Recognizing and Alleviating Moral Distress Among Obstetrics and Gynecology Residents

摘要

What was known Moral distress after clinical encounters can contribute to unsafe or poor-quality patient care and reduced job satisfaction.;What is new Focus groups with obstetrics-gynecology residents confirm presence of moral distress, originating from the difficult clinical encounters and moral dilemmas that are regularly experienced.;Limitations Small sample size limits generalizability.;Bottom line Educators should recognize moral distress in residents to promote improved resident well-being and professional development.;Introduction Obstetrics and gynecology residents who have to cope with difficult patient encounters struggle to prevent the disintegration of the therapeutic relationship and the accompanying feelings of moral distress. Moral distress, often cited in nursing literature, has not been adequately explored in graduate medical education and physician practice. “[M]oral distress is [defined as] when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.”1 Moral distress after clinical encounters, along with moral dilemmas, has been implicated in emotional distress, unsafe or poor-quality patient care, reduced job satisfaction, and attrition in nursing.2–6 An extensive literature identifies the “difficult” patient and common characteristics and behaviors that compromise the therapeutic relationship, such as social class, occupation or employment status, appearance, age, cleanliness, and attire.7–11 Previous studies confirm the characterizations of difficult patients and, more broadly, difficult clinical encounters. However, there is a gap in the literature identifying moral distress among residents and its recognition and alleviation in residency education. We examined how residents characterize difficult clinical encounters, the emotional responses to these encounters, and how judgments about patients are formulated, confirmed, or modified. By delving into what residents thought and felt about difficult clinical encounters, we identified that moral distress is correlated to unresolved situations or issues within those encounters. Finally, we recommend how residency education can provide obstetrics-gynecology residents with the tools to understand and resolve difficult encounters, ultimately alleviating their moral distress.;Methods The authors developed open-ended focus group questions after conducting an extensive literature review about moral distress, difficult patient encounters, and gaps in obstetrics-gynecology resident education. One of the authors (J.A.) teaches in the residency programs at 2 of the 3 hospitals and regularly conducts clinical ethics consults (during which moral distress is often expressed by providers), serves as a member of an ethics committee, and is known to some of the residents who participated in this study. The authors facilitated 3 focus groups with 31 obstetrics-gynecology residents from 2 urban programs and 1 rural program. All are community-based, focusing on the care of underserved populations. Participants were invited via e-mail and in-person meetings. With the exception of postcall residents, nearly all of the residents from the 3 programs participated. Residents were diverse in level of training, sex, and race/ethnicity. Focus groups had 7 to 14 participants (a total of 23 women and 8 men) and were conducted in a private setting. Focus groups lasted up to 60 minutes. Beyond the sex of participants, no other demographic information was recorded to protect their confidentiality and the residency program in which they train. Participants were asked questions designed to encourage the expression of beliefs, feelings, and experiences surrounding difficult patient encounters, moral distress, and the process of making moral and nonmoral judgments. Digital recordings of the focus groups were transcribed verbatim by the second author and qualitatively evaluated using thematic analysis to determine repetitive