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Fronteira I, Mathews V, Dos Santos RLB, Matsumoto K, Amde W, Pereira A, de Oliveira APC, Craveiro I, Chança R, Boniol M, Ferrinho P, Poz MRD. Impacts for health and care workers of Covid-19 and other public health emergencies of international concern: living systematic review, meta-analysis and policy recommendations. HUMAN RESOURCES FOR HEALTH 2024; 22:10. [PMID: 38273317 PMCID: PMC10809470 DOI: 10.1186/s12960-024-00892-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 01/11/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Health and care workers (HCW) faced the double burden of the SARS-CoV-2 pandemic: as members of a society affected by a public health emergency and as HWC who experienced fear of becoming infected and of infecting others, stigma, violence, increased workloads, changes in scope of practice, among others. To understand the short and long-term impacts in terms of the COVID-19 pandemic and other public health emergencies of international concern (PHEICs) on HCW and relevant interventions to address them, we designed and conducted a living systematic review (LSR). METHODS We reviewed literature retrieved from MEDLINE-PubMed, Embase, SCOPUS, LILACS, the World Health Organization COVID-19 database, the ClinicalTrials.org and the ILO database, published from January 2000 until December 2021. We included quantitative observational studies, experimental studies, quasi-experimental, mixed methods or qualitative studies; addressing mental, physical health and well-being and quality of life. The review targeted HCW; and interventions and exposures, implemented during the COVID-19 pandemic or other PHEICs. To assess the risk of bias of included studies, we used the Johanna Briggs Institute (JBI) Critical Appraisal Tools. Data were qualitatively synthetized using meta-aggregation and meta-analysis was performed to estimate pooled prevalence of some of the outcomes. RESULTS The 1013 studies included in the review were mainly quantitative research, cross-sectional, with medium risk of bias/quality, addressing at least one of the following: mental health issue, violence, physical health and well-being, and quality of life. Additionally, interventions to address short- and long-term impact of PHEICs on HCW included in the review, although scarce, were mainly behavioral and individual oriented, aimed at improving mental health through the development of individual interventions. A lack of interventions addressing organizational or systemic bottlenecks was noted. DISCUSSION PHEICs impacted the mental and physical health of HCW with the greatest toll on mental health. The impact PHEICs are intricate and complex. The review revealed the consequences for health and care service delivery, with increased unplanned absenteeism, service disruption and occupation turnover that subvert the capacity to answer to the PHEICs, specifically challenging the resilience of health systems.
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Affiliation(s)
- Inês Fronteira
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Rua da Junqueira, 100, 1349-008, Lisbon, Portugal.
- National School of Public Health, Public Health Research Centre, Comprehensive Health Research Center, NOVA University of Lisbon, Avenida Padre Cruz, 1600-560, Lisbon, Portugal.
| | - Verona Mathews
- School of Public, Health University of the Western Cape, South Africa, Private Bag X17, Bellville, 7535, Republic of South Africa
| | - Ranailla Lima Bandeira Dos Santos
- Escola Nacional de Saúde Pública Sérgio Arouca, Fundação Osvaldo Cruz, Rua Leopoldo Bulhões, 1480 - Manguinhos, Rio de Janeiro, Brazil
| | - Karen Matsumoto
- Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, Rua São Francisco Xavier 524 - 7º andar, Blocos D e E - Maracanã, Rio de Janeiro, RJ, 20550-013, Brazil
| | - Woldekidan Amde
- School of Public, Health University of the Western Cape, South Africa, Private Bag X17, Bellville, 7535, Republic of South Africa
| | - Alessandra Pereira
- Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, Rua São Francisco Xavier 524 - 7º andar, Blocos D e E - Maracanã, Rio de Janeiro, RJ, 20550-013, Brazil
| | - Ana Paula Cavalcante de Oliveira
- Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, Rua São Francisco Xavier 524 - 7º andar, Blocos D e E - Maracanã, Rio de Janeiro, RJ, 20550-013, Brazil
| | - Isabel Craveiro
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Rua da Junqueira, 100, 1349-008, Lisbon, Portugal
| | - Raphael Chança
- Instituto Nacional de Cancer, Ministério da Saúde, Rua Marquês de Pombal, 125, Centro, Rio de Janeiro, RJ, 20230240, Brazil
| | - Mathieu Boniol
- Health Workforce Department, World Health Organization, Av. Appia 20, 1202, Geneva, Switzerland
| | - Paulo Ferrinho
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Rua da Junqueira, 100, 1349-008, Lisbon, Portugal
| | - Mario Roberto Dal Poz
- Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, Rua São Francisco Xavier 524 - 7º andar, Blocos D e E - Maracanã, Rio de Janeiro, RJ, 20550-013, Brazil
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Coimbra BM, Zylberstajn C, van Zuiden M, Hoeboer CM, Mello AF, Mello MF, Olff M. Moral injury and mental health among health-care workers during the COVID-19 pandemic: meta-analysis. Eur J Psychotraumatol 2024; 15:2299659. [PMID: 38189775 PMCID: PMC10776063 DOI: 10.1080/20008066.2023.2299659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/11/2023] [Indexed: 01/09/2024] Open
Abstract
Background: During the COVID-19 pandemic, health-care workers (HCWs) may have been confronted with situations that may culminate in moral injury (MI). MI is the psychological distress that may result from perpetrating or witnessing actions that violate one's moral codes. Literature suggests that MI can be associated with mental health problems.Objective: We aimed to meta-analytically review the literature to investigate whether MI is associated with symptoms of posttraumatic stress disorder (PTSD), anxiety, depression, burnout, and suicidal ideation among active HCWs during the COVID-19 pandemic.Method: We searched eight databases for studies conducted after the onset of the COVID-19 pandemic up to 18 July 2023, and performed random-effects meta-analyses to examine the relationship between MI and various mental health outcomes.Results: We retrieved 33 studies from 13 countries, representing 31,849 individuals, and pooled 79 effect sizes. We found a positive association between MI and all investigated mental health problems (rs = .30-.41, all ps < .0001). Between-studies heterogeneity was significant. A higher percentage of nurses in the samples was associated with a stronger relationship between MI and depressive and anxiety symptoms. Samples with a higher percentage of HCWs providing direct care to patients with COVID-19 exhibited a smaller effect between MI and depressive and anxiety symptoms. We observed a stronger effect between MI and PTSD symptoms in US samples compared to non-US samples.Conclusion: We found that higher MI is moderately associated with symptoms of PTSD, anxiety, depression, burnout, and suicidal ideation among HCWs during the COVID-19 pandemic. Our findings carry limitations due to the array of MI scales employed, several of which were not specifically designed for HCWs, but underscore the need to mitigate the effect of potentially morally injurious events on the mental health of HCWs.
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Affiliation(s)
- Bruno Messina Coimbra
- Programme for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
- Department of Methodology and Statistics, Faculty of Social and Behavioral Sciences, Utrecht University, Utrecht, The Netherlands
- Amsterdam UMC, Department of Psychiatry, Amsterdam Public Health Research Institute and Amsterdam Neuroscience Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Cecilia Zylberstajn
- Programme for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Mirjam van Zuiden
- Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands
| | - Chris Maria Hoeboer
- Amsterdam UMC, Department of Psychiatry, Amsterdam Public Health Research Institute and Amsterdam Neuroscience Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Andrea Feijo Mello
- Programme for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Marcelo Feijo Mello
- Programme for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Albert Einstein, São Paulo, Brazil
| | - Miranda Olff
- Amsterdam UMC, Department of Psychiatry, Amsterdam Public Health Research Institute and Amsterdam Neuroscience Research Institute, University of Amsterdam, Amsterdam, The Netherlands
- ARQ National Psychotrauma Centre, Diemen, The Netherlands
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Polizzi CP, McDonald CW, Sleight FG, Lynn SJ. Resilience, Coping, and the Covid-19 Pandemic Across the Globe - an Update: What Have we Learned? CLINICAL NEUROPSYCHIATRY 2023; 20:316-326. [PMID: 37791081 PMCID: PMC10544248 DOI: 10.36131/cnfioritieditore20230411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
The SARS-CoV-2 (COVID-19) pandemic is a mass traumatic event that has universally and indiscriminately negatively affected the world. The adverse consequences of the pandemic have globally impacted psychological health and well-being via increased stressors, such as uncertainty, health anxieties, and financial instability. During the initial months of the pandemic, we (Polizzi et al., 2020) identified coping strategies that may be well-suited to address the sequelae of the pandemic. These strategies included behavioral activation, acceptance-based coping, mindfulness practice, and loving-kindness meditation. We argued that these coping skills may foster resilience and recovery during the pandemic by generating a sense of social connection, encouraging meaning-making, and enhancing feelings of control amid uncertainty. Three years later, we update our initial suggestions by providing a narrative review that considers empirical evidence collected during the pandemic to support the utility of the previously identified coping strategies as well as additional strategies. We also discuss cross-cultural similarities and differences among these strategies and how research supports their application across diverse countries and groups. Finally, we conclude by synthesizing the literature within a regulatory flexibility framework that emphasizes flexible skill implementation with respect to sensitivity to context, coping repertoires, and feedback from the environment.
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Affiliation(s)
- Craig P. Polizzi
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts, United States
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine
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Policy Changes as a Context for Moral Injury Development in the Wake of Dobbs v Jackson Women's Health Organization. Obstet Gynecol 2023; 141:15-21. [PMID: 36701606 DOI: 10.1097/aog.0000000000005009] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 09/22/2022] [Indexed: 12/23/2022]
Abstract
The U.S. Supreme Court's 2022 ruling in Dobbs v Jackson Women's Health Organization held that the U.S. Constitution does not confer the right to an abortion, which set into motion an overhaul of reproductive health care services in certain states. Health care professionals are now operating within a rapidly changing landscape of clinical practice in which they may experience conflict between personal and professional morals (eg, bodily autonomy, patient advocacy), uncertainty regarding allowable practices, and fear of prosecution (eg, loss of medical license) related to reproductive health care services. The ethical dilemmas stemming from Dobbs create a context for exposure to potentially morally injurious events, moral distress, and moral injury (ie, functional impairment stemming from exposure to moral violations) among health care professionals. Considerations related to clinical intervention and approaches to policy are reviewed. Early identification of health care professionals' potentially morally injurious event exposure related to restricted reproductive services is critical for preventing and intervening on moral injury, with implications for improving functioning and retention within the medical field.
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Hinzmann D, Schütte-Nütgen K, Büssing A, Boenisch O, Busch HJ, Dodt C, Friederich P, Kochanek M, Michels G, Frick E. Critical Care Providers' Moral Distress: Frequency, Burden, and Potential Resources. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:333. [PMID: 36612657 PMCID: PMC9819312 DOI: 10.3390/ijerph20010333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/25/2022] [Accepted: 12/14/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Critical Care Providers (CCPs) experience situations that challenge their ethics and professional standards and may entail moral distress (MD). AIM To analyze MD perceived by CCPs in intensive care units (ICUs) or emergency departments (EDs) and further clarify whether CCPs who rely on spiritual resources differ in their perception of MD from those who do not utilize these resources. METHODS A cross-sectional anonymous survey was administered using a modified version of the German language version of the Moral Distress Scale (MDS) with 2 × 12 items to assess the frequency and the respective perceived burden of specific situations by applying a 5-point Likert scale. Explorative factor analysis was performed and the sub-constructs of the respective items regarding MD frequency and burden were identified. Job burden and professional satisfaction were measured using visual analogue scales (VAS) and a four-point Likert scale, respectively. The 15-item SpREUK questionnaire was applied to measure spiritual attitudes and behaviours and to differentiate between religious and spiritual persons. Data from 385 German-speaking CCPs were included (55% physicians, 45% nurses). RESULTS Conflict situations are similar for physicians and nurses although they are perceived as more burdensome by nurses. Among physicians, the MDS factor Looking away/Resignation scores highest for assistant physician residents, whereas distress caused by looking away is more often perceived by specialist physicians without a managerial position. Work satisfaction is inversely associated with MD and emotional exhaustion is positively associated with it. Participants' spirituality is marginally associated with MD. The best predictors of both MD frequency and burden are emotional exhaustion with further influences of work satisfaction, being a nurse, and being a non-believer on the frequency of MD perception. Being a nurse, participants' experience in ICU/ED, and being of the male gender are further predictors of MD burden. CONCLUSIONS MD is experienced differently by different groups of CCPs depending on their place in the hierarchy of responsibility. As MD perception is best predicted by emotional exhaustion, these situations should be avoided. Although some CCPs may rely on spiritual resources, all need individual and team support to cope with MD.
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Affiliation(s)
- Dominik Hinzmann
- Department of Anaesthesiology and Intensive Care, University Hospital Rechts der Isar, 81675 Munich, Germany
- School of Medicine, Technical University of Munich, 80333 München, Germany
| | | | - Arndt Büssing
- Quality of Life, Spirituality and Coping, Faculty of Health, Witten/Herdecke University, 58455 Witten, Germany
| | - Olaf Boenisch
- Department of Intensive Care, University Hospital Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Hans-Jörg Busch
- Department of Emergency Medicine, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Christoph Dodt
- Emergency Department, München Klinik, 81925 Munich, Germany
| | | | - Matthias Kochanek
- Department of Intensive Care, University Hospital Cologne, 50937 Cologne, Germany
| | - Guido Michels
- Emergency Department, Sankt Antonius Hospital, 52249 Eschweiler, Germany
| | - Eckhard Frick
- School of Medicine, Technical University of Munich, 80333 München, Germany
- Spiritual Care and Psychosomatic Health, Department of Psychosomatic Medicine and Psychotherapy, University Hospital Rechts der Isar, 80539 Munich, Germany
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Margherita G, Muzii B, Caffieri A, Di Francia A, Somma B. 'Isolated together': online group treatments during the COVID-19 pandemic. A systematic review. RESEARCH IN PSYCHOTHERAPY (MILANO) 2022; 25:639. [PMID: 36373389 PMCID: PMC9893046 DOI: 10.4081/ripppo.2022.639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 10/03/2022] [Indexed: 11/09/2022]
Abstract
Considering the emerging need to face the negative impact of the pandemic on mental health, social support, and access to health services, it became a critical issue to adapt to online group settings and create new group interventions to face the developing distress during this time. The aim of the current study is to investigate the main findings on OPGI conducted during the COVID-19 pandemic from March 2020 until March 2022, with a particular focus on: i) the therapeutic group factors; ii) what kind of OPGI works and for whom; iii) settings and emerging dimensions. In accordance with PRISMA guidelines, we performed a systematic review on scientific databases (PsychINFO, PubMed, Web of Science and EBSCO) searching for studies published between March 2020 and March 2022. 'Group intervention' or 'group therapy' or 'group treatment' crossed with 'COVID-19' and synonymous, were used as keywords. Internet based intervention was used as an eligibility criteria during the full-text screening. A total of 1326 articles were identified, of which 24 met the inclusion criteria. Among all studies, with different participants and different orientations, data extracted supported psychological online group interventions as an effective approach to reducing psychological distress and increasing psychological resources in the interpersonal field. Our findings also showed that COVID-19 has led to new needs and issues, that require the investigation of new dimensions for online psychological interventions. Methodological and clinical implications will be discussed through a descriptive table related to setting characteristics. Recommendations are made for future research.
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Affiliation(s)
- Giorgia Margherita
- Department of Humanistic Studies, University of Naples Federico II, Naples, Italy,I.I.P.G., Italian Institute of Group Psychoanalysis and European Federation for Psychoanalytic Psychotherapy in the Public Sector, Rome, Italy,Department of Humanistic Studies, University of Naples Federico II, Naples, Italy.
| | - Benedetta Muzii
- Department of Humanistic Studies, University of Naples Federico II, Naples, Italy
| | - Alessia Caffieri
- Department of Humanistic Studies, University of Naples Federico II, Naples, Italy
| | - Adriana Di Francia
- Department of Humanistic Studies, University of Naples Federico II, Naples, Italy
| | - Brenda Somma
- Department of Humanistic Studies, University of Naples Federico II, Naples, Italy
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Maguen S, Griffin BJ. Research Gaps and Recommendations to Guide Research on Assessment, Prevention, and Treatment of Moral Injury Among Healthcare Workers. Front Psychiatry 2022; 13:874729. [PMID: 35492723 PMCID: PMC9051037 DOI: 10.3389/fpsyt.2022.874729] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 03/21/2022] [Indexed: 11/30/2022] Open
Abstract
Healthcare workers face numerous occupational stressors, including some that may challenge personal and shared morals and values. This is particularly true during disasters and crises such as the COVID-19 pandemic, which require critical decisions to be made with little time and information often under personal distress and situational constraints. Consequently, healthcare workers are at risk for moral injuries characterized by stress-related and functional impacts. Although research on the evaluation and treatment of moral injury among military veterans burgeoned in the recent decade, addressing moral injury in healthcare workers and other civilians remains an important gap. In this perspective piece, we identify research gaps and make recommendations to advance future work on assessment, prevention, and treatment of moral injury in healthcare workers. We draw on empirical studies of moral injury in veterans, limited studies of moral injury in health professionals, and our clinical experiences with healthcare workers affected by moral injury.
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Affiliation(s)
- Shira Maguen
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States.,San Francisco VA Healthcare System, San Francisco, CA, United States
| | - Brandon J Griffin
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Central Arkansas VA Healthcare System, Little Rock, AR, United States
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Ter Heide FJJ, de Goede ML, van Dam S, Ekkers S. Development of an online supportive treatment module for moral injury in military veterans and police officers. Front Psychiatry 2022; 13:890858. [PMID: 36117648 PMCID: PMC9478510 DOI: 10.3389/fpsyt.2022.890858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Military members and police officers often operate in high stakes situations and under high levels of physical and psychological stress. Consequently, they may be confronted with morally injurious experiences and develop moral injury. Most treatments for moral injury are cognitive-behavioral, face-to-face treatments, which may be supported by online interventions. Online interventions have shown promise in the treatment of trauma-related psychopathology, but few such interventions for moral injury yet exist. OBJECTIVE To develop and conduct a preliminary evaluation of an online treatment module for moral injury in treatment-seeking military veterans and police officers, to be used in conjunction with regular face-to-face treatment. METHOD An online module was developed based on the moral injury literature, using elements from seven existing treatments. A preliminary evaluation was conducted using both quantitative and qualitative methods, and focusing on perceived feasibility, acceptability and engagement of the module, as well as potential benefits and harms. The concept module was evaluated by 15 assessors, including patient representatives, multidisciplinary caregivers and experts. RESULTS The module was rated favorably, with mean evaluation scores ranging from 7.9 to 8.8 on a 10-point scale. Several suggestions for improvement were made, especially concerning privacy issues, safety instructions, patient-therapist collaborations, and role plays, and the module was adapted accordingly. CONCLUSION Using input from literature, patient representatives and experts, we developed an online treatment module for moral injury in military veterans and police officers, to be used in conjunction with face-to-face therapy. Acceptability and feasibility will be further examined in a future pilot study.
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