Development and Testing of a Survey to Measure Moral Distress in Undergraduate Medical Students

Purpose To develop and test the construct validity of an instrument measuring variables related to moral distress resulting from the hidden curriculum of undergraduate medical education (UME) by identifying root causes and measuring their frequency and intensity among a cohort of learners. For this study, moral distress is defined as the perception of dissonance between an agent’s moral identity and values, standards, and situations attendant to human occupation in clinical environments, referred to collectively as moral events. Moral distress resulting from the hidden curriculum of academic medicine has not been measured. Method A scoping review was conducted to inform the development of a 26-item instrument, called the Moral Distress Scale–Hidden Curriculum (MDS-HC), describing potentially moral events that were potentially distressing to students in UME. The survey was vetted through 10 cognitive interviews, and seven pretests were conducted to debug and observe response process. The survey was administered to medical students at a single medical school who were invited by Slack channel during a four-week period in 2022. Results Seventy-one undergraduate medical students completed the survey portion of the MDS-HC, and all items were experienced at least once and caused some level of distress. The mean frequency of items was measured at 1.2 (95% Confidence Interval (CI) = 1.0 – 1.3), mean intensity was 2.3 (CI = 2.1 – 2.5), and the mean composite score was 3.2 (CI = 2.6 – 3.7). Cronbach’s alpha suggested high inter-item consistency in ratings of intensity (α = 0.95). Data suggest that respondents who never had experienced an event report higher intensity (by 0.58 points on average, CI = 0.46 - 0.70) than those who had not (p < 0.001). Respondents with higher composite MDR-HC scores were significantly more likely to report a change in specialty or career interest (Odds Ratio = 1.53, Confidence Interval (CI) = 1.18 – 2.10, p = 0.003). A four-factor model was found to have good fit indexes (chi-square (dgf = 227, N = 71) = 248.89, p = 0.152) and accounted for 48% of the total item variance. Conclusions Moral events have been observed early in medical training and are enculturated as part of the hidden curriculum. This study provides modest evidence for the validity and reliability of the MDS-HC, which could serve as a base for future research in moral distress in UME.