Potential Circumstances Associated With Moral Injury and Moral Distress in Healthcare Workers and Public Safety Personnel Across the Globe During COVID-19: A Scoping Review

Abstract

Healthcare workers (HCWs) and public safety personnel (PSP) across the globe have continued to face ethically and morally challenging situations during the COVID-19 pandemic that increase their risk for the development of moral distress (MD) and moral injury (MI). To date, however, the global circumstances that confer risk for MD and MI in these cohorts have not been systematically explored, nor have the unique circumstances that may exist across countries been explored. Here, we sought to identify and compare, across the globe, potentially morally injurious or distressful events (PMIDEs) in HCWs and PSP during the COVID-19 pandemic. A scoping review was conducted to identify and synthesize global knowledge on PMIDEs in HCWs and select PSP. Six databases were searched, including MEDLINE, EMBASE, Web of Science, PsychInfo, CINAHL, and Global Health. A total of 1,412 articles were retrieved, of which 57 articles were included in this review. These articles collectively described the experiences of samples from 19 different countries, which were comprised almost exclusively of HCWs. Given the lack of PSP data, the following results should not be generalized to PSP populations without further research. Using qualitative content analysis, six themes describing circumstances associated with PMIDEs were identified: (1) Risk of contracting or transmitting COVID-19; (2) Inability to work on the frontlines; (3) Provision of suboptimal care; (4) Care prioritization and resource allocation; (5) Perceived lack of support and unfair treatment by their organization; and (6) Stigma, discrimination, and abuse. HCWs described a range of emotions related to these PMIDEs, including anxiety, fear, guilt, shame, burnout, anger, and helplessness. Most PMIDE themes appeared to be shared globally, particularly the ‘Risk of contracting or transmitting COVID-19’ and the ‘Perceived lack of support and unfair treatment by their organization.’ Articles included within the theme of ‘Stigma, discrimination, and abuse’ represented the smallest global distribution of all PMIDE themes. Overall, the present review provides insight into PMIDEs encountered by HCWs across the globe during COVID-19. Further research is required to differentiate the experience of PSP from HCWs, and to explore the impact of social and cultural factors on the experience of MD and MI.

The Hidden Crisis: Understanding Potentially Morally Injurious Events Experienced by Healthcare Providers during COVID-19 in Canada

“…Here, moral stressors among HCPs during the pandemic include issues at the level of patient care (e.g., conflict between patient care and HCPs’ safety, witnessing inadequate care delivery), interpersonal relationships (e.g., working with HCPs who lacked knowledge of critical care, physician-nurse issues around treatment planning), and organizations (e.g., conflicts when distributing scare resources, lack of financial support, time, staff, and personal protective equipment) [ 7 ]. Relatedly, Xue and colleagues [ 8 ] conducted a scoping review to characterize extant knowledge surrounding circumstances related to moral distress and moral injury among HCPs worldwide during the COVID-19 pandemic. The results of this global scoping review revealed that potentially morally distressing or morally injurious events among HCPs worldwide during the pandemic included: (i) risk of contracting or transmitting the coronavirus; (ii) inability to work on the frontlines; (iii) provision of sub-optimal care; (iv) care prioritization and resource allocation; (v) perceived lack of support and unfair treatment by organization; and (vi) stigma, discrimination and abuse [ 8 ].…”

“…Relatedly, Xue and colleagues [ 8 ] conducted a scoping review to characterize extant knowledge surrounding circumstances related to moral distress and moral injury among HCPs worldwide during the COVID-19 pandemic. The results of this global scoping review revealed that potentially morally distressing or morally injurious events among HCPs worldwide during the pandemic included: (i) risk of contracting or transmitting the coronavirus; (ii) inability to work on the frontlines; (iii) provision of sub-optimal care; (iv) care prioritization and resource allocation; (v) perceived lack of support and unfair treatment by organization; and (vi) stigma, discrimination and abuse [ 8 ]. Despite a lack of consensus on the terms used to describe morally distressing or morally injurious events, collectively these reviews point towards widespread exposure to moral stressors, including PMIEs, among HCPs during the COVID-19 pandemic.…”

“…Moreover, those HCPs who were exposed to a PMIE showed little relative improvement in functioning over a 10-month period [ 10 ]. Notably, Xue et al’s [ 8 ] scoping review of circumstances related to moral distress and moral injury during the pandemic returned only four empirical investigations in Canada. As the impact of the pandemic varied greatly between nations given different waves, resources and crisis responses, understanding the types of PMIEs endured by Canadian HCPs remains a critical gap in the literature.…”

Anxiety Levels and Coping Strategies to Deal with COVID-19: A Cross-Cultural Study among the Spanish and Latin American Healthcare Populations

“…It is an unprecedented event in the 21st century and has posed a comprehensive challenge for everyone due to its impact on and consequences in different areas of life, such as health, the economy, and society in general [ 1 , 2 , 3 , 4 ]. As per [ 1 , 5 , 6 , 7 , 8 , 9 ] the COVID-19 health crisis has had a global impact in a short period of time, given that health professionals went from a stable situation, to living in a work environment characterized by overcrowded hospitals, lack of personal protection equipment, nonexistent or contradictory work protocols, and an increase in mortality.…”

“…Additionally, health professionals have been directly involved with their COVID-19 patients at different stages—diagnosis, treatment, care, and in the process of death—as family members were unable to accompany COVID-19 patients, who ended up dying alone. Because of this, they are more vulnerable to psychological disorders, such as anxiety [ 2 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ].…”