research into the intersection between resident well-being and training related to health equity.
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Affiliation(s)
- Javeed Sukhera
- Departments of Psychiatry/Paediatrics and Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Chetana Kulkarni
- Hospital for Sick Children (SickKids), Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Taryn Taylor
- Department of Obstetrics and Gynecology and Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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21
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Ribeiro DL, Costa M, Helmich E, Jaarsma D, de Carvalho‐Filho MA. 'I found myself a despicable being!': Medical students face disturbing moral dilemmas. MEDICAL EDUCATION 2021; 55:857-871. [PMID: 33386638 PMCID: PMC8248051 DOI: 10.1111/medu.14447] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 12/05/2020] [Accepted: 12/26/2020] [Indexed: 06/12/2023]
Abstract
CONTEXT The psychological realm of medical students' moral experiences is explored tangentially in medical education literature, often in the context of ethics or professionalism education. This study deepens our understanding by (a) investigating the nature of moral dilemmas experienced at the onset of clinical practice, (b) exploring students' emotional response to these dilemmas, and (c) examining how students perceive the influence of these dilemmas on their professional development. METHODS This is a cross-sectional qualitative study carried out in 2017 that applied thematic template analysis to individual interviews performed with last-year medical students. The interviews followed the drawing of a Rich Picture representing moral dilemmas experienced by medical students at the onset of clinical practice. RESULTS Moral dilemmas have four intertwined dimensions. The first relates to students' struggle to prioritise, balance and apply conflicting moral values; the second comprises the clash between students' inner motivation and the external constraints that limit the moral action; the third refers to the conflict between students' current attitudes with the desired/idealised attitudes of the doctor they intend to become; and the fourth corresponds to weighting conflicting ethical principles during the moral decision. Students' emotional responses are intense and long-lasting, and with a remarkable residue effect, particularly when the moral decision does not align with their moral beliefs. Moral dilemmas are impactful experiences that affect the professional development of medical students and can culminate in both detachment and growth in moral courage. CONCLUSION Moral dilemmas are memorable, complex and emotionally intense experiences that impact the professional development of medical students. Understanding students' moral dilemmas can help educators to devise pedagogical activities to anticipate and reflect on these experiences. These activities should happen under the guidance of a non-judgemental facilitator, capable of listening and legitimating students' thoughts and feelings while providing insights to nurture their professional development.
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Affiliation(s)
- Diego Lima Ribeiro
- Department of Ethics and Emergency MedicineUniversity of CampinasCampinasBrazil
| | - Marcos Costa
- University Medical Center AmsterdamAmsterdamThe Netherlands
| | - Esther Helmich
- Center for Education Development and Research in Health ProfessionsUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Debbie Jaarsma
- Center for Education Development and Research in Health ProfessionsUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Marco Antonio de Carvalho‐Filho
- Center for Education Development and Research in Health ProfessionsUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
- ICVS ‐ Life and Health Sciences Research InstituteUniversity of MinhoBragaPortugal
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22
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Ohel-Shani I, Yassour-Borochowitz D. Moral Distress and Feticide: Hearing the Voices of Maternal-Fetal Medicine Physicians. THE JOURNAL OF CLINICAL ETHICS 2021. [DOI: 10.1086/jce2021322114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Perlstein R, McLeod J, Bell C, Nowson C. Nutrition content of summative examinations within an Australian 4-year graduate entry medical course: 2013-2016. BMJ Nutr Prev Health 2021; 4:251-256. [PMID: 34308133 PMCID: PMC8258023 DOI: 10.1136/bmjnph-2021-000280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/03/2021] [Indexed: 11/12/2022] Open
Abstract
Background Poor nutrition is a major contributor to chronic disease, but the level of nutrition education in medical training is limited. Deakin University Medical School has been working to embed more nutrition into the curriculum since 2009. Aim To assess the nutrition content of all summative examinations in the Bachelor of Medicine, Bachelor of Surgery over a 4-year period. Methods The type, amount and scope of nutrition-related questions were assessed in all summative examinations delivered to all 4-year levels from 2013 to 2016. These were assessed independently and analysed for nutrition content. The amount of nutrition was quantified, and the nutrition topic areas and nutrition competencies addressed were documented. Results Less than 10% of summative examination questions contained any nutrition content. For first-year and second-year students, these examinations included an average yearly total of 433 multiple choice questions (MCQs) (range 337–530) and 47 short answer questions (SAQs) (range 33–62). Third-year and fourth-year students had 150 MCQs on average per year and no SAQs. The percentage of nutrition-related questions across all 4 years ranged from 6% in 2013 to 10% in 2016. The proportion of SAQs with nutrition content ranged from 12% in 2013 to 19% in 2016. Basic nutritional sciences, accounted for 60% of nutrition content and, 25% addressed dietary strategies for prevention and treatment of disease, and skills-based nutrition competencies represented approximately 10% of all questions. Summary and conclusions Minimal nutrition was included in the summative examinations. There did not appear to be any consistent increase in the nutrition content of MCQs over the 4-year period but there was some indication of an increase in nutrition content in SAQs. Longer term evaluation is required to confirm this trend. Only a small number of nutrition questions were skills based, most focused on basic nutritional science. Examinations included few skills-based nutrition questions, and consideration of setting a minimum level of nutrition in examinations could assist in ensuring the development of appropriate nutrition competencies in medical graduates.
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Affiliation(s)
- Robyn Perlstein
- Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Janet McLeod
- Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Colin Bell
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Caryl Nowson
- School of Exercise and Nutrition Sciences, Deakin University-Geelong Campus at Waurn Ponds, Waurn Ponds, Victoria, Australia
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Kherbache A, Mertens E, Denier Y. Moral distress in medicine: An ethical analysis. J Health Psychol 2021; 27:1971-1990. [PMID: 33938314 DOI: 10.1177/13591053211014586] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Moral distress is a negative emotional response that occurs when physicians know the morally correct action but are prevented from taking it because of internal or external constraints. Moral distress undermines a physician's ethical integrity, leading to anger, poor job satisfaction, reduced quality of care and burnout. Scarce literature exists on the ethical aspects of moral distress in medicine. We conducted an ethical analysis of moral distress as experienced by physicians and analysed it from the literature using two predominant ethical theories: principlism and care ethics. Finally, we consider the emergence of moral distress in medicine during the COVID-19 pandemic.
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Ritchie MJ, Parker LE, Kirchner JE. From novice to expert: methods for transferring implementation facilitation skills to improve healthcare delivery. Implement Sci Commun 2021; 2:39. [PMID: 33832549 PMCID: PMC8033694 DOI: 10.1186/s43058-021-00138-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 03/22/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND There is substantial evidence that facilitation can address the challenges of implementing evidence-based innovations. However, facilitators need a wide variety of complex skills; lack of these can have a negative effect on implementation outcomes. Literature suggests that novice and less experienced facilitators need ongoing support from experts to develop these skills. Yet, no studies have investigated the transfer process. During a test of a facilitation strategy applied at 8 VA primary care clinics, we explored the techniques and processes an expert external facilitator utilized to transfer her skills to two initially novice internal facilitators who became experts. METHODS In this qualitative descriptive study, we conducted monthly debriefings with three facilitators over a 30-month period and documented these in detailed notes. Debriefings with the expert facilitator focused on how she trained and mentored facilitation trainees. We also conducted, recorded, and transcribed two semi-structured qualitative interviews with each facilitator and queried them about training content and process. We used a mix of inductive and deductive approaches to analyze data; our analysis was informed by a review of mentoring, coaching, and cognitive apprenticeship literature. We also used a case comparison approach to explore how the expert tailored her efforts. RESULTS The expert utilized 21 techniques to transfer implementation facilitation skills. Techniques included both active (providing information, modeling, and coaching) and participatory ones. She also used techniques to support learning, i.e., cognitive supports (making thinking visible, using heuristics, sharing experiences), psychosocial supports, strategies to promote self-learning, and structural supports. Additionally, she transferred responsibility for facilitation through a dynamic process of interaction with trainees and site stakeholders. Finally, the expert varied the level of focus on particular skills to tailor her efforts to trainee and local context. CONCLUSIONS This study viewed the journey from novice to expert facilitator through the lens of the expert who transferred facilitation skills to support implementation of an evidence-based program. It identified techniques and processes that may foster transfer of these skills and build organizational capacity for future implementation efforts. As the first study to document the implementation facilitation skills transfer process, findings have research and practical implications.
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Affiliation(s)
- Mona J. Ritchie
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI), Department of Veterans Affairs, 2200 Ft Roots Dr, Building 58, North Little Rock, AR 72114 USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham St, #755, Little Rock, AR 72205 USA
| | - Louise E. Parker
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI), Department of Veterans Affairs, 2200 Ft Roots Dr, Building 58, North Little Rock, AR 72114 USA
- Department of Management, College of Management, University of Massachusetts, 100 Morrissey Blvd, Boston, MA 02125 USA
| | - JoAnn E. Kirchner
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI), Department of Veterans Affairs, 2200 Ft Roots Dr, Building 58, North Little Rock, AR 72114 USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham St, #755, Little Rock, AR 72205 USA
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Wald HS, Ruddy M. Surreal Becomes Real: Ethical Dilemmas Related to the COVID-19 Pandemic and Professional Identity Formation of Health Professionals. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2021; 41:124-129. [PMID: 33851809 DOI: 10.1097/ceh.0000000000000346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Fundamental quandaries of clinical and biomedical ethics for health care professionals, committees, and systems have been raised into stark relief by the COVID-19 pandemic. The nature and extent of critical issues raised by this ongoing crisis, including challenging ethical dilemmas for the health care profession, is likely to have an indelible impact on the professional identity formation (PIF) of learners and practitioners across the trajectory of the professional lifecycle. The lifelong process of PIF for health care practitioners, from learner through independent practice, is supported in medical education by intentional reflection, relationships within community of practice include guidance from mentoring, as well as resilience, both emotional and moral. We consider how grappling with ethical dilemmas related to the COVID-19 pandemic can challenge, inform, and even potentially transform the PIF process, thereby supporting development of a morally resilient, humanistic professional identity in health care trainees and health care professionals.
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Affiliation(s)
- Hedy S Wald
- Dr. Wald: Clinical Professor of Family Medicine, Warren Alpert Medical School of Brown University, Providence, RI; and
- Dr. Ruddy: Vice President for Academic Affairs, the Wright Center for Graduate Medical Education, Minneapolis, MN
| | - Meaghan Ruddy
- Dr. Wald: Clinical Professor of Family Medicine, Warren Alpert Medical School of Brown University, Providence, RI; and
- Dr. Ruddy: Vice President for Academic Affairs, the Wright Center for Graduate Medical Education, Minneapolis, MN
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Delgado J, Siow S, de Groot J, McLane B, Hedlin M. Towards collective moral resilience: the potential of communities of practice during the COVID-19 pandemic and beyond. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-106764. [PMID: 33762300 PMCID: PMC7992383 DOI: 10.1136/medethics-2020-106764] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 02/09/2021] [Accepted: 02/23/2021] [Indexed: 05/25/2023]
Abstract
This paper proposes communities of practice (CoP) as a process to build moral resilience in healthcare settings. We introduce the starting point of moral distress that arises from ethical challenges when actions of the healthcare professional are constrained. We examine how situations such as the current COVID-19 pandemic can exponentially increase moral distress in healthcare professionals. Then, we explore how moral resilience can help cope with moral distress. We propose the term collective moral resilience to capture the shared capacity arising from mutual engagement and dialogue in group settings, towards responding to individual moral distress and towards building an ethical practice environment. Finally, we look at CoPs in healthcare and explore how these group experiences can be used to build collective moral resilience.
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Affiliation(s)
- Janet Delgado
- NICU, University Hospital of the Canary Islands, La Laguna, La Laguna, Spain
- University Institute of Women's Studies, University of La Laguna, La Laguna, Spain
| | - Serena Siow
- Department of Family Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Janet de Groot
- Department of Psychiatry, Oncology and Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Brienne McLane
- Department of Psychiatry, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Margot Hedlin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Babamohamadi H, Bakuei Katrimi S, Paknazar F. Moral distress and its contributing factors among emergency department nurses: A cross-sectional study in Iran. Int Emerg Nurs 2021; 56:100982. [PMID: 33714726 DOI: 10.1016/j.ienj.2021.100982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/29/2021] [Accepted: 02/15/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Moral Distress (MD) is a common experience in nursing practice and constitutes one of the main reasons for professional burnout, job withdrawal, fatigue, and avoidance of patient care among nurses. The causes, frequency and severity of MD vary according to the ward and hospital of service. The present study was conducted to determine the frequency and severity of MD and its contributing factors among Emergency Department (ED) nurses in Iran. METHODS This descriptive cross-sectional study was conducted in 2019.A total of 203 participants were selected by census sampling from the 248 nurses working in the EDs of hospitals in Semnan Province, Iran. Data were collected using Corley's Moral Distress Scale-Revised and analyzed using descriptive and inferential statistics. FINDINGS The mean severity and frequency of MD were 1.36 ± 0.74 and 1.20 ± 0.68 out of 4, respectively. The MD levels were significantly higher in female nurses (p = 0.002), those under 30 years of age (p = 0.003), with less than ten years' work experience (p = 0.03), and with higher levels of education (p < 0.001). In addition, inverse and significant relationships were found between MD and the nurses' age (r = -0.202,p = 0.004) and work experience(r = -0.149, p = 0.034). CONCLUSION According to the results, nurses had moderate levels of MD. Numerous factors, including age, gender, work experience, and education, were associated with the total MD score.To reduce MD and its negative effects on nurses, it is necessary to address these factors and appropriately plan to identify and manage MD so as to improve the quality of nursing care.
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Affiliation(s)
- Hassan Babamohamadi
- Nursing Care Research Center, Semnan University of Medical Sciences, Semnan, Iran; Department of Nursing, School of Nursing and Midwifery, Semnan University of Medical Sciences, Semnan, Iran.
| | | | - Fatemeh Paknazar
- Social Determinants of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran; Department of Epidemiology and Biostatistics, School of Medicine, Semnan University of Medical Sciences, Semnan, Iran
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McDonald J, Graves J, Abrahams N, Thorneycroft R, Hegazi I. Moral judgement development during medical student clinical training. BMC MEDICAL EDUCATION 2021; 21:140. [PMID: 33653350 PMCID: PMC7927259 DOI: 10.1186/s12909-021-02572-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 02/15/2021] [Indexed: 05/16/2023]
Abstract
BACKGROUND Whereas experience and cognitive maturity drives moral judgement development in most young adults, medical students show slowing, regression, or segmentation in moral development during their clinical years of training. The aim of this study was to explore the moral development of medical students during clinical training. METHODS A cross-sectional sample of medical students from three clinical years of training were interviewed in groups or individually at an Australian medical school in 2018. Thematic analysis identified three themes which were then mapped against the stages and dimensions of Self-authorship Theory. RESULTS Thirty five medical students from years 3-5 participated in 11 interviews and 6 focus groups. Students shared the impacts of their clinical experiences as they identified with their seniors and increasingly understood the clinical context. Their accounts revealed themes of early confusion followed by defensiveness characterised by desensitization and justification. As students approached graduation, some were planning how they would make moral choices in their future practice. These themes were mapped to the stages of self-authorship: External Formulas, Crossroads and Self-authorship. CONCLUSIONS Medical students recognise, reconcile and understand moral decisions within clinical settings to successfully reach or approach self-authorship. Curriculum and support during clinical training should match and support this progress.
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Affiliation(s)
- Jenny McDonald
- School of Medicine, Western Sydney University, Penrith, NSW, Australia.
| | - Jane Graves
- School of Medicine, Western Sydney University, Penrith, NSW, Australia
| | - Neeshaan Abrahams
- School of Medicine, Western Sydney University, Penrith, NSW, Australia
| | - Ryan Thorneycroft
- School of Sociology, Western Sydney University, Penrith, NSW, Australia
| | - Iman Hegazi
- School of Medicine, Western Sydney University, Penrith, NSW, Australia
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Crisci T, Salih ZNI, Unaka N, Peerzada J, Antommaria AHM. What Should an Intern Do When She Disagrees With the Attending? Pediatrics 2021; 147:peds.2020-049646. [PMID: 33627371 DOI: 10.1542/peds.2020-049646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 11/24/2022] Open
Abstract
Disagreements, including those between residents and attending physicians, are common in medicine. In this Ethics Rounds article, we present a case in which an intern and attending disagree about discharging the patient; the attending recommends that the patient be hospitalized longer without providing evidence to support his recommendation. Commentators address different aspects of the case. The first group, including a resident, focus on the intern's potential moral distress and the importance of providing trainees with communication and conflict resolution skills to address inevitable conflicts. The second commentator, a hospitalist and residency program director, highlights the difference between residents' decision ownership and attending physicians' responsibilities and the way in which attending physicians' responsibilities for patients can conflict with their roles as teachers. She also highlights a number of ways training programs can support both trainees and attending physicians in addressing conflict, including cultivating a learning environment in which questioning is encouraged and celebrated. The third commentator, a hospitalist, notes the importance of shared decision-making with patients and their parents when decisions involve risk and uncertainty. Family-centered rounds can facilitate shared decision-making.
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Affiliation(s)
- Timothy Crisci
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana; .,Riley Hospital for Children, Indianapolis, Indiana
| | - Zeynep N Inanc Salih
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana.,Riley Hospital for Children, Indianapolis, Indiana
| | - Ndidi Unaka
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, School of Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | | | - Armand H Matheny Antommaria
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, School of Medicine, University of Cincinnati, Cincinnati, Ohio; and
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Wald HS, Monteverde S. COVID-19 era healthcare ethics education: Cultivating educational and moral resilience. Nurs Ethics 2021; 28:58-65. [PMID: 33427018 DOI: 10.1177/0969733020976188] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The COVID-19 pandemic crisis has had profound effects on global health, healthcare, and public health policy. It has also impacted education. Within undergraduate healthcare education of doctors, nurses, and allied professions, rapid shifts to distance learning and pedagogic content creation within new realities, demands of healthcare practice settings, shortened curricula, and/or earlier graduation have also challenged ethics teaching in terms of curriculum allotments or content specification. We propose expanding the notion of resilience to the field of ethics education under the conditions of remote learning. Educational resilience starts in the virtual classroom of ethics teaching, initially constituted as an "unpurposed space" of exchange about the pandemic's challenging impact on students and educators. This continuously transforms into "purposed space" of reflection, discovering ethics as a repertory of orientative knowledge for addressing the pandemic's challenges on personal, professional, societal, and global levels and for discovering (and then addressing) that the health of individuals and populations also has moral determinants. As such, an educational resilience framework with inherent adaptability rises to the challenge of supporting the moral agency of students acting both as professionals and as global citizens. Educational resilience is key in supporting and sustaining professional identify formation and facilitating the development of students' moral resilience and leadership amid moral complexity and potential moral transgression-not only but especially in times of pandemic.
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Affiliation(s)
- Hedy S Wald
- 12321Warren Alpert Medical School of Brown University, USA
| | - Settimio Monteverde
- Bern University of Applied Sciences, Switzerland; University of Zurich, Switzerland
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Grech M. The Effect of the Educational Environment on the rate of Burnout among Postgraduate Medical Trainees - A Narrative Literature Review. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2021; 8:23821205211018700. [PMID: 34104789 PMCID: PMC8170339 DOI: 10.1177/23821205211018700] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/22/2021] [Indexed: 05/10/2023]
Abstract
BACKGROUND Burnout among postgraduate medical trainees is common. It is a syndrome characterised by emotional exhaustion, depersonalisation and reduced personal accomplishment. Burnout is seen as an organisational problem rather than the result of an individual's ability to cope with the stress at work. The educational environment can play a pivotal role in the prevention of burnout among postgraduate medical trainees. This narrative literature review is aimed at assessing the effect of the educational environment on burnout in postgraduate doctors-in-training. METHODS A search of the databases Medline and PscyInfo for articles published between 2015 and 2020 was performed with the key words 'burnout' and 'educational environment' or 'clinical learning environment' or 'postgraduate medical education' or 'learning environment'. RESULTS A total of 27 studies were identified and reviewed by the author. The prevalence of burnout reported varied widely between studies, ranging from 10% to 62%. Many of the factors that contribute to burnout form part of the educational environment, for example, hours worked, mistreatment, harassment and perceptions of injustice. Residency itself is a stressful period wherein trainees have to balance their responsibilities towards their patients with their responsibilities at home, all while furthering their studies and taking on new responsibilities. Interventions to prevent burnout and tackle existing burnout are multiple but very little solid evidence exists to attest to their efficacy. More research is needed to identify the most effective ways to deal with burnout in postgraduate medical trainees.
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Castillo EG, Isom J, DeBonis KL, Jordan A, Braslow JT, Rohrbaugh R. Reconsidering Systems-Based Practice: Advancing Structural Competency, Health Equity, and Social Responsibility in Graduate Medical Education. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:1817-1822. [PMID: 32590465 PMCID: PMC8279228 DOI: 10.1097/acm.0000000000003559] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Health inequities stem from systematic, pervasive social and structural forces. These forces marginalize populations and create the circumstances that disadvantage these groups, as reflected in differences in outcomes like life expectancy and infant mortality and in inequitable access to and delivery of health care resources. To help eradicate these inequities, physicians must understand racism, sexism, oppression, historical marginalization, power, privilege, and other sociopolitical and economic forces that sustain and create inequities. A new educational paradigm emphasizing the knowledge, skills, and attitudes to achieve health equity is needed.Systems-based practice is the graduate medical education core competency that focuses on complex systems and physicians' roles within them; it includes topics like multidisciplinary team-based care, patient safety, cost containment, end-of-life goals, and quality improvement. This competency, however, is largely health care centric and does not train physicians to engage with the complexities of the social and structural determinants of health or to partner with systems and communities that are outside health care.The authors propose a new core competency centered on health equity, social responsibility, and structural competency to address this gap in graduate medical education. For the development of this new competency, the authors draw on existing, innovative undergraduate and graduate medical pedagogy and public health, health services research, and social medicine frameworks. They describe how this new competency would inform graduate medical education and clinical care and encourage future physicians to engage in the work of health equity.
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Affiliation(s)
- Enrico G Castillo
- E.G. Castillo is a psychiatrist, Los Angeles County Department of Mental Health, and assistant professor, Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Center for Social Medicine and Humanities, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; ORCID: https://orcid.org/0000-0002-3807-1125
| | - Jessica Isom
- J. Isom is a community psychiatrist, Codman Square Health Center, Dorchester, Massachusetts
| | - Katrina L DeBonis
- K.L. DeBonis is assistant professor, Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Ayana Jordan
- A. Jordan is assistant professor, Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, and addiction psychiatrist, Community Mental Health Center, New Haven, Connecticut; ORCID: https://orcid.org/0000-0002-7850-8096
| | - Joel T Braslow
- J.T. Braslow is professor, Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Center for Social Medicine and Humanities, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Robert Rohrbaugh
- R. Rohrbaugh is professor, Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut; ORCID: https://orcid.org/0000-0002-4969-4352
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[Moral distress in medical students and young professionals: research desiderata in the context of the COVID-19 pandemic]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020; 63:1483-1490. [PMID: 33180160 PMCID: PMC7659897 DOI: 10.1007/s00103-020-03244-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 10/09/2020] [Indexed: 11/29/2022]
Abstract
Hintergrund Die COVID-19-Pandemie stellt Menschen, die in der medizinischen Versorgung arbeiten, vor besondere Herausforderungen. Ein Teil der Medizinstudierenden und ärztlichen Berufseinsteigenden, die in dieser Zeit in Einrichtungen der Gesundheitsversorgung ihre Mitarbeit beginnen, wird mit außergewöhnlichen moralischen Herausforderungen konfrontiert. Einige verfügen noch nicht über ausreichend Bewältigungsmöglichkeiten, um adäquat mit diesen Herausforderungen umzugehen. Dies kann zu sogenanntem moralischen Stress (MoS; Englisch: „moral distress“, MoD) führen. Dauerhafte oder intensive Belastung durch MoS kann gravierende Folgen haben. Geeignete Unterstützungsangebote haben das Potenzial, den Umgang mit MoS zu verbessern. Ziel Der Beitrag hat das Ziel, einen Überblick über den Stand der Forschung zu MoS von Medizinstudierenden und ärztlichen Berufseinsteigenden zu geben, um Lehrende mit Aus- und Weiterbildungsverantwortung und Ärzt*innen in Leitungspositionen für die Problematik zu sensibilisieren. Hauptteil In diesem Beitrag werden das wissenschaftliche Konzept MoS, bekannte Auslöser sowie Präventions- und Interventionsmöglichkeiten vorgestellt. Dazu wird das Thema Bezug nehmend auf die Veränderungen in der Patientenversorgung im Kontext der COVID-19-Pandemie analysiert und es werden Forschungsdesiderate aufgezeigt. Fazit Der Beitrag verdeutlicht die Notwendigkeit eines deutschsprachigen, interdisziplinären Diskurses über MoS bei Medizinstudierenden und Berufseinsteigenden.
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35
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Beck J, Randall CL, Bassett HK, O'Hara KL, Falco CN, Sullivan EM, Opel DJ. Moral Distress in Pediatric Residents and Pediatric Hospitalists: Sources and Association With Burnout. Acad Pediatr 2020; 20:1198-1205. [PMID: 32492578 DOI: 10.1016/j.acap.2020.05.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 05/17/2020] [Accepted: 05/24/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Moral distress is increasingly identified as a major problem affecting healthcare professionals, but it is poorly characterized among pediatricians. Our objective was to assess the sources of moral distress in residents and pediatric hospitalist attendings and to examine the association of moral distress with reported burnout. METHODS Cross-sectional survey from January through March 2019 of pediatric residents and hospital medicine attending physicians affiliated with 4 free-standing children's hospitals. Moral distress was measured using the Measure of Moral Distress for Healthcare Professionals (MMD-HP). Burnout was measured using 2 items adapted from the Maslach Burnout Inventory. RESULTS Respondents included 288 of 541 eligible pediatric residents (response rate: 53%) and 118 of 168 pediatric hospitalists (response rate: 70%; total response rate: 57%). The mean MMD-HP composite score was 93.4 (SD = 42.5). Residents reported significantly higher frequency scores (residents: M = 38.5 vs. hospitalists: M = 33.3; difference: 5.2, 95% confidence interval [CI], 2.9-7.5) and composite scores (residents: M = 97.6 vs hospitalists: M = 83.0; difference:14.6, 95% CI, 5.7-23.5) than hospitalists. The most frequent source of moral distress was "having excessive documentation requirements that compromise patient care," and the most intense source of moral distress was "be[ing] required to work with abusive patients/family members who are compromising quality of care." Significantly higher mean MMD-HP composite scores were observed among participants reporting that they felt burned out at least once per week (M= 114.6 vs M= 82.3; difference: 32.3, 95% CI, 23.5-41.2). CONCLUSIONS Pediatric residents and hospitalists report experiencing moral distress from a variety of patient-, team-, and system-level sources, and this distress is associated with burnout.
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Affiliation(s)
- Jimmy Beck
- Department of Pediatrics, University of Washington (J Beck, EM Sullivan, and DJ Opel), Seattle, Wash.
| | - Cameron L Randall
- Department of Oral Health Sciences, University of Washington School of Dentistry (CL Randall), Seattle, Wash
| | - Hannah K Bassett
- Department of Pediatrics, Stanford University (HK Bassett), Palo Alto, Calif
| | - Kimberly L O'Hara
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado (KL O'Hara), Aurora, Colo
| | - Carla N Falco
- Department of Pediatrics, Baylor College of Medicine (CN Falco), Houston, Tex
| | - Erin M Sullivan
- Department of Pediatrics, University of Washington (J Beck, EM Sullivan, and DJ Opel), Seattle, Wash; Seattle Children's Core for Biomedical Statistics (EM Sullivan), Seattle, Wash
| | - Douglas J Opel
- Department of Pediatrics, University of Washington (J Beck, EM Sullivan, and DJ Opel), Seattle, Wash
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Ramos Toescher AM, Barlem ELD, Tomaschewski Barlem JG, Castanheira JS, Rocha LP. Moral distress among nursing professors: The exercise of parrhesia. Nurs Ethics 2020; 28:543-553. [PMID: 33021132 DOI: 10.1177/0969733020952109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mismatch between the perception of one's moral duty and one's real social contribution may trigger moral distress, especially when no specific resistance strategies are used to counteract morally distressing situations. Considering a philosophical-ethical conception, individuals need to first reflect upon themselves to later turn to the world and confront their current situation in order to change it. OBJECTIVES To understand moral distress experienced by nursing professors teaching in higher education institutions and the use of parrhesia as a coping strategy. METHOD This qualitative exploratory-descriptive study addressed 33 nursing professors working in Brazilian federal public universities using an open-ended question form. Data were collected between June and December 2018 and analyzed using discursive textual analysis. ETHICAL CONSIDERATIONS The Institutional Review Board at the Federal University of Rio Grande approved this study. FINDINGS Three categories emerged: performance of nursing professors and potentially distressing situations, the experience of moral distress, and parrhesia as a strategy to deal with moral distress. Nursing professors face situations that cause moral distress in the context of higher education, however, those who adopt parrhesia as a coping strategy find it easier to express their beliefs from the perspective of moral duty, even in the face of conflicts. CONCLUSION When the nursing professors in this study acknowledge elements in the power structure that hinder their actions, they express parrhesia, as an essential virtue in an attempt to modify unsymmetrical power relations that can trigger moral distress.
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Jacobs B, Manfredi RA. Moral Distress During COVID-19: Residents in Training Are at High Risk. AEM EDUCATION AND TRAINING 2020; 4:447-449. [PMID: 33150293 PMCID: PMC7592830 DOI: 10.1002/aet2.10488] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 05/25/2023]
Affiliation(s)
- Breanne Jacobs
- Department of Emergency MedicineThe George Washington University School of Medicine and Health SciencesWashingtonDCUSA
| | - Rita A. Manfredi
- Department of Emergency MedicineThe George Washington University School of Medicine and Health SciencesWashingtonDCUSA
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Wald HS. Optimizing resilience and wellbeing for healthcare professions trainees and healthcare professionals during public health crises - Practical tips for an 'integrative resilience' approach. MEDICAL TEACHER 2020; 42:744-755. [PMID: 32449867 DOI: 10.1080/0142159x.2020.1768230] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Public health crises, including pandemics, are associated with significant health risk and concomitant stress, fear, decreased sense of control, and uncertainty. Deleterious impact on both physical and mental health can result, including for healthcare professionals and health professions trainees. Changes in governmental policies and hospital protocols for healthcare professionals as well as disruption of educational formats and requirements for trainees can ensue. Difficult anxiety-provoking realities of public health crises including pandemics which involve caring for many seriously ill patients, moral distress including difficult care decisions, personal health risk, and/or potential risk to one's family can take a dire toll on the mental health of healthcare professionals at all stages of the professional lifecycle. Educational disruptions can create significant anxiety for trainees about completing requirements and achieving competencies. Within this, coping skills may be challenged and strengths may be elucidated as well. Such crises create an imperative for medical educators to support trainees' wellbeing through adaptive flexibility for curriculum innovation and culturally sensitive resilience and wellbeing interventions. Strategies ('tips') to optimize resilience and wellbeing with an integrative resilience approach of individual, learning environment, and organization/systems factors are presented.
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Affiliation(s)
- Hedy S Wald
- Clinical Professor of Family Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Salehi PP, Jacobs D, Suhail-Sindhu T, Judson BL, Azizzadeh B, Lee YH. Consequences of Medical Hierarchy on Medical Students, Residents, and Medical Education in Otolaryngology. Otolaryngol Head Neck Surg 2020; 163:906-914. [DOI: 10.1177/0194599820926105] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
ObjectiveTo (1) review concepts of medical hierarchy; (2) examine the role of medical hierarchy in medical education and resident training; (3) discuss potential negative impacts of dysfunctional hierarchy in medical and surgical training programs, focusing on otolaryngology; and (4) investigate solutions to these issues.Data SourcesOvid Medline, Embase, GoogleScholar, JSTOR, Google, and article reference lists.Review MethodsA literature search was performed to identify articles relating to the objectives of the study using the aforementioned data sources, with subsequent exclusion of articles believed to be outside the scope of the current work. The search was limited to the past 5 years.ConclusionsTwo types of hierarchies exist: “functional” and “dysfunctional.” While functional medical hierarchies aim to optimize patient care through clinical instruction, dysfunctional hierarchies have been linked to negative impacts by creating learning environments that discourage the voicing of concerns, legitimize trainee mistreatment, and create moral distress through ethical dilemmas. Such an environment endangers patient safety, undermines physician empathy, hampers learning, lowers training satisfaction, and amplifies stress, fatigue, and burnout. On the other hand, functional hierarchies may improve resident education and well-being, as well as patient safety.Implications for PracticeOtolaryngology–head and neck surgery programs ought to work toward creating healthy systems of hierarchy that emphasize collaboration and improvement of workplace climate for trainees and faculty. The goal should be to identify aspects of dysfunctional hierarchy in one’s own environment with the ambition of rebuilding a functional hierarchy where learning, personal health, and patient safety are optimized.
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Affiliation(s)
- Parsa P. Salehi
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Daniel Jacobs
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Timur Suhail-Sindhu
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Benjamin L. Judson
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Babak Azizzadeh
- Division of Head and Neck Surgery, Department of Otolaryngology–Head and Neck Surgery, Center for Advanced Facial Plastic Surgery, Beverly Hills, California, USA
- Division of Head and Neck Surgery, Department of Otolaryngology–Head and Neck Surgery, David Geffen School of Medicine at the University of California–Los Angeles, Los Angeles, California, USA
| | - Yan Ho Lee
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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Perni S, Pollack LR, Gonzalez WC, Dzeng E, Baldwin MR. Moral distress and burnout in caring for older adults during medical school training. BMC MEDICAL EDUCATION 2020; 20:84. [PMID: 32293416 PMCID: PMC7092500 DOI: 10.1186/s12909-020-1980-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 02/24/2020] [Indexed: 05/27/2023]
Abstract
BACKGROUND Moral distress is a reason for burnout in healthcare professionals, but the clinical settings in which moral distress is most often experienced by medical students, and whether moral distress is associated with burnout and career choices in medical students is unknown. We assessed moral distress in medical students while caring for older patients, and examined associations with burnout and interest in geriatrics. METHODS A cross-sectional survey study of second-, third-, and fourth-year medical students at an American medical school. The survey described 12 potentially morally distressing clinical scenarios involving older adult patients. Students reported if they encountered each scenario, and whether they experienced moral distress, graded on a 1-10 scale. We conducted a principal axis factor analysis to assess the dimensionality of the survey scenarios. A composite moral distress score was calculated as the sum of moral distress scores across all 12 scenarios. Burnout was assessed using the Maslach Abbreviated Burnout Inventory, and interest in geriatrics was rated on a 7-point Likert scale. RESULTS Two-hundred and nine students responded (47%), of whom 90% (188/209) reported moral distress in response to ≥1 scenario with a median (IQR) score of 6 (4-7). Factor analysis suggested a unidimensional factor structure of the 12 survey questions that reliably measured individual distress (Cronbach alpha = 0.78). Those in the highest tertile of composite moral distress scores were more likely to be burnt out (51%) than those in the middle tertile of scores (34%), or lowest tertile of scores (31%) (p = 0.02). There was a trend towards greater interest in geriatrics among those in the higher tertiles of composite moral distress scores (16% lowest tertile, 20% middle tertile, 25% highest tertile, p-for-tend = 0.21). Respondents suggested that moral distress might be mitigated with didactic sessions in inpatient geriatric care, and debriefing sessions with peers and faculty on the inpatient clerkships on medicine, neurology, and surgery, where students most often reported experiencing moral distress. CONCLUSIONS Moral distress is highly prevalent among medical students while caring for older patients, and associated with burnout. Incorporating geriatrics education and debriefing sessions into inpatient clerkships could alleviate medical student moral distress and burnout.
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Affiliation(s)
- Subha Perni
- Department of Radiation Oncology, Harvard Medical School, Boston, MA, USA
| | - Lauren R Pollack
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Wendy C Gonzalez
- Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Elizabeth Dzeng
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Matthew R Baldwin
- Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.
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Fontana MCP, Generoso IP, Sizilio A, Bivanco-Lima D. Burnout syndrome, extracurricular activities and social support among Brazilian internship medical students: a cross-sectional analysis. BMC MEDICAL EDUCATION 2020; 20:81. [PMID: 32188433 PMCID: PMC7081526 DOI: 10.1186/s12909-020-01998-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/10/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Burnout syndrome (BS) is highly prevalent among medical students and is associated with lower empathy and worsening of medical students ́ mental health. The aim of our study was to identify prevalence of BS during internship and its association with self-rated social support and participation in extracurricular activities in one medical school in Brazil. METHODS This was a cross-sectional study conducted in 2015, with 121 medical students on internship (56% response rate). They were evaluated using the Maslach Burnout Inventory - Human Services (MBI) and assessed about socio demographic data, social support and extracurricular activities. RESULTS The overall BS prevalence was 57.5% among medical interns. High emotional exhaustion was present in 33.1% (N = 38) of interns, high depersonalization was observed in 45.7% (N = 58) and 36.2% of participants (N = 46) had low personal accomplishment. Individuals with participation in community services had lower frequency of depersonalization (prevalence ratio 0.61 CI95% 0.42-0.88). BS was not associated with different types of extracurricular activities and no association was found among BS and the behaviour of seeking social support. CONCLUSIONS We found high prevalence of BS in medical interns, however the behaviour of seeking social support had no association with BS. The interns participating in community activities had lower frequency of high depersonalization.
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Affiliation(s)
| | | | | | - Danielle Bivanco-Lima
- Public Health Department of Faculdade de Ciências Médicas da Santa Casa de São Paulo, Rua Doutor Cesario Mota Júnior, 61, 5° andar, sala 3, São Paulo, SP 01221-906 Brazil
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Berhie AY, Tezera ZB, Azagew AW. Moral Distress and Its Associated Factors Among Nurses in Northwest Amhara Regional State Referral Hospitals, Northwest Ethiopia. Psychol Res Behav Manag 2020; 13:161-167. [PMID: 32110124 PMCID: PMC7037049 DOI: 10.2147/prbm.s234446] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 02/11/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Moral distress is the cognitive-emotional dissonance that arises when one feels compelled to act against one's moral requirements. The study aimed to assess the proportion of moral distress and associated factors among nurses working in Northwest Amhara Regional State referral hospitals in 2018. METHODS A cross-sectional study was conducted among nurses working at Northwest Amhara regional state referral hospitals from April 1-30/2018. A total of 423 study participants were enrolled in the study. A systematic random sampling technique was used to select the study participants. A pretested self-administered structured questionnaire was used to collect data. Moral Distress Scale-Revised (MDS-R) was used to assess the proportion of moral distress. Epi info version 7 for data entry and SPSS version 22 for data analysis were used. A binary logistic model was computed. Variables having p-value < 0.5 with 95% CI were used to declare the presence of significant associations. RESULTS A total of 423 study participants were enrolled in the study with a response rate of 97.4%. The mean (SD) age of the respondents was 30.62 ± 5.7 years. The majority of nurses 350 (85%) were degree and above holders in nursing. The proportion of moral distress among nurses was found to be 83.7%. Work experience 11-20 years [adjusted odds ratio (AOR)=2, 95% CI: 1.01, 3.34], perceived poor team communication [AOR=4.5, 95% CI: 1.78, 11.62], perceived powerlessness in decision making [AOR=3.3, 95% CI: 1.38, 7.87], inadequate staffing [AOR=2.96, 95% CI: 1.26, 6.97], and inappropriate provision of care [AOR=4.12, 95% CI: 1.55, 10.9] were significantly associated with moral distress. CONCLUSION Nurses frequently experienced moral distress in clinical settings. Perceived poor communication, perceived powerlessness in decision making, inadequate staffing, and inappropriate provision care were the factors associated with moral distress.
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Affiliation(s)
- Alemshet Yirga Berhie
- Department of Surgical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Zewdu Baye Tezera
- Department of Comprehensive Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Abere Woretaw Azagew
- Department of Medical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Chou CL, Kalet A, Costa MJ, Cleland J, Winston K. Guidelines: The dos, don'ts and don't knows of remediation in medical education. PERSPECTIVES ON MEDICAL EDUCATION 2019; 8:322-338. [PMID: 31696439 PMCID: PMC6904411 DOI: 10.1007/s40037-019-00544-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
INTRODUCTION Two developing forces have achieved prominence in medical education: the advent of competency-based assessments and a growing commitment to expand access to medicine for a broader range of learners with a wider array of preparation. Remediation is intended to support all learners to achieve sufficient competence. Therefore, it is timely to provide practical guidelines for remediation in medical education that clarify best practices, practices to avoid, and areas requiring further research, in order to guide work with both individual struggling learners and development of training program policies. METHODS Collectively, we generated an initial list of Do's, Don'ts, and Don't Knows for remediation in medical education, which was then iteratively refined through discussions and additional evidence-gathering. The final guidelines were then graded for the strength of the evidence by consensus. RESULTS We present 26 guidelines: two groupings of Do's (systems-level interventions and recommendations for individual learners), along with short lists of Don'ts and Don't Knows, and our interpretation of the strength of current evidence for each guideline. CONCLUSIONS Remediation is a high-stakes, highly complex process involving learners, faculty, systems, and societal factors. Our synthesis resulted in a list of guidelines that summarize the current state of educational theory and empirical evidence that can improve remediation processes at individual and institutional levels. Important unanswered questions remain; ongoing research can further improve remediation practices to ensure the appropriate support for learners, institutions, and society.
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Affiliation(s)
- Calvin L Chou
- Department of Medicine, University of California and Veterans Affairs Healthcare System, San Francisco, CA, USA.
| | - Adina Kalet
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Manuel Joao Costa
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Minho, Portugal
| | - Jennifer Cleland
- Centre for Healthcare Education Research and Innovation (CHERI), University of Aberdeen, Aberdeen, UK
| | - Kalman Winston
- Department of Public Health and Primary Care, Cambridge University, Cambridge, UK
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Schrepel C, Jauregui J, Brown A, Shandro J, Strote J. Navigating Cognitive Dissonance: A Qualitative Content Analysis Exploring Medical Students' Experiences of Moral Distress in the Emergency Department. AEM EDUCATION AND TRAINING 2019; 3:331-339. [PMID: 31637350 PMCID: PMC6795361 DOI: 10.1002/aet2.10380] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 07/25/2019] [Accepted: 07/27/2019] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- Caitlin Schrepel
- Department of Emergency MedicineUniversity of WashingtonSeattleWA
| | - Joshua Jauregui
- Department of Emergency MedicineUniversity of WashingtonSeattleWA
| | - Alisha Brown
- Department of Emergency MedicineUniversity of WashingtonSeattleWA
| | - Jamie Shandro
- Department of Emergency MedicineUniversity of WashingtonSeattleWA
| | - Jared Strote
- Department of Emergency MedicineUniversity of WashingtonSeattleWA
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Bader CS, Herschkopf MD. Trainee Moral Distress in Capacity Consultations for End-of-Life Care. PSYCHOSOMATICS 2019; 60:508-512. [DOI: 10.1016/j.psym.2018.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 08/03/2018] [Accepted: 08/06/2018] [Indexed: 11/29/2022]
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Epstein EG, Whitehead PB, Prompahakul C, Thacker LR, Hamric AB. Enhancing Understanding of Moral Distress: The Measure of Moral Distress for Health Care Professionals. AJOB Empir Bioeth 2019; 10:113-124. [PMID: 31002584 DOI: 10.1080/23294515.2019.1586008] [Citation(s) in RCA: 237] [Impact Index Per Article: 47.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND As ongoing research explores the impact of moral distress on health care professionals (HCPs) and organizations and seeks to develop effective interventions, valid and reliable instruments to measure moral distress are needed. This article describes the development and testing of a revision of the widely used Moral Distress Scale-Revised (MDS-R) to measure moral distress. METHODS We revised the MDS-R by evaluating the combined data from 22 previous studies, assessing 301 write-in items and 209 root causes identified through moral distress consultation, and reviewing 14 recent publications from various professions in which root causes were described. The revised 27-item scale, the Measure of Moral Distress for Healthcare Professionals (MMD-HP), is usable by all HCPs in adult and pediatric critical, acute, or long-term acute care settings. We then assessed the reliability of the MMD-HP and evaluated construct validity via hypothesis testing. The MMD-HP, Hospital Ethical Climate Survey (HECS), and a demographic survey were distributed electronically via Qualtrics to nurses, physicians, and other health care professionals at two academic medical centers over a 3-week period. RESULTS In total, 653 surveys were included in the final analysis. The MMD-HP demonstrated good reliability. The four hypotheses were supported: (1) MMD-HP scores were higher for nurses (M 112.3, SD 73.2) than for physicians (M 96.3, SD 54.7, p = 0.023). (2) MMD-HP scores were higher for those considering leaving their position (M 168.4, SD 75.8) than for those not considering leaving (M 94.3, SD 61.2, p < 0.001). (3) The MMD-HP was negatively correlated with the HECS (r = -0.55, p < 0.001). (4) An exploratory factor analysis revealed a four-factor structure, reflective of patient, unit, and system levels of moral distress. CONCLUSIONS The MMD-HP represents the most currently understood causes of moral distress. Because the instrument behaves as would be predicted, we recommend that the MMD-HP replace the MDS-R.
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Affiliation(s)
- Elizabeth G Epstein
- a University of Virginia School of Nursing , Charlottesville , Virginia , USA
| | - Phyllis B Whitehead
- b Carilion Roanoke Memorial Hospital, Palliative Medicine Clinical Nurse Specialist , Roanoke , Virginia , USA
| | - Chuleeporn Prompahakul
- c School of Nursing , University of Virginia School of Nursing, Senior Lecturer Faculty of Nursing, Prince of Songkla University, Hatyai , Songkhla , Thailand
| | - Leroy R Thacker
- d Department of Biostatistics, One Capital Square , Virginia Commonwealth University , Richmond , Virginia , USA
| | - Ann B Hamric
- e School of Nursing , Virginia Commonwealth University , Richmond , Virginia , USA
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Munzer BW, Griffith M, Townsend WA, Burk-Rafel J. Medical Student- and Resident-Authored Publications in Academic Medicine From 2002 to 2016: A Growing Trend and Its Implications. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2019; 94:404-411. [PMID: 30256251 DOI: 10.1097/acm.0000000000002466] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE The extent of medical trainees' engagement in scholarly medical education publication is not well described. This study sought to quantify the prevalence of medical student- and resident-authored medical education publications over 15 years, a benchmark essential for understanding current and future trends in trainee scholarship. METHOD Of 91 identified journals, 16 met inclusion criteria as indexed general medical education journals. Only Academic Medicine provided complete author role information, allowing identification of medical student and resident authors. The authors retrospectively compiled and analyzed citation records from Academic Medicine from 2002 to 2016, tracking trainee authorship, author position, and publication type. RESULTS A total of 6,280 publications were identified, of which 4,635 publications, by 16,068 authors, met inclusion criteria. Trainees were 6.0% (966/16,068) of all authors and authored 14.5% (673/4,635) of all publications. Trainee authorship rates varied by publication type: Trainees authored 33.3% (160/480) of medical humanities publications versus 6.9% (27/392) of commentaries. From 2002-2004 to 2014-2016, the proportion of authors who were trainees increased from 3.9% (73/1,853) to 7.1% (330/4,632) (P < .001 for trend). Over the same period, the percentage of trainee-authored publications increased: 9.4% (58/620) to 18.8% (225/1,199) (P < .001 for trend), driven primarily by increased trainee first authorship. CONCLUSIONS Trainees constitute a small but growing proportion of authors and authored publications in Academic Medicine. Further work is needed to understand what trainee-, institutional-, and journal-level factors contribute to this trend, and whether similar increases in trainee authorship are occurring in other journals and fields.
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Affiliation(s)
- Brendan W Munzer
- B.W. Munzer is a medical education fellow and, at the time the study was conducted, was a resident, Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, Michigan. M. Griffith is an emergency medicine resident, Department of Emergency Medicine, University of Michigan Health System, and, at the time the study was conducted, was a medical student, University of Michigan Medical School, Ann Arbor, Michigan. W.A. Townsend is an informationist, University of Michigan Taubman Health Sciences Library, Ann Arbor, Michigan. J. Burk-Rafel is an internal medicine resident, Department of Medicine, New York University, New York, New York, and, at the time the study was conducted, was a medical student, University of Michigan Medical School, Ann Arbor, Michigan; ORCID: https://orcid.org/0000-0003-3785-2154
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Mulder H, Ter Braak E, Chen HC, Ten Cate O. Addressing the hidden curriculum in the clinical workplace: A practical tool for trainees and faculty. MEDICAL TEACHER 2019; 41:36-43. [PMID: 29490529 DOI: 10.1080/0142159x.2018.1436760] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION The hidden curriculum, commonly described in negative terms, is considered highly influential in medical education, especially in the clinical workplace. Structured approaches to address it are limited in number and scope. METHODS AND RESULTS This paper presents a practical, value-neutral method called REVIEW (Reflecting & Evaluating Values Implicit in Education in the Workplace), to facilitate reflection and discussion on the hidden curriculum by faculty members and trainees. REVIEW approaches the hidden curriculum as a reflection of the professional microculture of a clinical team. This microculture results from collective problem solving and mutual negotiation when facing different, often conflicting, demands and interests, and their underlying values in daily clinical practice. Using this nonjudgmental conceptual framework, REVIEW employs a series of 50 culture statements that must be prioritized using Q-sort methodology, reflecting how the culture in a particular clinical context (e.g. ward or department) is perceived by faculty members and trainees. This procedure can be done individually or in groups. Most important is the resulting team discussion after the exercise - a discussion about perceptions of actual team culture and the culture desired by the team. DISCUSSION AND CONCLUSIONS Our early experiences suggest that REVIEW can be a useful tool for addressing the hidden curriculum.
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Affiliation(s)
- Hanneke Mulder
- a Center for Research and Development of Education , University Medical Center Utrecht, Utrecht University , The Netherlands
| | - Edith Ter Braak
- b Unit for Postgraduate Medical Education , University Medical Center Utrecht, Utrecht University , The Netherlands
| | - H Carrie Chen
- c Department of Pediatrics , Georgetown University School of Medicine , Washington , DC , USA
| | - Olle Ten Cate
- a Center for Research and Development of Education , University Medical Center Utrecht, Utrecht University , The Netherlands
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Paros S, Tilburt J. Navigating conflict and difference in medical education: insights from moral psychology. BMC MEDICAL EDUCATION 2018; 18:273. [PMID: 30466415 PMCID: PMC6249911 DOI: 10.1186/s12909-018-1383-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 11/08/2018] [Indexed: 06/09/2023]
Abstract
Medical students and educators face a myriad of complex moral disagreements and conflicts both in preclinical and clinical training environments. Inability to deal with these conflicts effectively and compassionately can lead to undesirable consequences and threaten important relationships in high-stakes healthcare environments. We suggest that the integration of moral psychology into medical education can help trainees and faculty constructively respond to behavior they may find immoral or misguided. Here we focus on the application of Moral Foundations Theory (MFT), which demonstrates how the instantaneous gut reactions which guide reactionary behavior can be categorized into six foundational categories. These categories offer psychological explanations for human behavior which can help medical trainees and professionals navigate challenging moral conflicts.
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Affiliation(s)
- Samuel Paros
- College of Medicine, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425 USA
| | - Jon Tilburt
- Biomedical Ethics Research Program, Division of Health Care Policy and Research, Division of General Internal Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905 USA
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Mullin J, Bogetz J. Point: Moral distress can indicate inappropriate care at end-of-Life. Psychooncology 2018; 27:1490-1492. [DOI: 10.1002/pon.4713] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 02/28/2018] [Accepted: 03/14/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Jonathan Mullin
- Department of Pediatrics; Washington University School of Medicine; St. Louis MO USA
| | - Jori Bogetz
- Department of Pediatrics; University of California; San Francisco CA USA
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