Moral injury in nurses during COVID-19: A systematic review and meta-analysis.

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

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

This study investigated whether moral injury appraisals moderated the relationships between trauma, postmigration living difficulties, resilience, and mental health outcomes in adolescent refugees. Eighty-five adolescent refugees from a community sample completed an online survey. A significant interaction was found between moral injury and discrimination for externalizing and posttraumatic stress disorder (PTSD) symptoms; adolescents whom had experienced high levels of discrimination combined with high levels of moral injury had poorer mental health. A significant interaction was found between moral injury and resilience for internalizing symptoms: high levels of resilience appeared to buffer the association between moral injury and internalizing symptoms. Contrary to predictions, stressful life experiences and postmigration living difficulties did not interact significantly with moral injury to predict mental health. Discrimination may contribute to perpetuating poor mental health in adolescent refugees with high levels of moral injury. Resilience may buffer some of the negative effects of moral injury.

BackgroundThe COVID-19 pandemic has placed significant emotional and ethical burdens on healthcare workers (HCWs), leading to the emergence of moral injury (MI). Understanding the pooled mean and factors associated with MI is crucial for developing interventions and support systems for HCWs. This meta-analysis aims to examine the extent of MI among HCWs during the COVID-19 pandemic and identify potential contributing factors.MethodsA systematic literature search was conducted, and relevant studies reporting on MI in HCWs during the COVID-19 pandemic were included. Pooled means were calculated using random-effects or fixed effect models. Subgroup analyses were conducted based on demographic variables, such as gender, profession, and geographical region. Further, Sensitivity analysis was run to assess the individual study effect.ResultsA total of 36 studies met the inclusion criteria and were included in the meta-analysis. The pooled mean of MI among HCWs during the COVID-19 pandemic was ranged from 3.06 (CI95%: 2.35–3.77) to 119.17 (CI95%: 103.04–135.30), based on the instrument types. Further analyses revealed that females (P = 0.21), younger HCWs (P = 0.13), nurses (P = 0.55), and those in developing countries (P = 0.02) experienced higher levels of MI.ConclusionThis meta-analysis highlights the substantial MI experienced by healthcare workers (HCWs) during the COVID-19 pandemic, with nurses, younger HCWs, and those in developing countries being particularly affected. Although statistical significance was not observed in subgroup differences, trends suggest a heightened vulnerability among specific groups. These findings underscore the urgent need for targeted interventions and policies to support HCWs, particularly in high-risk demographics, and emphasize the importance of standardized MI assessment tools for future research.

Healthcare providers (HCPs) have described the onset of shame- and trust-violation-related moral injuries (MI) throughout the COVID-19 pandemic. Previous research suggests that HCPs may turn to various coping methods and supports, such as spirituality/religiosity, substance use, friends/family or organizational support, to manage workplace stress. It remains unknown, however, if similar coping methods and supports are associated with MI among this population. We explored associations between MI (including the shame and trust-violation presentations individually) and coping methods and supports. Canadian HCPs completed an online survey about their mental health and experiences during the COVID-19 pandemic, including demographic indices (e.g., sex, age, mental health history) and measures of MI, organizational support, social support, spiritual well-being, self-compassion, alcohol use, cannabis use and childhood adversity. Three hierarchical multiple linear regressions were conducted to assess the associations between coping methods/supports and (i) MI, (ii) shame-related MI and (iii) trust-violation-related MI, when controlling for age, mental health history and childhood adversity. One hundred and seventy-six (N = 176) HCPs were included in the data analysis. Spiritual well-being and organizational support were each significantly associated with reduced total MI (p’s < 0.001), shame-related MI (p = 0.03 and p = 0.02, respectively) and trust-violation-related MI (p’s < 0.001). Notably, comparison of the standardized beta coefficients suggests that the association between trust-violation-related MI and both spiritual well-being and organizational support was more than twice as great as the associations between these variables and shame-related MI, emphasizing the importance of these supports and the trust-violation outcomes particularly. Mental health history (p = 0.02) and self-compassion (p = 0.01) were additionally related to shame-related MI only. Our findings indicate that heightened levels of spiritual well-being and organizational support were associated with reduced MI among HCPs during the COVID-19 pandemic. Rather than placing sole responsibility for mental health outcomes on HCPs individually, organizations can instead play a significant role in mitigating MI among staff by implementing evidence-informed organizational policies and interventions and by considering how supports for spiritual well-being may be implemented into existing models of care where relevant for employees.

333 Prevalence of Moral Injury and its Clinical Consequences Among Filipino Emergency Physicians During the COVID-19 Pandemic: A Cross-Sectional Study

BackgroundHospital-based healthcare workers have experienced significant psychological stressors during the COVID-19 pandemic.AimTo evaluate the mental health of hospital workers during the third wave of the COVID-19 pandemic in Dublin, Ireland.MethodsCross-sectional anonymous online survey of hospital workers (n = 377; 181 doctors (48.0%), 166 nurses (44.0%), 30 radiographers (8.0%)), collecting demographic information, COVID-19 exposure history and mental health measures.ResultsThere were significant differences between profession groups in gender, experience, COVID-19 infection history, exposure to COVID-19 positive acquaintances, and work areas. Moderate-severe post-traumatic stress disorder (PTSD) symptoms were found in 45.1% (95% CI 40.1–50.1%) of all participants; significantly fewer doctors reported moderate-severe PTSD symptoms (26%; 95% CI 22–36%). A World Health Organisation-5 Wellbeing Index (WHO-5) score ≤ 32, indicating low mood, was reported by 52% (95% CI 47–57%) of participants; significantly fewer doctors reported low mood (46%; 95% CI 39–53%). One-week suicidal ideation and planning were reported respectively by 13% (95% CI 10–16%) and 5% (95% CI 3–7%) of participants with no between-group differences. Doctors reported significantly less moral injury than other groups. There were no significant between-group differences regarding coping styles. Work ability was insufficient in 39% (95% CI 34–44%) of staff; no between-group differences.ConclusionsDublin hospital workers reported high levels of PTSD symptoms, mood disturbance, and moral injury during the COVID-19 pandemic. Concerning levels of suicidal ideation and planning existed in this cohort. Differences in degrees of post-traumatic stress, moral injury, and wellbeing were found between profession groups, which should be considered when planning any supports.

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.

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.

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

Nursing leadership continue to grapple with the pre‐existing social, physical, spiritual, and emotional toll experienced by the nursing workforce, further exacerbated by the pandemic. The three‐fold purpose of this current quantitative study was to measure the impact of the pandemic on nurses’ levels of burnout, moral injury, and resilience; measure levels of compassion satisfaction, and secondary traumatic stress; and identify protective factors against burnout and moral injury that could bolster resilience. An electronic survey was created using three validated instruments and sent to nurses in one US state. Bivariate and multivariate analyses were performed. Survey response rate was 5.5%. Respondents reported high levels of burnout and moral injury, and reduced levels of resilience. Protective factors included age, experience, education, and religion, with the older, more experienced, and educated nurse who identified as Christian being found to represent the most protected group. Multipronged strategies are needed to support, sustain, and recover nurses’ mental health across demographics to meet current and future workforce needs.

The Wicked Problem of Physician Well-Being.

Objectives:The present research studied moral injury and psychological resilience in healthcare professionals amid COVID-19 pandemic. Relationship between moral injury and resilience was explored in addition to finding the difference in study variables based on socio-demographics factors.Methods:This cross-sectional research was carried out from August 2020 to January 2021. A sample of 108 healthcare professionals including doctors, nurses, and paramedical staff was collected through purposive sampling technique. Data was gathered through face-to-face survey method and online forum using psychometrically sound tools. Results:Findings revealed that more than two third of the sample (69.44%) has high level of moral injury which is clinically significant while only 30.56% fall within normal range. Moral injury has significant positive correlation with number of work hours (p < .05) whereas negative correlation with resilience (p < .01) and years of experience (p < .05). Women and health care professionals belonging to psychiatry department have reported to experience significantly high level of moral injury (p < .01).Conclusion:The findings of the study are helpful for stakeholders of health care system to better understand and prepare for the situations that brings moral injury and challenge psychological resilience particularly in times of pandemic, humanitarian crisis, or natural disasters.

The COVID-19 pandemic has been associated with various health-related issues among nurses, including mental health problems such as moral injury. This study aimed to evaluate the relationship between moral injury, general health, post-traumatic stress disorder (PTSD), and type of hospital among Iranian nurses working in different clinical settings during the COVID-19 outbreak. This cross-sectional study employed convenience sampling to recruit 334 nurses working in various clinical settings, including teaching and referral hospitals, in Kerman, Southeastern Iran from October 2021 to February 2022. The study used three measures, including the General Health Questionnaire (GHQ-12), the Impact of Event Scale-Revised (IES-R), and The Moral Injury Symptom Scale-Healthcare Professionals version (MISS-HP). Data analysis was conducted using SPSS25. The results indicated that moral injury was highly prevalent among Iranian nurses, with 47% of the participants reporting experiencing it. A total, 26.9% of the participants reported experiencing mental health disorders and 57.2% of the participants reported experiencing this disorder. Significant correlations were found between moral injury, general health, and PTSD. Specifically, moral injury levels were higher among female nurses with a history of mental disorders and those designated to treat all kinds of cases, compared to other participants. The results suggest that Iranian nurses are at a high risk of experiencing moral injury during the COVID-19 pandemic. Policymakers and health authorities should establish related health educational programs, provide counseling services to promote general health, and pay particular attention to moral injury and PTSD. Additionally, nurse educators should integrate materials related to moral injury into the nursing curriculum.

Physician Mental Health During COVID-19: A Call to Action