The new frontline: exploring the links between moral distress, moral resilience and mental health in healthcare workers during the COVID-19 pandemic

Abstract

Background Global health crises, such as the COVID-19 pandemic, confront healthcare workers (HCW) with increased exposure to potentially morally distressing events. The pandemic has provided an opportunity to explore the links between moral distress, moral resilience, and emergence of mental health symptoms in HCWs. Methods A total of 962 Canadian healthcare workers (88.4% female, 44.6 + 12.8 years old) completed an online survey during the first COVID-19 wave in Canada (between April 3rd and September 3rd, 2020). Respondents completed a series of validated scales assessing moral distress, perceived stress, anxiety, and depression symptoms, and moral resilience. Respondents were grouped based on exposure to patients who tested positive for COVID-19. In addition to descriptive statistics and analyses of covariance, multiple linear regression was used to evaluate if moral resilience moderates the association between exposure to morally distressing events and moral distress. Factors associated with moral resilience were also assessed. Findings Respondents working with patients with COVID-19 showed significantly more severe moral distress, anxiety, and depression symptoms (F > 5.5, p < .020), and a higher proportion screened positive for mental disorders (Chi-squared > 9.1, p = .002), compared to healthcare workers who were not. Moral resilience moderated the relationship between exposure to potentially morally distressing events and moral distress (p < .001); compared to those with higher moral resilience, the subgroup with the lowest moral resilience had a steeper cross-sectional worsening in moral distress as the frequency of potentially morally distressing events increased. Moral resilience also correlated with lower stress, anxiety, and depression symptoms (r > .27, p < .001). Factors independently associated with stronger moral resilience included: being male, older age, no mental disorder diagnosis, sleeping more, and higher support from employers and colleagues (B [0.02, |-0.26|]. Interpretation Elevated moral distress and mental health symptoms in healthcare workers facing a global crisis such as the COVID-19 pandemic call for the development of interventions promoting moral resilience as a protective measure against moral adversities.

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

“…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.…”

“…Of the extant quantitative studies of moral distress during the COVID-19 pandemic, most used convenience sampling with indeterminate response rates [ 9 , 10 , 16 – 23 , 25 ]. Two sampled defined populations but reported response rates less than 20% [ 11 , 13 ].…”

“…Both factors raise concerns about the possibility of selection bias. Most of the studies were based on non-U.S. samples [ 9 , 10 , 13 – 15 , 17 – 23 , 25 ]; applicability to the United States, given differences in health systems, and organizational responses to the pandemic, is unclear. The studies based on U.S. samples [ 13 , 16 , 24 ] assessed moral distress among health workers at one [ 13 , 16 ] or two [ 24 ] medical centers in the Northeast United States and the findings may not be applicable to physicians throughout the U.S.…”