Moral injury and mental health outcomes among Israeli health and social care workers during the COVID-19 pandemic: a latent class analysis approach

"COVID-19 and the New Hidden Curriculum of Moral Injury and Compassion Fatigue"

Medical students are educated through two dichotomous curriculums, the formal, planned curriculum and the hidden curriculum unintentionally taught through socialization within the culture of medicine. As a consequence of shared trauma amongst the physician workforce during the COVID-19 pandemic, moral injury (MoI) and compassion fatigue (CoF) have become prevalent within the health care system, including palliative care medicine, with echoing ramifications on the observing trainee population. Thus, it is imperative to determine risk factors, protective factors and targeted interventions to offset MoI and CoF within the health care workforce and trainee population. Methods of strengthening personal and institutional resilience are vital to developing long-term structural change replacing the hidden curriculum of MoI and CoF with one of resilience and support. As palliative care providers are especially vulnerable to MoI and CoF, this article will examine the impact of the COVID-19 pandemic on MoI, CoF, and resilience within the hidden curriculum through the lens of palliative care.

Using the Moral Injury and Distress Scale to identify clinically meaningful moral injury

Despite the proliferation of moral injury studies, a remaining gap is distinguishing moral injury from normative distress following exposure to potentially morally injurious events (PMIEs). Our goal was to leverage mental health and functional measures to identify clinically meaningful and functionally impairing moral injury using the Moral Injury and Distress Scale (MIDS). Participants who endorsed PMIE exposure (N = 645) were drawn from a population-based sample of military veterans, health care workers, and first responders. Using signal detection methods, we identified the optimally efficient MIDS score for detecting clinically significant posttraumatic stress and depressive symptom severity, trauma-related guilt, and functional impairment. The most efficient cut scores across outcomes converged between 24 and 27. We recommend a cut score of 27 given that roughly 70% of participants who screened positive on the MIDS at this threshold reported clinically significant mental health symptoms, and approximately 50% reported severe trauma-related guilt and/or functional impairment. Overall, 10.2% of respondents exposed to a PMIE screened positive for moral injury at this threshold, particularly those who identified as a member of a minoritized racial or ethnic group (17.9%) relative to those who identified as White, non-Hispanic (8.0%), aOR = 2.52, 95% CI [1.45, 4.42]. This is the first known study to establish a cut score indicative of clinically meaningful and impairing moral injury. Such scores may enhance clinicians' abilities to conduct measurement-based moral injury care by enabling them to identify individuals at risk of negative outcomes and better understand risk and protective factors for moral injury.

Longitudinal associations between exposure to potentially morally injurious events and suicidal ideation among recently discharged veterans - The mediating roles of depression and loneliness

BACKGROUND

Exposure to potentially morally injurious events (PMIEs) during military service is associated with heightened suicidal ideation (SI). However, no longitudinal study has established temporal associations between these variables and examined the possible mediating roles of depression and loneliness in this effect.

METHODS

Participants were 374 active-duty Israeli combatants who participated in a five-year longitudinal study with four measurement points: T1- one year before enlistment, T2- one month before discharge from army service, and then again six months and twelve months following their discharge (T3 and T4, respectively). Data were assessed through semi-structured interviews and validated self-report questionnaires.

RESULTS

Above and beyond pre-enlistment personal characteristics (T1) and combat exposure (T2), PMIEs-'betrayal' (T2) predicted more frequent SI over the past twelve months (T4) through the mediation of depression. Moreover, both PMIEs-'betrayal' and 'self' (T2) predicted more frequent SI over the past twelve months (T4) through the mediation of loneliness.

LIMITATIONS

We used self-report measures to assess PMIEs and SI, which may suffer from various biases.

CONCLUSIONS

Our findings are the first to provide evidence of longitudinal, temporal associations between exposure to PMIEs and SI. Notably, potential interventions might consider addressing the loneliness experienced following exposure to PMIEs during military service, among recently discharged traumatized veterans.

Moral Injury Post-COVID-19: More Than Military? A Theological Perspective

The author of this article considers moral distress theologically, as a potential shattering of core sustaining belief systems, hope, securities, self-identities, and organizing principles of one's existence. Shattering of individual moral expectations can occur in both medical and military moral injury.

The independent and combined impact of moral injury and moral distress on post-traumatic stress disorder symptoms among healthcare workers during the COVID-19 pandemic

Background: Healthcare workers (HCWs) across the globe have reported symptoms of Post-Traumatic Stress Disorder (PTSD) during the COVID-19 pandemic. Moral Injury (MI) has been associated with PTSD in military populations, but is not well studied in healthcare contexts. Moral Distress (MD), a related concept, may enhance understandings of MI and its relation to PTSD among HCWs. This study examined the independent and combined impact of MI and MD on PTSD symptoms in Canadian HCWs during the pandemic.Methods: HCWs participated in an online survey between February and December 2021, with questions regarding sociodemographics, mental health and trauma history (e.g. MI, MD, PTSD, dissociation, depression, anxiety, stress, childhood adversity). Structural equation modelling was used to analyze the independent and combined impact of MI and MD on PTSD symptoms (including dissociation) among the sample when controlling for sex, age, depression, anxiety, stress, and childhood adversity.Results: A structural equation model independently regressing both MI and MD onto PTSD accounted for 74.4% of the variance in PTSD symptoms. Here, MI was strongly and significantly associated with PTSD symptoms (β = .412, p < .0001) to a higher degree than MD (β = .187, p < .0001), after controlling for age, sex, depression, anxiety, stress and childhood adversity. A model regressing a combined MD and MI construct onto PTSD predicted approximately 87% of the variance in PTSD symptoms (r2 = .87, p < .0001), with MD/MI strongly and significantly associated with PTSD (β = .813, p < .0001), after controlling for age, sex, depression, anxiety, stress, and childhood adversity.Conclusion: Our results support a relation between MI and PTSD among HCWs and suggest that a combined MD and MI construct is most strongly associated with PTSD symptoms. Further research is needed better understand the mechanisms through which MD/MI are associated with PTSD.

Digital Interventions for Stress Among Frontline Health Care Workers: Results From a Pilot Feasibility Cohort Trial

BACKGROUND

The COVID-19 pandemic has challenged the mental health of health care workers, increasing the rates of stress, moral distress (MD), and moral injury (MI). Virtual reality (VR) is a useful tool for studying MD and MI because it can effectively elicit psychophysiological responses, is customizable, and permits the controlled study of participants in real time.

OBJECTIVE

This study aims to investigate the feasibility of using an intervention comprising a VR scenario and an educational video to examine MD among health care workers during the COVID-19 pandemic and to use our mobile app for longitudinal monitoring of stress, MD, and MI after the intervention.

METHODS

We recruited 15 participants for a compound intervention consisting of a VR scenario followed by an educational video and a repetition of the VR scenario. The scenario portrayed a morally challenging situation related to a shortage of life-saving equipment. Physiological signals and scores of the Moral Injury Outcome Scale (MIOS) and Perceived Stress Scale (PSS) were collected. Participants underwent a debriefing session to provide their impressions of the intervention, and content analysis was performed on the sessions. Participants were also instructed to use a mobile app for 8 weeks after the intervention to monitor stress, MD, and mental health symptoms. We conducted Wilcoxon signed rank tests on the PSS and MIOS scores to investigate whether the VR scenario could induce stress and MD. We also evaluated user experience and the sense of presence after the intervention through semi-open-ended feedback and the Igroup Presence Questionnaire, respectively. Qualitative feedback was summarized and categorized to offer an experiential perspective.

RESULTS

All participants completed the intervention. Mean pre- and postintervention scores were respectively 10.4 (SD 9.9) and 13.5 (SD 9.1) for the MIOS and 17.3 (SD 7.5) and 19.1 (SD 8.1) for the PSS. Statistical analyses revealed no significant pre- to postintervention difference in the MIOS and PSS scores (P=.11 and P=.22, respectively), suggesting that the experiment did not acutely induce significant levels of stress or MD. However, content analysis revealed feelings of guilt, shame, and betrayal, which relate to the experience of MD. On the basis of the Igroup Presence Questionnaire results, the VR scenario achieved an above-average degree of overall presence, spatial presence, and involvement, and slightly below-average realism. Of the 15 participants, 8 (53%) did not answer symptom surveys on the mobile app.

CONCLUSIONS

Our study demonstrated VR to be a feasible method to simulate morally challenging situations and elicit genuine responses associated with MD with high acceptability and tolerability. Future research could better define the efficacy of VR in examining stress, MD, and MI both acutely and in the longer term. An improved participant strategy for mobile data capture is needed for future studies.

TRIAL REGISTRATION

ClinicalTrails.gov NCT05001542; https://clinicaltrials.gov/study/NCT05001542.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/32240.

Moral injury and mental health among health-care workers during the COVID-19 pandemic: meta-analysis

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.

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.

Exploring experiences of moral injury and distress among health care workers during the Covid-19 pandemic

OBJECTIVE

Health care workers have been exposed to a variety of practical and emotional challenges because of the Covid-19 pandemic, leaving them vulnerable to experiencing moral injury and distress. However, there is currently sparse research which directly explores such experiences. This study aimed to explore and characterise the experiences and impacts of moral injury and distress among health care workers during the pandemic.

METHODS

Twenty semi-structured interviews were conducted with health care workers employed across both mental and physical health care services. Interviews were analysed from a critical realist perspective using thematic analysis.

RESULTS

Three key themes were identified: attitudes towards moral injury, experiences of moral injury and consequences of moral injury. Participants appeared to identify with the idea of acting against their morals to varying extents based on their job roles. Participants experienced a range of potentially morally injurious and distressing events throughout the pandemic and many ultimately felt that they provided sub-standard levels of care due to extreme pressures on services. Detrimental impacts upon wellbeing were commonly reported, including high levels of emotional distress and feelings of guilt and shame. Some reported a loss of enthusiasm for their job and a desire to leave the profession entirely.

CONCLUSION

Moral injury and distress presents a real concern for staff wellbeing and retention within the profession. During and beyond the Covid-19 pandemic, there is an urgent need for health care providers to implement wider strategies to target moral injury and distress, and support staff within health care settings.

Moral injury in a global health emergency: a validation study of the Italian version of the Moral Injury Events Scale adjusted to the healthcare setting

Background: When exposed to events that transgress one's moral beliefs, a plethora of negative consequences may follow, which are captured by the concept of moral injury (MI). Despite its relevance to experiences of healthcare workers during a global health emergency, there is lack of validated MI instruments adapted to the healthcare setting.Objective: The present study aims to provide a validation of the Italian version of the Moral Injury Events Scale (MIES) adjusted to the healthcare setting by assessing its factor structure, internal consistency and construct validity.Methods: A sample of 794 healthcare workers (46% nurses, 51% female) engaged in hospital facilities during the COVID-19 pandemic in Italy completed measures of MI, PTSD, anxiety, depression, burnout, meaning in life and positive affect.Results: Using an exploratory structural equation modelling (ESEM) we assessed the scale factor structure for the entire sample and separately for nurse professional and female healthcare worker groups. Findings support a three-factor solution: Factor 1 'perceived transgressions by others'; Factor 2 'perceived transgressions by self'; and Factor 3 'perceived betrayals by others'. Findings also indicate some level of convergence with measures of PTSD, anxiety, depression and burnout.Conclusion: Results suggest that the MIES may be useful in capturing unique experiences of moral injury amongst healthcare workers engaged in a global health emergency. The low range correlations with measures of psychological distress might potentially indicate that MI, which captures cognitive value judgements rather than manifest symptomatology, may uniquely explain a certain amount of variance. Implications for the development of new empirically derived and theoretical guided tools are discussed, highlighting the need for future research to examine the role of individualising and social binding moral principles in gaining a more nuanced understanding of moral injury experiences amongst healthcare professionals across different socio-cultural settings.

Challenges and improvements associated with transitions between hospitals and care homes during the COVID-19 pandemic: a qualitative study with care home and healthcare staff in England

BACKGROUND

Care home residents transitioning from hospital are at risk of receiving poor-quality care with their safety being challenged by the SARS-CoV-2 virus (COVID-19) pandemic. Little is known about how care home staff worked with hospital staff and other healthcare professionals to address these challenges and make improvements to increase patient safety.

OBJECTIVE

To gain insight into how the COVID-19 pandemic influenced the safety of transitions between hospital and care home.

METHOD

Semi-structured interviews were conducted with care home staff and healthcare professionals involved in hospital to care home transitions including doctors, nurses, paramedics, pharmacists, social workers, and occupational therapists. Commonalities and patterns in the data were identified using thematic analysis.

RESULTS

Seventy participants were interviewed. Three themes were developed, first, 'new challenges', described care homes were pressurised to receive hospital patients amidst issues with COVID-19 testing, changes to working practices and contentious media attention, which all impacted staff negatively. Second, 'dehumanisation' described how care home residents were treated, being isolated from others amounted to feelings of being imprisoned, caused fear and engendered negative reactions from families. Third, 'better ways of working' described how health and social care workers developed relationships that improved integration and confidence and benefited care provision.

CONCLUSION

The COVID-19 pandemic contributed to and compounded high-risk hospital-to-care home discharges. Government policy failed to support care homes. Rapid discharge objectives exposed a myriad of infection control issues causing inhumane conditions for care home residents. However, staff involved in transitions continued to provide and improve upon care provision.

Moral Injuries in Healthcare Workers: What Causes Them and What to Do About Them?

Moral injury (MI) refers to the persisting distress which may occur following exposure to potentially morally injurious events (PMIEs). The COVID-19 pandemic has drawn attention to MI in healthcare workers, who have been found to experience more frequent PMIEs in their day-to-day work than those in other occupational groups such as the military. These events may occur on an individual, team, organizational or system level and have been associated with increased clinician burnout and distress, and poor psychological wellbeing. This paper focuses on healthcare workers' experiences of MI, including potential causes and ways to reduce them. There are myriad challenges that influence the development of MI, such as chronic understaffing and the pressure to treat high numbers of patients with limited resources. There are also multiple impacts of MI: at the individual-level, MI can lead to increased staff absences and understaffing, and prolonged patient contact with limited decision-making power. COVID-19 exacerbated such impacts, with a lack of organizational support during a time of increased patient mortality, and uncertainty and heightened pressure on the clinical frontline associated with scarce resources and understaffing. Potential methods for reduction of MI in healthcare workers include pre-exposure mitigation, such as fostering work environments which treat PMIEs in the same way as other occupational hazards and post-exposure mitigation, such as facilitating healthcare workers to process their experiences of PMIEs in peer support groups or with spiritual advisors and, if MI is associated with mental ill-health, talking therapies using trauma-focused and compassion-oriented frameworks.

The Association of Moral Injury and Healthcare Clinicians' Wellbeing: A Systematic Review

Research focused on elucidating moral injury amongst healthcare workers (HCWs) is essential due to the deep connection with morality and individuals' overall wellbeing. Examining moral injury provides an avenue through which researchers can connect individual experiences with systemic level causes (i.e., structural power imbalances between clinicians and health systems) to better study workplace wellbeing. The omnipresence of the COVID-19 pandemic has amplified the need to study moral injury. This paper describes a systematic review conducted using PRISMA-P guidelines to answer the question, "what is the association between moral injury and professional wellbeing and mental health amongst healthcare workers." Twelve databases were searched to identify specified studies. This study's criteria included: (1) articles published through December 2022; (2) qualitative and quantitative empirical studies; (3) articles written in English; (4) articles including moral injury; and (5) articles including at minimum one other measure of professional or personal wellbeing. The initial search produced 248 articles, and 18 articles were ultimately included in the final review. To confirm that no articles were left out of this study, the first author of each included article was contacted to inquire about any additional works that met the inclusion criteria of this study. The elements of the 18 included articles described in this review are discussed. The results indicate that moral injury is associated with both professional wellbeing factors and mental health outcomes. Further theoretical development, including (professional- and identity-based) exploratory research on moral injury, and evidenced-based interventions for moral injury are needed.

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.

Perceived workplace support and mental health, well-being and burnout among health care professionals during the COVID-19 pandemic: a cohort analysis

BACKGROUND

Little is known about the relationship between workplace support and mental health and burnout among health care professionals (HCPs) during the COVID-19 pandemic. In this cohort study, we sought to evaluate the association between perceived level of (and changes to) workplace support and mental health and burnout among HCPs, and to identify what constitutes perceived effective workplace support.

METHODS

Online surveys at baseline (July-September 2020) and follow-up 4 months later assessed the presence of generalized anxiety disorder (using the 7-item Generalized Anxiety Disorder scale [GAD-7]), clinical insomnia, major depressive disorder (using the 9-item Patient Health Questionnaire), burnout (emotional exhaustion and depersonalization) and mental well-being (using the Short Warwick-Edinburgh Mental Wellbeing Score). Both surveys assessed self-reported level of workplace support (single-item Likert scale). For baseline and follow-up, independently, we developed separate logistic regression models to evaluate the association of the level of workplace support (tricohotomized as unsupported, neither supported nor unsupported and supported) with mental health and burnout. We also developed linear regression models to evaluate the association between the change in perceived level of workplace support and the change in mental health scores from baseline and follow-up. We used thematic analyses on free-text entries of the baseline survey to evaluate what constitutes effective support.

RESULTS

At baseline (n = 1422) and follow-up (n = 681), HCPs who felt supported had reduced risk of anxiety, depression, clinical insomnia, emotional exhaustion and depersonalization, compared with those who felt unsupported. Among those who responded to both surveys (n = 681), improved perceived level of workplace support over time was associated with significantly improved scores on measures of anxiety (adjusted β -0.13, 95% confidence interval [CI] -0.25 to -0.01), depression (adjusted β -0.17, 95% CI -0.29 to -0.04) and mental well-being (adjusted β 0.19, 95% CI 0.10 to 0.29), independent of baseline level of support. We identified 5 themes constituting effective workplace support, namely concern or understanding for welfare, information, tangible qualities of the workplace, leadership and peer support.

INTERPRETATION

We found a significant association between perceived level of (and changes in) workplace support and mental health and burnout of HCPs, and identified potential themes that constitute perceived workplace support. Collectively, these findings can inform changes in guidance and national policies to improve mental health and burnout among HCPs. Trial registration: ClinicalTrials.gov, no. NCT04433260.

On the Frontlines: The Impact of the COVID-19 Pandemic on Social Workers' Well-Being

The crisis created by the spread of COVID-19 brought increasing needs and referrals to social welfare services in many countries. However, at the same time, social services suffered from staff cutbacks and service closures, resulting in significant workload increases to address the hardships associated with the pandemic. This article investigates the impact of the COVID-19 pandemic on Israeli social workers' well-being, using a mixed-methods design with a sample of 2,542 licensed social workers. Findings show that over 70 percent of social workers suffered from at least one health problem related to their work. Path analysis findings indicated that social workers who experienced greater service restrictions reported a greater decrease in job satisfaction and experienced higher levels of stress and work-related problems. Machine learning emotion-detection analysis revealed that the pandemic affected their lives, causing feelings of fear, frustration, and sadness. This article demonstrates how social workers whose work was characterized by greater service restrictions were less satisfied with their jobs, more stressed, and experienced greater job-related health problems, and concludes with a discussion of the implications for social work practice in times of crisis.

Moral injury events and behavioral health outcomes among American veterans

Among American veterans, the behavioral health impact of potentially morally injurious experiences (PMIEs) has recently garnered attention. There is heterogeneity in the types of experiences that are classified as PMIEs, and different PMIEs may be differentially associated with various outcomes. We aimed to explore heterogeneity in PMIEs among veterans, and whether PMIE classes are differentially associated with several behavioral health outcomes (i.e., symptoms of posttraumatic stress disorder, depression, anxiety, and anger). Data were from a survey study of veteran health attitudes and behavior (N=1004). We employed a Latent Class Analysis approach to identify sub-groups of participants with similar PMIE response patterns on the Moral Injury Events Scale and to determine the relationship between class membership and behavioral health outcomes. A 4-class solution best fit our data, with classes including (1) high all, (2) witnessed transgressions, (3) troubled by failure to act, and (4) moderate all. There was a link between class membership and behavioral health, with the high all class and moderate all classes consistently reporting especially poor outcomes. Our results are in line with cumulative stress models suggesting exposure to multiple forms of adversity may place individuals at particular risk of poor health and functioning. Clinicians working with veterans should screen for exposure to the full range of PMIE types and be prepared to address the multitude of behavioral health impacts.

The Moral Impact of the COVID-19 Pandemic on Nurses’ Burnout, Work Satisfaction and Adaptive Work Performance: The Role of Autobiographical Memories of Potentially Morally Injurious Events and Basic Psychological Needs

The COVID-19 pandemic resulted in unprecedented exposure to Potentially Morally Injurious Events (PMIEs) for nurses, in which they were both moral transgressors and moral victims, with deleterious consequences on their psycho-social health and functioning. Our experimental design compared memories of PMIEs with memories of severe moral transgressions (SMTs), in which participants were only moral transgressors. Drawing from Self-Determination Theory and research on moral auto-biographical episodic memories, we assessed a conceptual model describing the impact of recalling a single PMIE or SMT event on nurses’ burnout, work satisfaction and adaptive performance. Our convenience sample comprised 614 Romanian nurses, and data was analyzed with path analysis, general linear modelling, and t-tests. Findings showed that memories of PMIEs, compared to SMTs, were more autonomy thwarting, being associated with more controlled work motivation, less moral learning, higher burnout, less work satisfaction, and adaptive performance. Burnout, moral learning, and work satisfaction were significant mediators of the relationships between PMIE and SMT recall and, respectively, adaptive performance. Our results highlight the urgency for organizational practices of moral repair for nurses after the pandemic, along with interventions meant to increase their autonomy and self-determined work motivation.

Associations between moral injury and ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD among help-seeking nurses: a cross-sectional study

OBJECTIVES

This study aimed to evaluate how moral injury (MI), traumatic experiences and daily stressors were related to the symptoms of post-traumatic stress disorder (PTSD) and International Classification of Diseases 11th revision specific complex PTSD (CPTSD) symptoms of disturbances in self-organisation (DSO) in a treatment-seeking sample of nurses.

DESIGN

A cross-sectional study.

SETTING

Nurses from all regions of Lithuania participated in the study. The data were collected between April and May 2021.

PARTICIPANTS

A total of 206 nurses, mean age 42.34 years (SD=11.68), 97.1% women and with 65% >10 years of work experience.

RESULTS

The prevalence of PTSD and CPTSD in the treatment-seeking sample of nurses was 9.2% and 10.2%, respectively. The results of structural equation modelling indicated an acceptable model fit for the model regarding the links between trauma exposure, daily stressors, MI, PTSD and DSO symptoms, (χ2 (df)=219.718 (123), p<0.001, Comparative Fit Index/Tucker-Lewis Index=0.937/0.922, root mean square error of approximation (90% CI)=0.062 (0.048 to 0.075), standardised root mean square residual=0.049). MI had a large effect on DSO symptoms, β=0.667, p<0.001, and a medium effect on PTSD symptoms, β=0.394, p<0.001. Daily stress but not trauma exposure was significantly related to MI, β=0.618, p<0.001.

CONCLUSIONS

The prevalence of PTSD and CPTSD in a treatment-seeking sample of nurses inform healthcare administrators, policymakers and medical staff about the demand for psychosocial interventions for healthcare workers focused on stress management to address their daily stressors and mitigate effects on MI or trauma-focused treatments for PTSD/CPTSD.

TRIAL REGISTRATION NUMBER

NCT04817995; Pre-results.

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.

'It hurts your heart': frontline healthcare worker experiences of moral injury during the COVID-19 pandemic

Background: Moral injury is defined as the strong emotional and cognitive reactions following events which clash with someone's moral code, values or expectations. During the COVID-19 pandemic, increased exposure to Potentially Morally Injurious Events (PMIEs) has placed healthcare workers (HCWs) at risk of moral injury. Yet little is known about the lived experience of cumulative PMIE exposure and how NHS staff respond to this. Objective: We sought to rectify this knowledge gap by qualitatively exploring the lived experiences and perspectives of clinical frontline NHS staff who responded to COVID-19. Methods: We recruited a diverse sample of 30 clinical frontline HCWs from the NHS CHECK study cohort, for single time point qualitative interviews. All participants endorsed at least one item on the 9-item Moral Injury Events Scale (MIES) [Nash et al., 2013. Psychometric evaluation of the moral injury events scale. Military Medicine, 178(6), 646-652] at six month follow up. Interviews followed a semi-structured guide and were analysed using reflexive thematic analysis. Results: HCWs described being routinely exposed to ethical conflicts, created by exacerbations of pre-existing systemic issues including inadequate staffing and resourcing. We found that HCWs experienced a range of mental health symptoms primarily related to perceptions of institutional betrayal as well as feeling unable to fulfil their duty of care towards patients. Conclusion: These results suggest that a multi-facetted organisational strategy is warranted to prepare for PMIE exposure, promote opportunities for resolution of symptoms associated with moral injury and prevent organisational disengagement. HIGHLIGHTS Clinical frontline healthcare workers (HCWs) have been exposed to an accumulation of potentially morally injurious events (PMIEs) throughout the COVID-19 pandemic, including feeling betrayed by both government and NHS leaders as well as feeling unable to provide duty of care to patients.HCWs described the significant adverse impact of this exposure on their mental health, including increased anxiety and depression symptoms and sleep disturbance.Most HCWs interviewed believed that organisational change within the NHS was necessary to prevent excess PMIE exposure and promote resolution of moral distress.