Systematic scoping review on moral distress among physicians

An Exploratory Model of How Ethical Indicators Predict Health Professional Burnout

The objectives of this study were to characterize burnout in five different health professions (i.e., pharmacists, nurses, occupational therapists, psychologists, and mental health counselors) as well as to determine if moral distress, ethical stress, and/or ethical climate were predictive of burnout and job satisfaction. Cross-sectional survey data were collected in the USA using validated measures from a sample of 291 in early 2022 (COVID-19 Omicron wave). The average age of participants was 51 years (s.d. = 12.59) and most identified as female (78%), White/Caucasian (82%), married/in a domestic partnership (72%), without dependents (57%), and had > 20 years of experience (53%). Results demonstrated that two of the three dimensions of burnout (i.e., emotional exhaustion and depersonalization) reached clinically significant levels among nurses, occupational therapists, and pharmacists, but not among psychologists or mental health counselors. In testing an exploratory structural equation model, moral distress, ethics stress, and ethical climate contributed significantly to the burnout and job satisfaction of all professionals (CFI = 0.905; SRMR = 0.056; Gamma hat scaled = 0.931). These findings support a theoretical framework for explaining associations between ethical indicators and burnout and job satisfaction. Future research should explore if professions with less burnout experience differences in the organizational environment, autonomy, and independence of clinical work, and/or professional identity. Exploration into professional socialization, such as strategies learned as part of training and development, may be warranted to identify factors that buffer or mitigate burnout risk.

Perceived Quality of Care and Pediatricians' Moral Distress Caring for Children with Mental Health Conditions

OBJECTIVE

This study describes general and subspecialty pediatricians' experience of moral distress in providing care to children with mental health conditions, variation in moral distress across subspecialties, and associations between perceived care quality, practice characteristics, and moral distress.

METHODS

This study analyzed survey data collected during 2022 American Board of Pediatrics Maintenance of Certification enrollment. Questions included perceived frequency with which high quality care was provided to children with mental health conditions (with suboptimal care quality defined as the lowest 2 response options on a 5-point Likert scale) and 4 potential sources of moral distress; high moral distress was defined as a top quartile composite score. Multivariable logistic regression was used to estimate associations between perceived suboptimal care quality, practice characteristics, and high moral distress.

RESULTS

5363 eligible pediatricians (55.2%) participated in the survey, including 3254 (60.7%) general pediatricians and 2109 (39.3%) subspecialists. Overall, 1147 (22.7%) reported perceived suboptimal care quality. Composite moral distress scores were highest for emergency medicine (n=106, 45.9% in highest quartile), child abuse (n=9, 39.1% in highest quartile), and hospital medicine physicians (n=109,32.5% in highest quartile). In regression analysis, high moral distress was associated with perceived suboptimal care quality, female gender, subspecialty, rurality, public insurance in practice, and academic appointment.

CONCLUSIONS

Approximately one-in-five pediatricians perceived suboptimal care quality for children with mental health conditions; this was associated with greater moral distress and several practice characteristics. Improving mental healthcare access, resources, and pediatricians' capacities to provide high quality care may benefit clinicians as well as children.

Experiences of healthcare professionals providing palliative care in home settings - a scoping review

BACKGROUND

The growing preference for home-based end-of-life care accords a dignified death for terminally ill patients. However, for healthcare professionals (HCPs) involved, this caregiving approach is embedded with unique psychosocial, practical and emotional stressors. Without sufficient support, HCPs face higher risks of moral distress, compassion fatigue, vicarious trauma, secondary traumatic stress and burnout-collectively known as the costs of caring-that precipitate depersonalisation and compromised patient care. Despite its far-reaching implications, current understanding of the costs of caring amongst HCPs in home-based settings remains remiss. Thus, we conduct a scoping review to investigate the experiences of HPCs providing home-based palliative care to terminally ill adult oncology patients.

METHODS

Outlined by the Systematic Evidence-Based Approach and PRISMA guidelines, searches for relevant articles published between 1st January 2000 and 1st October 2024 were performed on PubMed, Embase, Scopus, PsycINFO and CINAHL databases. Selected articles underwent concurrent and independent thematic and content analyses. Central themes and categories were extracted and merged, forming key domains that framed the discussion.

RESULTS

Of 5676 titles and abstracts screened, 543 full-text articles were reviewed. 20 full-text articles were analysed for inclusion. Four key domains emerged: (1) motivations to practice palliative care; (2) impact on personhood of HCPs (3) challenges faced by HCPs; and (4) support systems for HCPs.

CONCLUSION

Providing home-based palliative care to adult oncology patients is fulfilling for HCPs-fostering meaningful professional relationships with patients, a more holistic perspective of life and death and a heightened sense of personal accomplishment. However, HCPs may encounter dissonance amidst conflicts between their dominant beliefs and new experiences, leading to burnout, depersonalisation and poor care delivery that are further exacerbated by the costs of caring, if inadequately addressed. Longitudinal and accessible personalised and organisational support is key to sustaining HCPs' capacity to deliver compassionate and high-quality palliative care. The use of the Ring Theory of Personhood framework in this review provides an avenue for the structuring of such support systems.

Moral Distress and the Cost of Caring Amongst Medical Oncologists in Singapore

BackgroundMoral distress (MD), the notion of not being permitted to act in a morally and ethically correct manner, is evident amongst oncologists caring for terminally ill patients. Oncologists often contend with complex decisions, such as withholding treatment and managing family distress. Sociocultural and individual considerations also influence an oncologist's perception of MD, which can vary in severity due to changing ethical, practical, clinical, moral and professional considerations and shifting contextual circumstances. Their impact compromises an oncologist's wellbeing, patient outcomes and care of their family. Recent data suggests long-term consequences to MD and alludes to a broader cost of caring that encompasses compassion fatigue, vicarious trauma, secondary traumatic stress and burnout.MethodsThis study aims to determine how oncologists in Singapore experience MD and the costs of caring through secondary analysis of interviews with 12 oncologists.ResultsAnalysis of the interview transcripts revealed the following domains: 1) sources of MD; 2) sources of the costs of caring; and 3) protective factors.ConclusionThis secondary analysis of Singaporean oncologists suggests that MD is not frequently an isolated experience; rather, it leads to growing distress amongst oncologists-contributing to a wider cost of caring. This then impacts oncologists' decisioning, actions, practice and career trajectories. Longitudinal structured training, establishing personalised support for all oncologists and creating a safe working environment supported by the host organisation are thus critical to ensure sustainable practice.

The influence of the hidden curriculum on the risk of burnout in junior doctors in a palliative medicine rotation - a qualitative exploratory study

BACKGROUND

Palliative Care (PC) provides person-centred care for patients with life-limiting diseases and their families. Studies have shown that healthcare professionals delivering PC are predisposed to moral distress and burnout due to constant exposure to death and dying and aspects of the hidden curriculum (HC) through which culture and values are transmitted implicitly. However, there are limited studies focusing on the latter through the lens of junior doctors. Using the Ring Theory of Personhood (RToP) and the Krishna-Pisupati Model (KPM), which categorize and map conflicts between personal and professional values, beliefs, and principles within the four domains of personhood, this study investigates the impact of palliative care experiences on the risk of burnout in junior doctors.

METHODS

This qualitative exploratory study was conducted at the Division of Supportive and Palliative Care in the National Cancer Centre Singapore, involving medical residents who had completed at least one month with the division between 2020 and 2022. 13 participants were recruited for individual semi-structured interviews carried out by an independent research assistant. Acknowledging HC and burnout as sociocultural constructs, we adopted a constructivist ontological position and a relativist epistemological lens to guide thematic analysis of the data.

RESULTS

The themes identified were: (1) The Nature of PC (2), Moral Distress, and (3) Impact of Environment on Wellbeing. Junior doctors saw the value of the philosophy of care in PC and felt compelled to adopt values espoused by the discipline. However, compounded by consistent exposure to death and dying and limitations to manpower and time, elements of the HC, such as staff support measures, proved to be significant stressors-contributing to burnout and moral distress.

CONCLUSION

This is the first study on the effects of the HC on burnout for junior doctors in a PC rotation. It provides unique insights into the impact of complex clinical, personal, social, ethical and organizational factors on burnout and suggests that all factors need to be addressed in tandem for any attempts at staff support to be successful. This study can guide current and future research and programs that support wellbeing for junior doctors.

The impact of death and caring for the dying and their families on surgeons - an AI assisted systematic scoping review

CONTEXT

Surgeons are taking central roles in caring for patients leaving them prone to the emotional turmoil and grief of patients and families and the moral, psychological and existential distress of members of the interprofessional team and trainees. This has implications on patient safety and surgeon welfare.

OBJECTIVES

A systematic scoping review was carried out to address the primary research question "what is known of the effects of caring for the dying and the impact of patient's death on surgeons?". It is hoped that the insights gained will better guide support and assessment of surgeons in their evolving roles.

METHODS

Guided by the Systematic Evidence-based Approach (SEBA), we conducted a systematic scoping review (SSR). This review included articles published between 1st January 2000 and 2nd September 2024 on Pubmed, Embase, Scopus, Google Scholar, ERIC databases. To enhance trustworthiness and enhance the comprehensiveness of our review the articles identified were also evaluated using ChatGPT 4o and Notebook LM. The findings of these assistive processes were compared with the independent thematic and content analysis carried out by the two research teams.

RESULTS

In total, 4966 titles and abstracts were identified, 174 full-text articles were reviewed, and 26 full-text articles analysed. With the findings of the assistive analysis by the AI tools echoing the findings of the research teams- two key domains were identified: (1) the impact on personhood, (2) predisposing factors.

CONCLUSION

This AI assisted SSR in SEBA confirms that surgeons do suffer from the cumulative effects of caring for dying patients and their families and from the death of the patient and supporting the family and members of the interprofessional team and trainees. Without timely and personalized support surgeons are prone to depression, burnout, and substance abuse, and compromises to patient and family experiences, outcomes, safety and satisfaction. The need for effective longitudinal and personalized assessment tools is clear.

Concepts of Suffering at the End of Life Amongst Emergency, Palliative Care and Geriatric Medicine Physicians in Malaysia

BACKGROUND

Palliative Care, Geriatrics and Emergency physicians are exposed to death, terminally ill patients and distress of patients and their families. As physicians bear witness to patients' suffering, they are vulnerable to the costs of caring-the emotional distress associated with providing compassionate and empathetic care to patients. If left unattended, this may culminate in burnout and compromise professional identity. This study aims to provide a better understanding of suffering across various practice settings and specialties to guide the design of support frameworks for physicians and their patients.

METHODS

From August 2023 to September 2024, semi-structured interviews were conducted with sixteen Palliative Care, 12 Geriatrics and 13 Emergency physicians from various hospitals in Malaysia. Interview transcripts were analyzed using both inductive and deductive qualitative analyses.

RESULTS

Data analysis revealed three key domains: (1) living and dying well, (2) definition of suffering, and (3) impact of patient suffering on physicians.

CONCLUSION

Physicians' concepts of a good life and death frame their notions of suffering beyond the antithesis of a good life. Suffering is found to be distress at a loss of control, independence and dignity, alongside the presence of physical, emotional and existential distress. Witnessing patient suffering predisposes to physician suffering as they question their goals and roles in patient care. Our findings underscore the need for host organizations, hospitals and clinical departments to invest more in the care of their physicians. We believe these findings ought to be applicable to many resource-limited nations and other health care professionals beyond Malaysian shores.

Towards a Theory of Compassion Fatigue in Palliative Care and Oncology: A Systematic Scoping Review

BACKGROUND

In their care of terminally ill patients, palliative care physicians and oncologists are increasingly predisposed to physical and emotional exhaustion, or compassion fatigue (CF). Challenges faced by physicians include complex care needs; changing practice demands, and sociocultural contextual factors. Efforts to better understand CF have, however, been limited. We propose a systematic scoping review (SSR) to determine "What is known about theories of CF in physicians?".

METHODS

Guided by the PRISMA-based Systematic Evidence-based Approach (SEBA) methodology, our SSR comprised searches for articles published between 1 January 2000 and 31 December 2023 on MEDLINE, EMBASE, PsycINFO, Wiley, CINAHL and Google Scholar databases. Both thematic and content analyses were carried out.

RESULTS

Of the 10 505 titles identified, 80 articles were included. 15 current theories of CF were evaluated, leading to two key domains: theories of CF and theories related to the costs of caring. Overall, theories of CF evolved from Figley's model with gradual encompassing of moral distress, vicarious trauma and burnout, alongside the inclusion of individual characteristics, decisioning and nous in later theories.

CONCLUSION

CF was found to be part of a wider cost of caring that links clinical experiences with self-concepts of personhood and identity. The Ring Theory of Personhood has been able to shed light on how physicians will respond to such experiences and is key to guiding physician support and the creation of nurturing working environments.

Preventing burnout from moral distress among prehospital emergency personnel through action research and targeted clinical ethics support

Ethical challenges are integral to health care and are associated with moral distress among health professionals. Moral distress can turn into burnout with a range of negative effects for professionals, patients, relatives, collaborators, and the organisation. Based on action research a focus group study was conducted inclucing prehospital personnel from the emergency services in the Region of Southern Denmark. Results showed that ethical challenges arise in contexts of (1) caring for patients, (2) managing organisational demands, (3) collaborating. Ethical challenges are addressed informally among personnel in emergency vehicles, at ambulance stations, outside working hours, and ocationally involve family or friends with a background in healthcare. Prehospital physicians have the added opportunity to address ethically sensitive issues during monthly meetings. Voicing ethical challenges presupposes confidence, trust, and feeling safe in relation to colleagues, management, and the organisation. Existing forms of ethics support do not lend themselves to the present organisational setup of the studied emergency services. Targeted clinical ethics support initiatives are needed to address moral distress, prevent burnout, and build a supportive working environment. Initiatives must be developed collaboratively and tested bottom-up to identify and eliminate barriers for implementation.

A systematic scoping review of mentoring support on professional identity formation

BACKGROUND

Mentoring's success in nurturing professional identity formation (PIF) has been attributed to its ability to build personalised and enduring mentoring relationships. However, beyond functioning as communities of practice (CoPs) supporting socialisation processes, how mentoring integrates programme values and instils a shared identity amongst mentees remains unclear. The need for personalised guidance and timely attention to a mentee's unique needs in evolving mentoring relationships point to the critical role of support mechanisms ('mentoring support'). We conducted a systematic scoping review (SSR) studying "What is known about mentoring support's role in nurturing PIF?".

METHODS

Adopting PRISMA-ScR guidelines, this SSR was guided by the Systematic Evidence-Based Approach (SEBA). Independent searches were carried out on publications featured between 1st January 2000 and 30th June 2023 in PubMed, Embase, ERIC and Scopus databases. The Split Approach saw concurrent, independent thematic and content analyses of the included articles. The Jigsaw Perspective combined complementary themes and categories, creating broader themes/categories. The subsequent Funnelling Process formed key domains that platformed the synthesis of the discussion.

RESULTS

Two thousand three hundred forty-one abstracts were reviewed, 323 full-text articles were appraised and 151 articles were included and analysed. The key domains identified were (1) definitions and roles; (2) personalisation; (3) shepherding; and (4) PIF.

CONCLUSION

The success of mentoring in PIF lies in its ability to blend role modelling, supervision, mentoring, coaching and teaching, with self-care, guided reflection, apprenticeship and assessment to meet the individual needs of the mentee and their changing circumstances. Blending the contents of the mentoring umbrella emphasises the critical role of the mentor and host organisation in supporting mentor training, communications, support and assessment mechanisms. Mentee engagement and its active role in support measures complement the CoP-like mentoring programme's use of blending mentoring support to advance the socialisation process. These insights reflect a complex interactive process scaffolding the development of mentoring relationships and PIF. The effect of the mentoring umbrella on clinical practice requires further study.

Development of the Japanese Version of Rushton Moral Resilience Scale (RMRS) for Healthcare Professionals: Assessing Reliability and Validity

Aim: To translate the Rushton Moral Resilience Scale (RMRS) into Japanese and validate its applicability among Japanese healthcare professionals. Background: To overcome daily challenges in the field of healthcare, in which moral difficulties are routinely encountered, the development of intervention methods to address moral suffering and moral distress is crucial. Methods: We conducted a cross-sectional survey using a web-based questionnaire. The RMRS-16 was translated into Japanese and confirmed through back-translation. Reliability analyses (Cronbach's alpha and intraclass correlation coefficient [ICC]), confirmatory factor analyses (CFAs), correlation analyses, t-tests, and analysis of variance (ANOVA) were used to assess the validity of the scale. Results: Participants comprised 1295 healthcare professionals, including 498 nurses. All subscales and the total scale had acceptable reliability values (α ≥ 0.70). CFA supported the original four-factor structure (response to moral adversity, personal integrity, relational integrity, and moral efficacy), with acceptable fit indices. The ANOVA results suggested that, among Japanese healthcare professionals, nurses and individuals from other professions showed lower average moral resilience scores compared to physicians, consistent with previous research on mental health and moral distress. In addition, women scored lower for moral resilience than men. However, the ICC values for the subscales of the RMRS were below acceptable levels, and the results of the standardized residual covariances also suggested a model misfit. Conclusion and Implications: The reliability, validity, and utility of the Japanese version of the RMRS were generally supported. However, there were areas at the item level that required structural examination. The current findings suggest that there are cultural differences in the concept of moral resilience. Therefore, for future cultural comparisons, the original four-factor structure was maintained in the Japanese version without modifications. Further conceptual development of moral resilience is needed in Japanese healthcare.

Caring for terminally Ill patients: the impact on oncologists

BACKGROUND

Journeying with patients throughout their cancer trajectory and caring for them at the end of life can lead to emotional and moral distress in oncologists, negatively impacting their personal and professional identities. A better understanding of how transitions in care goals affect oncologists can shed light on the challenges faced and the support required. This study explored the impact of care transitions on oncologists' professional identity formation (PIF).

METHODS

From September to December 2023, semi-structured interviews were conducted with oncologists in a palliative care center in Singapore. The Ring Theory of Personhood (RToP) was used as a framework to capture the effects of experiences with patients transitioning from curative to palliative care on the oncologists' sense of self and identity. Data were analyzed using both inductive and deductive qualitative analysis.

RESULTS

Participants included six female and six male physicians, aged 30 to 53 years (mean 38 years), with an average of 9.75 years of experience as oncologists. The main domains identified were 1) challenges faced in transitioning patients to palliative care, 2) the impact of dealing with dying patients on oncologists, and 3) coping mechanisms.

CONCLUSION

Oncologists experience self-doubt and moral distress as they manage transitions in care. The PIF of oncologists can be supported through reflection and introspection, peer support, and interventions to promote self-care - ultimately enabling them to make meaning of their experiences, renew family ties, and reaffirm their commitment to the profession.

Causes of moral distress among midwives: A scoping review

Numerous studies have evidenced moral distress among midwives; however, to date no research synthesis on causes of moral distress among midwives has been conducted. A scoping review was carried out to identify, comprehensively map, and categorize possible causes of moral distress among midwives, and to identify knowledge gaps. Six data bases were searched using Boolean logic. To be included, studies had to (a) present empirical findings on (b) causes of moral distress (c) among midwives (d) in English, German, French, or Italian. We included a final set of 43 studies. The vast majority of studies came from high-income countries (83.7%) and used a qualitative approach (69.8%); 48.8% of the studies were published in the past 5 years. Identified single reasons of moral distress were grouped into eight broader clusters, forming a coherent framework of reasons of moral distress: societal disregard, contemporary birth culture, resources, institutional characteristics, interprofessional relationships, interpersonal mistreatment of service users, defensive practice, and challenging care situations. These clusters mostly capture moral distress resulting from a conflict between external constraints and personal moral standards, with a smaller proportion also from an intraindividual conflict between multiple personal moral standards. Despite projected increases in demand for midwives, the midwifery workforce globally faces a crisis and is experiencing substantial strain. Moral distress further exacerbates the shortage of midwives, which negatively affects birth experiences and birth outcomes, ultimately rendering it a public health issue. Our findings offer points of leverage to better monitor and alleviate moral distress among midwives, contributing to reducing attrition rates and improving birth experiences and birth outcomes. Further research is essential to explore the issue of ecological moral distress, develop evidence-based interventions aimed at alleviating moral distress among midwives, and evaluate the effects of both individual and system-level interventions on midwives, intrapartum care, and service users' outcomes.

When Fulfilling a Professional Obligation Causes Moral Distress: A New Evaluative Approach

PURPOSE

The term 'moral distress' was coined by Andrew Jameton to name the anguish that clinicians feel when they cannot pursue what they judge to be right because of institutional constraints. We argue that moral distress in critical care should also be addressed as a function of the constraints of ethics and propose an evaluative approach to the experience considering its implications for professional identity.

METHOD

We build on a selective review of the literature and analyze a paradigmatic example of moral distress, namely, clinicians who feel compelled to perform procedures on patients that seem futile. Such cases are commonly cited by clinicians as among the most morally distressing.

RESULTS

Our analysis shows that (1) physicians' experiences of moral distress can stem not only from toxic workplace cultures and institutional constraints on their time and resources for patient care but also from the limits of ethical reasoning and (2) an emotion-based evaluative approach to analyzing moral distress is needed to address its hazards for professional identity.

CONCLUSION

We propose a new evaluative approach to moral distress with implications for professional identity and the need for institutional education and support.

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.

From moral distress to resilient ethical climate among general practitioners: Fostering awareness. A qualitative pilot study

BACKGROUND

Moral distress in and ethical climate of health care institutions are highly intertwined subjects and have been linked to various quality of care indicators as well as job turnover intentions among health care professionals. Predominantly, both phenomena have been studied in intensive care, palliative and in-hospital settings. We aimed to explore the experience of moral distress by general practitioners (GPs), the role of ethical climate in GP moral distress and how ethical climate and moral distress can result in moral resilience in general practice.

METHODS AND FINDINGS

Between April and October 2021, we interviewed 13 doctors active in general practice in Flanders, Belgium, through semi-structured interviews. Data were processed and analysed using the Qualitative Analysis Guide of Leuven (QUAGOL). Most GPs had ample experience with morally distressing situations. Causes, determinants, and consequences do not differ significantly from other care settings. Moral distress can arise from conflicting views of good care, communication problems, and impending harm to third parties. We detected determinants of moral distress on micro-, meso- and macrolevels. GPs associate moral distress with job turnover and emotional, physical, existential, and quality of care effects. Several malleable factors can contribute to resilient ethical climates. This requires acquisition of vocabulary, skills, and knowledge.

CONCLUSIONS

Moral distress and ethical climate are important emerging themes for GPs. This research identifies determinants and effects of moral distress and ethical climate in primary care and could help GPs leverage moral distress experiences into morally resilient primary care through multiple suggested strategies.

State Abortion Policy and Moral Distress Among Clinicians Providing Abortion After the Dobbs Decision

Importance

Moral distress occurs when individuals feel powerless to do what they think is right, including when clinicians are prevented from providing health care they deem necessary. The loss of federal protections for abortion following the Dobbs v Jackson Women's Health Organization Supreme Court decision may place clinicians providing abortion at risk of experiencing moral distress, as many could face new legal and civil penalties for providing care in line with professional standards and that they perceive as necessary.

Objective

To assess self-reported moral distress scores among abortion-providing clinicians following the Dobbs decision overall and by state-level abortion policy.

Design, Setting, and Participants

This survey study, conducted from May to December 2023, included US abortion-providing clinicians (physicians, advanced practice clinicians, and nurses). A purposive electronic survey was disseminated nationally through professional listservs and snowball sampling.

Exposure

Abortion policy in each respondent's state of practice (restrictive vs protective using classifications from the Guttmacher Institute).

Main Outcomes and Measures

Using descriptive statistics and unadjusted and adjusted negative binomial regression models, the association between self-reported moral distress on the Moral Distress Thermometer (MDT), a validated psychometric tool that scores moral distress from 0 (none) to 10 (worst possible), and state abortion policy was examined.

Results

Overall, 310 clinicians (271 [87.7%] women; mean [SD] age, 41.4 [9.7] years) completed 352 MDTs, with 206 responses (58.5%) from protective states and 146 (41.5%) from restrictive states. Reported moral distress scores ranged from 0 to 10 (median, 5) and were more than double for clinicians in restrictive compared with protective states (median, 8 [IQR, 6-9] vs 3 [IQR, 1-6]; P < .001). Respondents with higher moral distress scores included physicians compared with advanced practice clinicians (median, 6 [IQR, 3-8] vs 4 [IQR, 2-7]; P = .005), those practicing in free-standing abortion clinics compared with those practicing in hospitals (median, 6 [IQR, 3-8] vs 4 [IQR, 2-7]; P < .001), those no longer providing abortion care compared with those still providing abortion care (median, 8 [IQR, 4-9] vs 5 [IQR, 2-8]; P = .004), those practicing in loss states (states with the greatest decline in abortion volume since the Dobbs decision) compared with those in stable states (unadjusted incidence rate [IRR], 1.72 [95% CI, 1.55-1.92]; P < .001; adjusted IRR, 1.59 [95% CI, 1.40-1.79]; P < .001), and those practicing in surge states (states with the greatest increase in abortion volume since the Dobbs decision) compared with those in stable states (unadjusted IRR, 1.27 [95% CI, 1.11-1.46]; P < .001; adjusted IRR, 1.24 [95% CI, 1.09-1.41]; P = .001).

Conclusions and Relevance

In this purposive national survey study of clinicians providing abortion, moral distress was elevated among all clinicians and more than twice as high among those practicing in states that restrict abortion compared with those in states that protect abortion. The findings suggest that structural changes addressing bans on necessary health care, such as federal protections for abortion, are needed at institutional, state, and federal policy levels to combat widespread moral distress.

Teaching Moral Courage & Rights-Based Leadership in Medicine: A Cross-Disciplinary Exploration

Clinical medicine's complexities and demands often surpass the scope of formal ethics and leadership training that medical schools and residency programs provide. The discrepancy between medical education and the realities of clinical work may contribute to ethical erosion among learners, namely, medical students and residents. Unlike traditional approaches to teaching professional ethics and leadership in medicine, rights-based (aspirational) pedagogies approach trainees as autonomous moral agents, whose work has moral value to themselves and others, who live with the ethical consequences of their professional choices, and whose work shapes their individual moral character. By incorporating teaching strategies that intentionally build learners' rights-based leadership through the development of moral courage, medical educators may counter important aspects of ethical erosion while promoting learner preparedness, outcomes, and well-being. Military teaching approaches offer a valuable example to medical educators seeking to create structured curricula that foster moral courage to promote rights-based leadership, given the high level of moral and managerial complexity present in both medicine and the military. Through a comparative analysis of professional ethics in the medical and military disciplines, this Observation article explores the validity of applying precedents from military ethics and leadership education to medical training. Through arguments rooted in moral philosophy, military history, and military organizational research, we explore the expansion of rights-based teaching methods within the predominantly traditional and rules-based norms of medical education. In relating these findings to real-life clinical scenarios, we offer six specific, rights-based modifications to medical ethics curricula that have potential to promote morally courageous leadership and counteract the ethical erosion medical students and residents face.

Moral distress among physicians in Norway: a longitudinal study

OBJECTIVES

To explore and compare physicians' reported moral distress in 2004 and 2021 and identify factors that could be related to these responses.

DESIGN

Longitudinal survey.

SETTING

Data were gathered from the Norwegian Physician Panel Study, a representative sample of Norwegian physicians, conducted in 2004 and 2021.

PARTICIPANTS

1499 physicians in 2004 and 2316 physicians in 2021.

MAIN OUTCOME MEASURES

The same survey instrument was used to measure change in moral distress from 2004 to 2021. Logistic regression analyses examined the role of gender, age and place of work.

RESULTS

Response rates were 67% (1004/1499) in 2004 and 71% (1639/2316) in 2021. That patient care is deprived due to time constraints is the most severe dimension of moral distress among physicians, and it has increased as 68.3% reported this 'somewhat' or 'very morally distressing' in 2004 compared with 75.1% in 2021. Moral distress also increased concerning that patients who 'cry the loudest' get better and faster treatment than others. Moral distress was reduced on statements about long waiting times, treatment not provided due to economic limitations, deprioritisation of older patients and acting against one's conscience. Women reported higher moral distress than men at both time points, and there were significant gender differences for six statements in 2021 and one in 2004. Age and workplace influenced reported moral distress, though not consistently for all statements.

CONCLUSION

In 2004 and 2021 physicians' moral distress related to scarcity of time or unfair distribution of resources was high. Moral distress associated with resource scarcity and acting against one's conscience decreased, which might indicate improvements in the healthcare system. On the other hand, it might suggest that physicians have reduced their ideals or expectations or are morally fatigued.

Moral caring competency and moral distress among Ghanaian nurses in adult care settings: A descriptive-correlational study

Background

Nurses in adult care settings frequently encounter moral distress due to the daily ethical obligations they must fulfill. In contrast to other healthcare professionals, nurses often grapple with a heightened frequency of moral dilemmas, resulting in increased moral distress.

Objective

This study aimed to explore the levels and relationship between moral caring competency and moral distress among Ghanaian nurses in adult care settings.

Methods

This quantitative study utilized a descriptive-correlational design. A multistage sampling was used to select three public hospitals. Simple random sampling was used to recruit 231 nurses from the three public hospitals. Data were collected from June to July 2023 using validated questionnaires. The study utilized frequency and percentages, mean and standard deviation, and Spearman's Correlation.

Results

The nurses had a low level of moral caring competency (M = 2.18, SD = 0.340). The composite moral distress score was 227.31, indicating a high level of moral distress among the nurses. Furthermore, there was a moderate, negative significant relationship between moral caring competency and moral distress (rs = -.474, N = 231, p <0.001).

Conclusions

Nurses in public hospitals had limited personal cognitive, affective, and psychomotor abilities to address patient moral issues. The nurses also experience significant moral distress when delivering patient care. Furthermore, to decrease the level of moral distress, moral caring competency should be strengthened among nurses. Therefore, it is recommended that nurse administrators provide adequate organizational support and implement continuous moral training to improve nurses' moral caring competency and mitigate their moral distress. Healthcare policymakers are encouraged to develop or refine policies to navigate moral dilemmas and reduce moral distress among nurses. Future studies employing qualitative designs can explore the influence of culture on moral caring competency within the Ghanaian setting.

Structural Equation Modeling Analysis on Associations of Moral Distress and Dimensions of Organizational Culture in Healthcare: A Cross-Sectional Study of Healthcare Professionals

OBJECTIVE

Moral distress is a complex phenomenon experienced by healthcare professionals. This study examined the relationships between key dimensions of Organizational Culture in Healthcare (OCHC)-perceived psychological safety, ethical climate, patient safety-and healthcare professionals' perception of moral distress.

DESIGN

Cross-sectional survey.

SETTING

Pediatric and adult critical care medicine, and adult hospital medicine healthcare professionals in the United States.

PARTICIPANTS

Physicians (n = 260), nurses (n = 256), and advanced practice providers (n = 110) participated in the study.

MAIN OUTCOME MEASURES

Three dimensions of OCHC were measured using validated questionnaires: Olson's Hospital Ethical Climate Survey, Agency for Healthcare Research and Quality's Patient Safety Culture Survey, and Edmondson's Team Psychological Safety Survey. The perception of moral distress was measured using the Moral Distress Amidst a Pandemic Survey. The hypothesized relationships between various dimensions were tested with structural equation modeling (SEM).

RESULTS

Adequate model fit was achieved in the SEM: a root-mean-square error of approximation =0.072 (90% CI 0.069 to 0.075), standardized root mean square residual = 0.056, and comparative fit index =0.926. Perceived psychological safety (β= -0.357, p <.001) and patient safety culture (β = -0.428, p<.001) were negatively related to moral distress experience. There was no significant association between ethical climate and moral distress (β = 0.106, p = 0.319). Ethical Climate, however, was highly correlated with Patient Safety Culture (factor correlation= 0.82).

CONCLUSIONS

We used structural equation model to test a theoretical model of multi-dimensional organizational culture and healthcare climate (OCHC) and moral distress.Significant associations were found, supporting mitigating strategies to optimize psychological safety and patient safety culture to address moral distress among healthcare professionals. Future initiatives and studies should account for key dimensions of OCHC with multi-pronged targets to preserve the moral well-being of individuals, teams, and organizations.

A Systematic Scoping Review on Dignity Assessment Tools

CONTEXT

The provision of person-centered dignity-conserving care is central to palliative care. It is important to reevaluate current methods of assessing dignity as the concept of dignity is multifaceted.

OBJECTIVES

The aim of this study is to understand the tools which are used to assess a patient's dignity and the elements of dignity evaluated in these tools.

METHODS

Two independent and concurrent Systematic Evidence-Based Approach guided systematic scoping reviews (SSR in SEBA) on existing dignity assessment tools and on accounts of assessments of dignity were carried out. The SSR in SEBA on dignity assessment tools involving PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Scopus, and CINAHL databases saw 22 full-text articles included from the 645 articles reviewed. The SSR in SEBA on accounts of assessments of dignity featured in the PubMed database identified 102 full-text articles which saw 46 articles included.

RESULTS

The domains identified were factors affecting patients' definition of dignity; elements of dignity-conserving care; and components of effective tools.

CONCLUSION

Current accounts to assess dignity and assessment tools fail to capture shifting self-concepts of dignity holistically. A portfolio-like appraisal of dignity is proposed to achieve assessments that are timely, longitudinal, and patient-specific. Portfolio-based assessments by members of the multidisciplinary team will better direct timely evaluations of relevant aspects of changing concepts of dignity, without losing the patient's holistic perception of dignity.

The employment of art therapy to develop empathy and foster wellbeing for junior doctors in a palliative medicine rotation - a qualitative exploratory study on acceptability

BACKGROUND

The interdisciplinary realm of medical humanities explores narratives and experiences that can enhance medical education for physicians through perspective-taking and reflective practice. However, there is a gap in comprehension regarding its appropriateness at the postgraduate level, especially when utilising art therapists as faculty. This study aims to assess the acceptability of an innovative art therapy-focused educational initiative among junior doctors during a palliative care rotation, with the goal of cultivating empathy and promoting well-being.

METHODS

A qualitative research project was conducted at the Division of Supportive and Palliative Care (DSPC) in the National Cancer Centre Singapore (NCCS). The study involved the recruitment of junior doctors who had successfully completed a three-month palliative care rotation program, spanning from January 2020 to April 2021. In a single small-group session lasting 1.5 h, with 3 to 4 participants each time, the individuals participated in activities such as collage making, group reflection, and sharing of artistic creations. These sessions were facilitated by an accredited art therapist and a clinical psychologist, focusing on themes related to empathy and wellbeing. To assess the acceptability of the program, two individual interviews were conducted three months apart with each participant. An independent research assistant utilised a semi-structured question guide that considered affective attitude, burden, perceived effectiveness, coherence, and self-efficacy. Thematic analysis of the transcribed data was then employed to scrutinise the participants' experiences.

RESULTS

A total of 20 individual interviews were completed with 11 participants. The three themes identified were lack of pre-existing knowledge of the humanities, promotors, and barriers to program acceptability.

CONCLUSIONS

The participants have mixed perceptions of the program's acceptability. While all completed the program in its entirety, the acceptability of the program is impeded by wider systemic factors such as service and manpower needs. It is vital to address these structural limitations as failing to do so risks skewing current ambivalence towards outright rejection of future endeavours to integrate humanities programs into medical education.

The role of patients' stories in medicine: a systematic scoping review

BACKGROUND

Patients' stories provide Palliative Care physicians with a glimpse into the former's lives and their psycho-emotional, sociocultural, and contextual considerations. Yet, few physicians are trained to interpret and apply patients' stories in their practice. Inherent variability in how stories are transmitted and interpreted raises questions over their potential effects on care. Amidst a dearth of accounts in Palliative Care, we map current use of patient stories to guide the training, assessment, and oversight of this 'care influencing' practice in medicine.

METHODS

This systematic scoping review was guided by the Systematic Evidence-Based Approach (SEBA) to ensure a reproducible and structured approach. The themes and categories identified through the Split Approach's concurrent and independent thematic and directed content analyses provided a comprehensive sketch of the included articles. The Jigsaw Perspective combined the themes and categories identified. The last stage of SEBA compared these results with two recent reviews of storytelling to ensure consistency of the domains created that guided the discussion.

RESULTS

Ten thousand two hundred seven articles were reviewed, 963 full text articles were evaluated, and 199 articles were included. The four domains identified were study characteristics, benefits, approaches, and positive effects and concerns.

CONCLUSION

Stories support patient-centered, personalized, and holistic clinical care. However, variability in the stories, their interpretations and use in care decisions underscore the need for further study on the structuring, teaching, assessing, and delivery of this 'care influencing' practice.

Clinician Moral Distress: Toward an Ethics of Agent-Regret

Moral distress names a widely discussed and concerning clinician experience. Yet the precise nature of the distress and the appropriate practical response to it remain unclear. Clinicians speak of their moral distress in terms of guilt, regret, anger, or other distressing emotions, and they often invoke them interchangeably. But these emotions are distinct, and they are not all equally fitting in the same circumstances. This indicates a problematic ambiguity in the moral distress concept that obscures its distinctiveness, its relevant circumstances, and how individual clinicians and the medical community should practically respond to it. We argue that, in a range of situations that are said to be morally distressing, the characteristic emotion can be well-understood in terms of what Bernard Williams calls "agent-regret." We show what can thereby be gained in terms of a less ambiguous concept and a more adequate ethical response to this distinctive and complex clinician experience.

Moral distress in nurse leaders-A scoping review of the literature

Nurse leaders face immense organizational pressures exacerbating their distress, which has not been prioritized as much as frontline nurses. This review synthesized the literature to examine theoretical models, measures, contributing factors, outcomes, and coping strategies related to moral distress in nurse leaders. PubMed, Embase, CINAHL, and PsycINFO were searched, and 15 articles-2 quantitative and 13 qualitative studies were extracted. The scoping review identified one study using a theoretical model and two measures-the ethical dilemmas questionnaire and the Brazilian moral distress scale. Contributing factors of moral distress include internal and organizational constraints, increased workload, and lack of support impacting physical and emotional well-being and intention to quit. This review did not yield any intervention studies emphasizing the need for research to identify specific predictors of moral distress and examine their relationship to nurse leader retention, so organizations can explore targeted interventions to promote coping and mitigate distress.

Ethical considerations in the prehospital treatment of out-of-hospital cardiac arrest: A multi-centre, qualitative study

BACKGROUND

Prehospital emergency physicians have to navigate complex decision-making in out-of-hospital cardiac arrest (OHCA) treatment that includes ethical considerations. This study explores Danish prehospital physicians' experiences of ethical issues influencing their decision-making during OHCA.

METHODS

We conducted a multisite ethnographic study. Through convenience sampling, we included 17 individual interviews with prehospital physicians and performed 22 structured observations on the actions of the prehospital personnel during OHCAs. We collected data during more than 800 observation hours in the Danish prehospital setting between December 2019 and April 2022. Data were analysed with thematic analysis.

RESULTS

All physicians experienced ethical considerations that influenced their decision-making in a complex interrelated process. We identified three overarching themes in the ethical considerations: Expectations towards patient prognosis and expectations from relatives, bystanders, and colleagues involved in the cardiac arrest; the values and beliefs of the physician and values and beliefs of others involved in the cardiac arrest treatment; and dilemmas encountered in decision-making such as conflicting values.

CONCLUSION

This extensive qualitative study provides an in-depth look at aspects of ethical considerations in decision-making in prehospital resuscitation and found aspects of ethical decision-making that could be harmful to both physicians and patients, such as difficulties in handling advance directives and potential unequal outcomes of the decision-making. The results call for multifaceted interventions on a wider societal level with a focus on advance care planning, education of patients and relatives, and interventions towards prehospital clinicians for a better understanding and awareness of ethical aspects of decision-making.

Assessing the Needs of Those Who Serve the Underserved: A Qualitative Study among US Oncology Clinicians

BACKGROUND

The American Society of Clinical Oncology established the 'Supporting Providers Serving the Underserved' (SUS) Task Force with a goal to develop recommendations to support cancer clinicians who deliver care for populations at risk for cancer disparities. As a first step, the Task Force explored barriers and facilitators to equitable cancer care delivery.

METHODS

Clinicians across the United States who deliver care predominantly for low-income and racially and ethnically minoritized populations were identified based on lists generated by the Task Force and the Health Equity Committee. Through purposive sampling based on geographical location, clinicians were invited to participate in 30-60 min semi-structured interviews to explore experiences, barriers, and facilitators in their delivery of cancer care. Interviews were recorded, transcribed, imported into qualitative data management software, and analyzed using thematic analysis.

RESULTS

Thematic analysis revealed three major themes regarding barriers (lack of executive leadership recognition of resources; patient-related socio-economic needs; clinician burnout) and two major themes regarding facilitators (provider commitment, experiential training).

CONCLUSIONS

Findings reveal modifiable barriers and potential solutions to facilitate equitable cancer care delivery for populations at risk for cancer disparities.

Moral distress among intensive care unit professions in the UK: a mixed-methods study

OBJECTIVE

To assess the experience of moral distress among intensive care unit (ICU) professionals in the UK.

DESIGN

Mixed methods: validated quantitative measure of moral distress followed by purposive sample of respondents who underwent semistructured interviews.

SETTING

Four ICUs of varying sizes and specialty facilities.

PARTICIPANTS

Healthcare professionals working in ICU.

RESULTS

227 questionnaires were returned and 15 interviews performed. Moral distress occurred across all ICUs and professional demographics. It was most commonly related to providing care perceived as futile or against the patient's wishes/interests, followed by resource constraints compromising care. Moral distress score was independently influenced by profession (p=0.02) (nurses 117.0 vs doctors 78.0). A lack of agency was central to moral distress and its negative experience could lead to withdrawal from engaging with patients/families. One-third indicated their intention to leave their current post due to moral distress and this was greater among nurses than doctors (37.0% vs 15.0%). Moral distress was independently associated with an intention to leave their current post (p<0.0001) and a previous post (p=0.001). Participants described a range of individualised coping strategies tailored to the situations faced. The most common and highly valued strategies were informal and relied on working within a supportive environment along with a close-knit team, although participants acknowledged there was a role for structured and formalised intervention.

CONCLUSIONS

Moral distress is widespread among UK ICU professionals and can have an important negative impact on patient care, professional wellbeing and staff retention, a particularly concerning finding as this study was performed prior to the COVID-19 pandemic. Moral distress due to resource-related issues is more severe than comparable studies in North America. Interventions to support professionals should recognise the individualistic nature of coping with moral distress. The value of close-knit teams and supportive environments has implications for how intensive care services are organised.

Physician-patient boundaries in palliative care

BACKGROUND

Nurturing effective physician-patient relationships is essential to the provision of patient-centred care. Palliative care physicians may apply boundary-crossings or breaches in professional standards to nurture effective physician-patient relationships. Being highly individualized and shaped by the physician's narratives, clinical experience, and contextual considerations, boundary-crossings are susceptible to ethical and professional violations. To better appreciate this concept, we employ the Ring Theory of Personhood (RToP) to map the effects of boundary-crossings on the physician's belief systems.

METHODS

As part of the Tool Design SEBA methodology, a Systematic Evidence-Based Approach (SEBA) guided systematic scoping review was employed to guide the design of a semi-structured interview questionnaire with palliative care physicians. The transcripts were simultaneously content and thematically analysed. The themes and categories identified were combined using the Jigsaw Perspective and the resulting domains formed the basis for the discussion.

RESULTS

The domains identified from the 12 semi-structured interviews were catalysts and boundary-crossings. Boundary-crossings attempt to address threats to a physician's belief systems (catalysts) and are highly individualized. Employ of boundary-crossings depend on the physician's sensitivity to these 'catalysts', their judgement and willingness to act, and their ability to balance various considerations and reflect on their actions and their ramifications. These experiences reshape belief systems, understandings of boundary-crossings and may influence decision-making and practice, underscoring the potential for greater professional breaches when unchecked.

CONCLUSION

Underlining its longitudinal effects, the Krishna Model underscores the importance of longitudinal support, assessment and oversight of palliative care physicians, and lays the foundation for a RToP-based tool to be employed within portfolios.

Evidence-guided approach to portfolio-guided teaching and assessing communications, ethics and professionalism for medical students and physicians: a systematic scoping review

OBJECTIVES

Guiding the development of longitudinal competencies in communication, ethics and professionalism underlines the role of portfolios to capture and evaluate the multiple multisource appraisals and direct personalised support to clinicians. However, a common approach to these combined portfolios continues to elude medical practice. A systematic scoping review is proposed to map portfolio use in training and assessments of ethics, communication and professionalism competencies particularly in its inculcation of new values, beliefs and principles changes attitudes, thinking and practice while nurturing professional identity formation. It is posited that effective structuring of portfolios can promote self-directed learning, personalised assessment and appropriate support of professional identity formation.

DESIGN

Krishna's Systematic Evidence-Based Approach (SEBA) is employed to guide this systematic scoping review of portfolio use in communication, ethics and professionalism training and assessment.

DATA SOURCES

PubMed, Embase, PsycINFO, ERIC, Scopus and Google Scholar databases.

ELIGIBILITY CRITERIA

Articles published between 1 January 2000 and 31 December 2020 were included.

DATA EXTRACTION AND SYNTHESIS

The included articles are concurrently content and thematically analysed using the split approach. Overlapping categories and themes identified are combined using the jigsaw perspective. The themes/categories are compared with the summaries of the included articles in the funnelling process to ensure their accuracy. The domains identified form the framework for the discussion.

RESULTS

12 300 abstracts were reviewed, 946 full-text articles were evaluated and 82 articles were analysed, and the four domains identified were indications, content, design, and strengths and limitations.

CONCLUSIONS

This review reveals that when using a consistent framework, accepted endpoints and outcome measures, longitudinal multisource, multimodal assessment data fashions professional and personal development and enhances identity construction. Future studies into effective assessment tools and support mechanisms are required if portfolio use is to be maximised.

A systematic scoping review of reflective writing in medical education

BACKGROUND

Reflective writing (RW) allows physicians to step back, review their thoughts, goals and actions and recognise how their perspectives, motives and emotions impact their conduct. RW also helps physicians consolidate their learning and boosts their professional and personal development. In the absence of a consistent approach and amidst growing threats to RW's place in medical training, a review of theories of RW in medical education and a review to map regnant practices, programs and assessment methods are proposed.

METHODS

A Systematic Evidence-Based Approach guided Systematic Scoping Review (SSR in SEBA) was adopted to guide and structure the two concurrent reviews. Independent searches were carried out on publications featured between 1st January 2000 and 30th June 2022 in PubMed, Embase, PsychINFO, CINAHL, ERIC, ASSIA, Scopus, Google Scholar, OpenGrey, GreyLit and ProQuest. The Split Approach saw the included articles analysed separately using thematic and content analysis. Like pieces of a jigsaw puzzle, the Jigsaw Perspective combined the themes and categories identified from both reviews. The Funnelling Process saw the themes/categories created compared with the tabulated summaries. The final domains which emerged structured the discussion that followed.

RESULTS

A total of 33,076 abstracts were reviewed, 1826 full-text articles were appraised and 199 articles were included and analysed. The domains identified were theories and models, current methods, benefits and shortcomings, and recommendations.

CONCLUSIONS

This SSR in SEBA suggests that a structured approach to RW shapes the physician's belief system, guides their practice and nurtures their professional identity formation. In advancing a theoretical concept of RW, this SSR in SEBA proffers new insight into the process of RW, and the need for longitudinal, personalised feedback and support.