Mediating Effect of Thriving from Work in the Relationship Between Moral Injury and Post-Traumatic Growth Among Healthcare Workers in China.

A Global Call for Action to Prioritize Healthcare Worker Suicide Prevention During the COVID-19 Pandemic and Beyond.

Postpandemic Psychological Recovery and Emergency Nursing: Creating a Narrative for Change

BackgroundThe pandemic of COVID-19 has significantly increased the burden on healthcare workers and potentially affect their risk of workplace violence (WPV). This study aimed to explore the prevalence and risk factors of WPV among healthcare workers during the peaking and the remission of the COVID-19 pandemic in China.MethodsUsing the snowball method, a repeated online questionnaire survey was conducted among Chinese healthcare workers from March 27th to April 26th in 2020 and 2021, respectively. Data included healthcare workers' socio-demographic and occupational characteristics, psychological status, and workplace violence.ResultsA total of 3006 samples in 2020 and 3465 samples in 2021 were analyzed. In 2020, the prevalence of WPV and witnessing colleagues suffering from WPV among healthcare workers were 64.2% and 79.7% respectively. Compared with 2020, the prevalence decreased by 11.0% and 14.4% in 2021, respectively. Logistic regression showed that WPV in 2020 was influenced by males, long working experience, working in the psychiatric department, direct contact with COVID-19 patients, self-discovery of medical errors, moral injury, depression, and anxiety (minimum OR = 1.22, maximum OR = 2.82). While risk factors of WPV in 2021 included males, working in psychiatric departments, self-discovery of medical errors, moral injury, depression, and anxiety (minimum OR = 1.33, maximum OR = 3.32); and protective factors were holding a master's degree (OR = 0.78) and working in other departments (OR = 0.54).ConclusionThis study retains the common effects of WPV among healthcare workers, though after the baptism of the COVID-19 pandemic, the prevalence of WPV among healthcare workers decreased; however, part of the influencing factors changed. In addition, COVID-19 has seriously affected the mental health of healthcare workers, and the effect of mental health problems on WPV should also attract more attention.

Moral injury: the effect on mental health and implications for treatment

Invisible Moral Wounds of the COVID-19 Pandemic: Are We Experiencing Moral Injury?

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.

The COVID-19 pandemic impacted mental health across different groups, including healthcare workers (HWs). To date, few studies focused on potential positive aspects that may follow the exposure to the pandemic. We investigated the prevalence of posttraumatic stress disorder (PTSD) in Italian HWs and whether posttraumatic growth (PTG) dimensions affected the risk of suicidal ideation (SI) during the first COVID-19 wave. An online self-report survey was conducted between April and May 2020. Sociodemographic data, information about COVID-19-related stressful events, Impact of the Event Scale-revised, and Post-Traumatic Growth Inventory-Short Form (PTGI-SF) scores were collected and compared between participants. Patient Health Questionnaire-9 scores were also collected to assess SI through item 9. Multivariate logistic regression was used to assess the relationship between PTGI and SI. Among 948 HWs, 257 (27.0%) reported a provisional PTSD diagnosis. The median PTGI-SF score was 24. Participants reporting PTSD symptoms had higher scores in the Spiritual change, Appreciation of life, and New possibilities domains, and in the total PTG scale. A total of 100 HWs (10.8%) screened positive for SI. Improvements in Relating to others domain of PTGI-SF (odds ratioOR: .46; 95% confidence interval: .25-.85) were associated with lower odds of SI. COVID-19 pandemic has been indicated as a risk factor for SI, also among HWs. PTG may have a protective role on suicide risk. Improvements in Relating to others domain reduced odds of SI, consistently with the role of loneliness and lack of connectedness with others in enhancing suicidal risk.

IntroductionThe Coronavirus disease 2019 (COVID-19) pandemic is a global traumatic event that has profoundly struck individuals’ mental health. However, this might potentially promote positive transformation such as posttraumatic growth (PTG). Studies have indicated that the COVID-19 pandemic negatively affected the well-being of resident physicians, but little is known about PTG among this vulnerable population in China. Therefore, this study investigated the prevalence and associated factors of PTG among Chinese resident physicians after 3-years outbreak of COVID-19.MethodsAn online survey was conducted from 9 March to 20 March in 2023. PTG was assessed using the 10-item Posttraumatic Growth Inventory-Short Form (PTGI-SF). Scores ≥30 implied moderate-to-high PTG. We also collected possible associated factors for PTG, including socio-demographic and psychological variables. Data was analyzed by applying descriptive statistics, univariable and multivariable logistic regression models.ResultsIn total, 2267 Chinese resident physicians provided validated data. 38.7% of them reported moderate-to-high PTG. In the multivariable logistic regression models, age (odds ratio, OR = 1.039; 95% confidence interval, 95%CI = 1.008–1.070), female (OR = 1.383, 95%CI = 1.151–1.662), satisfied or neutral with annual income (OR = 2.078, 95%CI = 1.524–2.832; OR = 1.416, 95%CI = 1.157–1.732), sufficient support at work (OR = 1.432, 95%CI = 1.171–1.751) and resilience (OR = 1.171, 95%CI = 1.096–1.252) were significantly positively associated with moderate-to-high PTG. On the contrary, burnout (OR = 0.653, 95%CI = 0.525–0.812), depression symptoms (OR = 0.700, 95%CI = 0.552–0.889), and stress (OR = 0.757, 95%CI = 0.604–0.949) were significantly negatively associated with moderate-to-high PTG.DiscussionOverall, resident physicians in China experienced relatively high prevalence of PTG that could be associated with several psychosocial factors. Findings may provide evidence to develop interventions for resident physicians to systematically and constructively process traumatic events related to the pandemic and foster their PTG.

BackgroundEmerging cross-sectional data indicate that healthcare workers (HCWs) in the COVID-19 era face particular mental health risks. Moral injury – a betrayal of one’s values and beliefs, is a potential concern for HCWs who witness the devastating impact of acute COVID-19 illness while too often feeling helpless to respond. This study longitudinally examined rates of depression, generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), and moral injury among United States HCWs in the COVID-19 era. We anticipated finding high levels of clinical symptoms and moral injury that would remain stable over time. We also expected to find positive correlations between clinical symptoms and moral injury.MethodsThis three-wave study assessed clinical symptoms and moral injury among 350 HCWs at baseline, 30, and 90 days between September and December 2020. Anxiety, depression, PTSD, and moral injury were measured using the Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Primary Care PTSD Screen (PC-PTSD), and Moral Injury Events Scale (MIES).ResultsOf the 350 HCWs, 72% reported probable anxiety, depression, and/or PTSD disorders at baseline, 62% at day 30, and 64% at day 90. High level of moral injury was associated with a range of psychopathology including suicidal ideation, especially among healthcare workers self-reporting COVID-19 exposure.ConclusionsFindings demonstrate broad, persisting, and diverse mental health consequences of the COVID-19 pandemic among United States HCWs. This study is the first to longitudinally examine the relationships between moral injury and psychopathology among HCWs, emphasizing the need to increase HCWs’ access to mental healthcare.

This scoping review examined the bidirectional impact of spirituality on active duty military service members and Veterans with combat-related Posttraumatic Stress Disorder (PTSD). The rationale for this work was to characterize how spirituality influences this population, considering moderators such as social support and resilience, as well as social determinants of health (SDoH), adverse childhood experiences, and family religious experiences in order to (1) explore the associations between spirituality and PTSD outcomes, (2) screen for spirituality and religiosity, (3) provide integrated care models that incorporate spiritual guidance, and (4) where possible, work to address modifiable factors. Objective: To characterize the impact of spirituality on active duty military and Veterans with combat-related PTSD. Eligibility Criteria:Articles were included if they examined active duty military or Veterans diagnosed with combat-related PTSD and assessed spirituality. Sources of Evidence: A systematic search was conducted on July 23, 2024, across Academic Search Premier, APA PsycINFO, APA PsycArticles, Atla Religion, CINAHL Ultimate, Cochrane Central Register of Controlled Trials, MEDLINE, and SocINDEX. Charting Methods: Data extraction followed the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis and was conducted using Covidence. A data extraction template was developed to compare study aims, population, eligibility criteria, combat exposure, PTSD and mental health diagnoses, spiritual and religious variables, and validated measures. The template also captured pre- and post-deployment factors, including spirituality before combat exposure, educational, marital status, and other demographic or social variables. Key outcomes included PTSD symptom severity, posttraumatic growth, moral injury, and resilience. Moderators such as positive social factors, SDoH, adverse childhood experiences, and service era were also recorded. Studies were grouped thematically and geographically to identify patterns across military populations and research frameworks. A total of 59 studies met inclusion criteria, with 50 (84.7%) being cross-sectional, reflecting the predominance of observational research. Randomized controlled trials accounted for 3 (5.1%), although cohort studies were limited to 4 (6.8%). Research primarily focused on U.S. Veterans, with limited global representation from Bosnia and Herzegovina, Canada, Croatia, Iran, Mexico, and Sri Lanka. The most commonly used measures followed a framework of combat exposure, moral injury, PTSD, spirituality, and posttraumatic growth. Mixed associations between religious/spiritual (R/S) factors and mental health were observed. Positive religious coping, organizational religious activities, and religious service attendance generally predicted better mental health, whereas negative religious coping and spiritual struggles consistently predicted worse mental health. However, paradoxical findings were also observed, such that greater intrinsic religiosity and pre-military religious commitment predicted worse posttraumatic outcomes in some studies. Spirituality was variably associated with PTSD severity but more consistently linked to moral injury, resilience, and posttraumatic growth. Given the limited number of studies and variability in findings, it is not possible to draw definite conclusions about associations between R/S and combat-related PTSD at this time. Findings highlight the need for longitudinal and interventional studies and support development of spiritually integrated, culturally informed care models to improve outcomes for diverse military and Veteran populations.

Purpose of ReviewHealthcare workers (HCWs) may be exposed to potentially morally injurious events (PMIEs) while on the job and consequently experience acute, functional moral distress to prolonged, impairing moral injury.Recent FindingsWe reviewed 185 articles on moral distress and/or injury among HCWs. This included 91 empirical studies (approximately 50% of the retained articles), 68 editorials (37%), 18 reviews (10%), and 8 protocol papers (4%). Themes were explored using bibliometric network analysis of keyword co-citation. Empirical studies found evidence of PMIE exposure among a considerable proportion of HCWs. Greater moral distress severity was associated with worse mental and occupational health outcomes, especially among women (vs. men), younger HCWs (vs. older), nurses (vs. physicians), those who worked more hours, and HCWs with less experience. Programs to prevent and treat moral injury among HCWs lack empirical evidence.SummaryEfforts to maintain the well-being and effectiveness of HCWs should consider the potential impact of moral injury. To that end, we introduce a dimensional contextual model of moral injury in healthcare settings and discuss recommendations for prevention and treatment.

IntroductionThe COVID-19 pandemic has strongly impacted mental health outcomes of healthcare workers (HWs). In spite of the large literature reporting on Post-Traumatic Stress Disorder (PTSD) symptoms, only a few studies focused on potential positive aspects that may follow the exposure to the COVID-19 pandemic, namely post-traumatic growth (PTG) among HWs.ObjectivesIn a large sample of Italian HWs, we aimed to investigate the prevalence of PTSD, its correlates and whether PTG dimensions independently affect the risk of PTSD during the first COVID-19wave.MethodsAn online self-report survey was submitted to HWs throughout physicians’ and nurses’ associations, social networks and researchers’ direct contacts, between April 4th and May 13th, 2020. Sociodemographic data, information about possible COVID-19 related stressful events, Impact of Event Scale-Revised (IES-R) and PTG Inventory-Short Form (PTGI-SF) scores were collected. IES-R and PTGI-SF scores were compared between subjects based on main sociodemographic, work- and COVID-19-related variables using the Student T-test or the one-way ANOVA where appropriate. Post-hoc comparisons were conducted using the Tukey test. Participants with total IES-R score >32 were assigned a provisional PTSD diagnosis and binary logistic regression analysis was conducted to investigate the contribution of each variable to the provisional PTSD diagnosis.ResultsOut of 930 respondents, 256 (27,1%) reported a provisional PTSD diagnosis. Female sex (p<.001), separation from cohabiting family (p<.001), family members infected with (p<.05) or deceased due to (p<.05) COVID-19, increased workload (p<.05), relocation to a different work unit (p<.05) and unusual exposure to sufferance (p<.001) were significantly associated with higher IES-R mean scores. The median PTGI-SF score was 24. Factors associated with greater mean PTGI-SF scores were female gender (p<.001), being a nurse (p<.05), being older than 40 years (p<.05), and increased workload (p<.05). The logistic regression model showed that previous mental disorders (OR=1.65; 95% CI= 1.06-2.57) working in medical (OR=2.20; 95% CI=1.02-4.75), or service units (OR=2.34; 95% CI=1.10-4.98) (compared to frontline unit), relocation to a COVID-19 unit (OR=1.90; 95% CI=1.06-3.36), unusual exposure to sufferance (OR=2.83; 95% CI=1.79-4.48) and exposure to a traumatic event implying threat to self (compared to other work-related events) (OR=2.07; 95% CI=1.10, 3.89) significantly increase the risk of receiving a provisional diagnosis of PTSD, while the availability of personal protective equipment (OR=.61; 95% CI=.40-.94) and moderate or greater scores on PTGI-SF, particularly in the spiritual change domain (OR=.552; 95% CI=.35-.85), were found to be protective factors in relation to the PTSD diagnosis.ConclusionsOur results shed light on possible protective factors against PTSD symptoms in HWs facing COVID-19 pandemic.Disclosure of InterestNone Declared

People can experience posttraumatic growth (PTG) when faced with potentially traumatic events. One of the most widely-used instruments to measure PTG is the Posttraumatic Growth Inventory-Short Form (PTGI-SF). However, it has not been validated for the Spanish population. This study explored the psychometric properties of the PTGI-SF in adults living in Spain during the COVID-19 pandemic. Since it is a global disaster, two items were added to assess communal PTG. The participants were adult inhabitants of Spain during the COVID-19 pandemic (N = 855). They completed the PTGI-SF in July 2020, along with the Impact of Event Scale – Revised to measure symptoms of posttraumatic stress disorder (PTSD). They also rated the degree to which they perceived the COVID-19 crisis as being severe. In November 2020, 592 participants once again completed the PTGI-SF. The factorial validity o was tested by Structural Equations Modeling (SEM). McDonald’s ω coefficients were calculated to test internal consistency. The Intra-class Correlation Coefficient (ICC) was obtained to assess test–retest reliability. Sensitivity and criterion-related validity were assessed by exploring the association of the PTGI-SF scores with gender, age, PTSD symptoms, and perceived severity. Results indicated good psychometric properties for an eight-item, four-factor structure of the inventory in terms of structural validity, reliability, sensitivity and criterion-related validity. These factors were: Relating to Others, Personal Strength, Spiritual Change, and Life Value and Opportunities. Communal PTG overlapped with social PTG, and therefore it was not included. Cultural differences need to be addressed when measuring PTG, especially in terms of spiritual growth.

This research was conducted to assess the posttraumatic growth (PTG) experienced by the healthcare workers during the COVID-19 pandemic. The purpose was to observe whether religious beliefs predicted PTG during a pandemic and the mediating role of work motivation for the relationship between religious beliefs and PTG in the healthcare workers. It was also investigated if the risk perception regarding the virus had any implicating effects on the relationship of religious beliefs and posttraumatic growth. The sample (N=97) consisted of resident doctors (n=56), physicians (n=23), surgeons (n=03) and a nurse (n=01); which was comprised of both men (n=52) and women (n=45). The Religious Belief Scale (RBS), Work Intrinsic Extrinsic Motivation Scale (WEIMS), and Posttraumatic Growth Inventory-Short Form (PTGI-SF) were employed to collect data. The Perception of Risk was measured through items that had been previously used to assess the risk perception of healthcare workers during Severe Acute Respiratory Syndrome (SARS) epidemic. The responses from participants was collected through both online and in person. The Pearson Product Moment Correlation was used to assess the significance of relationships while Hierarchal Regression was used to assess the role of religious beliefs of healthcare workers. Moreover, PROCESS macro was used to evaluate the presence of mediation and moderation. The results revealed that religious beliefs and self-regulated motivation were significant predictors of PTG while self-regulated motivation also mediated the direct relationship between religious beliefs and PTG. Investigation of possible factors that bring about growth after experiencing trauma is an essential need of these turbulent times.

The Psychiatric Ramifications of Moral Injury Among Veterans