Association of Moral Distress with Anxiety, Depression, and an Intention to Leave among Nurses Working in Intensive Care Units during the COVID-19 Pandemic

Abstract

Background: Wide geographical variations in depression and anxiety rates related to the ethical climate have been reported during the COVID-19 pandemic in intensive care units (ICUs). The objective was to investigate whether moral distress is associated and has predictive values for depression, anxiety, and intention to resign. Methods: 79 consenting ICU nurses completed MMD-HP and PHQ-4 scales in this cross-sectional study between October 2020–February 2021, after ethical approval. The association between MMD-HP and PHQ-4, and the predictive value of MMD-HP for anxiety, depression, and an intention to leave were analyzed (linear regression and receiver operating characteristics curve analysis). Results: From MMD-HP items, system related factors had highest scores (Kruskal–Wallis test, p < 0.0001). MMD-HP and PHQ-4 were weakly correlated (r = 0.41 [0.21–0.58]). MMD-HP and its system-related factors discriminate between nurses with and without depression or anxiety, while system-related factors differentiate those intending to resign (p < 0.05). The MMD-HP score had 50 [37.54–62.46] sensitivity with 80.95 [60–92.33] specificity to predict the intention to leave, and 76.12 [64.67–84.73] sensitivity with 58.33 [31.95–80.67] specificity to detect anxiety or depression symptoms. Conclusions: During the COVID-19 pandemic, system-associated factors seem to be the most important root factors inducing moral distress. Moral distress is associated with negative psychological outcomes.

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

“…Results from this study are consistent with most studies conducted during the pandemic, which have generally shown low levels of moral distress intensity, on average, and low frequency of episodes of compromised care among physicians and other health disciplines [ 11 , 13 – 21 ]. However, we also found that about 1 in 10 physicians experienced compromised care due to resource limitations frequently and had high levels of moral distress; those with high levels of moral distress had markedly elevated adverse mental health outcomes, burnout and intention to leave patient care.…”

“…Studies of moral distress related to the COVID-19 pandemic have reported that approximately 60% to 80% of health care workers have experienced at least some situations that generate moral distress [ 9 – 13 ]. However, the intensity (severity) of moral distress among health workers during the pandemic, in those studies that reported mean moral distress levels, has been found to be low in most [ 11 , 13 – 21 ] though not all [ 22 – 24 ] studies. Among these studies, some assessed the intensity of moral distress for specific situations [ 15 , 20 ], some assessed both the frequency and intensity of moral distress for specific situations [ 13 , 14 , 17 , 18 , 21 , 22 , 24 , 25 ] and others assessed it with a global measure of moral distress without anchoring the assessment to specific potentially-morally-distressing situations [ 11 , 19 , 23 ].…”

“…However, the intensity (severity) of moral distress among health workers during the pandemic, in those studies that reported mean moral distress levels, has been found to be low in most [ 11 , 13 – 21 ] though not all [ 22 – 24 ] studies. Among these studies, some assessed the intensity of moral distress for specific situations [ 15 , 20 ], some assessed both the frequency and intensity of moral distress for specific situations [ 13 , 14 , 17 , 18 , 21 , 22 , 24 , 25 ] and others assessed it with a global measure of moral distress without anchoring the assessment to specific potentially-morally-distressing situations [ 11 , 19 , 23 ]. The systematic reviews by Gianetta and colleagues [ 1 ] and by Tian and colleagues [ 26 ] provide comprehensive discussions of instruments that have been used to measure moral distress.…”

Critical care nurses’ perception of moral distress in intensive care during the COVID-19 pandemic – A pilot study

“…The frequency (i.e., how often situation arose) and level of intensity (i.e., how disturbing the situation was when it occurred) of each item was evaluated using a five-point Likert scale; frequency ranged from 0 (never) to 4 (very frequently) and the level of disturbance ranged from 0 (none) to 4 (to a great extent). Previous research using MDS-R ( Lamiani et al, 2017 ) or variations of the scale ( Donkers et al, 2021 , Petrișor et al, 2021 , Rodriguez-Ruiz et al, 2021 ) are reported with a total score for each item meaning the frequency and intensity is computed by multiplying the two scores. However, reporting the two aspects of moral distress separately could provide further knowledge about the nuances of moral distress.…”

“…They were also forced to contend with inadequate personal protective equipment and their obligations to provide nursing care for patients ( Brown, 2020 ). Recent research ( Donkers et al, 2021 , Petrișor et al, 2021 , Rodriguez-Ruiz et al, 2021 , Silverman et al, 2021 ) have described health care professionals such as CCNs experiencing moral distress because COVID-19 pandemic created new challenges for CCNs.…”