In this issue of Pediatrics, Layman et al examine the moral distress of pediatric residents and conclude that interventions based in empathy and partnership at the program level or the faculty level mitigate moral distress for trainees.1 The authors surveyed pediatric residents and asked them to rate the degree of moral distress generated by clinical scenarios commonly encountered within training. Using a randomized approach, the authors subsequently demonstrated a reduction in resident moral distress when scenarios included elements of emotional support and shared responsibility.1
Moral distress has been demonstrated among health care providers for decades2 and has recently garnered significant attention because of the experience of providers during the COVID-19 pandemic.3,4 Mitigating moral distress is of utmost importance to training programs because of the significant association between moral distress and burnout in trainees.5,6 Yet, solutions have remained elusive. Those that have been suggested are often infeasible for program directors to reasonably put in place.7,8
Our health care system is plagued by an epidemic of physician burnout, which has not spared our trainees.9 The National Academy of Medicine launched the Action Collaborative on Clinician Well-Being and Resilience to bring attention and resources to this critical situation.10 The Accreditation Council for Graduate Medical Education has made clear in its program requirements that: “Programs, in partnership with their Sponsoring Institutions, have the same responsibility to address well-being as other aspects of resident competence. Physicians and all members of the health care team share responsibility for the well-being of each other.”11 Understanding and effectively mitigating moral distress among pediatric residents is an important part of a holistic plan to address trainee well-being.
By demonstrating decreased moral distress for scenarios in which residents receive personal or structural supports, Layman et al hypothesize that the Empathy and Shared Perspective or Responsibility (EASER) strategies (“providing the resident with both empathy and shared perspective or responsibility, in partnership with a supervisor, or shared accountability with structural aspects of the program”) might account for this.1 Examples include supportive statements made by a supervising physician (supervision of resident procedures or discussing a patient’s goals of care) or program supports such as a systematic review of medical errors. These examples suggest that partnership with supervisors or structural supports may reduce the burden of moral agency. However, how can supervising attending physicians incorporate EASER strategies with their learners?
If Layman et al’s brief hypothetical scenarios are an indicator, support statements do not need to be lengthy to succeed.1 However, attending physicians require significant faculty development focused on the topics of moral distress and burnout to incorporate these strategies into daily practice. This is challenging when faculty themselves face moral distress and burnout.6,12 Faculty, who are burned out with additional administrative burdens, are less likely to implement changes.9,13,14 Faculty development is vital for EASER strategies to work, but creating engaging and successful faculty development programs is an ongoing challenge for academic institutions.15–17
Rather than add 1 more task to already full plates, we should work within existing frameworks to incorporate EASER strategies. As medical educators, we know that psychological safety is an important component of the clinical learning environment.18 This should be the larger umbrella from which to target moral distress. Optimistically, pediatric residents believe that their supervising attending physicians can mitigate moral distress, such as through proactive strategies that create a positive learning environment or by responsive strategies that occur after a “morally distressing event.”19 Proactive strategies embedded within the clinical learning environment may help reduce the crescendo effect of moral distress that builds up over time.20,21 For example, with an “Everyday Resilience” practice, faculty members were trained to incorporate daily, reflective exercises with trainees to build and recognize resilience.22 Moral distress may be amenable to a similar train-the-trainer technique.
Faculty want to create a positive learning environment and may report faculty development sessions as improving these skills,23 but it is difficult to measure the true success of these efforts. Even if faculty members create positive learning environments, it is unclear if the simple, supportive statements put forth by Layman et al will hold up in complex clinical environments.1 It will be important to assess the impact of EASER strategies in ways that more closely imitate the complexity of the clinical learning environment. This may include simulated environments with standardized learners and “mock moral distress codes” to demonstrate whether this simple intervention can be effective in higher fidelity simulations.
If we fail to teach our faculty to recognize and prevent moral distress, we perpetuate a hidden curriculum that acculturates trainees into clinical practices that allow moral distress and burnout to fester.24 Faculty development is challenging, but EASER strategies offer a possible solution that can be readily adapted to the clinical learning environment. It is encouraging that Layman et al demonstrated that residents respond well to supports from supervising physicians.1 These supports flatten the hierarchy and provide a safety net for our trainees as they develop their own clinical practices.
Moral distress has become the unintended side effect of working within complex health care systems and organizational hierarchies. When we don our white coats for the first time and recite the Hippocratic Oath, we become moral agents by default. We subsequently step into a hospital milieu fraught with complex, value-based decision-making. If this is the case, prophylaxis is key. EASER strategies offer faculty an encouraging new role to help target moral distress. For our trainees, perhaps the first step is simply saying to them, “We’ve got your back.”
Drs Chieco and Poitevien drafted the commentary and reviewed it critically for important intellectual content; and both authors 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 online at www.pediatrics.org/cgi/doi/10.1542/peds.2022-060269.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.