# Hard then, harder now: internal medicine residents’ moral distress pre and amidst COVID-19

## TL;DR

This study found that the COVID-19 pandemic worsened moral distress among internal medicine residents, highlighting new ethical challenges and the need for better crisis preparedness.

## Contribution

The study uniquely compares moral distress in internal medicine residents before and during the pandemic, identifying new ethical stressors and their impact.

## Key findings

- Moral distress scores increased significantly during the pandemic, particularly in ventilator care and fear of retaliation.
- Qualitative analysis revealed new drivers of moral distress, such as PPE policies and visitor restrictions.
- The pandemic exacerbated existing moral distress and introduced new ethical dilemmas for trainees.

## Abstract

Moral distress, which occurs when the ethically correct action cannot be taken because of internal or external constraints, is associated with depression, burnout, and the desire to leave the healthcare profession among healthcare workers. This study compares internal medicine (IM) residents’ experiences of moral distress while caring for patients with COVID-19 in the year prior to and during the first year of the COVID-19 pandemic.

This is a mixed methods prospective observational cohort study that enrolled IM residents on a rolling basis beginning December 2018. Moral distress was evaluated via the validated Moral Distress Score-Revised (MDS-R) and Measure of Moral Distress for Healthcare Professionals (MDD-HP) and open-ended questions every 4-months via online surveys and through five resident focus groups. The moral distress scores (MDS) before and during the COVID-19 pandemic were compared using paired t-tests. Transcripts and free text were independently coded by investigators and analyzed by major themes and sub-themes.

Forty-five residents (42% response rate) completed at least one survey during the pre-COVID and COVID periods. Analysis revealed no significant difference in individuals’ pre-to-COVID mean MDS, but significant differences between the overall MDS mean intensity scores pre-to-COVID (62.2 to 68.3 p < .05). Of the 36 items, there was a significant mean increase in two items: (1) continue to participate in care for a hopelessly ill person who is being sustained on a ventilator, when no one will decide to withdraw life support (3.89 to 5.91, p < .05); fear of retribution if I speak up (2.13 to 4.20, p < .05). Qualitive findings included the exacerbation of existing moral distress and the emergence of new drivers of moral distress, including personal protective equipment, visitor policies, lack of moral framework, and tension between protecting one’s own health and caring for others.

The results of this preliminary analysis suggest that the COVID-19 pandemic exacerbated pre-existing experiences of moral distress and brought to light new and different morally distressing situations for trainees. This analysis of the impact of the pandemic is valuable not only for identifying leverage points for intervention, but also for informing future crisis preparedness and cultivating moral resilience in trainees and the healthcare workforce.

The online version contains supplementary material available at 10.1186/s12910-025-01274-6.