Moral distress in medical education and training

Learning environment as a predictor for medical students' empathy: a multicenter cross-sectional study from 12 medical schools in China

BACKGROUND

Empathy of medical students is crucial, yet it tends to decline as students enter later academic years. Empathy appeared to be affected by the learning environment (LE), which could be a potential contributor. We conducted a cross-sectional study to investigate the association between LE and empathy.

METHOD

The study comprised overall 10,901 medical students from 12 Chinese medical schools. Jefferson Scale of Empathy (JSE) was utilized to assess empathy, while a 5-point question and the Johns Hopkins Learning Environment Scale were employed to evaluate LE. JSE scores were compared across LE levels using Pearson Chi-square, Welch's ANOVA, and univariable linear regression. After adjusting for covariates, multivariable linear and logistic regression were used to assess the independent connection between LE and empathy. Confounders were controlled by stratified subgroup analysis.

RESULTS

LE was significantly associated with medical students' empathy, as shown by the Pearson Chi-square test (p < 0.001) and Welch's ANOVA (p < 0.001). In multivariable logistic regression analysis, lower JSE scores were linked to common, bad, and terrible LE (OR = 2.226, 95% CI = [2.011, 2.465], p < 0.001; OR = 2.558, 95% CI = [1.745, 3.751], p < 0.001; OR = 1.889, 95% CI = [1.131, 3.153], p = 0.015), while excellent LE was associated with higher JSE scores (OR = 0.348, 95% CI = [0.312, 0.388], p < 0.001). Linear regression and stratified subgroup analysis confirmed logistic regression's findings.

CONCLUSION

LE was a significant predictor for empathy. Better LE was associated with higher empathy and worse LE was related to lower empathy. This inspired us to improve LE to enhance medical students' empathy.

"Do No Harm?" Moral Distress Among Medical Students During the Surgical Clerkship

OBJECTIVES

Moral distress, reported among healthcare workers across a variety of settings, is associated with negative mental health consequences, burnout, and intention to leave a position. The scant literature exploring medical students' moral distress does not specifically examine moral distress during the surgical clerkship nor does it characterize the type of moral distress experienced by medical students. Thus, we aimed to explore and characterize medical students' moral distress during the surgical clerkship.

SETTING/PARTICIPANTS

This study was conducted at the University of Michigan Medical School evaluating narrative essays written by 3 cohorts of students (2018-19, 2019-20, 2020-21) who completed the surgical clerkship during their third year of medical school.

DESIGN

Deductive content analysis was used to evaluate 180 narrative essays for the presence of moral distress using a 5-subcategorization schema developed by Morley et al. (constraint-distress, tension-distress, dilemma-distress, uncertainty-distress, and conflict-distress).

RESULTS

Four of the 5 sub-categories of moral distress (constraint-distress, tension-distress, dilemma-distress and uncertainty-distress) were identified in medical student essays. There were no examples of conflict-distress.

CONCLUSIONS

Medical students described 4 of the 5 sub-types of moral distress during their surgical clerkship. The sub-types of moral distress most often experienced by medical students are different than sub-types of moral distress previously reported among nurses, suggesting the varied roles and responsibilities of the healthcare team impact the scenarios most likely to present moral distress. Additionally, medical students were hesitant to raise concerns with their team when they experienced events discordant with their moral beliefs; they cited their position in the medical hierarchy, fearing implications on their future career, and perceived lack of knowledge and experience as factors limiting their willingness to share. Finally, this study identifies morally distressing scenarios as opportunities for transformative learning for medical students specifically in the realm of professional identity formation.

"What's Going to Happen?": Internal Medicine Resident Experiences of Uncertainty in the Care of Older Adults

PURPOSE

Internal medicine residents care for clinically complex older adults and may experience increased moral distress due to knowledge gaps, time constraints, and institutional barriers. We conducted a phenomenological study to explore residents' experiences and challenges through the lens of uncertainty.

METHODS

Between January and March 2022, six focus groups were conducted comprising a total of 13 internal medicine residents in postgraduate years 2 and 3, who had completed a required 2-week geriatrics rotation. Applying the Beresford taxonomy of uncertainty as a conceptual model, data were analyzed using the framework method.

RESULTS

All challenging experiences described by residents caring for older adults were linked to uncertainty. Sources of uncertainty were categorized and mapped to the Beresford taxonomy: (1) lack of geriatrics knowledge or clinical guidelines (technical); (2) difficulty applying knowledge to complex older adults (conceptual); and (3) lack of longitudinal relationship with the older patient (personal). Residents identified capacity evaluation and discharge planning as two major geriatric knowledge areas linked with uncertainty. While the majority of residents reacted to uncertainty with some degree of distress, several reported positive coping strategies.

CONCLUSIONS

Internal medicine residents face uncertainty when caring for older adults, particularly related to technical and conceptual factors. Strategies for mitigating uncertainty in the care of older adults are needed given links with moral distress and trainee well-being.

The influence of hierarchy as an Implicit curriculum on medical trainees during the COVID-19 pandemic

BACKGROUND

Understanding the hierarchy in medical education is considered one of the hidden curriculum agendas that help to guide the medical trainees throughout their careers in healthcare. However, many negative aspects to the hierarchy and a few positive aspects have been uncovered in recent years. The COVID-19 pandemic had a tremendous impact on the healthcare system, deploying healthcare workers, including trainees from their primary speciality training to help caring for COVID-19 patients. The effect of hierarchy on medical trainees in such situations has not been discussed before. This study aims to uncover whether the COVID-19 pandemic emergency had any impact on the hierarchical system among healthcare workers.

METHODS

Individual semi-structured virtual interviews were conducted with six residents from different residency programs who were redeployed from their primary subspeciality to work with COVID-19 patients in different healthcare facilities across the country. The interviews aimed to uncover the resident's experience with the hierarchical structure while working in a diverse COVID-19 team. Responses were analysed qualitatively using an interpretive approach.

RESULT

Interviews yielded data broadly covered the aspects of 1. The impact of hierarchy during the pandemic on the resident's training in the absence of academic and clinical teaching and the limited exposure to clinical cases where the primary focus was treating COVID-19 patients. 2. The functional and dysfunctional impact of hierarchy on team dynamic before the COVID-19 pandemic from the residents 'perspective when they worked with different teams before the pandemic. 3. The functional and dysfunctional impact of hierarchy on team dynamic during the COVID-19 pandemic where some aspects of hierarchy, like mentorship, were prominent among teams. 4. The resident personal experience with the COVID-19 team during the pandemic in terms of team diversity and the war zone experience. The trainees described in a narrative approach the hierarchy impact on their experience during the COVID-19 pandemic.

CONCLUSIONS

The COVID-19 pandemic impacted the hidden curriculum of medical hierarchy in both functional and dysfunctional ways. This period underscored positive hierarchical elements, such as role clarity and team leadership, which were often overlooked pre-pandemic, while also exposing limitations that hindered flexibility and inclusivity.

Decreasing Perceived Moral Distress in Pediatrics Residents: A Pilot Study

Pediatric residents experience ethical dilemmas and moral distress during training. Few studies have identified meaningful methods in reducing moral distress in pediatric trainees. The authors aimed to determine how residents perceive ethics case discussions, whether such a program affects trainee ethics knowledge and perceived moral distress, and if residents' perceived moral distress changes before, during, and after a discussion series. Participants included pediatric residents in a single residency program. Five separate 1-hour sessions were presented over a 5-month period. Each session consisted of a case presentation by a resident developed under the guidance of an ethicist. Multidisciplinary services and content experts were present during sessions. Baseline, postsession, and final surveys were distributed to resident attendees. Open-ended responses were recorded. When comparing baseline and final responses, the only significance was increased preparedness to navigate ethical decisions (p = 0.004). A 10.2% decline was observed in perceived moral distress. An increase in ethics knowledge was observed. Residents favored case-based, multidisciplinary discussions. Residents desire more sessions, time for small-group discussions, and legal insight. Satisfaction was high with 90.7% of respondents feeling better prepared to address ethical concerns. Pediatric trainees desire case-based ethics training that incorporates small-group discussions and insight from multidisciplinary topic experts.

Medical Student Perspectives on Professionalism in a Third-Year Surgery Clerkship - A Mixed Methods Study

OBJECTIVE

The norms governing surgical training warrant a deeper understanding of students' experiences and interpretations of professionalism issues in their learning environment. However, there is scant empirical evidence to describe this process. To fill this gap, we analyzed students' perceptions related to professionalism, moral distress, and communication in the surgical clerkship, particularly regarding their clinical supervisors, whom we refer to as mentors.

DESIGN

We retrospectively evaluated written case vignettes and survey responses from medical students on their surgical clerkships regarding their experiences of cases which raised professionalism concerns. Vignettes and surveys were part of standard curricular exercises and analyzed using both qualitative and quantitative methods.

SETTING

Our study was conducted at a private academic medical college in the northeast with an affiliated institute of bioethics.

PARTICIPANTS

Two-hundred forty-one third year medical students on their surgical clerkships participated through required curricular submissions of case vignettes and surveys.

RESULTS

Vignettes and surveys from all 241 students were collected and analyzed. Of these, 106 (43.9%) were identified by the students as relating to professionalism, whereas the research team identified 148 (61.4%) cases as such. Major subtypes of professionalism concerns were categorized as "not showing proper respect" (38.5%), bias (30.4%) and "failure to meet medical standards of care" (29.1%). In professionalism cases, only 27.7% of students would emulate their mentor, 19.7% shared concerns with the mentor, and 58.8% experienced moral distress, all significantly worse than in nonprofessionalism cases (p < 0.001).

CONCLUSIONS

With an abundance of professionalism concerns noted, students experienced high rates of moral distress and were unlikely to share concerns with clinical mentors who they generally did not wish to emulate. Attention should be paid to providing a formal curricular venue in which students can discuss their concerns, as untoward experiences in the learning environment risk harming their learning and professional identity development.

A Phenomenological Exploration of Physicians' Moral Distress: Situating Emotion Within Lived Experiences

PURPOSE

Physicians often experience moral distress from being prevented from taking what they believe to be the right course of action. Although causes and consequences of moral distress have been studied, little research offers insight into the significance of feeling morally challenged, especially in medicine. This study was undertaken to advance understanding of what physicians experience when encountering morally challenging situations and to examine how those experiences influence their interactions with the world of health care.

METHOD

Guided by hermeneutic phenomenology, the authors conducted semistructured interviews with purposefully sampled Canadian physicians from September 2022 to January 2023. Analysis used Van Manen's 6 activities of hermeneutic research and included "story crafting" to sharpen insights. Late in that process, Van Manen's "lived existentials" was determined to provide a strong framework for physicians' experiences of moral distress.

RESULTS

Of the 12 physicians interviewed, all experienced varied and long-lasting emotional reactions to morally challenging experiences. The emotions associated with moral distress, reported as inevitable, were experienced in ways that aligned with the lived existentials of body, space, time, and relations.

CONCLUSIONS

A richer understanding of physicians' lived experiences with moral distress can help mentors and educators more thoughtfully engage in conversations about it with colleagues and learners. This study highlights the core dimensions of moral distress through body, space, time, and relations, thereby providing a means to enrich discussion about emotions and their transformational power. Through such nuanced consideration, calls for emotional candor may be strengthened to enhance practice by acknowledging the scope of impact that efforts to deliver care are likely to provoke.

Moral distress from professionalism dilemmas and its association with self-rated professionalism behaviors among Chinese residents

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.

Developing culturally competent physicians: Empathy, inclusivity, moral distress training and ethical reflections during the Medicine Clerkship

PURPOSE

We aimed to develop a tool that would allow assessment of ethics competency and moral distress during the Internal Medicine Clerkship and to introduce curricular changes that could empower students to better address ethical dilemmas and challenges encountered during the clerkship.

MATERIALS AND METHODS

A structured ethics assignment was introduced where students could reflect on impactful stressful scenarios and address questions related to emotional responses, identified ethical issues, management themes, and professional obligations. A 4-tiered grading rubric and individual narrative feedback was provided for each assignment, and small-group debriefing sessions were introduced for reflective thought and future planning. De-identified assignments were analyzed and classified into subgroups according to 5 main ethical issue subgroups and 10 specific management themes. Assignments were also analyzed for the presence of moral distress.

RESULTS

357 students completed the reflective ethics activities. The most commonly identified ethical issues were related to Shared Medical Decision Making (>40%), Primary of Patient Welfare challenges, (>20%), and Social/Organizational dilemmas. Management themes often pertained to Patient Wishes/Legal Obligations, Professional Behaviors, and Limited Resources. 87% of assignments demonstrated moral distress.

CONCLUSION

Medical school is a stressful time and challenges are augmented during clinical years. Our reflective activity demonstrated significant exposures to ethical dilemmas, reviewed earlier principles of ethics training, and provided a safe forum in which to discuss these important aspects of healthcare. We captured powerful images of challenging situations eliciting moral distress, and students greatly appreciated the activity. We encourage future investigations that support student well-being and enable smooth transitions into residency training.

"I Went Into This Field to Empower Other People, and I Feel Like I Failed": Residents Experience Moral Distress Post-Dobbs

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.

Challenges for Medical Students in Applying Ethical Principles to Allocate Life-Saving Medical Devices During the COVID-19 Pandemic: Content Analysis

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.

Violence and Clinical Learning Environments in Medical Residencies

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.

From Battles to Burnout: Investigating the Role of Interphysician Conflict in Physician Burnout

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.

The Nurses' Second Victim Syndrome and Moral Distress

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.

Moral Orientation, Moral Decision-Making, and Moral Distress Among Critical Care Physicians: A Qualitative Study

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.

Implications of the Dobbs Decision for Medical Education: Inadequate Training and Moral Distress

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.

From distress to detachment: exploring how providing care for stigmatized patients influences the moral development of medical trainees

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.

The Norms and Corporatization of Medicine Influence Physician Moral Distress in the United States

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.

The workplace and psychosocial experiences of Australian junior doctors during the COVID-19 pandemic

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.

Experiences of staff providing specialist palliative care during COVID-19: a multiple qualitative case study

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.

Experience of General Practice Residents Caring for Dependent Elderly during the First COVID-19 Lockdown-A Qualitative Study

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.

The role of philosophy and ethics at the edges of medicine

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.

How Attendings Can Help Residents Navigate Moral Distress: A Qualitative Study

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.

Structural distress: experiences of moral distress related to structural stigma during the COVID-19 pandemic

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.

'I found myself a despicable being!': Medical students face disturbing moral dilemmas

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.

Nutrition content of summative examinations within an Australian 4-year graduate entry medical course: 2013-2016

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.

Moral distress in medicine: An ethical analysis

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.

From novice to expert: methods for transferring implementation facilitation skills to improve healthcare delivery

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.

Surreal Becomes Real: Ethical Dilemmas Related to the COVID-19 Pandemic and Professional Identity Formation of Health Professionals

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.

Towards collective moral resilience: the potential of communities of practice during the COVID-19 pandemic and beyond

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.

Moral distress and its contributing factors among emergency department nurses: A cross-sectional study in Iran

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.

Moral judgement development during medical student clinical training

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.

What Should an Intern Do When She Disagrees With the Attending?

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.

COVID-19 era healthcare ethics education: Cultivating educational and moral resilience

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.

The Effect of the Educational Environment on the rate of Burnout among Postgraduate Medical Trainees - A Narrative Literature Review

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.

Reconsidering Systems-Based Practice: Advancing Structural Competency, Health Equity, and Social Responsibility in Graduate Medical Education

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.

[Moral distress in medical students and young professionals: research desiderata in the context of the COVID-19 pandemic]

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.

Moral Distress in Pediatric Residents and Pediatric Hospitalists: Sources and Association With Burnout

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.

Moral distress among nursing professors: The exercise of parrhesia

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.

Optimizing resilience and wellbeing for healthcare professions trainees and healthcare professionals during public health crises - Practical tips for an 'integrative resilience' approach

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.

Consequences of Medical Hierarchy on Medical Students, Residents, and Medical Education in Otolaryngology

Objective

To (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 Sources

Ovid Medline, Embase, GoogleScholar, JSTOR, Google, and article reference lists.

Review Methods

A 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.

Conclusions

Two 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 Practice

Otolaryngology–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.

Moral distress and burnout in caring for older adults during medical school training

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.

Burnout syndrome, extracurricular activities and social support among Brazilian internship medical students: a cross-sectional analysis

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.