Chronicling moral distress among healthcare providers during the COVID-19 pandemic: A longitudinal analysis of mental health strain, burnout, and maladaptive coping behaviours

Positive mental health, depression and burnout in healthcare workers during the second wave of COVID-19 pandemic

WHAT IS KNOWN ON THE SUBJECT?: In the past 2 years, the COVID-19 pandemic had a robust negative impact on the mental health of healthcare providers, with increasing rates of depression, anxiety, acute stress and burnout. Healthcare workers experiencing poor mental health are reluctant to seek help and treatment because they are afraid of being stigmatized and excluded by their colleagues and employers. During the pandemic positive emotions, resilience and psychological well-being buffered distress and burnout in healthcare workers. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This paper describes positive mental health, depression, anxiety and burnout in healthcare workers during the second wave of the pandemic. Forty-eight per cent of healthcare workers were flourishing (high levels of positive emotions and well-being), 10% languishing (absence of well-being and positivity). Flourishing individuals reported lower levels of depression, anxiety and burnout. These findings documented a relevant number of resilient healthcare workers, who restored/maintained their well-being also under stressful conditions. Vulnerable healthcare workers were less than 20%, and they reported severe anxiety, depression and burnout. No differences emerged between languishing and moderate mental health groups in their levels of anxiety, depression and burnout. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The condition of flourishing is the only one that provides protection from depression and anxiety and burnout, while moderate mental health does not differ substantially from the languishing state. The study confirms the importance of maintaining and/or promoting the well-being of healthcare workers. Interventions for promoting positive mental health of vulnerable workers are needed. Mental health nurses can have the skills and expertise for evaluating early symptoms of psychological distress and for implementing interventions for promoting and restoring well-being. These interventions may include informational campaign (i.e. preparing and distributing pamphlets and guidelines) and emotional support programmes (psychoeducation and training, mental health support team, peer support and counselling) that can be delivered also via digital platforms.

ABSTRACT

INTRODUCTION: Few studies focused on healthcare workers' positive mental health (i.e. high levels of psychological well-being) and its association with anxiety, depression and burnout in the second wave of the pandemic.

AIMS

To evaluate the protective role of well-being in buffering burnout and psychological distress.

METHODS

We evaluated 173 Italian healthcare workers with indicators of psychological distress (Depression Anxiety Stress Scales [DASS]-21), burnout (Copenhagen Burnout Inventory [CBI]) and positive mental health (Mental Health Continuum) and we cross-classified them according to their levels of mental health (flourishing, languishing and moderate mental health) and their levels of anxiety, depression and burnout.

RESULTS

Forty-eight per cent of health workers were classified as flourishing, 10% as languishing and 42% as moderate mental health. Flourishing individuals presented lower scores on DASS and CBI scales, whereas no differences emerged between languishing and moderate mental health groups. More than 80% of health workers with clinically significant symptoms of anxiety, depression and risk of burnout were classified as not flourishing.

DISCUSSION

This investigation documented the presence of flourishing mental health in almost half of the sample of Italian healthcare workers. However, those with moderate or languishing mental health manifested higher levels of anxiety, depression and higher risks of burnout.

IMPLICATION FOR PRACTICE

The study confirms the importance of maintaining and/or promoting the well-being of this population, with a crucial role of mental health nurses who can easily approach other healthcare workers and provide them informational (training, guidelines) and emotional support programmes (psychoeducation, mental health support team, peer support and counselling) when facing adverse working conditions.

Extending the concept of moral distress to parents of infants hospitalized in the NICU: a qualitative study in Greece

BACKGROUND

The hospitalization of infants in the neonatal intensive care unit (NICU) is an ethically challenging situation. A limited number of studies have extended the concept of moral distress to parents of infants hospitalized in the NICU. This topic requires further investigation.

METHODS

The present prospective qualitative study was conducted from February 2023 to May 2023. Data were collected through semistructured in-depth interviews, which were conducted in-person with fifteen parents of infants who were hospitalized in the NICU at the time of the interviews. Purposive sampling was used. The data were classified and analyzed using thematic analysis.

RESULTS

Three themes emerged from the data analysis performed for this empirical study. One intrapersonal dimension featuring two aspects (one dynamic and one static) and another interpersonal dimension focusing on parental moral distress emerged from the data analysis. Furthermore, seven subthemes emerged across these themes: (1) self-directed negative feelings were experienced by parents due to their inability to fulfill their caregiving/parental roles; (2) intense internal conflict was experienced by parents in response to a moral dilemma that was difficult, which was perceived as irresolvable; (3) objectively unjustified, self-directed negative feelings of guilt or failure were experienced by parents; (4) parents experienced moral distress due to the poor image of the ill infants; (5) inadequate information may predispose parents to experience moral distress (6) neonatologists' caring behaviors were unduly perceived by parents as paternalistic behaviors; (7) reasonable or justified institutional rules were unduly perceived by parents as constraint.

CONCLUSIONS

In general, the results of this study support the integrated definition of parental moral distress proposed by Mooney-Doyle and Ulrich. Furthermore, the present study introduces new information. The study distinguishes between the dynamic and static aspects of the intrapersonal dimension of the phenomenon of parental moral distress. Moreover, participants experienced moral distress because they unduly perceived certain situations as causing moral distress. In addition, inadequate information may predispose parents to experience moral distress. The findings of this study may contribute promote family-centered care in the NICU context.

Explaining the Impact of the COVID-19 Pandemic on Massage Therapists in Australia and Canada: A Mixed Methods Study

Background: The COVID-19 pandemic was a time of rapid change and uncertainty, with individual jurisdictions within countries implementing a variety of preventative measures. At the onset of the pandemic, as little was known about how COVID-19 was transmitted, restrictions, such as lockdowns, were implemented to prevent further spread of this virus. In many jurisdictions, massage therapists were deemed as nonessential for a period. This disruption to their livelihood, as a professional group and without autonomy to decide, was unprecedented. This prompted the question as to whether this experience had impacted massage therapists' professional identity. Methods: A sequential explanatory mixed methods design was used and massage therapists in Australia and Canada were recruited to participate. Results from a quantitative questionnaire completed by 649 respondents and from 31 semistructured interviews from a subset of the questionnaire participants were used in the mixed analysis. Results: Massage therapists, impacted by the pandemic, experienced a discord between what it means to be a massage therapist, providing patient-centered care and the public health initiatives implemented during the pandemic. This discord occurred in multiple situations and the type of discord was influenced by a number of factors, including how therapists identified themselves within the workforce (i.e., as a health care provider or a service provider). Conclusion: This study sought to understand how the COVID-19 pandemic impacted massage therapists' professional identity. Massage therapists reported that the pandemic impacted their professional identity through a lack of congruence and discord between their identity-constituting beliefs and what it means to be a massage therapist. The sequela to this discord was therapists experiencing different types of moral distress and or moral injury. Future research is needed to determine the longer-term impacts of COVID-19 on massage therapists.

COVID-19- related work, managerial factors and exhaustion among general practitioners in Sweden: a cross-sectional study

INTRODUCTION

A significant number of international studies show that general practitioners (GPs) suffered from burnout when working during the COVID-19 pandemic. A Swedish study found that more than 16% of GPs had exhaustion in spring 2021. Exhaustion can be regarded as an initial stage of burnout. A knowledge gap remains on GPs´ working conditions, the impact of management during the pandemic and how it was associated with exhaustion. This study aims to explore the association between severe symptoms of exhaustion and COVID-19 pandemic-related work and managerial factors among Swedish GPs and whether managerial factors have an impact on the association between exhaustion and COVID-19-related work factors.

METHODS

Cross-sectional data was drawn from the Longitudinal Occupational Health survey in Health Care Sweden (LOHHCS), which included a representative sample of practicing doctors in Sweden. The sample consisted of 6699 doctors with a response rate of 41.2%. This study constitutes a sample of doctors who reported working in primary care facilities at the time of data collection, i.e. 1013 GPs. The Burnout Assessment Tool (BAT) was used to assess severe symptoms of exhaustion. Questions were also asked about pandemic-related work and managerial factors. The data was analysed using descriptive statistics and multivariate logistic regression to identify the association between exhaustion, work and managerial factors.

RESULTS

The multivariate analysis showed that GPs who managed COVID-19 patients were about twice as likely to report severe symptoms of exhaustion. Further, GPs who reported that management was unsupportive, provided unsatisfactory working conditions and unsatisfactory policies for patient prioritisation were between two and four times more likely to report severe symptoms of exhaustion.

CONCLUSIONS

COVID-19-related work and managerial factors had a significant impact on the mental health of GPs. Furthermore, the potentially protective effect that satisfactory management actions had on mental health was limited. In the aftermath of the COVID-19 pandemic and in preparation for future major crises that have a high impact on healthcare, there is a need to investigate the measures that can be taken to enable GPs to carry out their work, while maintaining their wellbeing.

On the path to recovery: traumatic stress research during the COVID-19 pandemic 2021-2023

This Special Issue of the European Journal of Psychotraumatology (EJPT) presents 51 articles published between 2021 and 2023 and follows the Special Issue on pandemic-related traumatic stress research published in 2021 (O'Donnell, M. L., & Greene, T. [2021]. Understanding the mental health impacts of COVID-19 through a trauma lens. European Journal of Psychotraumatology, 12(1), 1982502). Research on traumatic stress during the pandemic has cast the spotlight on vulnerable populations and groups, notably front-line healthcare workers; people faced with major losses including the deaths of loved ones; those who personally survived debilitating and often life-threatening viral infection; and students who were isolated and experienced profound delays in their education, relationships, and emerging independence. The papers in this collection underscore the associations between COVID-19 related stressors and a plethora of adverse mental health sequelae, including posttraumatic stress reactions, and draw attention to the ubiquity of grief and moral injury and their wide-ranging and detrimental impact. Currently, there is a paucity of evidence on interventions to enhance resources, self-efficacy, and hope for affected groups and individuals through societal, organisational, and healthcare systems; however early research on the prevention of COVID-related traumatic stress disorders provides a basis for both hope and preparedness for the future.

Associação do Sofrimento Moral e Síndrome de Burnout em enfermeiros de hospital universitário

Resumo Objetivo: analisar a associação entre sofrimento moral e síndrome de Burnout em enfermeiros de hospital universitário. Método: estudo descritivo-analítico, realizado com 269 enfermeiros atuantes em um hospital universitário localizado no Rio Grande do Sul, Brasil. A coleta de dados ocorreu de maneira presencial no ano de 2019 por coletadores previamente capacitados. Aplicaram-se questionário sociodemográfico e laboral, Escala Brasileira de Distresse Moral em Enfermeiros e o Inventário Maslach de Burnout. Empregou-se análise estatística descritiva e analítica. Resultados: identificou-se associação entre intensidade e frequência de sofrimento moral e suas dimensões com a síndrome de Burnout e suas dimensões. Enfermeiros em baixa realização profissional e alta exaustão emocional apresentaram prevalências mais elevadas para sofrimento moral. Conclusão: evidenciou-se a associação entre sofrimento moral e síndrome de Burnout bem como entre suas dimensões. Os resultados sinalizam a necessidade de investigar intervenções urgentes para amenizar as situações e as manifestações do sofrimento moral e a síndrome de Burnout, elaborando estratégias para a saúde dos trabalhadores.

The lived experiences of hematology healthcare providers during and beyond the COVID-19 crisis: A qualitative study

OBJECTIVE

Amid the COVID-19 pandemic, healthcare providers (HCPs) of hematology patients face unique challenges due to the vulnerability of their patients. This study explores the lived experiences of these providers during and beyond the crisis.

METHODS

Twenty-one Australian HCPs caring for hematology patients completed semi-structured interviews exploring their experiences and needs during the COVID-19 pandemic, adequacy of support and information provided by healthcare organizations, impact on hematology patients, and the benefits and challenges of telehealth care. Data were analyzed using reflexive thematic analysis.

RESULTS

Four themes were identified: (1) Managing an initial state of flux (unsettling uncertainty and fear, unique needs of hematology patients, getting on with the job together); (2) Concerns about care provision (questioning care efficacy, burden of compassion); (3) Disconnect between HCP needs and system-level responses (burnout, isolation, and poor work-life balance, broadcast fatigue, protecting mental health), and; (4) Reflecting on the future (ongoing challenges for hematology patients, higher staff turnover and heavier workloads, innovation in the healthcare field).

CONCLUSION

This study sheds light on the challenges that hematology HCPs face during and beyond the COVID-19 crisis, impacting their wellbeing. Addressing these challenges is paramount for the healthcare system at large. Provider-led peer support programs may be beneficial for addressing moral distress and building resilience. Additionally, specific consideration for the ongoing vulnerability of hematology patients could have positive impacts on providers' professional satisfaction.

Asociación del Sufrimiento Moral y Síndrome de Burnout en enfermeros de un hospital universitario

Resumen Objetivo: analizar la asociación entre sufrimiento moral y síndrome de Burnout en enfermeros de un hospital universitario. Método: estudio descriptivo y analítico, realizado en 269 enfermeros que actuaban en un hospital universitario localizado en el estado de Rio Grande del Sur, en Brasil. La recogida de datos se realizó de manera presencial en el año de 2019 por colectores previamente capacitados. Se aplicaron el cuestionario sociodemográfico y laboral, la Escala Brasileña de Estrés Moral en Enfermeros y el Inventario Maslach de Burnout. Se empleó el análisis estadístico descriptivo y analítico. Resultados: se identificó asociación entre intensidad y frecuencia de sufrimiento moral y sus dimensiones con el síndrome de Burnout y sus dimensiones. Los enfermeros que tuvieron baja realización profesional y alta extenuación emocional, presentaron prevalencias más elevadas para el sufrimiento moral. Conclusión: se evidenció asociación entre sufrimiento moral y síndrome de Burnout así como entre sus dimensiones. Los resultados señalan la necesidad urgente de investigar intervenciones para amenizar las situaciones y las manifestaciones del sufrimiento moral y el síndrome de Burnout, elaborando estrategias para la salud de los trabajadores.

Analysis of healthcare workers' mental health during the COVID-19 pandemic: Evidence from a three-wave longitudinal study

The "Healthcare workers' wellbeing [Benessere Operatori]" project is an exploratory longitudinal study assessing healthcare workers' mental health at three different time points over a 14-month period during the COVID-19 pandemic. We collected socio-demographic and work-related information and assessed the perceived social support, coping strategies, and levels of depression, anxiety, insomnia, anger, burnout, and PTSD symptoms. In total, 325 Italian healthcare workers (i.e. physicians, nurses, other healthcare workers, and clerks) participated in the first initial survey and either the second or third subsequent survey. Participants reported subclinical levels of psychiatric symptoms that remained mostly unchanged across time, except for an increase in stress, depression, state anger, and emotional exhaustion symptoms. Despite subclinical levels, healthcare workers' distress can adversely affect the quality of care, patient satisfaction, and medical error rates. Therefore, implementing interventions to improve healthcare workers' wellbeing is required.

Changes in anxiety and depression among public health workers during the COVID-19 pandemic response

OBJECTIVES

The COVID-19 pandemic has negatively impacted mental health indicators, leading to an increase in symptoms of anxiety and depression in both the general population of adults and children and many occupational groups. This study aims to examine changes in anxiety and depression among a cohort of public health workers in the U.S. during the first year of the COVID-19 pandemic and identify potential risk factors.

METHODS

Longitudinal data were collected from a sub-sample (N = 85) of public health workers in 23 U.S. states who completed two surveys in 2020 and 2021. Information on background characteristics, personal well-being, and work environment as well as validated scales to assess generalized anxiety disorder (GAD), depressive disorder, and burnout was collected. Data were analyzed using Stata Version 17, and significant differences were determined using Pearson's Chi2 and Fisher's Exact tests.

RESULTS

The proportion of those reporting GAD (46.3% to 23.2%) or depression (37.8% to 26.8%) improved from Survey 1 to Survey 2 overall; symptoms of anxiety saw the largest improvement. Persistent depression was associated with sustained burnout, changes in social support, and days worked per week.

CONCLUSION

Public health workers experienced elevated levels of anxiety and depression during the initial pandemic response, but a reduction in these symptoms was observed in the subsequent year after vaccines had become widely available. However, unmet needs remain for ongoing workplace mental health supports to address burnout, as well as for additional emotional supports outside of work for public health professionals.

Adverse Childhood Experiences and Burnout in Athletic Trainers: An Exploratory Study

CONTEXT

Burnout, a state of physical or emotional exhaustion, is a concern within athletic training, as between 17% and 40% of athletic trainers (ATs) report high levels of burnout. Adverse childhood experiences (ACEs) are linked with higher levels of burnout in other health professions.

OBJECTIVE

To compare burnout with ACEs in ATs.

DESIGN

Cross-sectional study.

SETTING

Web-based survey.

PATIENTS OR OTHER PARTICIPANTS

One thousand ATs were selected at random to participate in the study. Of these, 78 ATs started the survey, and 75 ATs completed it.

MAIN OUTCOME MEASURE(S)

Burnout, as measured by the Copenhagen Burnout Inventory (CBI) overall and subscale scores, was compared across groups based on the number of adverse experiences as measured by the ACEs survey. Multiple analysis of variance tests were used to determine the association between ACEs score and overall, personal, work-related, and patient-related burnout.

RESULTS

At least 1 adverse experience was reported by 37 (49.33%) participants. Those with ≥4 ACEs had higher odds of describing overall, personal, and work-related burnout than those with 0 to 3 ACEs. Moderate burnout (CBI score ≥ 50.00) was noted in 27 (36.00%, overall), 44 (58.67%, personal), 34 (45.3%, work related), and 15 (20.00%, patient related) ATs. Participants with 4 ACEs had higher overall burnout (67.11 ± 19.89; F6,68 = 2.59, P = .03) than those with 0 (40.53 ± 17.12, P = .04), 1 (38.42 ± 20.99, P = .04), or 7 (19.08 ± 12.09, P = .03) ACEs. The same pattern existed with personal burnout, as participants with 4 ACEs (76.67 ± 17.33) had higher scores (F6,68 = 3.40, P = .00) than those with 0 (46.60 ± 17.49, P = .02), 1 (42.78 ± 21.48, P = .01), or 7 (27.08 ± 20.62, P = .03) ACEs. No other differences were observed.

CONCLUSIONS

Between 20.00% and 58.67% of ATs surveyed reported some form of burnout. Higher levels of overall and personal burnout were found in those with 4 ACEs. Although we expected to see lower levels of burnout in those with fewer ACEs, it was surprising that those with 7 ACEs had some of the lowest CBI scores. Athletic trainers with childhood trauma may find it beneficial to engage in self-regulation exercises to reduce or limit triggers and burnout. Additionally, employers should explore developing trauma-informed workplaces to better support employees.

Multidimensional stressors and protective factors shaping physicians' work environments and work-related well-being in two large US cities during COVID-19

INTRODUCTION

Clinician burnout and poor work-related well-being reached a critical inflection point during the COVID-19 pandemic. This article applies a novel conceptual model informed by the Total Worker Health® approach to identify and describe multilevel stressors and protective factors that affected frontline physicians' work environments and work-related well-being.

METHODS

We conducted a qualitative study of hospital-based physicians from multiple hospital types in Los Angeles and Miami who cared for COVID-19 patients. Semistructured interviews lasting 60-90 min were conducted over Zoom. Interview transcripts were thematically coded using Dedoose qualitative software.

RESULTS

The final sample of 66 physicians worked in 20 hospitals. Stressors in the social, political, and economic environment included dealing with the politicization of COVID-19, including vaccine hesitancy; state and federal governmental COVID-19 policies and messaging; and shifting CDC guidance. Employment and labor pattern stressors included the national nursing shortage, different policies for paid time off, furloughs, reduced pay, and layoffs. Organizational-level stressors included institutional policies, staffing constraints and high patient volume (i.e., increased number of cases and longer lengths of stay), and perceived poor leadership. At the individual worker level, stressors included concerns about viral transmission to family, strained personal relationships, and work-life fit, particularly for those with young children. Respondents identified promising protective factors at multiple levels, including responsive state leadership, job security, concrete opportunities to provide input into institutional policy, strong leadership and communication, and feeling cared for by one's institution.

CONCLUSION

Findings support a multi-level strategy that acknowledges internal organizational and external factors shaping clinicians' work-related well-being, consistent with the Total Worker Health® approach.

Addressing clinician moral distress: Implications from a mixed methods evaluation during Covid-19

Clinician moral distress has been documented over the past several decades as occurring within numerous healthcare disciplines, often in relation to clinicians' involvement in patients' end-of-life decision-making. The resulting harms impact clinician well-being, patient well-being, and healthcare system functioning. Given Covid-19's catastrophic death toll and associated demands on end-of-life decision-making processes, the pandemic represents a particularly important context within which to understand clinician moral distress. Thus, we conducted a convergent mixed methods study to examine its prevalence, associations with clinicians' demographic and professional characteristics, and contributing circumstances among Veterans Health Administration (VA) clinicians. The study, conducted in April 2021, consisted of a cross-sectional on-line survey of VA clinicians at 20 VA Medical Centers with professional jurisdiction to place life-sustaining treatment orders working who were from a number of select specialties. The survey collected quantitative data on respondents' demographics, clinical practice characteristics, attitudes and behaviors related to goals of care conversations, intensity of moral distress during "peak-Covid," and qualitative data via an open-ended item asking for respondents to describe contributing circumstances if they had indicated any moral distress. To understand factors associated with heightened moral distress, we analyzed quantitative data using bivariate and multivariable regression analyses and qualitative data using a hybrid deductive/inductive thematic approach. Mixed methods analysis followed, whereby we compared the quantitative and qualitative datasets and integrated findings at the analytic level. Out of 3,396 eligible VA clinicians, 323 responded to the survey (9.5% adjusted response rate). Most respondents (81%) reported at least some moral distress during peak-Covid. In a multivariable logistic regression, female gender (OR 3.35; 95% CI 1.53-7.37) was associated with greater odds of moral distress, and practicing in geriatrics/palliative care (OR 0.40; 95% CI 0.18-0.87) and internal medicine/family medicine/primary care (OR 0.46; 95% CI 0.22-0.98) were associated with reduced odds of moral distress compared to medical subspecialties. From the 191 respondents who completed the open-ended item, five qualitative themes emerged as moral distress contributors: 1) patient visitation restrictions, 2) anticipatory actions, 3) clinical uncertainty related to Covid, 4) resource shortages, and 5) personal risk of contracting Covid. Mixed methods analysis found that quantitative results were consistent with these last two qualitative themes. In sum, clinician moral distress was prevalent early in the pandemic. This moral distress was associated with individual-, system-, and situation-level contributors. These identified contributors represent leverage points for future intervention to mitigate clinician moral distress and its negative outcomes during future healthcare crises and even during everyday clinical care.

The relationship between moral distress, burnout, and considering leaving a hospital job during the COVID-19 pandemic: a longitudinal survey

BACKGROUND

Previous research suggests that moral distress contributes to burnout in nurses and other healthcare workers. We hypothesized that burnout both contributed to moral distress and was amplified by moral distress for hospital workers in the COVID-19 pandemic. This study also aimed to test if moral distress was related to considering leaving one's job.

METHODS

A cohort of 213 hospital workers completed quarterly surveys at six time-points over fifteen months that included validated measures of three dimensions of professional burnout and moral distress. Moral distress was categorized as minimal, medium, or high. Analyses using linear and ordinal regression models tested the association between burnout and other variables at Time 1 (T1), moral distress at Time 3 (T3), and burnout and considering leaving one's job at Time 6 (T6).

RESULTS

Moral distress was highest in nurses. Job type (nurse (co-efficient 1.99, p < .001); other healthcare professional (co-efficient 1.44, p < .001); non-professional staff with close patient contact (reference group)) and burnout-depersonalization (co-efficient 0.32, p < .001) measured at T1 accounted for an estimated 45% of the variance in moral distress at T3. Moral distress at T3 predicted burnout-depersonalization (Beta = 0.34, p < .001) and burnout-emotional exhaustion (Beta = 0.38, p < .008) at T6, and was significantly associated with considering leaving one's job or healthcare.

CONCLUSION

Aspects of burnout that were associated with experiencing greater moral distress occurred both prior to and following moral distress, consistent with the hypotheses that burnout both amplifies moral distress and is increased by moral distress. This potential vicious circle, in addition to an association between moral distress and considering leaving one's job, suggests that interventions for moral distress may help mitigate a workforce that is both depleted and burdened with burnout.

The paradox of the impact of the COVID-19 pandemic on massage therapists in Australia and Canada: The reporting of a qualitative strand of a mixed methods study

INTRODUCTION

In both Australia and Canada, healthcare providers considered essential were allowed to operate during the COVID-19 pandemic. The impact of the global pandemic on professional identity included opportunities for role expansion, a focus on ethical principles and social accountability, and professional pride. These results were found only for those considered to be essential and do not likely resonate with those classified as non-essential, such as massage therapists, leaving a gap in understanding.

MATERIALS AND METHODS

This qualitative strand of a sequential explanatory mixed methods study used qualitative description. Individuals who expressed interest were purposefully selected, based on age, gender, type of practice, and experience with the four key phenomena of interest. Data collected through semi-structured interviews was analyzed using qualitative content analysis. Member checking enhanced the trustworthiness of the results.

RESULTS

Thirty-one (16 Australian and 15 Canadian) participants were interviewed. The main theme described was the pandemic paradox. At some point during the pandemic, most participants were labelled by government agencies as a non-essential service. However, participants reported feeling both essential and non-essential. Two subthemes were also described: factors contributing to creating the paradox and consequences of the paradox.

CONCLUSION

A number of pre-existing factors around professional identity, such as patient relationships combined with the conditions instituted to manage the COVID-19 pandemic included designating health care services as essential or non-essential, created the paradox experienced by respondents and the subsequent experience of moral distress. Further research into moral distress experienced by massage therapists is needed.

Changes in Burnout and Moral Distress Among Veterans Health Administration (VA) Physicians Before and During the COVID-19 Pandemic

BACKGROUND

We investigated the impacts of workload, resources, organizational satisfaction, and psychological safety on changes in physician burnout and moral distress among physicians during the early pandemic.

METHODS

We obtained national administrative and survey data on burnout, moral distress, organizational satisfaction, psychological safety, COVID-19 burden, and state-level restrictions for 11,877-14,246 Veterans Health Administration (VA) physicians from 2019 and 2020. We regressed the changes in burnout and moral distress on the changes in reasonable workload, appropriate job resources, organizational satisfaction, and psychological safety, controlling for COVID-19 burden and restrictions, and individual and medical center characteristics.

RESULTS

Burnout and moral distress were not related to COVID-19 cases or restrictions but were reduced by improvements in workload, organizational satisfaction, and psychological safety.

CONCLUSIONS

Health systems should be conscious of factors that can harm or improve physician well-being, especially in the context of external stressors.

Experiencing Moral Distress Within the Intimate Partner Violence & Sexual Assault Workforce

Purpose

Moral distress (MD) refers to the psychological disequilibrium that emerges when institutional policies and/or practices conflict with an individual's professional values and ethics. MD has been interrogated frequently in health care and ancillary medical settings, and has been identified as a critical barrier to enhanced organizational climate and patient care. However, little work has investigated experiences of MD among members of the intimate partner violence (IPV) and sexual violence (SV) workforce.

Methods

This study investigates MD in a sample of IPV and SV service providers via secondary analysis of 33 qualitative interviews conducted with service providers in the summer and fall of 2020 as the COVID-19 pandemic response was unfolding.

Results

Qualitative content analysis revealed multiple overlapping vectors of MD experienced by IPV and SV service providers related to institutional resource constraints, providers working beyond their capacity and/or competency, shifting responsibilities within service agencies creating burdens among staff; and breakdowns in communication. Impacts of these experiences at individual, organizational, and client levels were identified by participants.

Conculsions

The study uncovers the need for further investigation of MD as a framework within the IPV/SV field, as well as potential lessons from similar service settings which could support IPV and SV agencies in addressing staff experiences of MD.

Correlation between moral distress and clinical competence in COVID-19 ICU nurses

BACKGROUND

Nurses' clinical competence is one of the fundamental necessities for providing safe and effective care. Moral distress, as one type of occupational stressors, can affect various aspects of clinical competence, especially under conditions of complicated medical settings such as the coronavirus disease 2019 (COVID-19) epidemic. This study was conducted with the aim of determining the relationship between moral distress and clinical competence in nurses working in COVID-19 intensive care units (ICUs).

METHODS

The study was a cross-sectional study. A total of 194 nurses working in COVID-19 ICU affiliated to Shahid Sadoughi University of Medical Sciences, Yazd, central Iran, participated in the study. Data were collected using Demographic Information Questionnaire, Moral Distress Scale, and Clinical Competence Checklist. Data were analyzed with SPSS20 using descriptive and analytical statistics.

RESULTS

The mean score of moral distress, clinical competence, and skills application were 1.79 ± 0/68, 65.16 ± 15.38, and 145.10 ± 38.20, respectively. Based on Pearson correlation coefficient, there was an inverse and significant relationship between the moral distress score and its dimensions with clinical competence and skills application (P < 0.001). Moral distress was a significant negative predictor that accounted for 17.9% of the variance in clinical competence (R² = 0.179, P < 0.001) and 16% of the variance in utilization of clinical competence (R² = 0.160, P < 0.001).

CONCLUSION

Considering the relationship between moral distress, clinical competence and skills application, to maintain the quality of nursing services, nursing managers can strengthen clinical competence and skills application by using strategies to deal with and reduce moral distress in nurses, especially in critical situations.

The Hidden Crisis: Understanding Potentially Morally Injurious Events Experienced by Healthcare Providers during COVID-19 in Canada

BACKGROUND

Healthcare providers (HCPs) may be at elevated risk for moral injury due to increased exposure to potentially morally injurious events (PMIEs) throughout the COVID-19 pandemic. Identifying PMIEs experienced during the COVID-19 pandemic is a critical first step for understanding moral injury in HCPs. Accordingly, the purpose of the present study was to gain a deeper understanding of the work-related PMIEs experienced by HCPs in Canada during the pandemic.

METHODS

Canadian HCPs completed an online survey between February and December 2021 about mental health and functioning, including demographics and the Moral Injury Outcome Scale (MIOS). We conducted a qualitative thematic analysis of PMIEs described extemporaneously by HCPs in the open-text field of the MIOS.

RESULTS

One-hundred and twenty-four (N = 124) HCPs were included in analysis. Eight PMIE-related themes were identified, comprising patients dying alone; provision of futile care; professional opinion being ignored; witnessing patient harm; bullying, violence and divided opinions; resources and personal protective equipment; increased workload and decreased staffing; and conflicting values.

CONCLUSIONS

Understanding broad categories of PMIES experienced by Canadian HCPs during the COVID-19 pandemic provides an opportunity to enhance cultural competency surrounding their experiences which will aid the development of targeted prevention and intervention approaches.

Moral distress among neonatologists working in neonatal intensive care units in Greece: a qualitative study

BACKGROUND

Working as a neonatologist in a neonatal intensive care unit (NICU) is stressful and involves ethically challenging situations. These situations may cause neonatologists to experience high levels of moral distress, especially in the context of caring for extremely premature infants (EPIs). In Greece, moral distress among neonatologists working in NICUs remains understudied and warrants further exploration.

METHODS

This prospective qualitative study was conducted from March to August 2022. A combination of purposive and snowball sampling was used and data were collected by semi-structured interviews with twenty neonatologists. Data were classified and analyzed by thematic analysis approach.

RESULTS

A variety of distinct themes and subthemes emerged from the analysis of the interview data. Neonatologists face moral uncertainty. Furthermore, they prioritize their traditional (Hippocratic) role as healers. Importantly, neonatologists seek third-party support for their decisions to reduce their decision uncertainty. In addition, based on the analysis of the interview data, multiple predisposing factors that foster and facilitate neonatologists' moral distress emerged, as did multiple predisposing factors that are sometimes associated with neonatologists' constraint distress and sometimes associated with their uncertainty distress. The predisposing factors that foster and facilitate neonatologists' moral distress thus identified include the lack of previous experience on the part of neonatologists, the lack of clear and adequate clinical practice guidelines/recommendations/protocols, the scarcity of health care resources, the fact that in the context of neonatology, the infant's best interest and quality of life are difficult to identify, and the need to make decisions in a short time frame. NICU directors, neonatologists' colleagues working in the same NICU and parental wishes and attitudes were identified as predisposing factors that are sometimes associated with neonatologists' constraint distress and sometimes associated with their uncertainty distress. Ultimately, neonatologists become more resistant to moral distress over time.

CONCLUSIONS

We concluded that neonatologists' moral distress should be conceptualized in the broad sense of the term and is closely associated with multiple predisposing factors. Such distress is greatly affected by interpersonal relationships. A variety of distinct themes and subthemes were identified, which, for the most part, were consistent with the findings of previous research. However, we identified some nuances that are of practical importance. The results of this study may serve as a starting point for future research.

Physicians' Distress Related to Moral Issues and Mental Health In-Between Two Late Waves of COVID-19 Contagions

In addition to the sanitary constrains implemented due to the pandemic, frontline physicians have faced increased workloads with insufficient resources, and the responsibility to make extraordinary clinical decisions. In 108 physicians who were at the forefront of care of patients with COVID-19 during the first two years of the pandemic, mental health, moral distress, and moral injury were assessed twice, in between two late waves of COVID-19 contagions, according to their adverse psychological reactions, in-hospital experience, sick leave due to COVID-19, quality of sleep, moral sensitivity, clinical empathy, resilience, and sense of coherence. Three months after the wave of contagions, the adverse emotional reactions and moral distress decreased, while moral injury persisted. Moral distress was related to clinical empathy, with influence from burnout and sick leave due to COVID-19, and moral injury was related to the sense of coherence, while recovery from moral distress was related to resilience. The results suggest that measures to prevent physician infection, as well as strengthening resilience and a sense of coherence, may be helpful to prevent persistent mental damage after exposure to a sanitary crisis.

Health workforce perceptions on telehealth augmentation opportunities

BACKGROUND

The availability and use of telehealth to support health care access from a distance has expanded in response to the COVID-19 pandemic. Telehealth services have supported regional and remote health care access for many years and could be augmented to improve health care accessibility, acceptability and overall experiences for both consumers and clinicians. This study aimed to explore health workforce representatives' needs and expectations to move beyond existing telehealth models and plan for the future of virtual care.

METHODS

To inform recommendations for augmentation, semi-structured focus group discussions were held (November-December 2021). Health workforce representatives with experience in health care delivery via telehealth across country Western Australia were approached and invited to join a discussion.

RESULTS

Focus group participants included 53 health workforce representatives, with between two and eight participants per discussion. In total, 12 focus groups were conducted: seven were specific to regions, three with staff in centralised roles, and two with a mixture of participants from regional and central roles. Findings identified four key areas for telehealth augmentation: improvements required to existing service practice and processes; equity and access considerations; health workforce-focussed opportunities; and consumer-focussed opportunities.

CONCLUSIONS

Following the onset of the COVID-19 pandemic and the rapid increase in health services delivered via telehealth modalities, it is timely to explore opportunities to augment pre-existing models of care. Workforce representatives consulted in this study suggested modifications to existing process and practice that would improve the current models of care, and recommendations on ways to improve clinician and consumer experiences with telehealth. Improving experiences with virtual delivery of health care is likely to support continued use and acceptance of this modality in health care delivery.

Association between Moral Distress and Burnout Syndrome in university-hospital nurses

OBJECTIVE

to analyze the association between moral distress and Burnout Syndrome among nurses in a university hospital.

METHOD

descriptive, analytical study conducted with 269 nurses working in a university hospital located in Rio Grande do Sul, Brazil. Data were collected in person in 2019 by previously trained collectors. A sociodemographic and employment questionnaire, the Brazilian Scale of Moral Distress in Nurses and the Maslach Burnout Inventory were applied. Descriptive and analytical statistical analysis was used.

RESULTS

an association was identified between moral distress intensity and frequency and its dimensions with Burnout Syndrome and its dimensions. Nurses with low professional achievement and high emotional exhaustion showed a higher prevalence of moral distress.

CONCLUSION

an association between moral distress and Burnout Syndrome, as well as between their dimensions, was evidenced. The results suggest the need to investigate urgent interventions to mitigate the situations and manifestations of moral distress and Burnout Syndrome by developing strategies for workers' health.

"The hierarchy is your constraint:" a qualitative investigation of social workers' moral distress across a U.S. health system

This paper reports findings from a qualitative study on the triggers of hospital social workers' moral distress at a large southern U.S. health system. Moral distress occurs when ethical conflict cannot be resolved in a way that aligns with an individual's personal and professional values and ethics. Participants indicated that moral distress derives from both individual interactions and the culture and climate of health systems. For example, participants expressed how sources of moral distress derived from client-centered decisions, such as end-of-life care and patient autonomy; interpersonal dynamics, including team or supervisory conflict; structural issues, such as insurance barriers or internal hospital policies; and organizational values, such as perceptions of institutional support and validation. Implications of this research suggest that health systems need to foster positive ethical environments that nurture clinicians' health and mental health through programs that aim to increase moral resilience, promote empowerment, and foster wellness.

The effect of the COVID-19 social distancing measures on Turkish women's mental well-being and burnout levels: A cross-sectional study

Lockdown and social distancing measures during the COVID-19 pandemic increase women's responsibilities and influence their mental health. This study aimed to assess the effect of COVID-19 social distancing measures on mental well-being and burnout levels of women using an online cross-sectional survey in Turkey. The Warwick-Edinburgh Mental Well-being Scale, The Burnout Measure, and Sociodemographic form were used in this study. All analyses were performed on a sample of 438 women aged between 18 and 65. The mean score of mental well-being was 47.86 (SD = 10.04) and the mean score of burnout was 3.86 (SD = 1.16). Being younger than 30 years old (t = 2.14, P = 0.033), having undergraduate education or above (F = 5.09, P = 0.007), part-time working (F = 5.39, P = 0.005), attending to school (t = 2.68, P = 0.008), having COVID-19 symptoms (t = 6.01, P < 0.001), and perceiving spousal emotional support (F = 3.47, P = 0.016) were the factors associated with high burnout. Being older than 30 years old (z = -3.11, P = 0.002), full time working (H = 11.96, P = 0.003), not attending to school (z = -2.09, P = 0.036), perceiving spousal emotional (H = 13.22, P = 0.004), or social (H = 13.11, P = 0.004) support were the factors associated with higher mental well-being. Age (β = -0.03, P = 0.001), having two or more children (β = 0.42, P = 0.015), and perceiving COVID-19 symptoms (β = -0.73, P < 0.001) were the predictors of women's burnout. This study shows that mental well-being and burnout levels of women in Turkey have been considerably affected as a result of social distancing measures taken with the first wave of the pandemic. Findings signal the immediate need for targeted mental health nursing interventions. Therefore, technology-based mental health support programmes are recommended to be designed and utilized by mental health nurses.

Moral and exhausting distress working in the frontline of COVID-19: a Swedish survey during the first wave in four healthcare settings

OBJECTIVES

To describe the prevalence and sources of experienced moral stress and anxiety by Swedish frontline healthcare staff in the early phase of COVID-19.

DESIGN

Cross-sectional survey, quantitative and qualitative.

PARTICIPANTS AND SETTING

1074 healthcare professionals (75% nurses) in intensive, ward-based, primary and municipal care in one Swedish county.

MEASURES

A study-specific closed-ended and an open-ended questionnaire about moral stress and the Generalised Anxiety Disorder 7-item scale measuring anxiety, followed by an open question about anxiety.

FINDINGS

Moral stress was experienced by 52% of respondents and anxiety by 40%. Moral stress in concern for others attributed to institutional constraints comprised experiences of being deprived of possibilities to respond to humane and professional responsibility. Staff experienced being restricted in fulfilling patients' and families' need for closeness and security as well as being compelled to provide substandard and inhumane care. Uncertainty about right and good, without blame, was also described. However, a burdensome guilt also emerged as a moral distress, blaming oneself. This comprised feeling complicit in the spread of COVID-19, inadequacy in care and carrying patients' suffering. Staff also experienced an exhausting distress as a self-concern in an uncontrollable work situation. This comprised a taxing insecurity by being in limbo, being alone and fear of failing, despair of being deprived control by not being heard; unable to influence; distrusting management; as well as an excessive workload.

CONCLUSIONS

We have not only contributed with knowledge about experiences of being in the frontline of COVID-19, but also with an understanding of a demarcation between moral stress/distress as a concern for patients and family, and exhausting distress in work situation as self-concern. A lesson for management is that ethics support should first include acknowledgement of self-concern and mitigation of guilt before any structured ethical reflection. Preventive measures for major events should focus on connectedness between all parties concerned, preventing inhumane care and burn-out.

A national study of moral distress among U.S. internal medicine physicians during the COVID-19 pandemic

Background

There have been no studies to date of moral distress during the COVID-19 pandemic in national samples of U.S. health workers. The purpose of this study was to determine, in a national sample of internal medicine physicians (internists) in the U.S.: 1) the intensity of moral distress; 2) the predictors of moral distress; 3) the outcomes of moral distress.

Methods

We conducted a national survey with an online panel of internists, representative of the membership of the American College of Physicians, the largest specialty organization of physicians in the United States, between September 21 and October 8, 2020. Moral distress was measured with the Moral Distress Thermometer, a one-item scale with a range of 0 (“none”) to 10 (“worst possible”). Outcomes were measured with short screening scales.

Results

The response rate was 37.8% (N = 810). Moral distress intensity was low (mean score = 2.4, 95% CI, 2.2–2.6); however, 13.3% (95% CI, 12.1% - 14.5%) had a moral distress score greater than or equal to 6 (“distressing”). In multiple linear regression models, perceived risk of death if infected with COVID-19 was the strongest predictor of higher moral distress (β (standardized regression coefficient) = 0.26, p < .001), and higher perceived organizational support (respondent belief that their health organization valued them) was most strongly associated with lower moral distress (β = -0.22, p < .001). Controlling for other factors, high levels of moral distress, but not low levels, were strongly associated (adjusted odds ratios 3.0 to 11.5) with screening positive for anxiety, depression, posttraumatic stress disorder, burnout, and intention to leave patient care.

Conclusions

The intensity of moral distress among U.S. internists was low overall. However, the 13% with high levels of moral distress had very high odds of adverse mental health outcomes. Organizational support may lower moral distress and thereby prevent adverse mental health outcomes.

A Scoping Review of Moral Stressors, Moral Distress and Moral Injury in Healthcare Workers during COVID-19

Ethical dilemmas for healthcare workers (HCWs) during pandemics highlight the centrality of moral stressors and moral distress (MD) as well as potentially morally injurious events (PMIEs) and moral injury (MI). These constructs offer a novel approach to understanding workplace stressors in healthcare settings, especially in the demanding times of COVID-19, but they so far lack clear identification of causes and consequences. A scoping review of moral stressors, moral distress, PMIEs, and MI of healthcare workers during COVID-19 was conducted using the databases Web of Science Core Collection and PsycINFO based on articles published up to October 2021. Studies were selected based on the following inclusion criteria: (1) the measurement of either moral stress, MD, PMIEs, or MI among HCWs; (2) original research using qualitative or quantitative methods; and (3) the availability of the peer-reviewed original article in English or German. The initial search revealed n = 149,394 studies from Web of Science and n = 34 studies from EBSCOhost. Nineteen studies were included in the review. Conditions representing moral stressors and PMIEs as well as MD and MI as their potential outcomes in healthcare contexts during COVID-19 are presented and discussed. Highlighting MD and MI in HCWs during COVID-19 brings attention to the need for conceptualizing the impact of moral stressors of any degree. Therefore, the development of a common, theoretically founded model of MD and MI is desirable.

Downstream consequences of moral distress in COVID-19 frontline healthcare workers: Longitudinal associations with moral injury-related guilt

OBJECTIVE

To examine the longitudinal associations between dimensions of COVID-19 pandemic-related moral distress (MD) and moral injury (MI)-related guilt in a large sample of frontline COVID-19 healthcare workers (FHCWs).

METHODS

Data from a diverse occupational cohort of 786 COVID-19 FHCWs were collected during the initial peak of the COVID-19 pandemic in New York City and again 7 months later. Baseline MD and MI-related guilt at follow-up were assessed in three domains: family-, work-, and infection-related. Social support was evaluated as a potential moderator of associations between MD and MI-related guilt.

RESULTS

A total of 66.8% of FHCWs reported moderate-or-greater levels of MI-related guilt, the most prevalent of which were family (59.9%) or work-related (29.4%). MD was robustly predictive of guilt in a domain-specific manner. Further, among FHCWs with high levels of work-related MD, those with greater perceptions of supervisor support were less likely to develop work-related guilt 7 months later.

DISCUSSION

MD was found to be highly prevalent in FHCWs during the initial wave of the COVID-19 pandemic and was linked to the development of MI-related guilt over time. Prevention and early intervention efforts to mitigate MD and bolster supervisor support may help reduce risk for MI-related guilt in this population.