Moral Distress in Hospitals During the First Wave of the COVID-19 Pandemic: A Web-Based Survey Among 3,293 Healthcare Workers Within the German Network University Medicine

Abstract

Objective: The present study aimed to investigate the correlation between moral distress and mental health symptoms, socio-demographic, occupational, and COVID-19-related variables, and to determine differences in healthcare workers’ (HCW) moral distress during the first wave of the COVID-19 pandemic.Method: Data from 3,293 HCW from a web-based survey conducted between the 20th of April and the 5th of July 2020 were analyzed. We focused on moral distress (Moral Distress Thermometer, MDT), depressive symptoms (Patient Health Questionnaire-2, PHQ-2), anxiety symptoms (Generalized Anxiety Disorder-2, GAD-2), and increased general distress of nurses, physicians, medical-technical assistants (MTA), psychologists/psychotherapists, and pastoral counselors working in German hospitals.Results: The strongest correlations for moral distress were found with depressive symptoms, anxiety symptoms, occupancy rate at current work section, and contact with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Nurses and MTA experienced significantly higher moral distress than physicians, psychologists/psychotherapists, and pastoral counselors. The average level of moral distress reported by nurses from all work areas was similar to levels which before the pandemic were only experienced by nurses in intensive or critical care units.Conclusion: Results indicate that moral distress is a relevant phenomenon among HCW in hospitals during the COVID-19 pandemic, regardless of whether they work at the frontline or not and requires urgent attention.

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

“…Our study, like prior studies of moral distress during the COVID-19 pandemic, found strong links between degree of exposure to COVID-19 (and its consequences) and moral distress [ 13 , 14 , 16 , 19 , 25 ]. Health care workers who have high levels of exposure or risk of death from COVID-19 believe that the pandemic makes it difficult for them to provide optimal patient care because of fear of being infected or dying from COVID-19 [ 44 ].…”

“…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.…”

“…Multiple studies have attempted to identify individual and organizational factors that are associated with moral distress during the COVID-19 pandemic because those clues may lead to interventions to prevent it or mitigate its impact. Of the studies on moral distress conducted during the COVID-19 pandemic that used standard instruments to measure moral distress [ 11 , 13 – 25 ], frequency of exposure to patients with COVID-19 was positively associated with moral distress [ 16 , 19 , 25 ], and adequacy of personal protective equipment [ 16 , 17 ] and a positive ethical climate in the health organization [ 17 ] was negatively associated However, the effects of other individual characteristics, such as perceived risk of developing COVID-19 or risk of dying, if infected, on moral distress are unknown as are the effects of organizational characteristics, such organizational support of their health workers and leadership communication during the pandemic. In addition, it is unknown whether punitive organizational policies during the pandemic, such as sanctioning workers who speak out about COVID-19 safety, cause moral distress.…”

“…Several studies during the COVID-19 pandemic have demonstrated that moral distress is associated with adverse mental health. Specifically, studies have demonstrated associations between moral distress and screening positive for anxiety [ 17 , 19 – 23 , 25 ], depression [ 17 , 19 – 23 , 25 ], burnout [ 17 , 23 ] and PTSD [ 12 , 17 ]. However, no studies have evaluated the impact of specific levels of moral distress (low, moderate, high) during the pandemic on adverse mental health outcomes.…”

Moral distress amongst palliative care doctors working during the COVID-19 pandemic: A narrative-focussed interview study

“… 2 The changes we have seen may be in place long-term and it is therefore important to understand the impact on doctors and to investigate the ways in which they are adapting and coping. Previous literature has explored the experiences of healthcare workers across a broad range of settings during the pandemic 3 , 4 and the impact of mask wearing on communication. 5 Studies in palliative care have shown an increase in anxiety and psychological distress amongst healthcare workers, 6 and a struggle to communicate and connect effectively with patients due to work pressures and national restrictions.…”