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BACKGROUND AND OBJECTIVES

Pediatric residents are at high risk for moral distress, knowing the moral or ethically right thing to do but feeling unable to do it, which is associated with poor patient care and burnout. Researchers have proposed numerous interventions to reduce distress, but few (if any) have been supported by experimental evidence. In this study, we used an experimental method to provide proof-of-concept evidence regarding the effect of various simple supports on pediatric residents’ reported degree of moral distress.

METHODS

We conducted a study of pediatric residents using a split sample experimental design. The questionnaire contained 6 clinical vignettes describing scenarios expected to cause moral distress. For each case, participants were randomly assigned to see 1 of 2 versions that varied only regarding whether they included a supportive statement. After reading each of the 6 cases, participants reported their level of associated moral distress.

RESULTS

Two hundred and twenty respondents from 5 residency programs completed the experiment. Cases were perceived to represent common scenarios that cause distress for pediatric residents. The addition of a supportive statement reduced moral distress in 4 of the 6 cases.

CONCLUSIONS

In this proof-of-concept study, simple yet effective interventions provided support by offering the resident empathy and shared perspective or responsibility. Interventions that were purely informational were not effective in reducing moral distress.

What’s Known on This Subject:

Moral distress is pervasive and problematic among pediatric residents. Interventions to mitigate distress lack rigorous experimental evidence.

What This Study Adds:

On the basis of responses to our split sample, randomized, controlled experiment, simple interventions that offer empathy and shared perspective or responsibility were effective in decreasing residents’ moral distress. Interventions that were purely informational were not effective in reducing distress.

Pediatric residents are at high risk for moral distress, which is to say the psychological, emotional, and physiologic suffering that clinicians experience when they feel powerless or unable to do what they think is right.17  Moral distress was first described in a medical setting among nurses for whom autonomy limitations frequently collide with poor communication and leadership.1  Unsurprisingly, residents, who also work within complicated hierarchies, experience similar feelings as they implement plans without the authority to alter the plans, dissent, or refuse.811  This predisposes residents to moral distress, particularly when communication and collaboration are weak.8,9,12  For residents, moral distress is most often related to inexperience, concerns over telling the truth, respecting patients’ wishes, concerns about competency, and worries of failing to prevent harm.10  Residents in pediatrics must also deal with issues of parental authority that may amplify moral distress.13  In studies of internal medicine and pediatric residents, moral distress has been linked to depersonalization,14  medical errors,15  considerations of quitting medicine, and burnout.1618  The stresses of the current medical climate, exacerbated by the recent coronavirus disease 2019 pandemic, have led to increasing moral distress, burnout, and even physician suicide.9,19,20  Understanding the causes of moral distress and developing successful strategies to address distress is, therefore, essential for medical educators.

Three aspects of the response to pediatric resident moral distress thus far are noteworthy. First, many articles on moral distress interventions lack empirical evidence; even most studies on interventions have been theoretical or observational.1,1315,21,22 A few cohort studies have been completed,15,23,24  but no randomized trials have been published, nor have any preliminary proof-of-concept experimental results upon which interventions could (and should) be designed.25  Second, techniques proposed to combat moral distress have included expanded education in medical ethics,26,27  resilience and wellness interventions,28  and workload modifications.21  In addition to lacking sufficient evidence to support them, these interventions are easier said than done: expanded education and interventions compete for residents’ scarce time, whereas structural change regarding resident workload is not always feasible. Second, supervisors and educators are increasingly called upon to mitigate moral distress by using good leadership and communication to create a supportive environment.12,29,30  How to actually create such an environment is, however, unclear and validation of such strategies is limited.

For this study, working within an established intervention development and testing paradigm,31  we sought to quantify the effects of various simple supports on pediatric residents’ reported moral distress using a proof-of-concept randomized, controlled experiment. Using a questionnaire with clinical vignettes (a technique that has been shown to accurately simulate responses observed in practice32 ), these supports were either a statement by a supervising physician, containing either informational or empathic content, or a residency program structural element. We sought to test the broad hypothesis that adding supports to vignettes would decrease residents’ moral distress. As a secondary aim, we sought to compare the efficacy of both statements by a supervising physician and elements of program structure.

We distributed the questionnaire entitled “MD-REST: Minimizing Moral Distress in pediatric RESidency Training Questionnaire” through the program directors of 5 pediatric residency programs. We used intentional sampling to invite pediatric residency programs situated at large volume, high acuity hospitals where residents would be more likely to have experienced the scenarios described in the questionnaire. We initially emailed program directors about their willingness to participate in February 2022 and provided them with a sample introductory e-mail and link to distribute. We offered a $10 Amazon gift card to every participant who completed the questionnaire and asked program directors to send 1 reminder e-mail at the 2 week mark in accordance with the tailored design method.33 

We sent the questionnaire to 607 residents from the 5 participating residency programs: Children’s Hospital of Philadelphia, PA (∼150 residents); Seattle Children’s, WA (∼131 residents); Zucker School of Medicine, NY (∼126 residents); Children’s National Medical Center, DC (∼120 residents); and New York Presbyterian Hospital-Columbia Campus, NY (∼80 residents).34  We collected data for 16 weeks and managed the data using the Research Electronic Data Capture tool (REDCap) hosted at Children’s Hospital of Philadelphia.35  This study received Institutional Review Board exemption from the Children’s Hospital of Philadelphia.

We developed a case-based randomized, controlled experimental questionnaire after review of the literature and consultation with pediatric trainees and ethicists. The questionnaire consisted of 6 hypothetical clinical cases expected to cause moral distress for residents. We pilot-tested the cases for clarity with 12 fellow physicians from diverse clinical specialties who had recently completed pediatrics residency. In response to their feedback, we provided a simpler definition of moral distress and revised the primary outcome question to remove the word “substantial” from before “moral distress,” as this was felt to be leading. Case 1 is included as an example in Fig 1, and the full questionnaire is available in the supplemental material. We developed 2 versions of each case that differed only in whether they included a resident support, either from a supervising physician or the program structure, (henceforth, supported version) or excluded this support (unsupported version). For each participant, each case in the questionnaire was randomly displayed as either the supported or unsupported version. Random assignment was performed by a hidden calculated field that upon opening the questionnaire link, randomly generated a number 1 or 2, representing 1 of the 2 versions. Another hidden field rebalanced the makeup of the groups to keep differences in the number of participants seeing the supported and unsupported versions roughly equal, within 10 participants. Each case was followed by the same 2 questions: (1) “Over the course of your training, have you encountered a similar scenario?” and (2) “How much do you agree with the following statement? The situation would cause me moral distress.” Answer options for the first question were “yes,” “no,” or “not sure,” and for the second, were on a 5-point Likert scale from strongly disagree to strongly agree. The question on moral distress is similar to other quantitative measures that have been validated and found to converge with the widely used Moral Distress Scale.25 

FIGURE 1

Sample case vignette. This provides the full case describing a resident’s procedural distress. Half of residents saw the unsupported version; the remainder saw the supported version with an additional supportive statement by the supervising attending.

FIGURE 1

Sample case vignette. This provides the full case describing a resident’s procedural distress. Half of residents saw the unsupported version; the remainder saw the supported version with an additional supportive statement by the supervising attending.

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The first 3 cases evaluate the effect of supportive statements by a supervising physician. Case 1 centers on a resident performing a lumbar puncture for only the second time. The patient’s parent asks the resident how many prior procedures they have performed. In the unsupported version, the supervising attending says nothing. In the supported version, the supervising attending reassures the parent that the supervisor has ample experience and will oversee the procedure. In Case 2, the resident is asked to place a nasoduodenal tube, a procedure they are not comfortable performing. In the unsupported version, the supervising physician states that the task is easy and asks the resident call for help if needed. In the supported version, the supervising physician offers to be present for the procedure. In Case 3, the resident is tasked with coordinating a tracheostomy for a child with severe neurologic impairment, which the resident believes is futile care. In the unsupported version, the supervising physician does not engage the resident’s concerns. In the supported version, the supervising physician describes previous discussions with the family demonstrating that the family’s decision is informed and thoughtful.

The latter 3 cases evaluate the effect of simple elements of program structure. In Case 4, a resident discovers that their coresident made a medication error. In the unsupported version, the resident is left to navigate the situation alone and chooses not to raise the issue with their coresident. In the supported version, the care system has a built-in review process to investigate such errors. In Case 5, the resident must oversee nasogastric tube placement in a patient with anorexia nervosa against the patient’s wishes. In the supported version, the resident has the additional experience of time spent in an eating disorders follow-up clinic and has met patients who have recovered from anorexia; the unsupported version lacks this additional context. In Case 6, a parent in the newborn nursery declines a routine Vitamin K shot for their child. In the unsupported version, the supervising physician tells the resident to document the refusal. In the supported version, the supervising physician provides additional educational material that the resident can share with the parents. Respondents saw the cases in this order: 1, 5, 4, 2, 3, and 6. We reordered the cases in this paper to aggregate the types of scenarios and interventions and facilitate interpretation of the study.

We analyzed the responses using Stata version 17.1 (StataCorp, College Station, TX). We examined pediatric resident demographics, residency program size, training year, and gender for the entire study population, as well as for randomization subgroups. We calculated a mean moral distress value for each participant by averaging values from all 6 cases. Our primary outcome was reported moral distress, which we compared between the supported and unsupported versions of cases. We compared data between case versions using 2-tailed tests with significance set at P < .05. Because this outcome was ordinal output from a 5-point Likert scale, we used the Wilcoxon–Mann-Whitney test to assess for differences in responses between the groups that saw unsupported and supported versions of each case. We calculated Cohen’s d effect sizes to determine the magnitude of differences in the degree of moral distress reported between case versions, as this is a commonly used measure of the importance of an effect in decision-making.36,37 

A total of 220 pediatric residents from 5 residency programs completed the entire questionnaire (Fig 1), representing an evaluable response rate of 36% (607 possible respondents). Randomization successfully balanced groups for a between-group difference of 10 participants or less for all cases (Fig 2). Respondents were distributed across training years with 39%, 33%, and 25% in their first, second, and third years, respectively. Most respondents were female (78%), similar to nationwide data for all pediatric residents (71% female).38  Demographic characteristics were balanced by randomization in each case, with no significant between-group differences (Table 1).

FIGURE 2

Consolidated Standards of Reporting Trials (CONSORT) flow diagram of the experimental study. This flow diagram displays the progress through the phases of sequential randomization into 2 groups for each case.

FIGURE 2

Consolidated Standards of Reporting Trials (CONSORT) flow diagram of the experimental study. This flow diagram displays the progress through the phases of sequential randomization into 2 groups for each case.

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TABLE 1

Respondent Characteristics for Overall Sample and by Case Randomization Group

AllCase 1Case 2Case 3Case 4Case 5Case 6
N = 220U n = 111S n = 109PU n = 111S n = 109PU n = 105S n = 115PU n = 109S n = 111PU n = 107S n = 113PU n = 111S n = 109P
PGY1 38.5 35.1 42.1 .56 35.8 41.3 .55 32.7 43.9 .07 40.4 36.7 .61 37.1 39.8 .54 42.2 34.9 .50 
PGY2 33.5 36.9 29.9  37.6 29.4  42.3 25.4  33.9 33.0  30.5 36.3  33.9 33.0  
PGY3 23.9 25.2 22.4  22.0 25.7  21.2 26.3  22.9 24.8  27.6 20.4  22.0 25.7  
PGY4 3.2 2.7 3.7  3.7 2.8  1.9 4.4  1.8 4.6  3.8 2.7  1.8 4.6  
PGY5 1.0 0.0 1.9  0.9 0.9  2.0 0.0  0.9 0.9  1.0 0.9  0.0 1.9  
Female 77.0 76.4 77.6 .98 78.7 75.2 .25 76.9 77.0 .999 78.9 75.0 .79 75.0 78.8 .26 76.9 77.1 .998 
Male 22.1 22.7 21.5  19.4 24.8  22.1 22.1  24.1 25.0  20.2 19.5  22.2 22.0  
Other 0.9 0.9 0.9  1.9 0.0  1.0 0.9  0.9 0.09  0.0 1.8  0.9 0.9  
AllCase 1Case 2Case 3Case 4Case 5Case 6
N = 220U n = 111S n = 109PU n = 111S n = 109PU n = 105S n = 115PU n = 109S n = 111PU n = 107S n = 113PU n = 111S n = 109P
PGY1 38.5 35.1 42.1 .56 35.8 41.3 .55 32.7 43.9 .07 40.4 36.7 .61 37.1 39.8 .54 42.2 34.9 .50 
PGY2 33.5 36.9 29.9  37.6 29.4  42.3 25.4  33.9 33.0  30.5 36.3  33.9 33.0  
PGY3 23.9 25.2 22.4  22.0 25.7  21.2 26.3  22.9 24.8  27.6 20.4  22.0 25.7  
PGY4 3.2 2.7 3.7  3.7 2.8  1.9 4.4  1.8 4.6  3.8 2.7  1.8 4.6  
PGY5 1.0 0.0 1.9  0.9 0.9  2.0 0.0  0.9 0.9  1.0 0.9  0.0 1.9  
Female 77.0 76.4 77.6 .98 78.7 75.2 .25 76.9 77.0 .999 78.9 75.0 .79 75.0 78.8 .26 76.9 77.1 .998 
Male 22.1 22.7 21.5  19.4 24.8  22.1 22.1  24.1 25.0  20.2 19.5  22.2 22.0  
Other 0.9 0.9 0.9  1.9 0.0  1.0 0.9  0.9 0.09  0.0 1.8  0.9 0.9  

Descriptive statistics for physician characteristics and practice settings are presented for the full sample as well as for randomization group by case and are reported as percentages. P values reflect groups compared using Pearson’s χ2 test. PGY, postgraduate year; U, unsupported version; S, supported version.

For all but Case 2, >70% of residents reported having encountered a similar situation during their training (84%, 48%, 77%, 73%, 86%, and 87% for Cases 1–6, respectively). Mean moral distress of all cases was 3.5 (SD 0.63) on the 5-point Likert scale, with 1 being “strongly disagree” that a case would cause moral distress and 5 being “strongly agree.” Reported moral distress was highest for Case 3 (3.9, SD: 1.1), independent of the presented version, followed by Cases 1 (3.8, SD:0.9), 6 (3.6, SD:1.2), 2 (3.6, SD:1.2), 5 (3.4, SD:1.1), and 4 (3.3, SD:1.1).

The primary outcome, reported moral distress, differed between the supported and unsupported versions of the cases in 4 of 6 cases (Cases 1, 2, 3 and 4; Fig 3). In Case 1, a supervising physician’s response to a parent’s query about procedural inexperience reduced moral distress (P < .002; Cohen’s d: 0.45). In Case 2, a supervising physician’s offer to be present during a procedure also reduced moral distress (P < .001; Cohen’s d: 0.82). In Case 3, moral distress was reduced when a supervising physician provided additional context for care the resident feared was futile (P < .006; Cohen’s d: 0.38). In Case 4, a standardized system for addressing errors decreased moral distress (P < .001; Cohen’s d: 0.65).

FIGURE 3

Primary outcome measures by case. This matrix displays means and confidence intervals for the primary outcome measure, reported moral distress. For each case, responses are stratified by whether participants saw the unsupported or supported version of the case. CI, confidence interval.

FIGURE 3

Primary outcome measures by case. This matrix displays means and confidence intervals for the primary outcome measure, reported moral distress. For each case, responses are stratified by whether participants saw the unsupported or supported version of the case. CI, confidence interval.

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By contrast, in Cases 5 and 6, providing additional information to a resident through an outpatient experience and to a parent through educational materials, respectively, did not reduce moral distress (P = .59 and P = .57, respectively).

This randomized controlled experiment evaluated the effect of simple supports from a supervising physician or program structure on the degree of moral distress reported by pediatric residents. Of the 6 cases presented in the questionnaire, residents reported that all were more likely than not to cause moral distress and were commonly experienced. The level of reported moral distress and residents’ familiarity with the cases together suggest that the questionnaire created an accurate simulation of resident moral distress. Four out of the 6 interventions trialed were effective in decreasing resident moral distress, with effect sizes in the moderate to large range.36 

How can we interpret these findings? We suggest that the successful interventions had in common something we might call EASER aspects: providing the resident with both empathy and shared perspective or responsibility, in partnership with a supervisor, or shared accountability with structural aspect of the program. (Of note, an “EASER” is an object or process that eases stress or tension.) Three of the successful interventions (Case 1, 2, and 3) entailed empathic statements by a supervising physician and 1 (Case 6) was a structural support. Case 1 and 2 both involve distress related to a resident’s inexperience performing a procedure. In both cases, a supervising physician recognizes potential distress and affirms their presence and supervision, and thereby their shared responsibility. Though the supportive statements in these cases were similar, the intervention had a larger effect on distress in Case 2. Perhaps a supportive statement from a peer, in this case a senior resident, is more effective than one from an attending, though our ability to generalize is limited. Case 3 trials a supportive statement by an attending in response to a resident’s concern that a tracheostomy is not the best interest of their patient. In the supported version, the attending shares the resident’s recognition of the limitations of this intervention and provides context for the family’s informed decision to proceed, presumably offloading some of the resident’s feeling of responsibility as they call to schedule a tracheostomy. The intervention in Case 4, a standardized process for reviewing medication errors, is also effective in decreasing moral distress. The standardized process relieves a resident of feeling they must independently confront their colleague or accept the guilt of choosing not to. This, in turn, diffuses responsibility and creates a collaborative environment.

The ability of emotional support and shared responsibility to reduce distress is consistent with evidence from related studies of relationships, leadership, and medical education. Research in the context of relationships has shown that emotional support from another person can be more effective than using intrapersonal or individual strategies to reduce distress.39  For instance, having another person name or label a negative emotion related to an aversive experience is more effective in reducing distress than self-labeling the emotion.40  The supportive statements trialed here may additionally be effective because they occur in “real time,” during a distressing scenario. Recent work demonstrates that more proximal event debriefings, or “microdebriefings” embedded during an event, may be more effective for reducing distress than interventions following the event.41  Research on leadership shows that good leaders reduce distress by identifying situations likely to cause negative feelings and sharing responsibility—and even blame.42,43  Medical education experts recognize this, as shared responsibility with supervisors and tailoring of responsibility to meet a trainee’s practice level is a central tenet of effective medical education.44,45  Similarly, error reporting systems that emphasize shared and systemic over individual failures have been demonstrated to improve patient safety, in large part because clinicians are more comfortable reporting errors if they feel responsibility will be shared.46,47  Recognition and targeting of distress through supportive statements or program structure imply that supervisors care about residents, thereby creating an environment that feels supportive and collaborative.29,48  As residents learn and confront new and distressing scenarios, they need to know that they are not alone in their responsibility or distress.

In contrast, the interventions that were unsuccessful provide information without empathy or partnership. In Case 5, the resident is provided additional information through meeting patients who have recovered from eating disorders. Programmed experiences may not lead to perspective shifts for an individual. In Case 6, a supervising physician asks the resident to share additional information on Vitamin K with the parents, assigning responsibility to the parents. Broadly, the failure of these interventions calls into question the common suggestion that information and education alone can resolve ethical issues and alleviate residents’ moral distress.8,49,50  Information and education may not themselves provide agency.

We interpret our findings within the constraints of our study design. First, the clinical cases and interventions were hypothetical and we cannot evaluate the extent to which our findings would generalize to actual practice.32  Relatedly, some interventions (e.g., supportive statements) may be more realistically captured in a hypothetical case than others (e.g., experience of meeting outpatients). Nevertheless, the reported high moral distress and residents’ familiarity with the hypothetical scenarios suggest fidelity to residents’ experience, and substantial prior evidence supports the ability of hypothetical clinical vignettes to capture clinical practice.5153  Second, our response rate of 36%, although not affecting the internal validity of our findings and typical of national resident questionnaires,5456  may nonetheless limit the findings’ generalizability to residents who declined to participate.

Our study design also has strengths. First, randomization and control enhance internal validity. We are therefore able to confidently conclude that the 1 experimental variable—the presence or absence of a support—is responsible for the between-version differences we document. Because randomization occurred after respondents enrolled, this mechanism ensures that response rate does not affect the recorded efficacy of interventions. Another strength of our study design is that it could in the future be adapted to evaluate the efficacy of other interventions for moral distress. The method offers a way to “pretrial test” such supports experimentally before investing resources to trial them in practice. This methodology could also be used to evaluate which subgroups of residents may benefit most from such interventions. Third, all the interventions in this experiment require relatively few resources for residency programs, particularly compared with larger scale curricula in ethics or wellness that have been proposed. Therefore, implementation may be faster and easier, or an excellent complement to larger-scale changes.

This study provides proof-of-concept experimental evidence that several simple EASER interventions, focused on empathy and partnership, may be effective in reducing moral distress among pediatric residents. Purely informational interventions did not decrease distress. The effective interventions can be interpreted as offloading some moral responsibility to either a supervising physician or program system. Future work should evaluate the efficacy of the studied interventions in practice.

Drs Layman and Callahan conceptualized and designed the study, created the study instrument, collected and analyzed the data, and drafted the initial manuscript; Dr Feudtner assisted in designing the study, creating the study instrument, and analyzing the data; Ms Nathanson assisted in creating the study instrument and analyzing the data; Dr Hill assisted in analyzing the data; Ms Lechtenberg assisted in creating the study instrument; and all authors reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

COMPANION PAPER: A companion to this article can be found at www.pediatrics.org/cgi/doi/10.1542/peds.2023-061372.

FUNDING: This study was supported by T32 Training Grant No. HG009496 from the National Human Genome Research Institute (K.P.C.) and the Steven D. Handler Endowed Chair of Medical Ethics at the Children’s Hospital of Philadelphia.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose.

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