“Sip & Share”: Building Resilience in Surgery Residency Through Moral Distress Rounds

Abstract

OBJECTIVE

Resident moral distress rounds were instituted during the COVID-19 pandemic to provide a safe zone for discussion, reflection, and the identification of the ethical challenges contributing to moral distress. The sessions, entitled “Sip & Share,” also served to foster connectedness and build resilience.

DESIGN

A baseline needs assessment was performed and only 36% of general surgery residents in the program were satisfied with the current non-technical skills curriculum. Only 62% were comfortable with navigating ethical issues in surgery. About 72% were comfortable with leading a goals-of-care discussion, and 63% of residents were comfortable with offering surgical palliative care options. Case-based discussions over video conferencing were organized monthly. Each session was structured based on the eight-step methodology described by Morley and Shashidhara. Participation was voluntary. The sessions explored moral distress, and the ethical tensions between patient autonomy and beneficence, and beneficence and non-maleficence.

SETTING

Large general surgery residency in an urban tertiary medical center.

PARTICIPANTS

General surgery residents.

RESULTS

A post-intervention survey was performed with improvement in the satisfaction with the non-technical skills curriculum (70% from 36%). The proportion of residents feeling comfortable with navigating ethical issues in surgery increased from 62% to 72%. A survey was performed to assess the efficacy of the moral distress rounds after eight Sip & Share sessions over ten months. All thirteen respondents agreed that the discussions provided them with the vocabulary to discuss ethical dilemmas and define the ethical principles contributing to their moral distress. 93% were able to apply the templates learned to their practice, 77% felt that the discussions helped mitigate stress. All respondents recommended attending the sessions to other residents.

CONCLUSIONS

Moral distress rounds provide a structured safe zone for residents to share and process morally distressing experiences. These gatherings mitigate isolation, promote a sense of community, and provide a support network within the residency. In addition, residents are equipped with the vocabulary to identify the ethical principles being challenged and are provided practical take-aways to avoid similar conflicts in the future.

INTRODUCTION

The concept of moral distress was first introduced in the nursing literature by Andrew Jameton in 1984, and was described as the psychological distress of being in a situation in which one is constrained from acting on what one knows to be right.¹ This insight was based on his observations of nursing students during classroom discussions of bioethical dilemmas, where they described scenarios such as performing painful procedures on patients they that believed to be futile. This concept has since expanded beyond Jameton's original definition to include any psychological distress causally related to a moral event.² Causes of moral distress can be further subcategorized into five types:

• •Moral-constraint distress
• •Moral-uncertainty distress
• •Moral-conflict distress
• •Moral-dilemma distress
• •Moral-tension distress³

Moral distress is certainly apropos to the field of surgery as surgery has been described as an “intense form of applied ethics”,⁴ where practitioners constantly make decisions and provide treatments with moral implications. Residents are the patient-facing constituent of the surgical service, are tasked with delivering bad news, guiding patients and their families, managing end-of-life care, and are vulnerable to moral distress. Accordingly, the prevalence of burnout among general surgery residents is high, and has been estimated to be between 20% to 69% on multiple large national surveys.5, 6, 7, 8 Unmitigated moral distress in residents can contribute to moral injury and burnout, with deleterious effects on mental and physical well-being, as well as on patient care and outcomes.^{6 , 9 , 10}

This distress was exacerbated during the COVID-19 pandemic, when surgical residents were deployed to care for COVID-19 patients.^{11 , 12} Residents of all training backgrounds faced moral dilemmas relating to diagnostic and therapeutic uncertainty, allocation of resources, and medical futility with the unprecedented surge in critically ill COVID patients.

As surgery residents were grappling with the practical and moral implications of caring for this new group of patients, and experiencing an unprecedented amount of death, our program launched virtual moral distress rounds to address how the pandemic was affecting them as an individual, as a surgical trainee, and as a member of the surgical workforce. These trainee-centric sessions focused on the resident's perspective, emotional reactions, and feelings, to ultimately equip participants with the vocabulary to deconstruct the dilemma, identify the ethical principles and values being challenged or violated, share coping strategies, and identify practical take-aways to diffuse conflicts in the future. This safe zone gave residents a revived sense of community in which they could share and validate feelings, reinforce a common humanity, allow for vulnerability and tolerance for expressing uncertainty, re-invigorate a sense of purpose, and confirm their surgical identity. This capacity of an individual to preserve or restore integrity in response to moral adversity or distress is described as moral resilience.¹³

After receiving positive feedback from residents on the utility of virtual moral distress rounds in decompressing the cumulative stress of COVID-19 patient care, we decided to expand moral distress rounds to address ethically challenging cases encountered by surgery residents. These moral distress rounds were named “Sip & Share”.

MATERIALS AND METHODS

Needs Assessment

Prior to the intervention, an internal program survey was performed to assess the residents’ satisfaction with the current education curriculum, including resident satisfaction with the non-technical skills curriculum as well as resident comfort with ethically challenging scenarios. The survey was completed by 67 general surgery residents out of 77 total residents in the program with a response rate of 87%. Senior residents (PGY4 and 5) comprised 20% of respondents. Only 36% of residents (24/67 residents) were satisfied or very satisfied with the current non-technical skills curriculum. Only 63% (42/67 residents) were comfortable with navigating ethical issues in surgery. About 72% (48/67 residents) were comfortable or very comfortable with leading a goals-of-care discussion with a patient and their family members, and 63% of residents (42/67 residents) were comfortable or very comfortable with offering surgical palliative care options to a patient and their family members. Senior residents (PGY4 and 5) were more comfortable than junior residents (PGY 1, 2 and 3) with navigating ethical issues (93% vs 55%), leading a goals-of-care discussion (100% vs 64%), and offering surgical palliative care options (93% vs 55%). Prior to the intervention, the non-technical skills curriculum consisted mainly of ethics case discussions and debates.

Goals & Objectives

The goals of the moral distress discussions were to: (1) provide a safe space for residents to share their feelings that lead to moral distress without being mired down in the clinical details, (2) equip residents with the vocabulary to deconstruct the case, identify the ethical principles and values being challenged, and discuss ethical dilemmas, (3) mitigate the isolation that can accompany moral distress through camaraderie reinforcing that they are a group with a shared common goal – the well-being of our patients, (4) to share coping strategies, and (5) provide practical take-aways.

Educational Strategies

One-hour “Sip & Share” discussions over video conferencing were organized monthly. General surgery residents were invited to submit their cases to the faculty facilitator, a surgeon-ethicist (M.B.S.) who serves as the residency program director of wellness. Before the session, the facilitator would send out an introductory email to the session often including a reading for background or to illustrate the teaching points of the case. The eight-step methodology described by Morley and Shashidhara (Figure 1 ) was utilized as a framework for these sessions.¹⁴ The sessions were optional to all residents and were attended by about 20 residents each time. At the beginning of the session the ‘rules’ are established: the faculty facilitator defines the goals and expectations, explains that the purpose of the gathering is to allow those in attendance to safely express their feelings, and discuss strategies to address future cases with similar challenges. Participants must be allowed to speak uninterrupted; all voices must be heard. It is imperative on a virtual platform that all participants are present – video is ‘on’ for participants to see each other – no ‘in and out’. The presenting resident provides a brief case summary, without getting mired down in the clinical details, labeling the emotions they experienced during and after this clinical encounter. The resident reflects on the experience and deconstructs the case identifying the ethical principles or core values that were being challenged that caused the moral distress. Participants are then invited to share their reactions to the case and their experience with similar cases again labeling their feelings. The facilitator then focuses on practical takeaways, including communication templates and tools that can be used to mitigate conflicts in future cases. The gathering is concluded by the facilitator thanking participants for their courage to speak openly and share with the group. The faculty facilitator sends out an email to the entire residency program the next day summarizing the case presented, lessons learned, and the practical take-aways, and pertinent references as a resource.

Figure 1.

Summary of eight-step process for moral distress rounds.

Implementation

Cases reviewed from previous sessions with practical take-aways:

Moral Injury

A common source of frustration for the mid-level surgical consult resident was when consulting services did not appreciate the patient's level of acuity and when urgent recommendations made by the surgical service were not executed in a timely fashion.

The case presented involved a consultation for abdominal distention and obstipation in an elderly patient that was admitted to the medical service for altered mental status. Suspecting a small bowel obstruction, the consult resident recommended placement of a sump decompression tube and abdominal imaging. The tube was not placed in a timely fashion and the patient suffered a terminal aspiration event. The surgical resident expressed regret that he did not simply place the tube himself, but also raised the question regarding the responsibility of the consulting physician to the patient and the necessary communication required to fulfill that obligation; specifically engaging the consulting team and emphasizing the level of acuity and the need for this intervention. This dilemma resonated with many of the residents; through the subsequent active discussion, residents appreciated that they are not alone in these experiences and parsed out what factors contribute to their moral distress in this interaction. In the surgeon-patient relationship the surgeon's action is intimately linked to the response and the outcome of the patient which differs in other areas of medicine. The inability to ‘do the right thing’ – in this case deferring to the consulting team to execute the recommendations, challenges the surgeon's sense of accountability, responsibility, and personal culpability. A surgeon's professional integrity stems from these attributes and violation of these core values results in moral distress. The feelings of frustration, guilt, and compromised integrity can linger if not acknowledged and shared, they can accumulate and intensify contributing to moral injury.

Tension Between Patient Autonomy vs. Beneficence

A resident described an encounter with a patient diagnosed with a superior mesenteric artery pseudoaneurysm where a recommendation was made for surgical repair to eliminate the risk of rupture. Despite a prolonged conversation regarding the natural history of pseudoaneurysms and the potentially devastating sequelae of foregoing repair, the patient declined surgery.

This case illustrates the ethical tension between beneficence and patient autonomy; the surgeon wanting to act in the best interest of their patient while respecting patient autonomy and choice. The presenting resident expressed frustration about the time he devoted to counseling the patient, and his frustration was validated by the other resident participants. When the resident was asked by his peers why the patient refused operative intervention, he admitted that he never asked the patient this question. This led to a robust discussion about the imperative of being curious and keeping our discussions patient centric instead of surgeon centric.

The concept of humble inquiry, based on the book by Edgar Schein of the same name, is the art of drawing someone out by asking questions derived from genuine curiosity.¹⁵ By exploring the patient's reasons for refusal we can attempt to address their concerns and fears, dispelling misinformation. Learning to be inquisitive and simply asking why can help us to identify the patient's true preferences and values which are integral to the shared decision-making process. This in turn can help us as practitioners cope with our frustrations regarding the choices that patients make that may not be in line with our own values.

Tension Between Beneficence vs. Non-maleficence

Transitioning from patient care ethics to public health ethics contributed to moral distress for all types of health care providers. At the height of the COVID pandemic, consultations requesting tracheostomies and feeding access contributed to moral confusion and moral distress in many surgical residents. Performing these procedures conflicted with the surgeon's personal values when the surgeon viewed them non-beneficial interventions. There was limited experience with the disease course of COVID and the outcomes after tracheostomy. Importantly, at the peak of the pandemic it was necessary to place tracheostomies and feeding tubes on patients in the intensive care unit (ICU) to allow for their transfer out of the ICU, making beds available for other COVID patients. Many of these patients died soon after transferring out of the ICU. Many residents experienced moral distress due to the tension between beneficence and maleficence; the intention of acting in the patient's best interest with the subsequent realization that the procedure may have caused more harm than benefit. Furthermore, with cessation of all non-emergent surgery at the peak of the pandemic, these procedures were the few operative opportunities available to surgical residents, which contributed to the cognitive dissonance of surgical training versus patient care.

Moral Uncertainty Distress

A middle-aged patient with significant comorbidities underwent emergent major abdominal surgery and subsequently experienced a complication requiring multiple invasive interventions and a prolonged ICU stay. The resident involved expressed frustration with the nature of a prolonged ICU course – “felt stuck in a holding pattern” and “it's not the pace of surgery”. The resident expressed further frustration in being caught up in the “therapeutic momentum” of proposing additional invasive solutions to each of the patient's maladies even when the patient failed to show any meaningful clinical improvement.

This case illustrates the recurrent ethical tension experienced by surgeons between beneficence, patient autonomy, and the concern for maleficence. We discussed how these cases create moral uncertainty distress in that there remains an element of uncertainty as to outcome; at every moment, it is unclear whether the patient will derive any long-term benefit from a string of invasive procedures. There is also moral dilemma distress and an ongoing ethical concern for respecting patient autonomy. While the patient may have agreed to the initial life-saving intervention, every subsequent procedure requires representative consent. Families themselves get caught up in the therapeutic momentum and seek guidance in deciding what is truly in the best interest of their loved one. For the surgeon, ‘wanting to do the right thing’ is challenged by the element of uncertainty as to the outcome and in providing potentially inappropriate treatment with the potential for inflicting harm. As a practical take-away, the option of a time-limited trial was discussed. This approach was described as a patient-centered approach to decrease the utilization of non-beneficial ICU care.¹⁶

RESULTS

A post-intervention programmatic survey was performed. The proportion of residents satisfied or very satisfied with this non-technical skills curriculum increased from 36% to 70%. The proportion of residents feeling comfortable or very comfortable with navigating ethical issues in surgery increased from 62% to 72%. Approximately 89% were comfortable or very comfortable with leading a goals of care discussion with a patient and their family members, an increase from 72%. In terms of comfort of offering surgical palliative care options, the proportion of residents feeling comfortable or very comfortable increased from 63% to 82%. Other additions to the non-technical skills curriculum included a Residents as Teachers and Leaders series and a Transition to Practice series.

Residents were then surveyed to assess the efficacy of these moral distress rounds after eight Sip & Share sessions over ten months. Of the thirteen respondents, all strongly agreed (61%) or agreed (39%) that the discussions provided them with the vocabulary to discuss ethical dilemmas. All respondents strongly agreed (54%) or agreed (46%) that the discussions helped them define the ethical principles that are challenged and contributing to their moral distress. Most respondents strongly agreed (54%) or agreed (39%) that they have been able to apply the lessons and templates learned to their daily interactions with patients. When asked if the discussions helped them mitigate stress, 15% of respondents strongly agreed and 62% agreed with the statement. These questions were used as a surrogate indicator for moral resilience. All respondents strongly recommended (69%) or recommended (31%) attending Sip & Share discussions to other residents.

Residents were also allowed to share their perceptions and experience of attending Sip & Share in the survey. This was used as a qualitative assessment of the efficacy of the program. Representative comments included:

“I was able to apply the vocabulary I previously learned to real clinical scenarios and thus gain a better understanding of the language used to discuss ethics. The session also reinforced the sense of community among residents where we were able to speak openly in a safe and private setting about our individual experiences and find shared lessons through discussion of our experiences. The session was inclusive and welcoming, and I look forward to participating throughout residency.”

“Sip & Share has helped me appreciate the universality of many of my experiences as a surgery resident and has also enabled me to learn from the moral distress of others. I think having it in a more relaxed setting than a formal M&M has enabled it to become a sort of emotional M&M space. It also enables us to share things that aren't appropriate for a setting that includes many attendings but having moderation by an attending helps us put things in context.”

“It is a safe space to discuss times where I have felt distressed, upset, or conflicted about a patient's care that I've participated in. These discussions with my peers help me better articulate what exactly I am feeling, and then I am better able to process those feelings and move forward.”

“One idea could be to have a session where multiple members from the same care team offer their various perspectives on certain clinical scenarios in order to display and create an opportunity for safe discussion of how different members of a care team experience a situation, whether similarly or differently.”

“I grapple with the appropriateness of having the entire residency participate in one discussion. On the one hand I love learning from the more senior residents, and I think that emotional intelligence can vary across years and doesn't necessarily correlate with years of training. There is also something meaningful about putting everyone on the same level. However, I do think there is a higher level of stress and moral responsibility that you feel as you progress through training, and I wonder if it would be good for more senior residents to have a unique forum for that.”

DISCUSSION

Our study demonstrates the efficacy of moral distress rounds in building resilience among surgery residents. Initially the ethics curriculum in the program included ethics case discussions and debates that were patient-centric where the focus was on identifying patient-centered ethical dilemmas. It became apparent that residents were experiencing moral distress from these cases, the discussions were then adapted to become surgeon-centric, focusing on clinical cases where there were personal or core ethical values that were violated. Residents who participated in the program expressed appreciation for the new set of vocabulary that they now had at their disposal and felt better equipped to define and address ethical challenges.

In recent years, the psychological well-being of healthcare providers, and surgery residents in particular, has become a topic of tremendous exploration and debate.⁷ This issue was exacerbated by the COVID-19 pandemic, where caregiver burnout due to both emotional and moral distress continues to be a threat to the healthcare workforce up to this day.¹⁷ Moral distress rounds during the pandemic were therapeutic to most residents. It was the only time we could in some way and be together in a time we had been forced apart. We grieved the losses of patients and even of colleagues. We shared the few success stories with hope to keep the rest motivated. We found it helpful to reframe moral dilemmas from the perspective of others. We channeled negative feelings into opportunities for learning and growth. Moral distress rounds fostered reflection, connectedness, and bolstered resilience. We demonstrate that by creating a safe space for residents to explore the experiences that effect their professional integrity and career identity, we have demonstrated that residents can be empowered with tools to mitigate the moral distress that they will certainly experience throughout their careers in surgery.

It is important to make the distinction between emotional distress and moral distress. While emotional distress describes the emotional reaction, sadness, or grief, moral distress is the perceived violation of one's core values with the feeling of being limited from taking an ethically appropriate action. The important distinction is that moral distress is more powerful because it includes the perception that one's professional, personal, or core values are infringed upon.^{18 , 19} The feelings described by those experiencing moral distress are anger, frustration, anxiety, guilt, powerlessness, and psychological disequilibrium. Moral distress is disruptive to professional and moral integrity. While each episode of moral distress may seem manageable, the cumulative effect of unaddressed moral distress can generate portentous psychological outcomes –depression, suicide, and burnout- and can also be directly dangerous to patient care. Moral distress has the potential to negatively impact work performance, retention, recruitment, and job satisfaction. The post intervention survey that we performed indicates that moral distress rounds were successful in equipping the residents with the vocabulary to define the ethical tension, mitigating moral distress and isolation, and providing practical take-aways to use in similar future encounters.

Barriers to education and intervention addressing moral distress and moral injury include the hierarchy inveterate to surgical culture and the stigma against admitting moral distress. Senior surgeons may seem impervious to moral injury and impede or intimidate a trainee from seeking help. Trainees who feel vulnerable within the power hierarchy may be reluctant to express feelings associated with moral distress because of fear of being perceived as weak, lacking confidence, or self-perceived inadequacy, or shame.²⁰ During and after an adverse event our emotions can escalate from ‘this is bad’ to ‘I am bad’. Shame is defined as an intensely painful feeling of believing we are flawed, inadequate and unworthy. Shame is different from guilt. In guilt, we judge our behavior as wrong. Guilt is “I did something bad”; shame is “I am bad”.²¹ Perfectionism can trigger shame in individuals who experience failure. As surgeons we tend to be perfectionists and therefore are exceptionally vulnerable to shame.²² Moral distress rounds created a forum to discuss this distinction so that residents can appropriately label their own thoughts and emotions in the throes of crisis without feeling shame in doing so.

One of the most important aspects of these gatherings was the creation of a non-judgmental safe zone. By expressing and labeling emotions amongst their peers, residents create a moral community that can both mitigate feelings of isolation and foster resilience. A survey comment suggested having separate sessions for each post-graduate year to address the perspectives unique to the level of training as intern, consult resident, and chief resident, which could be one iteration of moral distress rounds. In our experience, the purpose of these gatherings is to promote connection and the reassurance to all residents that residents at all levels of training make mistakes, face uncertainty, fail, and experience both emotional and moral distress. As trainees navigate the challenges of residency, the relationships within this communal support system allow for vulnerability, for questioning, and tolerance for expressing uncertainty.²³

One limitation to implementing this framework is the need for a clinical ethicist to serve as the facilitator. An option is utilizing regional or national clinical ethical expertise on the virtual platform. While the intention of these sessions was to add to ethics curriculum which also included case discussions and debates, the voluntary nature of the sessions meant that not all residents experienced these sessions. Inherently there is also a selection bias in that the sessions are voluntarily attended by residents interested in bioethics. Anecdotally the virtual format did allow for more frequent sessions at a time where social interaction in the residency was limited due to the pandemic, but participants did seem to experience Zoom fatigue with the return of in person social/education events. At this time more formal moral distress rounds were also organized during the residency's protected education time to allow all residents to attend.

Surgeons experience moral distress throughout their training and careers. We believe there is significant utility to the provision of these safe space gatherings within surgical programs for the resident in training, the surgeon transitioning into the attending role, and even for the seasoned surgeons to mitigate moral distress.

CONCLUSIONS

Moral distress rounds provide a structured discussion format within a safe zone for residents to share and process clinical experiences that challenge their professional and moral integrity. Addressing moral distress is integral to psychological, emotional, and physical well-being and fosters resilience. Self-care and the maintenance of well-being is constitutive to professionalism and necessary in the provision of quality patient care.

Conflict of interest

None.