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

Abstract

Background: Moral distress is a reason for burnout in healthcare professionals, but the clinical settings in which moral distress is most often experienced by medical students, and whether moral distress is associated with burnout and career choices in medical students is unknown. We assessed moral distress in medical students while caring for older patients, and examined associations with burnout and interest in geriatrics. Methods: A cross-sectional survey study of second-, third-, and fourth-year medical students at an American medical school. The survey described 12 potentially morally distressing clinical scenarios involving older adult patients. Students reported if they encountered each scenario, and whether they experienced moral distress, graded on a 1-10 scale. We conducted a principal axis factor analysis to assess the dimensionality of the survey scenarios. A composite moral distress score was calculated as the sum of moral distress scores across all 12 scenarios. Burnout was assessed using the Maslach Abbreviated Burnout Inventory, and interest in geriatrics was rated on a 7-point Likert scale. Results: Two-hundred and nine students responded (47%), of whom 90% (188/209) reported moral distress in response to ≥1 scenario with a median (IQR) score of 6 (4-7). Factor analysis suggested a unidimensional factor structure of the 12 survey questions that reliably measured individual distress (Cronbach alpha = 0.78). Those in the highest tertile of composite moral distress scores were more likely to be burnt out (51%) than those in the middle tertile of scores (34%), or lowest tertile of scores (31%) (p = 0.02). There was a trend towards greater interest in geriatrics among those in the higher tertiles of composite moral distress scores (16% lowest tertile, 20% middle tertile, 25% highest tertile, p-for-tend = 0.21). Respondents suggested that moral distress might be mitigated with didactic sessions in inpatient geriatric care, and debriefing sessions with peers and faculty on the inpatient clerkships on medicine, neurology, and surgery, where students most often reported experiencing moral distress. Conclusions: Moral distress is highly prevalent among medical students while caring for older patients, and associated with burnout. Incorporating geriatrics education and debriefing sessions into inpatient clerkships could alleviate medical student moral distress and burnout.

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

“…For example, moral distress can be perceived differently based on an individual’s place in the organizational hierarchy [ 26 ] or due to the power differential between different professions [ 27 ]. Other studies suggest power and hierarchy play a role in both moral distress and moral courage [ 8 , 17 , 27 , 28 ]. In one study that explored moral courage in nursing students, most students cited power differential, fear of consequences, and lack of confidence as key influences contributing to their hesitation to demonstrate moral courage, often remaining as passive spectators [ 29 ].…”

“…Health professionals can experience moral distress when their values conflict with their workplace. The consequences of moral distress can be lasting [ 5 , 6 ] and include feelings of powerlessness, sadness, anger, frustration [ 7 ], and burnout [ 8 ]. There are several other terms that are relevant to the phenomenon of moral distress.…”

Effective interventions for reducing moral distress in critical care nurses

“…14,15 The results of previous studies have shown that MD among nurses reduces the quality of working life, which can eventually lead to leaving the profession. 9,[15][16][17][18] Nearly all nurses experience MD at some point in their career, but nurses who worked in critical care units seem more at risk for experiences of MD due to challenges in their work environment. 12,14 Critical care nurses often encounter various ethical dilemmas, probably due to more experience in the frequency of providing palliative and end-of-life care, 19,20 excessive workload, direct observation of patients' pain and suffering, 21 uncertainty in clinical decision-making, [22][23][24][25] and conflicts with other healthcare providers.…”

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

“…Moral distress and burnout received particular focus in relation to health care professionals, as they spend most of their time providing care to people who are vulnerable by definition and place further pressure on their decisions [17,18]. Although MD received particular attention among nurses [16,19], physicians [14,20], physical therapists [21], and further healthcare assistants are also exposed to the same risks [22]. Feelings associated with the experience of MD include anger, guilt [23], and helplessness [24], which seem to occur more frequently during the early years of employment, where a discontinuity between the ideals of the profession and the harshness of daily work is often perceived [20,[25][26][27][28].…”

“…Although MD received particular attention among nurses [16,19], physicians [14,20], physical therapists [21], and further healthcare assistants are also exposed to the same risks [22]. Feelings associated with the experience of MD include anger, guilt [23], and helplessness [24], which seem to occur more frequently during the early years of employment, where a discontinuity between the ideals of the profession and the harshness of daily work is often perceived [20,[25][26][27][28].…”