1
|
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.
Collapse
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
| |
Collapse
|
2
|
Guinaudeau J, Baier PC, Kühlmeyer K, Borzikowsky C, Terheyden L, Witt VD, Rogge A. [Changes in the routine work and moral distress in psychiatric care during the COVID-19 pandemic : A survey among physicians active in inpatient care in Germany]. DER NERVENARZT 2023; 94:827-834. [PMID: 37405400 PMCID: PMC10499671 DOI: 10.1007/s00115-023-01499-z] [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] [Accepted: 04/16/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND During the COVID-19 pandemic a number of ethical challenges have arisen in the healthcare system. A psychological response to moral challenges is termed moral distress (MD). OBJECTIVE Identification of causes of MD in inpatient psychiatric care in the context of the COVID-19 pandemic in Germany. MATERIAL AND METHODS A survey was conducted using a self-administered non-validated online questionnaire as part of a cross-sectional study, in which 26 items about the experience of MD were examined and open questions about the handling of the pandemic and its effects on everyday work were posed. Physicians who worked in inpatient psychiatric care during the COVID-19 pandemic in Germany were surveyed anonymously with a convenience sample. The data acquisition took place between 17 November 2020 and 6 May 2021. RESULTS A total of 141 participants were included. They indicated multiple pandemic-related changes in their daily work partly resulting in MD. CONCLUSION MD is a neglected potential burden of inpatient psychiatric care under pandemic conditions (and beyond), which requires further research and an adequate handling. These results include implications for decision makers in crisis teams as well as a need for support services such as clinical ethics consultation services.
Collapse
Affiliation(s)
- Jeanne Guinaudeau
- Zentrum für Integrative Psychiatrie, Universitätsklinikum Schleswig-Holstein, Niemannsweg 147, 24105, Kiel, Deutschland.
| | - Paul Christian Baier
- Zentrum für Integrative Psychiatrie, Universitätsklinikum Schleswig-Holstein, Niemannsweg 147, 24105, Kiel, Deutschland
| | - Katja Kühlmeyer
- Institut für Ethik, Geschichte und Theorie der Medizin, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Christoph Borzikowsky
- Institut für Medizinische Informatik und Statistik, Christian-Albrechts-Universität zu Kiel, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| | - Laura Terheyden
- Klinik für Neurologie, Nordseeklinik Helgoland, Helgoland, Deutschland
| | | | - Annette Rogge
- Klinik für Neurologie, Nordseeklinik Helgoland, Helgoland, Deutschland
- Klinik für Neurologie, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| |
Collapse
|
3
|
Golz C, Oulevey Bachmann A, Defilippis TS, Kobleder A, Peter KA, Schaffert R, Schwarzenbach X, Kampel T, Hahn S. Preparing students to deal with the consequences of the workforce shortage among health professionals: a qualitative approach. BMC MEDICAL EDUCATION 2022; 22:756. [PMID: 36333793 PMCID: PMC9636659 DOI: 10.1186/s12909-022-03819-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/26/2022] [Accepted: 10/19/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Healthcare is facing a shortage of qualified healthcare professionals. The pandemic has brought to light the fragile balance that affects all healthcare systems. Governments have realized that these systems and the professionals working in them need support at different levels to strengthen the retention of the workforce. Health professionals' education can play an important role in ensuring that new generations of workers have sound personal and professional competencies to successfully face the challenges of professional practice. These challenges are described in the literature, but the extent to which they are considered in health professionals' education is less clear. METHODS This qualitative study compares the professional challenges and educational needs described in the literature with the current curricula for health professionals offered in Switzerland. Data were collected nationally through focus group interviews with 65% of Switzerland's directors of bachelor's and master's programs of health professions (nursing, physiotherapy, occupational therapy, midwifery, nutrition and dietetics, osteopathy, radiologic medical imaging technology, health promotion and prevention, and health sciences). The data attained were analyzed using knowledge mapping. RESULTS The results reveal a gap among education programs with regard to occupational health promotion and cultural diversity. Both topics are taught with a sole focus on patients, and students are expected to adopt similar strategies for their health promotion and stress management. Physicians are insufficiently involved in interprofessional education. The programs fail to enhance health professionals' political, economic and digital competencies. CONCLUSION The results of this study offer clear guidance about what topics need to be integrated into curricula to improve health professionals' well-being at work and their preparedness to face daily professional challenges.
Collapse
Affiliation(s)
- Christoph Golz
- Department of Health Professions, Bern University of Applied Sciences, Murtenstrasse 10, 3008, Bern, Switzerland.
| | - Annie Oulevey Bachmann
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
| | - Tiziana Sala Defilippis
- Department of Business Economics, Health and Social Care, University of Applied Sciences and Arts of Southern Switzerland, Locarno, Switzerland
| | - Andrea Kobleder
- Department of Health, Eastern Switzerland University of Applied Sciences, St. Gallen, Switzerland
| | - Karin Anne Peter
- Department of Health Professions, Bern University of Applied Sciences, Murtenstrasse 10, 3008, Bern, Switzerland
| | - René Schaffert
- School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Xenia Schwarzenbach
- Department of Health Professions, Bern University of Applied Sciences, Murtenstrasse 10, 3008, Bern, Switzerland
| | - Thomas Kampel
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
| | - Sabine Hahn
- Department of Health Professions, Bern University of Applied Sciences, Murtenstrasse 10, 3008, Bern, Switzerland
| |
Collapse
|
4
|
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.
Collapse
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.
| |
Collapse
|
5
|
Cho C, Ko WYK, Ngan OMY, Wong WT. Exploring Professionalism Dilemma and Moral Distress through Medical Students' Eyes: A Mixed-Method Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10487. [PMID: 36078203 PMCID: PMC9517822 DOI: 10.3390/ijerph191710487] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/15/2022] [Accepted: 08/17/2022] [Indexed: 06/15/2023]
Abstract
This study aims to understand professionalism dilemmas medical students have experienced during clinical clerkships and the resulting moral distress using an explanatory mixed-method sequential design-an anonymous survey followed by in-depth interviews. A total of 153 students completed and returned the survey, with a response rate of 21.7% (153/706). The top three most frequently occurring dilemmas were the healthcare team answering patients' questions inadequately (27.5%), providing fragmented care to patients (17.6%), and withholding information from a patient who requested it (13.7%). Students felt moderately to severely distressed when they observed a ward mate make sexually inappropriate remarks (81.7%), were pressured by a senior doctor to perform a procedure they did not feel qualified to do (77.1%), and observed a ward mate inappropriately touching a patient, family member, other staff, or student (71.9%). The thematic analysis based on nine in-depth interviews revealed the details of clinicians' unprofessional behaviors towards patients, including verbal abuse, unconsented physical examinations, bias in clinical decisions, students' inaction towards the dilemmas, and students' perceived need for more guidance in applying bioethics and professionalism knowledge. Study findings provide medical educators insights into designing a professional development teaching that equips students with coping skills to deal with professionalism dilemmas.
Collapse
Affiliation(s)
- Cordelia Cho
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Wendy Y. K. Ko
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Olivia M. Y. Ngan
- CUHK Centre for Bioethics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Wai Tat Wong
- Department of Anaesthesia and Intensive Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| |
Collapse
|
6
|
Toh RQE, Koh KK, Lua JK, Wong RSM, Quah ELY, Panda A, Ho CY, Lim NA, Ong YT, Chua KZY, Ng VWW, Wong SLCH, Yeo LYX, See SY, Teo JJY, Renganathan Y, Chin AMC, Krishna LKR. The role of mentoring, supervision, coaching, teaching and instruction on professional identity formation: a systematic scoping review. BMC MEDICAL EDUCATION 2022; 22:531. [PMID: 35804340 PMCID: PMC9270794 DOI: 10.1186/s12909-022-03589-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/23/2022] [Indexed: 05/13/2023]
Abstract
BACKGROUND Mentoring's pivotal role in nurturing professional identity formation (PIF) owes much to its combined use with supervision, coaching, tutoring, instruction, and teaching. However the effects of this combination called the 'mentoring umbrella' remains poorly understood. This systematic scoping review thus aims to map current understanding. METHODS A Systematic Evidence-Based Approach guided systematic scoping review seeks to map current understanding of the 'mentoring umbrella' and its effects on PIF on medical students and physicians in training. It is hoped that insights provided will guide structuring, support and oversight of the 'mentoring umbrella' in nurturing PIF. Articles published between 2000 and 2021 in PubMed, Scopus, ERIC and the Cochrane databases were scrutinised. The included articles were concurrently summarised and tabulated and concurrently analysed using content and thematic analysis and tabulated. The themes and categories identified were compared with the summaries of the included articles to create accountable and reproducible domains that guide the discussion. RESULTS A total of 12201 abstracts were reviewed, 657 full text articles evaluated, and 207 articles included. The three domains identified were definitions; impact on PIF; and enablers and barriers. The mentoring umbrella shapes PIF in 3 stages and builds a cognitive base of essential knowledge, skills and professional attitudes. The cognitive base informs thinking, conduct and opinions in early supervised clinical exposure in Communities of practice (COP). The COPs' individualised approach to the inculcation of desired professional characteristics, goals, values, principles and beliefs reshapes the individual's identity whilst the socialisation process sees to their integration into current identities. CONCLUSION The mentoring umbrella's provides personalised longitudinal support in the COP and socialisation process. Understanding it is key to addressing difficulties faced and ensuring holistic and timely support.
Collapse
Affiliation(s)
- Rachelle Qi En Toh
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961, Singapore
| | - Kai Kee Koh
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961, Singapore
| | - Jun Kiat Lua
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961, Singapore
| | - Ruth Si Man Wong
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961, Singapore
| | - Elaine Li Ying Quah
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961, Singapore
| | - Aiswarya Panda
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961, Singapore
| | - Chong Yao Ho
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961, Singapore
| | - Nicole-Ann Lim
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961, Singapore
| | - Yun Ting Ong
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961, Singapore
| | - Keith Zi Yuan Chua
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961, Singapore
| | - Victoria Wen Wei Ng
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961, Singapore
| | - Sabine Lauren Chyi Hui Wong
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961, Singapore
| | - Luke Yu Xuan Yeo
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961, Singapore
| | - Sin Yee See
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961, Singapore
| | - Jolene Jing Yin Teo
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961, Singapore
| | - Yaazhini Renganathan
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961, Singapore
| | - Annelissa Mien Chew Chin
- Medical Library, National University of Singapore Libraries, National University of Singapore Blk MD6, Centre for Translational Medicine, 14 Medical Dr, #05-01, Singapore, 117599, Singapore
| | - Lalit Kumar Radha Krishna
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore.
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961, Singapore.
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961, Singapore.
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, University of Liverpool, 200 London Rd, Liverpool, L3 9TA, UK.
- Centre for Biomedical Ethics, National University of Singapore, Blk MD11, 10 Medical Drive, #02-03, Singapore, 117597, Singapore.
- PalC, The Palliative Care Centre for Excellence in Research and Education, PalC c/o Dover Park Hospice, 10 Jalan Tan Tock Seng, Singapore, 308436, Singapore.
| |
Collapse
|
7
|
Ong RSR, Wong RSM, Chee RCH, Quek CWN, Burla N, Loh CYL, Wong YA, Chok AKL, Teo AYT, Panda A, Chan SWK, Shen GS, Teoh N, Chin AMC, Krishna LKR. A systematic scoping review moral distress amongst medical students. BMC MEDICAL EDUCATION 2022; 22:466. [PMID: 35710490 PMCID: PMC9203147 DOI: 10.1186/s12909-022-03515-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/01/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Characterised by feelings of helplessness in the face of clinical, organization and societal demands, medical students are especially prone to moral distress (MD). Despite risks of disillusionment and burnout, efforts to support them have been limited by a dearth of data and understanding of MD in medical students. Yet, new data on how healthcare professionals confront difficult care situations suggest that MD could be better understood through the lens of the Ring Theory of Personhood (RToP). A systematic scoping review (SSR) guided by the RToP is proposed to evaluate the present understanding of MD amongst medical students. METHODS The Systematic Evidence-Based Approach (SEBA) is adopted to map prevailing accounts of MD in medical students. To enhance the transparency and reproducibility, the SEBA methodology employs a structured search approach, concurrent and independent thematic analysis and directed content analysis (Split Approach), the Jigsaw Perspective that combines complementary themes and categories, and the Funnelling Process that compares the results of the Jigsaw Perspective with tabulated summaries to ensure the accountability of these findings. The domains created guide the discussion. RESULTS Two thousand six hundred seventy-one abstracts were identified from eight databases, 316 articles were reviewed, and 20 articles were included. The four domains identified include definitions, sources, recognition and, interventions for MD. CONCLUSIONS MD in medical students may be explained as conflicts between the values, duties, and principles contained within the different aspects of their identity. These conflicts which are characterised as disharmony (within) and dyssynchrony (between) the rings of RToP underline the need for personalised and longitudinal evaluations and support of medical students throughout their training. This longitudinal oversight and support should be supported by the host organization that must also ensure access to trained faculty, a nurturing and safe environment for medical students to facilitate speak-up culture, anonymous reporting, feedback opportunities and supplementing positive role modelling and mentoring within the training program.
Collapse
Affiliation(s)
- Rui Song Ryan Ong
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 11, 119228, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Dr, 169610, Singapore, Singapore
| | - Ruth Si Man Wong
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 11, 119228, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Dr, 169610, Singapore, Singapore
| | - Ryan Choon Hoe Chee
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 11, 119228, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Dr, 169610, Singapore, Singapore
| | - Chrystie Wan Ning Quek
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 11, 119228, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Dr, 169610, Singapore, Singapore
| | - Neha Burla
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 11, 119228, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Dr, 169610, Singapore, Singapore
| | - Caitlin Yuen Ling Loh
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 11, 119228, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Dr, 169610, Singapore, Singapore
| | - Yu An Wong
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 11, 119228, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Dr, 169610, Singapore, Singapore
| | - Amanda Kay-Lyn Chok
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 11, 119228, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Dr, 169610, Singapore, Singapore
| | - Andrea York Tiang Teo
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 11, 119228, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Dr, 169610, Singapore, Singapore
| | - Aiswarya Panda
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 11, 119228, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Dr, 169610, Singapore, Singapore
| | - Sarah Wye Kit Chan
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 11, 119228, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Dr, 169610, Singapore, Singapore
| | - Grace Shen Shen
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 11, 119228, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Dr, 169610, Singapore, Singapore
| | - Ning Teoh
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 11, 119228, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Dr, 169610, Singapore, Singapore
| | - Annelissa Mien Chew Chin
- Medical Library, National University of Singapore libraries, Singapore Blk MD6, Centre, 14 Medical Dr, #05-01 for Translational Medicine, Singapore, Singapore
| | - Lalit Kumar Radha Krishna
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 11, 119228, Singapore, Singapore.
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Dr, 169610, Singapore, Singapore.
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Dr, Singapore, 169610, Singapore.
- Duke-NUS Medical School, National University of Singapore, Singapore 8 College Rd,, Singapore, 169857, Singapore.
- Palliative Care Institute Liverpool, Academic Palliative and End of Life Care Centre, Cancer Research Centre, University of Liverpool, 200 London Rd, Liverpool, L3 9TA, UK.
- Centre of Biomedical Ethics, National University of Singapore, 21 Lower Kent Ridge Rd, Singapore, 119077, Singapore.
- PalC, The Palliative Care Centre for Excellence in Research and Education, PalC c/o Dover Park Hospice, 10 Jalan Tan Tock Seng, Singapore, 308436, Singapore.
| |
Collapse
|
8
|
Maffoni M, Olson K, Hynes J, Argentero P, Setti I, Giorgi I, Giardini A. A journey through roses and thorns: becoming a physician by learning from patients with life-threatening illnesses. A qualitative study with international medical students. Monaldi Arch Chest Dis 2021; 91. [PMID: 34092073 DOI: 10.4081/monaldi.2021.1800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/21/2021] [Indexed: 11/23/2022] Open
Abstract
The medical students' well-being may be threatened by various stressors associated with providing care to different kinds of patients. This study aims to explore students' clinical experiences with patients who suffer from life-threatening illnesses, focusing on potential risk and protective factors. Audio-recorded and face-to-face interviews were conducted and transcribed verbatim. The "Interpretive Description" approach was used to analyse data. Overall, ten medical students with a mean age of 28 years old were interviewed. Well-being promoting factors were the following: therapeutic relationships, work-life balance, social support and communication, perception of improvement in knowledge and availability of advanced directives. Whilst factors that may reduce well-being included death exposure, managing emotions, communication difficulties, internal conflicts and disagreements, lack of knowledge and subjective concerns. These findings shed light on facets that are inherent parts of clinical experience with patients suffering from a life-threatening illness and that may turn in risk or protective factors for the medical students. Understanding the students' subjective experiences may aid in the improvement of the current educational programs, as well as in the development of tailored supportive and preventative interventions to promote well-being and professional competencies among this kind of students.
Collapse
Affiliation(s)
- Marina Maffoni
- Department of Brain and Behavioral Sciences, Psychology Unit, University of Pavia.
| | - Karin Olson
- Faculty of Nursing, University of Alberta, Edmonton Clinic Health Academy, Edmonton.
| | - Julia Hynes
- Department of Primary Care and Population Health, Medical School, University of Nicosia.
| | | | - Ilaria Setti
- Department of Brain and Behavioral Sciences, Psychology Unit, University of Pavia.
| | - Ines Giorgi
- Psychology Unit, ICS Maugeri IRCCS, Institute of Pavia.
| | - Anna Giardini
- Information Technology Department, ICS Maugeri IRCCS, Institute of Pavia.
| |
Collapse
|
9
|
Hildesheim H, Rogge A, Borzikowsky C, Witt VD, Schäffer E, Berg D. Moral distress among residents in neurology: a pilot study. Neurol Res Pract 2021; 3:6. [PMID: 33517916 PMCID: PMC7849144 DOI: 10.1186/s42466-021-00104-5] [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: 10/01/2020] [Accepted: 01/11/2021] [Indexed: 11/18/2022] Open
Abstract
Background Medical progress, economization of healthcare systems, and scarcity of resources raise fundamental ethical issues. Physicians are exposed to increasing moral conflict situations, which may cause Moral Distress (MD). MD occurs when someone thinks he or she might know the morally correct action but cannot act upon this knowledge because of in- or external constraints. Correlations of MD among residents to job changes and burn-out have been shown previously. There are, however, hardly any quantitative studies about MD among physicians in Germany. The aim of this study was to investigate the frequency of occurrence, the level of disturbance, and reasons for MD among neurological residents in German hospitals. Methods 1st qualitative phase: Open interviews on workload and ethical conflicts in everyday clinical practice were conducted with five neurological residents. Ethical principles of medical action and potential constraints that could cause MD were identified and a questionnaire designed. 2nd quantitative phase: A preliminary questionnaire was tested and evaluated by five further neurological residents. The final questionnaire consisted of 12 items and was conducted online and anonymously via e-mail or on-site as part of an unrelated resident training event at 56 sites. Results One hundred seven neurological residents from 56 university/acute care and rehabilitation hospitals throughout Germany were examined (response rate of those requesting the questionnaire: 75.1%). 96.3% of the participants had experienced MD weekly (3.86, SD 1.02), because they were unable to invest the necessary time in a patient or relative consultation. Errors in medical care, which could not be communicated adequately with patients or relatives, were rated as most distressing. The most common reasons for MD were the growing numbers of patients, expectations of patient relatives, fears of legal consequences, incentives of the DRG-system, and the increasing bureaucratization requirement. 43.0% of participants mentioned they considered leaving the field of inpatient-care. 65.4% stated they would like more support in conflict situations. Conclusion MD plays an important role for neurological residents in German hospitals and has an impact on participants’ consideration of changing the workplace. Important aspects are rationing (time/beds) and incentives for overdiagnosis as well as lack of internal communication culture and mentoring. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-021-00104-5.
Collapse
Affiliation(s)
- Hanna Hildesheim
- Department of Neurology, Kiel University, University-Hospital-Schleswig-Holstein, Arnold-Heller-Str. 3, 24105, Kiel, Germany.
| | - Annette Rogge
- Institute for Experimental Medicine, Medical Ethics, Kiel University, University-Hospital-Schleswig-Holstein, Kiel, Germany
| | - Christoph Borzikowsky
- Institute of Medical Informatics and Statistics, Kiel University, University-Hospital-Schleswig-Holstein, Kiel, Germany
| | | | - Eva Schäffer
- Department of Neurology, Kiel University, University-Hospital-Schleswig-Holstein, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Daniela Berg
- Department of Neurology, Kiel University, University-Hospital-Schleswig-Holstein, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| |
Collapse
|
10
|
Corradi-Perini C, Beltrão JR, Ribeiro URVDCO. Circumstances Related to Moral Distress in Palliative Care: An Integrative Review. Am J Hosp Palliat Care 2020; 38:1391-1397. [PMID: 33280390 DOI: 10.1177/1049909120978826] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The practice of palliative care is involved with ethical conflicts related to the life-death process and relief of suffering. The inability to act in the face of such dilemmas, due to internal or external barriers, can cause moral distress in the healthcare professionals. OBJECTIVE The purpose of this integrative review is to analyze which circumstances cause moral distress in healthcare professionals who work in palliative care. METHODS An integrative review of the literature was made in the SCIELO and PubMed databases, based on the descriptors "palliative care" and "moral distress." Articles published between 2015-2020, in Portuguese, Spanish and English were included, following the PRISMA criteria. RESULTS From a selection of 97 documents, 56 were completed reviewed and 23 studies were included in the review. Most articles refer to the nursing area, followed by multidisciplinary studies. The circumstances related to moral distress were identified involving: personal aspects; patients and caregivers; team; environment and organization. Communication problems, lack of resources and witnessing professionals giving false hope to patient and family members were the events related to moral distress most mentioned by the articles in the review. Recommendations for reducing and preventing moral distress include empowerment and educational programs in bioethics and palliative care. CONCLUSIONS Moral distress is an evident phenomenon in palliative care, involving different situations that can impact on quality-of-care provided as well as the well-being of the healthcare professionals.
Collapse
Affiliation(s)
- Carla Corradi-Perini
- Graduated Program in Bioethics, School of Life Sciences, 28100Pontifícia Universidade Católica do Paraná, Rua Imaculada Conceição, Curitiba, Brazil
| | - Julianna Rodrigues Beltrão
- Graduated Program in Bioethics, School of Life Sciences, 28100Pontifícia Universidade Católica do Paraná, Rua Imaculada Conceição, Curitiba, Brazil
| | | |
Collapse
|
11
|
[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.
Collapse
|
12
|
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: 18] [Impact Index Per Article: 4.5] [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.
Collapse
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.
| |
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
Pieters J, Dolmans DHJM, Verstegen DML, Warmenhoven FC, Courtens AM, van den Beuken-van Everdingen MHJ. Palliative care education in the undergraduate medical curricula: students' views on the importance of, their confidence in, and knowledge of palliative care. BMC Palliat Care 2019; 18:72. [PMID: 31455326 PMCID: PMC6712798 DOI: 10.1186/s12904-019-0458-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 08/15/2019] [Indexed: 11/24/2022] Open
Abstract
Background The need for palliative care is increasing. Since almost every junior doctor will come across palliative care patients, it is important to include palliative care in the undergraduate curriculum. The objective of this research is to gather undergraduate students’ views on palliative care in terms of its importance, their confidence in and knowledge of the domain. Methods Final-year medical students at four Dutch medical faculties were surveyed. The questionnaire measured their views on the education they had received, their self-reported confidence in dealing with palliative care patients and their knowledge of palliative care. Results Two hundred twenty-two medical students participated in this study. Students considered palliative care education relevant, especially training in patient-oriented care and communication with the patient. Students felt that several topics were inadequately covered in the curriculum. Overall, the students did not feel confident in providing palliative care (59.6%), especially in dealing with the spiritual aspect of palliative care (77%). The knowledge test shows that only 48% of the students answered more than half of the questions correctly. Conclusion The students in this study are nearly junior doctors who will soon have to care for palliative patients. Although they think that palliative care is important, in their opinion the curriculum did not cover many important aspects, a perception that is also in line with their lack of confidence and knowledge in this domain. Therefore, it is important to improve palliative care education in the medical curriculum.
Collapse
Affiliation(s)
- Jolien Pieters
- Department of Educational Development and Research Faculty of Health, Medicine and Life Sciences, Maastricht University, Universiteitssingel 60, 6229, ER, Maastricht, The Netherlands.
| | - Diana H J M Dolmans
- Department of Educational Development and Research Faculty of Health, Medicine and Life Sciences, Maastricht University, Universiteitssingel 60, 6229, ER, Maastricht, The Netherlands
| | - Daniëlle M L Verstegen
- Department of Educational Development and Research Faculty of Health, Medicine and Life Sciences, Maastricht University, Universiteitssingel 60, 6229, ER, Maastricht, The Netherlands
| | - Franca C Warmenhoven
- Department of Educational Development and Research Faculty of Health, Medicine and Life Sciences, Maastricht University, Universiteitssingel 60, 6229, ER, Maastricht, The Netherlands
| | - Annemie M Courtens
- Centre of Expertise for Palliative Care, Maastricht UMC+, Maastricht, The Netherlands
| | | |
Collapse
|