Well-Being of Students Medical Students’ Experiences of Moral Distress: Development of a Web-Based Survey Catherine Wiggleton, MD, Emil Petrusa, PhD, Kim Loomis, MD, John Tarpley, MD, Margaret Tarpley, Mary Lou O’Gorman, MDiv, and Bonnie Miller, MD Abstract Purpose To develop an instrument for measuring moral distress in medical students, measuring the prevalence of moral distress in a cohort of students, and identifying the situations most likely to cause it. Moral distress, defined as the negative feelings that arise when one knows the morally correct thing to do but cannot act because of constraints or hierarchies, has been documented in nurses but has not been measured in medical students. Method The authors constructed a survey consisting of 55 items describing potentially distressing situations. Responders rated the frequency of these situations and the intensity of distress that they caused. The survey was administered to 106 fourth-year medical students during a three-week period in 2007; the response rate was 60%. Results Each of the situations was experienced by at least some of the 64 respondents, and each created some degree of moral distress. On average, students witnessed almost one-half of the situations at least once, and more than one-third of the situations caused mild-to-moderate distress. The survey measured individual distress (Cronbach alpha = 0.95), which varied among the students. Whereas women witnessed potentially distressing situations significantly more frequently than did men (P = .04), men tended to become more distressed by each event witnessed (P = .057). Conclusions Medical students frequently experience moral distress. Our survey can be used to measure aspects of the learning environment as well as individual responses to the environment. The variation found among student responses warrants further investigation to determine whether students at either extreme of moral distress are at risk of burnout or erosion of professionalism. Acad Med. 2010; 85:111–117. The practice of medicine is fundamentally a moral endeavor. As argued by Pellegrino, 1 knowledge and expertise place the physician in a position of authority, and illness places the patient in a position of vulnerability and need. This unbalanced relationship creates a moral imperative: Physicians must uphold the promise to use their skills in service to their patients, and they must be mindful and principled in negotiating the conflicts of interest that arise on a daily basis. 2 The moral development of medical students should thus be considered a matter of high priority for medical educators. Using validated instruments that measure stages of moral reasoning, investigators have found, however, that medical students do not show the progress that would be expected in others of similar age and educational level. Some students may, in fact, regress. 3,4 The question then arises as to whether the process of medical education impedes rather than promotes moral growth. 5 For seven years, we sponsored monthly meetings of medical students and faculty, in which students described experiences on their clinical rotations that raised ethical or moral questions. Participation in these sessions was voluntary, and the students were assured that these meetings provided a safe haven for frank discussion. The accumulated body of stories supported the notion that students struggle with moral issues on a regular basis. Specifically, students reported that they had a strong desire to do what they thought was in patients’ best interests, but they were frustrated by a variety of obstacles, including systems of care, the hierarchy of medical education, and conflicts with patients’ own values and wishes. These stories were recounted with a sense of distress and sometimes anguish. One might expect that the students’ position at the bottom of the medical hierarchy would absolve them of a sense of responsibility for the situations they encountered, but, paradoxically, it seemed to heighten that sense, because they often felt that they were the only ones who cared. If they didn’t act, then who would? In 1984, Jameton 6 described the concept of moral distress, defining it as the negative feelings that arise when one knows the morally correct response to a situation but cannot act because of institutional or hierarchal constraints. He also said that episodes of moral distress are distinct from moral dilemmas, which involve decisions between two potentially correct courses of action and which are not always accompanied by negative Dr. Wiggleton is resident, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee. Dr. Petrusa is director, Office for Teaching and Learning in Medicine, Center for Outcomes and Research in Education, Vanderbilt University School of Medicine, Nashville, Tennessee. Dr. Lomis is assistant professor, Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee. Dr. Tarpley is professor, Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee. Ms. Tarpley is associate in surgery, Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee. Ms. O’Gorman is director of pastoral care, St. Thomas Hospital, Nashville, Tennessee. Dr. Miller is senior associate dean for health sciences education, Vanderbilt University School of Medicine, Nashville, Tennessee. Correspondence should be addressed to Dr. Miller, 201 Light Hall, Vanderbilt University School of Medicine, Nashville, TN 37232-0685; telephone: (615) 343-7536; e-mail: bonnie.m.miller@ vanderbilt.edu. Academic Medicine, Vol. 85, No. 1 / January 2010 111