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      Structural distress: experiences of moral distress related to structural stigma during the COVID-19 pandemic

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          Abstract

          Introduction

          The COVID-19 pandemic has taken a significant toll on the health of structurally vulnerable patient populations as well as healthcare workers. The concepts of structural stigma and moral distress are important and interrelated, yet rarely explored or researched in medical education. Structural stigma refers to how discrimination towards certain groups is enacted through policy and practice. Moral distress describes the tension and conflict that health workers experience when they are unable to fulfil their duties due to circumstances outside of their control. In this study, the authors explored how resident physicians perceive moral distress in relation to structural stigma. An improved understanding of such experiences may provide insights into how to prepare future physicians to improve health equity.

          Methods

          Utilizing constructivist grounded theory methodology, 22 participants from across Canada including 17 resident physicians from diverse specialties and 5 faculty members were recruited for semi-structured interviews from April–June 2020. Data were analyzed using constant comparative analysis.

          Results

          Results describe a distinctive form of moral distress called structural distress, which centers upon the experience of powerlessness leading resident physicians to go above and beyond the call of duty, potentially worsening their psychological well-being. Faculty play a buffering role in mitigating the impact of structural distress by role modeling vulnerability and involving residents in policy decisions.

          Conclusion

          These findings provide unique insights into teaching and learning about the care of structurally vulnerable populations and faculty’s role related to resident advocacy and decision-making. The concept of structural distress may provide the foundation for future research into the intersection between resident well-being and training related to health equity.

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          Most cited references38

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          The Color of COVID-19: Structural Racism and the Pandemic’s Disproportionate Impact on Older Racial and Ethnic Minorities

          Abstract Objectives The aim of this evidence-based theoretically informed essay is to provide an overview of how and why the COVID-19 outbreak is particularly detrimental for the health of older Black and Latinx adults. Methods We draw upon current events, academic literature, and numerous data sources to illustrate how biopsychosocial factors place older adults at higher risk for COVID-19 relative to younger adults, and how structural racism magnifies these risks for older Black and Latinx adults. Results We identify three proximate mechanisms through which structural racism operates as a fundamental cause of racial/ethnic inequalities in COVID-19 burden among older adults: (1) Risk of exposure; (2) Weathering processes; and (3) Health care access and quality. Discussion While the ongoing COVID-19 pandemic is an unprecedented crisis, the racial/ethnic health inequalities among older adults it has exposed are long-standing and deeply rooted in structural racism within American society. This knowledge presents both challenges and opportunities for researchers and policymakers as they seek to address the needs of older adults. It is imperative that federal, state, and local governments collect and release comprehensive data on the number of confirmed COVID-19 cases and deaths by race/ethnicity and age to better gauge the impact of outbreak across minority communities. We conclude with a discussion of incremental steps to be taken to lessen the disproportionate burden of COVID-19 among older Black and Latinx adults, as well as the need for transformative actions that address structural racism in order to achieve population health equity.
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            Introduction to the special issue on structural stigma and health.

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              When healthcare professionals cannot do the right thing: A systematic review of moral distress and its correlates.

              Moral distress occurs when professionals cannot carry out what they believe to be ethically appropriate actions. This review describes the publication trend on moral distress and explores its relationships with other constructs. A bibliometric analysis revealed that since 1984, 239 articles were published, with an increase after 2011. Most of them (71%) focused on nursing. Of the 239 articles, 17 empirical studies were systematically analyzed. Moral distress correlated with organizational environment (poor ethical climate and collaboration), professional attitudes (low work satisfaction and engagement), and psychological characteristics (low psychological empowerment and autonomy). Findings revealed that moral distress negatively affects clinicians' wellbeing and job retention. Further studies should investigate protective psychological factors to develop preventive interventions.
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                Author and article information

                Contributors
                jsukhera@uwo.ca
                Journal
                Perspect Med Educ
                Perspect Med Educ
                Perspectives on Medical Education
                Bohn Stafleu van Loghum (Houten )
                2212-2761
                2212-277X
                29 April 2021
                29 April 2021
                : 1-8
                Affiliations
                [1 ]GRID grid.39381.30, ISNI 0000 0004 1936 8884, Departments of Psychiatry/Paediatrics and Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, , Western University, ; London, Ontario Canada
                [2 ]GRID grid.17063.33, ISNI 0000 0001 2157 2938, Hospital for Sick Children (SickKids), Department of Psychiatry, , University of Toronto, ; Toronto, Canada
                [3 ]GRID grid.39381.30, ISNI 0000 0004 1936 8884, Department of Obstetrics and Gynecology and Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, , Western University, ; London, Ontario Canada
                Author information
                http://orcid.org/0000-0001-8146-4947
                http://orcid.org/0000-0002-6464-0870
                http://orcid.org/0000-0003-0562-5045
                Article
                663
                10.1007/s40037-021-00663-y
                8082743
                33914288
                b445af99-2a4d-44f5-9cf4-bbfa6ff703b2
                © The Author(s) 2021

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                History
                : 22 January 2021
                : 17 March 2021
                : 30 March 2021
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100000241, Physicians’ Services Incorporated Foundation;
                Categories
                Original Article

                Education
                covid-19,moral distress,stigma,marginalized populations,professional identity formation
                Education
                covid-19, moral distress, stigma, marginalized populations, professional identity formation

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