A systematic scoping review moral distress amongst medical students

Characterised by feelings of helplessness in the face of clinical, organization and societal demands, medical students are especially prone to moral distress (MD). Despite risks of disillusionment and burnout, efforts to support them have been limited by a dearth of data and understanding of MD in medical students. Yet, new data on how healthcare professionals confront difficult care situations suggest that MD could be better understood through the lens of the Ring Theory of Personhood (RToP). A systematic scoping review (SSR) guided by the RToP is proposed to evaluate the present understanding of MD amongst medical students. The Systematic Evidence-Based Approach (SEBA) is adopted to map prevailing accounts of MD in medical students. To enhance the transparency and reproducibility, the SEBA methodology employs a structured search approach, concurrent and independent thematic analysis and directed content analysis (Split Approach), the Jigsaw Perspective that combines complementary themes and categories, and the Funnelling Process that compares the results of the Jigsaw Perspective with tabulated summaries to ensure the accountability of these findings. The domains created guide the discussion. Two thousand six hundred seventy-one abstracts were identified from eight databases, 316 articles were reviewed, and 20 articles were included. The four domains identified include definitions, sources, recognition and, interventions for MD. MD in medical students may be explained as conflicts between the values, duties, and principles contained within the different aspects of their identity. These conflicts which are characterised as disharmony (within) and dyssynchrony (between) the rings of RToP underline the need for personalised and longitudinal evaluations and support of medical students throughout their training. This longitudinal oversight and support should be supported by the host organization that must also ensure access to trained faculty, a nurturing and safe environment for medical students to facilitate speak-up culture, anonymous reporting, feedback opportunities and supplementing positive role modelling and mentoring within the training program.

The Ring Theory of Personhood (RtoP) [28] These ties are determined by the person and can change over time [23,28,29].
The Societal Ring is the outermost ring that consists of less intimate relationships such as those shared with colleagues and acquaintances. The Societal Ring also contains societal, religious, professional, and legal expectations set out in the individual's society to guide and police conduct [23,28,29].
Critically each ring also represents an element of the medical student's identity and the values, beliefs and principles associated with it [23,[28][29][30][31]. This link between personhood and identity affords the RToP a key role in this review. The Innate Identity drawn from the Innate Ring considers religious, gender, cultural, community-based beliefs, moral values and ethical principles. The Individual Identity encompasses personal values, beliefs, and personalities whilst the Relational and Societal Identities drawn from the outermost rings pivot on familial and societal values, beliefs, expectations, and principles, respectively [23,28,29,31] Kuek, Ngiam [29,31].
Chan, Chia [31] Kuek, Ngiam [25], and Ngiam, Ong [38]Chan, Chia [35] Ngiam, Ong [34] suggest that when the beliefs, moral values, ethical principles, familial mores, cultural norms, attitudes, thoughts, decisional preferences, roles, and responsibilities housed in each of these rings come into conflict in a variety of situations, disharmony and dyssynchrony arise. Disharmony refers to conflicts between values, beliefs, and principles within the rings whilst dyssynchrony refers to conflicts between the rings [28]. It is posited that unresolved disharmony and or dyssynchrony results in MD [25]. These considerations further explain our use of the RToP to guide this review.

Methodology
Krishna's Systematic Evidence-Based Approach (henceforth SEBA) [40] is employed to structure a systematic scoping review (henceforth SSR in SEBA) of accounts of MD amongst medical students. To enhance accountability and transparency the SSRs in SEBA employ an expert team to guide, oversee and support all stages of SEBA. In this case, the expert team is composed of medical librarians from the Yong Loo Lin School of Medicine (YLLSoM) at the National University of Singapore and the National Cancer Centre Singapore (NCCS), and local education experts and clinicians at NCCS, the Palliative Care Institute Liverpool, YLLSoM and Duke-NUS Medical School, henceforth the expert team. The expert team enhances the reflexivity of the review. The research team also maintained a reflexive diary to highlight their biases, positions, and assumptions.
SSRs in SEBA are built on a constructivist perspective which acknowledges MD as a sociocultural construct informed by prevailing clinical, academic, personal, research, professional, ethical, psychosocial, emotional, legal and educational factors, the individual's particular circumstances, their self-concept of personhood and the support available to them at the time [41][42][43][44][45]. SEBA's relativist lens considers various perspectives through data collected from quantitative, qualitative and knowledge synthesis articles.
To operationalise an SSR in SEBA the research team adopted the principles of interpretivist analysis, to enhance reflexivity and discussions [46][47][48][49] in the Systematic Approach, Split Approach, Jigsaw Perspective, Funnelling Process, analysis of data from the grey and black literature and Synthesis of SSR in SEBA which make up SEBA's 6 stages outlined in Fig. 2.

Stage 1 of SEBA: systematic approach Theoretical lens
The use of the RToP as a theoretical lens is consistent with the Social Cognitive Theory's posit of a "triadic reciprocal dynamic relationship between the learner, the environment and the behaviour itself" [50]. The RToP provides a sketch of the conflicts between a medical student's beliefs, moral values, ethical principles, familial mores, cultural norms, attitudes, thoughts, decisional preferences, roles, and responsibilities (henceforth values, beliefs, and thoughts) within the 4 aspects of the medical student's identity. The RToP also offers a better understanding of their contextual and environmental factors, enhancing understanding of their motivations, cognition, responses, thoughts, motivations, biases, ideas, Fig. 2 The SEBA process choices, actions, and goals providing a holistic appreciation of the conflicts that underpin MD [23,[25][26][27][28][29][30][31]51]

Determining the title and research question
To ensure a systematic approach, the research and expert teams established the goals of the SSR and the population, context, and concept (PCC) to be evaluated. The primary research question was determined to be: "What is known about MD amongst medical students?" and the secondary questions were: "What are the sources of MD in medical students?" and "What are the interventions employed to help medical students cope with MD?"

Inclusion criteria
A PICOS format was adopted to guide the research process as shown in Table 1 [52,53].

Searching
The six members of the research team carried out independent searches of seven bibliographic databases (PubMed, Embase, PsycINFO, ERIC, SCOPUS, Web of Science, Google Scholar) for articles published between 1st January 1990 and 31st December 2021. The searches were carried out between 13th February 2021 and 5th May 2021 and between 17th December 2021 and 17th January 2022. The PubMed search strategy may be found in Additional file 1: Appendix A.
Each member of the research team independently sieved through all titles and abstracts from the individual searches of the four databases and created their own lists of titles to be reviewed. Comparing these individual lists via online meetings, the teams used 'negotiated consensual validation' to achieve consensus on the final list of titles to be reviewed [54,55].
The research team then independently reviewed each of the full-text articles from this final list, created individual lists of articles to be included, discussed these online and achieved a consensus on the final list of full-text articles to be included in the SSR. The results of this process are outlined below.

Assessing the quality of included articles
Three research team members individually appraised the quality of the quantitative and qualitative studies using the Medical Education Research Study Quality Instrument (MERSQI) [56] and the Consolidated Criteria for Reporting Qualitative Studies (COREQ) [51,57]. The MERSQI tool had the following domains: study design, sampling, type of data, validity of evaluation instrument, data analysis and outcomes. The COREQ tool had the following domains: research team and reflexivity, study design, analysis and findings. This allowed the research team to evaluate the methodology employed in the included articles, aid readers and reviewers in appraising the weight afforded the data in the analysis and assist decision-makers in understanding the transferability of the findings. No articles were excluded based on the results of the appraisal.

Stage 2 of SEBA: split approach
Three teams of at least three researchers independently reviewed the included full-text articles. Wong, Greenhalgh [58] Popay, Roberts [59] The first team summarized and tabulated them in keeping with Wong, Greenhalgh [60]'s RAMESES publication standards: meta-narrative reviews and Popay, Roberts [61]'s "Guidance on the conduct of narrative synthesis in systematic reviews". The tabulated summaries ensure that key points of the articles are not lost (Additional file 2: Appendix B). Concurrently, the second team independently analysed the included articles using Braun and Clarke [62] Braun and Clarke's approach to thematic analysis while the third team adopted Hsieh and Shannon's Hsieh and Shannon [63] approach to directed content analysis. Radha Krishna and Alsuwaigh [31] Concurrent use of thematic and directed content analysis is a key feature of the 'Split Approach' and serves to enhance the reproducibility, transparency, and accountability of the analytic process. This concurrent analysis also serves to reduce the omission of new findings or negative reports and enable review of data from different perspectives.

Thematic analysis
In the absence of rigorous definitions of MD, three members of the research team adopted Braun and Clarke's approach to identify key themes across different learning settings and medical student populations. This allowed for the analysis of data derived from quantitative, qualitative, and mixed methodologies. This sub-team independently reviewed the included articles, constructed codes from the surface meaning of the text and collated these into a code book, which was used to code and analyse the rest of the articles in an iterative process. New codes were associated with prior codes and concepts. An inductive approach allowed us to identify codes and themes from the raw data without using existing frameworks or preconceived notions as to how the data should be organized. The sub-team discussed their independent analyses in online and face-to-face meetings and used "negotiated consensual validation" to derive the final themes.

Directed content analysis
Three members of the research team independently employed Hsieh and Shannon's approach [63] to directed content analysis. This involved "identifying and operationalizing a priori coding categories" by classifying text of similar meaning into categories drawn from prevailing theories. The research team first used deductive category application to extract codes and categories from Radha Krishna and Alsuwaigh [31]'s article, "Understanding the fluid nature of personhood -the Ring Theory of Personhood". A code book was developed and individual findings were discussed through online and face-to-face meetings. Differences in codes were resolved until consensus was achieved on a final list of categories.
As part of the reiterative process within the SEBA methodology, the initial data was reviewed by the expert and research teams who determined that with current evolutions in concepts of MD extended to various aspects of moral principles and subject to individual, religious, cultural and societal considerations. As a result the expert team advised that the included articles be evaluated using categories drawn from Kuek et alChan, Chia [35]'s article entitled "Extending the Ring Theory of Personhood to the Care of Dying Patients in Intensive Care Units", to determine the impact of dissonance or conflict between the values, beliefs and principles within individual rings and between the four rings.

Stage 3 of SEBA: jigsaw perspective
The Jigsaw Perspective employs adopted Phases 4 to 6 of France, Uny [64]'s adaptation of Noblit, Hare [65]'s seven phases of meta-ethnography to view themes and categories identified in the Split Approach as pieces of a jigsaw puzzle. Here overlapping/complementary pieces are combined to create a bigger piece of the puzzle to create a wider/holistic view of the overlying data. This process would see themes and subthemes compared with the categories and subcategories identified. Similarities between the subthemes and subcategories are further compared with the codes contained to confirm the similarities and indeed if they are complementary in nature. If this is confirmed, then the subtheme and subcategory are combined to create a bigger piece of the jigsaw puzzle. Guided by the Jigsaw Perspective, these overlaps and similarities were combined to provide a holistic picture of available data on MD in medical students.

Stage 4 of SEBA: funnelling process
A funnelling approach was adopted to streamline results from the three aspects of the Split Approach. It sees data compared and combined to reduce overlap and repetition whilst retaining a holistic perspective of the data.

Results
Two thousand six hundred seventy-one abstracts were identified from eight databases, 316 full text articles were reviewed, and 20 articles were included as shown in Fig. 3.
The themes identified were definitions, causes, impact, influencing factors, assessment, and interventions. The categories identified related to the four rings of the RToP, the Intra-ring conflicts (disharmony) and Inter-ring conflicts (dyssynchrony) ( Table 2).
The domains created by combining the themes and the subtheme and the categories and sub-categories are presented in Additional file 3: Appendix C to enhance reproducibility, accountability, and accountability of the Jigsaw Perspective.
The resultant domains were definitions of MD, sources of MD using RToP, recognition of MD and, interventions for MD.

Domain 1: definition of MD
JametonJameton [66] attributes MD to feelings of powerlessness to do what healthcare professionals deemed was morally correct due to organizational restrictions [54]. This definition is widely adopted amongst the included articles [56][57][58][59] and echoed in the definitions in other papers [56,57,59,62]. Recently the concept of MD has been expanded to include cognitive-emotional dissonance between one's ethical/moral beliefs and actions or behaviour that one is compelled to perform [63][64][65][66][67]. MD can occur immediately or later and at an individual, team or system levels ( Table 3).

Relational ring
Social support from family and close friends protects against harmful effects of moral distress [68,83].

Conflicts
Conflicts are central to the concept of MD and when viewed through the lens of the RToP highlights intraring (disharmony) and inter-ring (dyssynchrony) conflict. Though they may occur concurrently, we highlight individual examples of disharmony and dyssynchrony.

Intra-ring conflicts
Dissonance between values and beliefs within a particular ring results in intra-ring conflicts or 'disharmony' [77,84]. For example, 'disharmony' within the societal ring, may occur when a patient's proposed actions run contrary to medical advice [59,67,74], or when medical students do not have an opportunity to meet their professional responsibilities such as reporting the abuse of the patient for fear of compromising the patient's anonymity [76]. MD has also been reported when medical students feel conflicted about giving opioids to opioid dependent patients; witnessing patients undergoing unnecessarily 'burdensome' or even 'futile' treatment; or witnessing inadequate symptom control because the attending physician was not 'comfortable' to do so [56, 57, 59, 62-67, 69, 70, 74, 76, 78, 81].
Medical students also report MD when they struggle to maintain their professional responsibilities to the patient in the face of contradicting the decisions taken by the physicians [64,78,81] or when they feel conflicted when meeting their academic objectives [56,70,72,74,78] at the cost of what they conceive to be the patient's choice to refuse [59,62,69], or performing tasks that the medical student does not feel confident nor equipped to carry out [62]. Miller et al. [62] describe a student " [beginning] to worry that if she performs the lumbar puncture, she would be putting her own interests as a student before those of her patient, who should always receive the best care possible"(p. 538).
Moral distress in medical student reflective writing
Narrative, emotion and action: analysing 'most memorable' professionalism dilemmas Rees et al. 2013 [71] "Moral distress is when students feel unable to act in a manner consistent with their desire to do the 'right' thing. " (p. 93)

Antecedents and Consequences of Medical Students' Moral Decision-Making during Professionalism Dilemmas
Monrouxe et al. 2017 [72] "Moral distress, is emotional distress arising from the dissonance between one's ethical/ moral beliefs and one's behaviour, which occurs when one's actions are perceived as being limited by institutional constraints or unequal power relations. Moral distress can occur solely in the moment in which a person feels upset or uncomfortable (classified as mild distress) or continues for weeks or even months after an event (moderate distress). In extreme circumstances, distress is experienced many months or even years later (severe distress). Moral distress is different from other feelings. " (p. 568) How Should Integrity Preservation and Professional Growth Be Balanced during Trainees' Professionalization?
Weber and Gray 2017 [73] Moral distress is "a negatively-valenced feeling state where one perceives a conflict between what one is expected to do and what morality requires. " (p. 545) How Should Trainees Respond in Situations of Obstetric Violence?
Rubashkin and Minckas 2018 [74] Moral distress is "the cognitive-emotional dissonance that arises when one feels compelled to act against one's moral requirements. " (p. 240) Joining the Club Fuks 2018 [75] The construct of moral distress is when "believes he or she knows the morally correct response to a situation but cannot act because of hierarchical or institutional constraints" (Lomis, Carpenter, and Miller 2009, p. 107 In some cases, MD may even compromise patient care [56,62,67,70]. MD is also detected through self-reporting via a variety of methods including self-administered surveys [58,59,65,66] and or reflective essays [56,64]. Yet self-reporting of MD may be compromised by concerns over the impact of such admissions upon career prospects [69,85] and the lack of clear reporting processes [76].

Stage 5 of SEBA: analysis of evidence-based and non-data driven literature
Concerns over the quality of the data included from nondata-based articles (grey literature, opinion, perspectives, editorial, letters) and its potential impact upon the analysis of this review saw the themes drawn from evidenced-based publications were compared with those from non-data-based articles. This process found that the themes from both groups to be similar suggesting that information drawn from non-data based articles did not bias the analysis untowardly.
Stage 6 of SEBA: discussion and synthesis of SSR in SEBA [87,88]The narrative produced by consolidating the tabulated summaries, themes and categories was guided by the Best Evidence Medical Education (BEME) Collaboration guide [87] and the STORIES (STructured apprOach to the Reporting In healthcare education of Evidence Synthesis) statement [88].
In addressing its primary and secondary research questions on what is known about MD, its causes, and the interventions to address MD in medical students, this SSR in SEBA highlights several key findings.
To begin, MD arises when conflicts that impact deeply held beliefs, values, and principles rooted in the medical student's identity are not easily resolved. Through the lens of the RToP, such conflicts that underlie MD can be explained by the concepts of disharmony within and/or dyssynchrony between the rings. This process is further influenced by the medical student's personal, existential, spiritual, familial, societal, cultural, and demographic factors, contextual considerations that influence the severity of these conflicts; their ability to process these conflicts; motivations; and the support structures available to them in addressing these conflicts.
Accounts of MD in medical students and physicians were also largely similar, particularly amongst junior physicians [1,19,20,93,97,100,103,105,108]. Junior doctors, like their medical student counterparts, are more prone to MD due to their limited role in treatment decisions within the medical hierarchy [104,[109][110][111][112][113]. For both groups, there is an associated sense of helplessness that appears to recede with progress along the medical hierarchy.
Evidencing the notion that MD is a sociocultural construct informed by psychosocial, individual and contextual considerations, it is clear that assessment requires careful elucidation and a personalised and longitudinal approach. It is here that due consideration of the various values, beliefs and principles of each ring is key and the potential adaptation of the RToP as a tool to evaluate MD comes to light.
Concurrently treating MD requires a holistic and longitudinal perspective of MD and reiterates the need for active involvement of the medical schools in recognising, addressing, and attenuating the effects of MD and supporting medical students facing such distress. Aside from aiding in the diagnosis of MD and identifying medical students 'at risk' of MD, medical schools must provide robust and accessible means of support by training faculty to recognise and address MD [71,85,114,115], and ensure the presence of a timely, personalised and 'safe' environment where medical students can discuss their concerns without fear of 'reprisals' upon their professional reputations and careers. In addition, there is a need to evaluate the hidden curriculum, and the introduction of initiatives such as speak-up culture [70,79,81]and anonymous reporting and feedback opportunities [67,74] and supplementing positive role modelling and mentoring within the training program [68][69][70]79], would be helpful. These considerations should also be accompanied by a clear delineation of the role and responsibilities of the medical student within the medical teams and the support available to them.

Limitations
Even though we had the guidance of an expert team, the use of specific search terms and inclusion of only English language articles compounds the risk of omitting key articles and limiting the findings to North American and European settings. This may lead to the unintended exclusion of articles from other settings. As concepts of MD and personhood are sociocultural constructs, the omission of non-English articles may have significant ramifications on the applicability of these findings in Confucian-inspired societies [31,[116][117][118][119]. [31] Here relational autonomy, filial piety and family-centric associations play a critical role in self-concepts of identity and personhood and thus suggest that concepts of MD [120][121][122][123][124][125] in these settings may be different and not fully reflected by our findings.

Conclusions
MD is a unique phenomenon determined by a medical student's values, beliefs, goals, principles, perspectives, and contextual and psychoemotional considerations. In evidencing the complexity of this concept, the RToP has shown the potential to be adapted as a tool to evaluate MD holistically and in a socioculturally [119] appropriate manner. Such a tool could guide the support of medical students in need, and help design and oversee a safer learning and working environment for medical students. Concurrently with identity, contextual factors and psycho-emotional considerations constantly changing an RToP tool could also provide longitudinal follow up of medical students who have suffered MD.
Drawing on recent studies on longitudinal support and assessments of medical students the use of a tool to assess MD based on the RToP could be included within a medical student's [126] to assess progress and direct support. As we look forward to engaging in this growing field, we are especially hopeful for greater understanding of the long-term effects of MD in various cultures and to evaluate the efficacy of support mechanisms for 'at risk' and 'recovering' medical students.