Table 2 Themes from Thematic Analysis (TA) and Direct Content Analysis (DCA)

Definition of MD

1. Dissonance between one’s ethical/moral beliefs and one’s action or behaviour

2. Constrained from doing the perceived ethically right thing

Theme 1: Innate Ring

Factors increasing levels of MD

a. Gender

b. Religions, philosophies, and cultures

c. Number of clinical years and experience

Theme 2: Individual Ring

1. Precipitants for occurrence of moral distress

a. Observation/participation in self-perceived professional lapses

b. Breaches in patient safety, confidentiality, consent

c. Unpleasant experiences between healthcare providers and patient/patient’s family

d. Students ‘ perception of ethical conflict due to moral stand

2. Personal conception of morality

a. Personalized trade-offs in morally distressing situations determine a student’s choice of action

b. Perspective on the morals of an ideal doctor

c. Inadequate understanding of clinical ethics and its implications in medicine

3. Coping with moral distress individually

a. Habituating to morally distressing scenarios

b. Follow-up action by individuals to remedy moral distress

c. Identifying role models to learn from

4. Beliefs and perspectives that guard against moral distress

a. Doing what was requested will benefit patient

b. Doing the act will aid learning

c. Doing the act will help gain acceptance into medical fraternity

d. Students are not directly responsible for the medical treatments decreases MD intensity

5. Beliefs and perspectives that predispose to moral distress

a. Predisposition to moral distress when in conflict with personal beliefs of morality or medical care

b. Perception of poor working environment

c. Perception of power differential and its consequences

d. Belief that patient is unable to make a sound medical decision and conflicts with appropriate medical care

e. Failure to meet personal standard of morals and medical outcomes or treatment

f. Underdeveloped, poor perspective of the role of medicine

g. Self-perceived inadequacy to provide quality patient care

h. Perceived societal constraints or inequalities that hamper access to treatment

i. Self-perceived inability to cope with moral distress

j. Poor professional identity

6. The influence of emotions

a. Dual Process Theory - emotions influence beliefs or perspectives

b. Discordant emotional responses from medical professionals

c. Positive attitudes towards elderly patients

7. Impact of moral distress on the individual

a. Burnout

b. Wanting to quit the job

c. Erosion of empathy

d. Moral residue from previous MD

e. Interest in geriatrics form increased MD occurrence

f. Feelings of anger, sadness, anxiety

Theme 3: Societal Ring

1. Victims of medical hierarchy

a. Difficulty in following instructions from senior doctors that they do not agree with

b. Difficulty in speaking out against seniors due to vulnerable position in the hierarchy

c. Afraid to clarify doubts about doctor’s actions

d. Doubt arising from actions discordant from rest of medical term

e. Inability to confront patient’s families about decisions that they disagree with

f. Unclear role in the hierarchy / medical team

2. Resource constraints compromising patient care

a. Insufficient time spent with patients

b. Stretching of hospital resources

3. Administrative impairment

a. Ineffective leadership and management

b. Uncertainty regarding reporting protocol

c. Inadequate knowledge of what is considered appropriate consent

d. Medical curricula insufficient for moral growth

4. Role of community in managing MD

a. Mentors enlightening medical students and developing their perspective

b. Poor relationship with co-workers and poor sense of community

c. Appropriate role modelling

d. Negative role models

e. Discussions and reflections to fabricate a ‘safe space’ for students to share and learn from one another

f. Culture shift away from speaking up as an act of insubordination

g. School responsibility to support students and intervene in morally distressing situations

5. Societal pressures

a. The role of medical team to learn and gain skills and knowledge to become a doctor

b. Implications of reporting an illegal medical conduct

c. Students taught to prioritise patient autonomy

d. Administration of medical therapy for safety of others

e. Failure to care for less fortunate and at-risk

f. Difficulty in ascertaining what is truly in patient’s best interests

g. Inability to provide adequate treatment due to social problems

6. Harmful societal effects of MD

a. Decreased manpower leading to resource constraints

b. Negative impacts on patient care due to resource constraints, loss of empathy

7. Personal involvement and choice

a. Face-to-face interpersonal situations

Theme 4: Intra-ring conflicts (Societal and Societal Ring)

1. Disconnection of one’s own ideals and actual actions

a. Participating in professional lapses despite knowing that one should not

b. Not being in control of patient’s outcome despite wanting to

c. Balancing between prolonging patient’s life and preserving their quality of life

d. Respecting patient autonomy despite knowing that action is not in the best interest of the patient

e. Providing medications despite being aware of potential abuse or reliance

f. Laughing off comments that one deems as inappropriate

g. Wanting to do more for the patient but limited by resource constraints

2. Respecting ethical principles while training to achieve competence

a. Practicing skills and procedures on patients without consent

b. Practicing on more vulnerable groups of patients

Theme 5: Inter-ring conflicts

1. Innate and Societal Ring conflict

a. Religion and the sanctity of life and the need to meeting clinical obligations

Causes of MD

Hierarchical structures

3. Fear of repercussions

4. Fear of offending superiors

5. Fear of negative professional consequences

Healthcare systems

1. Failure of healthcare system to give appropriate care

2. Lack of adequate follow-up, discharge plan

3. Sub-optimal care due to resource reduction

4. Level of care based on insurance

5. Lack of resources

Interactions of medical team with others

1. Language barriers, poor communication

2. Lack of respect to other healthcare professionals

3. Lack of respect to patients

Ethical conflicts

1. Patient autonomy and perceived beneficence to patient

2. Family’s wishes misaligned with assessed best interest of patient

3. Medical team’s actions and decisions and medical students’ perceived beneficence to patient

4. Patient autonomy and safety of others

Difference in values and beliefs

2. Difference in beliefs from other HCP

3. Difference in ideals of profession and reality of role

4. Living up to expectations of others and core beliefs about professional identity

Self-doubt

A. Perceived lack of knowledge

B. Perceived powerlessness due to lack of autonomy

C. Lack of understanding of decision-making process

D. Lower level of competency

Factors affecting MD

Risk factors

1. Gender

2. Poor workplace relationships

3. Challenging, high-risk environments (ICU, ED)

4. Underdeveloped skills or professional identity

5. Interactions with vulnerable populations (elderly, children, disabled)

6. Institutional policies

Protective factors

1. Frequency of exposure to distressing situations

2. Conducive health environments

3. Presence of training programmes

4. Guidance from positive role models

5. Good intra-HCP team relationships

6. Institutional policies

Impact of MD

Negative impacts to self

1. Emotional and psychological distress (depression, anger, anxiety)

2. Erosion of empathy, emotional desensitization, and detachment

3. Feelings of guilt

4. Burnout, fatigue, and decreased well-being

5. Questioning of one’s moral integrity

6. Loss of passion and drive for medicine

7. Doubting one’s own career choices

8. Dropping out of medical school

Positive impact to self

1. Develop new perspectives on purpose and meaning of medicine

2. Transformation of values, actions, or perception of actions

Impact on patient care

1. Sub-optimal patient care, decreased quality of care

2. Withdrawal from direct patient care activities

Tools to assess MD

Moral Distress Scale (MDS)

Moral Distress Scale-Revised (MDS-R)

Measure of Moral Distress – Healthcare Professionals (MMD-HP)

Interventions to address MD

Individual coping mechanisms

1. Changing personal perceptions

2. Confronting the issue causing MD

3. Avoidance or inaction

Organisational interventions to increase communication

1. Case-based small group discussion

2. Large group lecture

3. Reflective writings

Support and education

1. Incorporating MD material into clinical teaching

2. Coinciding ethical teachings with clinical education

3. Training students on communication with colleagues and superiors

4. Educating mentors on how to deal with MD in medical students

5. Educating mentors with up-to-date professionalism policies

Principles behind interventions

1. Incorporating case-based ethics education

2. “Speak up” culture

3. System oriented approaches to foster conducive environments

4. Early interventions to prevent build-up of moral residue

Recommendations for the future

1. Medical training through curriculum changes

2. Institutional outreach to increase support

3. Changes in workplace culture