Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California, USA.
University of Global Health Equity, Burera, Rwanda.
Oncologist. 2021 Jul;26(7):e1189-e1196. doi: 10.1002/onco.13818. Epub 2021 May 28.
Moral distress and burnout are highly prevalent among oncology clinicians. Research is needed to better understand how resource constraints and systemic inequalities contribute to moral distress in order to develop effective mitigation strategies. Oncology providers in low- and middle-income countries are well positioned to provide insight into the moral experience of cancer care priority setting and expertise to guide solutions.
Semistructured interviews were conducted with a purposive sample of 22 oncology physicians, nurses, program leaders, and clinical advisors at a cancer center in Rwanda. Interviews were recorded, transcribed verbatim, and analyzed using the framework method.
Participants identified sources of moral distress at three levels of engagement with resource prioritization: witnessing program-level resource constraints drive cancer disparities, implementing priority setting decisions into care of individual patients, and communicating with patients directly about resource prioritization implications. They recommended individual and organizational-level interventions to foster resilience, such as communication skills training and mental health support for clinicians, interdisciplinary team building, fair procedures for priority setting, and collective advocacy for resource expansion and equity.
This study adds to the current literature an in-depth examination of the impact of resource constraints and inequities on clinicians in a low-resource setting. Effective interventions are urgently needed to address moral distress, reduce clinician burnout, and promote well-being among a critical but strained oncology workforce. Collective advocacy is concomitantly needed to address the structural forces that constrain resources unevenly and perpetuate disparities in cancer care and outcomes.
For many oncology clinicians worldwide, resource limitations constrain routine clinical practice and necessitate decisions about prioritizing cancer care. To the authors' knowledge, this study is the first in-depth analysis of how resource constraints and priority setting lead to moral distress among oncology clinicians in a low-resource setting. Effective individual and organizational interventions and collective advocacy for equity in cancer care are urgently needed to address moral distress and reduce clinician burnout among a strained global oncology workforce. Lessons from low-resource settings can be gleaned as high-income countries face growing needs to prioritize oncology resources.
肿瘤学临床医生普遍存在道德困境和职业倦怠。为了制定有效的缓解策略，需要研究资源限制和系统不平等如何导致道德困境，以更好地了解这一点。在中低收入国家，肿瘤学提供者在确定癌症优先治疗方案的道德体验方面具有独特的优势，并拥有专业知识来指导解决方案。
在卢旺达一家癌症中心，对 22 名肿瘤学医生、护士、项目负责人和临床顾问进行了半结构式访谈。对访谈进行了录音、逐字记录，并使用框架方法进行了分析。
参与者确定了资源优先级设置中三个层面的道德困境来源：见证项目层面的资源限制导致癌症的差异；将优先排序决策实施到对个体患者的护理中；以及直接与患者沟通资源优先级排序的影响。他们建议采取个人和组织层面的干预措施来培养韧性，例如为临床医生提供沟通技巧培训和心理健康支持、跨学科团队建设、公平的优先排序程序以及集体倡导资源扩展和公平。
本研究深入探讨了资源限制和不平等对资源匮乏环境中临床医生的影响，这增加了当前文献。迫切需要有效的干预措施来解决道德困境、减少临床医生的倦怠并促进关键但紧张的肿瘤学劳动力的健康。同时需要集体倡导来解决不成比例地限制资源和使癌症护理和结果持续存在差异的结构性力量。
对全世界许多肿瘤学临床医生来说，资源限制限制了常规临床实践，并需要决定优先考虑癌症护理。据作者所知，这是首次深入分析资源限制和优先排序如何导致资源匮乏环境中的肿瘤学临床医生产生道德困境。需要采取有效的个人和组织干预措施以及集体倡导来实现癌症护理的公平，以解决道德困境并减少全球紧张的肿瘤学劳动力中的临床医生倦怠。在高收入国家面临日益增长的肿瘤学资源优先排序需求之际，可以借鉴来自资源匮乏环境的经验教训。
