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

Associations between medical students' stress, academic burnout and moral courage efficacy

BACKGROUND

Medical students, especially during the clinical years, are often exposed to breaches of safety and professionalism. These contradict personal and professional values exposing them to moral distress and to the dilemma of whether and how to act. Acting requires moral courage, i.e., overcoming fear to maintain one's core values and professional obligations. It includes speaking up and "doing the right thing" despite stressors and risks (e.g., humiliation). Acting morally courageously is difficult, and ways to enhance it are needed. Though moral courage efficacy, i.e., individuals' belief in their capability to act morally, might play a significant role, there is little empirical research on the factors contributing to students' moral courage efficacy. Therefore, this study examined the associations between perceived stress, academic burnout, and moral courage efficacy.

METHODS

A cross-sectional study among 239 medical students who completed self-reported questionnaires measuring perceived stress, academic burnout ('exhaustion,' 'cynicism,' 'reduced professional efficacy'), and moral courage efficacy (toward others' actions and toward self-actions). Data analysis via Pearson's correlations, regression-based PROCESS macro, and independent t-tests for group differences.

RESULTS

The burnout dimension of 'reduced professional efficacy' mediated the association between perceived stress and moral courage efficacy toward others' actions. The burnout dimensions 'exhaustion' and 'reduced professional efficacy' mediated the association between perceived stress and moral courage efficacy toward self-actions.

CONCLUSIONS

The results emphasize the importance of promoting medical students' well-being-in terms of stress and burnout-to enhance their moral courage efficacy. Medical education interventions should focus on improving medical students' professional efficacy since it affects both their moral courage efficacy toward others and their self-actions. This can help create a safer and more appropriate medical culture.

"COVID-19 and the New Hidden Curriculum of Moral Injury and Compassion Fatigue"

Medical students are educated through two dichotomous curriculums, the formal, planned curriculum and the hidden curriculum unintentionally taught through socialization within the culture of medicine. As a consequence of shared trauma amongst the physician workforce during the COVID-19 pandemic, moral injury (MoI) and compassion fatigue (CoF) have become prevalent within the health care system, including palliative care medicine, with echoing ramifications on the observing trainee population. Thus, it is imperative to determine risk factors, protective factors and targeted interventions to offset MoI and CoF within the health care workforce and trainee population. Methods of strengthening personal and institutional resilience are vital to developing long-term structural change replacing the hidden curriculum of MoI and CoF with one of resilience and support. As palliative care providers are especially vulnerable to MoI and CoF, this article will examine the impact of the COVID-19 pandemic on MoI, CoF, and resilience within the hidden curriculum through the lens of palliative care.

Is There a Burnout Epidemic among Medical Students? Results from a Systematic Review

Background and Objectives: Medical students represent the ideal target group for promoting mental health and mental wellbeing, being exposed to specific risk factors, such as the content of medical training, the exposure to sickness and death, and a stressful academic routine. Medical students report high levels of cynicism and emotional exhaustion, which represent two of the essential features of burnout syndrome. In this systematic review, studies assessing the levels of burnout among medical students through validated tools worldwide were analyzed. Materials and Methods: A systematic review has been performed in order to identify studies: (1) focusing on samples of medical students; (2) evaluating burnout syndrome using validated tools; (3) providing prevalence data on burnout; and (4) written in English. Results: Out of the 5547 papers initially obtained, 64 were finally included in the analysis. The sample sizes ranged from 51 to 2682 participants. Almost all studies had a cross-sectional design; the Maslach Burnout Inventory and its related versions were the most frequently used assessment tools. The prevalence of burnout, which was stratified based on gender and academic stage, ranged from 5.6 to 88%. Burnout was mostly predicted by thoughts of stopping medical education, negative life events, lack of support, dissatisfaction, and poor motivation. Conclusions: The prevalence of burnout syndrome in medical students is quite heterogeneous, reaching a peak of 88% in some countries. However, several predictors have been identified, including negative life events or poor motivation. These findings highlight the need to develop preventive interventions targeting the future generation of medical doctors, in order to improve their coping strategies and resilience styles.

Multi-professional perspectives to reduce moral distress: A qualitative investigation

BACKGROUND

Encounters of moral distress have long-term consequences on healthcare workers' physical and mental health, leading to job dissatisfaction, reduced patient care, and high levels of burnout, exhaustion, and intentions to quit. Yet, research on approaches to ameliorate moral distress across the health workforce is limited.

RESEARCH OBJECTIVE

The aim of our study was to qualitatively explore multi-professional perspectives of healthcare social workers, chaplains, and patient liaisons on ways to reduce moral distress and heighten well-being at a southern U.S. academic medical center.

PARTICIPANTS & RESEARCH CONTEXT

Purposive sampling and chain-referral methods assisted with recruitment through hospital listservs, staff meetings, and newsletters. Interested participants contacted the principal investigator and all interviews were conducted in-person. Consent was attained prior to interviews. All interviews were recorded and transcribed verbatim.

RESEARCH DESIGN

Directed content analysis was used to deductively organize codes and to develop themes in conjunction with the National Academy of Medicine's National Plan for Health Workforce Well-Being. Rigor was attained through peer-debriefing, data triangulation methods, and frequent research team meetings.

ETHICAL CONSIDERATIONS

Ethics approval was obtained from the university and medical center institutional review boards.

FINDINGS

Themes demonstrate that rather than offering interventions in the aftermath of moral distress, multilevel daily practices ought to be considered that pre-emptively identify and reduce morally distressing encounters through (1) the care team, (2) management and leadership, and (3) the health care industry. Strategies include interdisciplinary decision-making, trusting managerial relationships, and organizational policies and practices that explicitly invest in mental health promotion and diverse leadership opportunities.

CONCLUSION

Moral distress interventions ought to target short-term stress reactions while also addressing the long-term impacts of moral residue. Health systems must financially commit to an ethical workplace culture that explicitly values mental health and well-being.

Training Ethical Competence in a World Growing Old: A Multimethod Ethical Round in Hospital and Residential Care Settings

Ethical challenges are traditionally described in a negative light, even though moral conflict can express the individual ability to perceive when something is not working and promote change. The true question, therefore, is not to how to silence moral conflict but how to educate it. Although the need for ethical support of health- and social-care professionals in elderly care is clearly perceived, there is no universal method for providing effective interventions. The authors hypothesize that adequate training sessions can help care professionals enhance this skill, once clear goals and specific educational techniques are set. This research tests the hypothesis on twenty care professionals working in acute and residential care settings for the elderly, building on the ethics round method. Mixed methods drawn from literature and the experience of educators were adapted to meet different educational goals. Moral issues can hardly be removed from a context characterized by increasing demand and decreasing resources, but they can be recognized and addressed with common efforts, a critical attitude, and a growth mindset. Enhancing these skills in qualified workers can help them accept the reality of work, release pressure, and identify common team goals. Introducing these skills before graduation can help future workers avoid unreal expectations and reduce frustration and early job quit rates.

Moral Distress: What Are We Measuring?

While various definitions of moral distress have been proposed, some agreement exists that it results from illegitimate constraints in clinical practice affecting healthcare professionals' moral agency. If we are to reduce moral distress, instruments measuring it should provide relevant information about such illegitimate constraints. Unfortunately, existing instruments fail to do so. We discuss here several shortcomings of major instruments in use: their inability to determine whether reports of moral distress involve an accurate assessment of the requisite clinical and logistical facts in play, whether the distress in question is aptly characterized as moral, and whether the moral distress reported is an appropriate target of elimination. Such failures seriously limit the ability of empirical work on moral distress to foster appropriate change.

The Effectiveness of Family Medicine-Driven Interprofessional Collaboration on the Readmission Rate of Older Patients

Interprofessional collaboration (IPC) for older patient care among family physicians, dentists, therapists, nutritionists, nurses, and pharmacists in the rural hospital care of older patients could improve the hospital readmission rate. However, there is a lack of interventional studies on IPC for improving the readmission rate among Japanese older patients in rural hospitals. This quasi-experimental study was performed on patients >65 years who were discharged from a rural community hospital. The intervention was IPC implementation with effective information sharing and comprehensive management of older patients’ conditions for effective discharge and readmission prevention; implementation started on 1 April 2021. The study lasted 2 years, from 1 April 2021 to 31 March 2022 for the intervention group and from 1 April 2020 to 31 March 2021 for the comparison group. The average participant age was 79.86 (standard deviation = 15.38) years and the proportion of men was 45.0%. The Cox hazard model revealed that IPC intervention could reduce the readmission rate after adjustment for sex, serum albumin, polypharmacy, dependent condition, and Charlson Comorbidity Index score (hazard ratio = 0.66, 95% confidence interval: 0.54−0.81). Rural IPC intervention can improve inpatient care for older patients and decrease readmission rates. Thus, for effective rural IPC interventions, family physicians in hospitals should proactively collaborate with various medical professionals to improve inpatient health outcomes.

"Death audit is a fight" - provider perspectives on the ethics of the Maternal and Perinatal Death Surveillance and Response (MPDSR) system in Ethiopia

BACKGROUND

Maternal and neonatal health are regarded as important indicators of health in most countries. Death auditing through, for example, the Maternal and Perinatal Death Surveillance and Response (MPDSR) is viewed as key to preventing maternal and newborn mortality. However, little is known about the implications of implementing perinatal auditing for healthcare professionals in low-income contexts. This study aimed to explore the ethical and practical consequences clinicians experience concerning MPDSR reporting practices in Ethiopia.  METHODS: Qualitative semi-structured in-depth individual interviews were conducted with 16 healthcare workers across professions at selected facilities in Ethiopia. The interview questions were related to clinicians' experiences with, and perceptions of, death auditing. Their strategies for coping with newborn losses and the related reporting practices were also explored. The material was analyzed following systematic text condensation, and the NVivo11 software was used for organizing and coding the data material.

RESULTS

Participants experienced fear of punishment and blame in relation to the perinatal death auditing process. They found that auditing did not contribute to reducing perinatal deaths and that their motivation to stick to the obligation was negatively affected by this. Performing audits without available resources to provide optimal care or support in the current system was perceived as unfair. Some hid information or misreported information in order to avoid accusations of misconduct when they felt they were not to blame for the baby's death. Coping strategies such as engaging in exceedingly larger work efforts, overtreating patients, or avoiding complicated medical cases were described.

CONCLUSIONS

Experiencing perinatal death and death reporting constitutes a double burden for the involved healthcare workers. The preventability of perinatal death is perceived as context-dependent, and both clinicians and the healthcare system would benefit from a safe and blame-free reporting environment. To support these healthcare workers in a challenging clinical reality, guidelines and action plans that are specific to the Ethiopian context are needed.

Exploring Professionalism Dilemma and Moral Distress through Medical Students' Eyes: A Mixed-Method Study

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.

The role of mentoring, supervision, coaching, teaching and instruction on professional identity formation: a systematic scoping review

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.

A systematic scoping review moral distress amongst medical students

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.

Effective interventions for reducing moral distress in critical care nurses

Moral distress (MD) has received considerable attention in the nursing literature over the past few decades. It has been found that high levels of MD can negatively impact nurses, patients, and their family and reduce the quality of patient care. This study aimed to investigate the potentially effective interventions to alleviate MD in critical care nurses. In this systematic review, a broad search of the literature was conducted in the international databases including PubMed/MEDLINE, Web of Science, and Scopus, as well as Google Scholar search engine using keywords such as moral distress, intensive care unit, ICU, nurses, and critical care nurses from 1984, when the concept of MD was first introduced in the nursing literature, up to 29 October 2020. Studies focusing on the interventions for managing MD in critical care nurse were evaluated. The quality of eligible papers was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist. A total of 8 studies fulfilled the eligibility criteria. Three studies had RCT design and five studies had quasi-experimental design. All studies were conducted in the United States or Iran. Educational workshop, moral empowerment program, social work intervention, nursing ethics huddles, and multifaceted resiliency bundle intervention were effective interventions for managing of MD among critical care nurses. There is limited but promising research evidence evaluating the efficacy of educational interventions for managing of MD among critical care nurses. Although some positive results have been reported, there is limited generalizable evidence due to the variability of interventions. These findings highlight the need for further studies to validate the efficacy of these interventions or develop more potent and efficient interventions for reducing MD in critical care nurses.

A scoping review of the changing landscape of geriatric medicine in undergraduate medical education: curricula, topics and teaching methods

PURPOSE

The world's population is ageing. Therefore, every doctor should receive geriatric medicine training during their undergraduate education. This review aims to summarise recent developments in geriatric medicine that will potentially inform developments and updating of undergraduate medical curricula for geriatric content.

METHODS

We systematically searched the electronic databases Ovid Medline, Ovid Embase and Pubmed, from 1st January 2009 to 18th May 2021. We included studies related to (1) undergraduate medical students and (2) geriatric medicine or ageing or older adults and (3) curriculum or curriculum topics or learning objectives or competencies or teaching methods or students' attitudes and (4) published in a scientific journal. No language restrictions were applied.

RESULTS

We identified 2503 records and assessed the full texts of 393 records for eligibility with 367 records included in the thematic analysis. Six major themes emerged: curriculum, topics, teaching methods, teaching settings, medical students' skills and medical students' attitudes. New curricula focussed on minimum Geriatrics Competencies, Geriatric Psychiatry and Comprehensive Geriatric Assessment; vertical integration of Geriatric Medicine into the curriculum has been advocated. Emerging or evolving topics included delirium, pharmacotherapeutics, healthy ageing and health promotion, and Telemedicine. Teaching methods emphasised interprofessional education, senior mentor programmes and intergenerational contact, student journaling and reflective writing, simulation, clinical placements and e-learning. Nursing homes featured among new teaching settings. Communication skills, empathy and professionalism were highlighted as essential skills for interacting with older adults.

CONCLUSION

We recommend that future undergraduate medical curricula in Geriatric Medicine should take into account recent developments described in this paper. In addition to including newly emerged topics and advances in existing topics, different teaching settings and methods should also be considered. Employing vertical integration throughout the undergraduate course can usefully supplement learning achieved in a dedicated Geriatric Medicine undergraduate course. Interprofessional education can improve understanding of the roles of other professionals and improve team-working skills. A focus on improving communication skills and empathy should particularly enable better interaction with older patients. Embedding expected levels of Geriatric competencies should ensure that medical students have acquired the skills necessary to effectively treat older patients.

Exploring moral distress in Australian midwifery practice

PROBLEM

Australian midwives are considering leaving the profession. Moral distress may be a contributing factor, yet there is limited research regarding the influence of moral distress on midwifery practice.

BACKGROUND

Moral distress was first used to describe the psychological harm incurred following actions or inactions that oppose an individuals' moral values. Current research concerning moral distress in midwifery is varied and often focuses only on one aspect of practice.

AIM

To explore Australian midwives experience and consequences of moral distress.

METHODS

Semi-structured interviews were used to understand the experiences of moral distress of 14 Australian midwives. Interviews were recorded and transcribed verbatim. Data were analysed using thematic analysis and NVIVO12©.

FINDINGS

Three key themes were identified: experiencing moral compromise; experiencing moral constraints, dilemmas and uncertainties; and professional and personal consequences. Describing hierarchical and oppressive health services, midwives indicated they were unable to adequately advocate for themselves, their profession, and the women in their care.

DISCUSSION

It is evident that some midwives experience significant and often ongoing moral compromise as a catalyst to moral distress. A difference in outcomes between early career midwives and those with more than five years experiences suggests the cumulative nature of moral distress is a significant concern. A possible trajectory across moral frustration, moral distress, and moral injury with repeated exposure to morally compromising situations could explain this finding.

CONCLUSION

This study affirms the presence of moral distress in Australian midwives and identified the cumulative effect of moral compromise on the degree of moral distress experienced.

Moral Distress in Community and Hospital Settings for the Care of Elderly People. A Grounded Theory Qualitative Study

Background: Moral distress has frequently been investigated in single healthcare settings and concerning a single type of professional. This study aimed to describe the experience of moral distress in all the types of professionals providing daily care to elderly patients and residents. Methods: The Grounded Theory approach, developed by Corbin and Strauss, was used. This study included participants from hospital and nursing homes of northern Italy. Purposive and theoretical sampling was used. Between December 2020 and April 2021, semi-structured interviews were conducted. Results: Thirteen participants were included in the study. Four categories were derived from the data: talking and listening, care provider wellbeing, decision making, protective factors, and potential solutions. The core category identified was “sharing daily”. Interviewees confirm how hard it may be to communicate to the elderly, but at the same time, how adequate communication with the leader is a protective factor of moral distress. They also confirm how communication is key to managing or downsizing misunderstandings at all levels. Findings highlight the scarcity of operators as a fundamental trigger of moral distress. Conclusions: Many determinants of this phenomenon lie behind the direct control of professionals, but education can help them learn how to prevent, manage, or downsize the consequences.

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.

[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.