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Special Issue "Moral Distress and Mental Health among Healthcare Professionals"

A special issue of International Journal of Environmental Research and Public Health (ISSN 1660-4601). This special issue belongs to the section "Mental Health".

Deadline for manuscript submissions: closed (15 June 2022) | Viewed by 21047

Special Issue Editors

Dr. Giulia Lamiani
E-Mail Website
Guest Editor
Department of Health Sciences, University of Milan, 20142 Milan, Italy
Interests: clinical psychology; moral distress; intensive care; health psychology
Dr. Lidia Borghi
E-Mail Website
Assistant Guest Editor
Department of Health Sciences, University of Milan, 20142 Milan, Italy
Interests: clinical psychology; health psychology; healthcare communication; moral distress
Dr. Marina Maffoni
E-Mail Website
Assistant Guest Editor
Istituti Clinici Scientifici Maugeri, IRCCS, Psychology Unit of Montescano Institute, 27040 Montescano, Italy
Interests: qualitative and mixed-methods research; healthcare professionals’ distress and well-being, moral distress; psychosocial risk factors; medication and behavioural adherence; clinical psychology; health psychology

Special Issue Information

Dear Colleagues,

Moral distress is a frequent experience in the healthcare landscape. Moral distress was defined by Jameton (1984) as the painful feeling that occurs when clinicians cannot carry out what they believe to be appropriate because of personal or institutional constraints. Since this definition, the concept of moral distress has been theoretically refined and scales have been developed to measure it among nurses and other healthcare professionals. Research showed that moral distress has a profound impact on the individual and organizational well-being, affecting job satisfaction and retention and leading to depression and depersonalization. The suffering caused by moral distress has become more evident during the COVID-19 pandemic, where many clinicians have found themselves need to provide care in a context of limited resources. However, evidence is needed to better comprehend the relationship between moral distress and mental health outcomes among healthcare professionals. As moral distress may lead to positive behavioral and organizational changes if it is recognized and respected, the search protective factors for organizations and individuals should be promoted. Finally, as moral distress is becoming an emerging issue during the COVID-19 pandemic, new evidence is needed to design effective interventions to counteract it. In this Special Issue, we invite authors to contribute research exploring the links between moral distress and mental health, and on the factors and interventions that can address this phenomenon. New research papers, reviews, and case reports are welcome to this Issue. Papers reporting new approaches to assess and address moral distress are also welcome.

Dr. Giulia Lamiani
Guest Editor
Dr. Lidia Borghi
Dr. Marina Maffoni
Assistant Guest Editor

Manuscript Submission Information

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Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. International Journal of Environmental Research and Public Health is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2500 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • moral distress
  • resilience
  • occupational well-being
  • nursing
  • critical care medicine
  • clinical psychology
  • COVID-19
  • bioethics
  • risk and protective factors

Published Papers (15 papers)

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Research

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Article
Moral Distress among Frontline Physicians and Nurses in the Early Phase of COVID-19 Pandemic in Italy
Int. J. Environ. Res. Public Health 2022, 19(15), 9682; https://doi.org/10.3390/ijerph19159682 - 05 Aug 2022
Viewed by 287
Abstract
During the COVID-19 health emergency, healthcare professionals faced several ethical demanding job stressors, becoming at particular risk of moral distress. To date, only a few scales have been developed to evaluate moral distress among frontline professionals working in contact with COVID-19 patients. Moreover, [...] Read more.
During the COVID-19 health emergency, healthcare professionals faced several ethical demanding job stressors, becoming at particular risk of moral distress. To date, only a few scales have been developed to evaluate moral distress among frontline professionals working in contact with COVID-19 patients. Moreover, although many healthcare professionals from various disciplines were converted to COVID-19 patient care, no study has yet analyzed whether the resulting change in duties might represent a risk factor for moral distress. Thus, this study aimed to investigate how and when the change in duties during the emergency would be related to healthcare professionals’ psycho-physical malaise. To this aim, a first Italian adaptation of the Stress of Conscience Questionnaire (SCQ) was provided. In total, 272 Italian healthcare professionals participated in this cross-sectional study. Healthcare professionals who had to perform tasks outside their usual clinical duties were more likely to experience moral distress and then psycho-physical malaise. This was particularly likely for those who were extremely concerned about becoming infected with the virus. The results also indicated that the Italian adaptation of the SCQ had a one-factor solution composed of six items. This study provides the first Italian adaptation of SCQ and practical suggestions on how supporting professionals’ well-being during emergencies. Full article
(This article belongs to the Special Issue Moral Distress and Mental Health among Healthcare Professionals)
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Article
Understanding Moral Distress among Eldercare Workers: A Scoping Review
Int. J. Environ. Res. Public Health 2022, 19(15), 9303; https://doi.org/10.3390/ijerph19159303 - 29 Jul 2022
Viewed by 252
Abstract
The aging of the population in Western countries will increase the use of social and health services in the future. Employees in eldercare are at risk for experiencing moral distress, which is associated with poor work ability. The causes and consequences of moral [...] Read more.
The aging of the population in Western countries will increase the use of social and health services in the future. Employees in eldercare are at risk for experiencing moral distress, which is associated with poor work ability. The causes and consequences of moral distress among eldercare workers remain undiscovered. This scoping review investigates the existing studies of causes and consequences of moral distress among eldercare workers. Additionally, it seeks evidence of interventions designed to mitigate moral distress in eldercare workers. Fourteen studies were included in the final review. Most of the included studies were qualitative, aiming to increase understanding of morally challenging situations in eldercare. We also found quantitative studies with cross-sectional designs and small sample sizes. Thus, no reliable evidence of causal effects between moral distress and worker wellbeing in eldercare was found. We found no interventions undertaken to resolve moral distress among eldercare workers, either. More research is needed on the causes and consequences of moral distress and on interventions to mitigate moral distress among eldercare workers. This is of utmost importance to increase the attractiveness of eldercare as a workplace and to improve eldercare workers’ ability to work and sustain long working careers. Full article
(This article belongs to the Special Issue Moral Distress and Mental Health among Healthcare Professionals)
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Article
Moral Distress and Burnout in Neonatal Intensive Care Unit Healthcare Providers: A Cross-Sectional Study in Italy
Int. J. Environ. Res. Public Health 2022, 19(14), 8526; https://doi.org/10.3390/ijerph19148526 - 12 Jul 2022
Viewed by 507
Abstract
Moral distress (MD) in healthcare providers is widely recognized as a serious issue in critical care contexts. It has the potential to have negative impacts on both personal and professional wellbeing, the quality of care provided and staff turnover. The aim of this [...] Read more.
Moral distress (MD) in healthcare providers is widely recognized as a serious issue in critical care contexts. It has the potential to have negative impacts on both personal and professional wellbeing, the quality of care provided and staff turnover. The aim of this study was to investigate the relationship between MD and burnout among neonatal intensive care unit (NICU) healthcare professionals and identify the possible factors associated with its occurrence. Participants were asked to complete an online survey, which covered sociodemographic and professional information and included two self-report questionnaires (Italian Moral Distress Scale-Revised and Maslach Burnout Inventory). The sample comprised 115 healthcare providers (nurses and physiotherapists: 66.1%; physicians: 30.4%; healthcare assistants: 3.5%) working in four NICUs located within the province of Turin, Italy. The results revealed overall low levels of MD, with no significant differences between nurses/physiotherapists and physicians. Nurses/physiotherapists showed a statistically significant higher percentage of personal accomplishment burnout (32.9%) compared with physicians (8.6%; p = 0.012). MD was associated with the emotional exhaustion dimension of burnout. Spirituality and/or religiousness was shown to be a moderating variable. Further research is needed to deepen our understanding of the correlation between MD and burnout and the role of spirituality and/or religiousness as moderators. Full article
(This article belongs to the Special Issue Moral Distress and Mental Health among Healthcare Professionals)
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Article
Moral Distress Events and Emotional Trajectories in Nursing Narratives during the COVID-19 Pandemic
Int. J. Environ. Res. Public Health 2022, 19(14), 8349; https://doi.org/10.3390/ijerph19148349 - 08 Jul 2022
Viewed by 605
Abstract
The COVID-19 pandemic produced several ethical challenges for nurses, impacting their mental health and moral distress. In the moral distress model the categories of events related to moral distress are: constraint, dilemma, uncertainty, conflict, and tension, each one related to different emotions. This [...] Read more.
The COVID-19 pandemic produced several ethical challenges for nurses, impacting their mental health and moral distress. In the moral distress model the categories of events related to moral distress are: constraint, dilemma, uncertainty, conflict, and tension, each one related to different emotions. This study explored moral events’ memories and emotions in narratives of a sample of 43 Italian nurses who worked during the COVID-19 pandemic. We constructed an ad-hoc narrative interview asking nurses to narrate the memory, and the associated emotion, of an event in which they felt they could not do the right thing for the patient. We conducted a theory-driven analysis, using the categories proposed by the literature, identifying the main emotion for each category. Results show that 36 memories of events are representative of moral distress; among these, 7 are representative of none of the categories considered, and we categorized them as moral compromise. The main emotional trajectories are powerlessness, worthlessness, anger, sadness, guilt, and helplessness. From a clinical psychological point of view, our findings highlight the narration of the memories of moral events as a tool to use in the ethical sense-making of critical experiences, in order to promote well-being and moral resilience among nurses in emergency situations. Full article
(This article belongs to the Special Issue Moral Distress and Mental Health among Healthcare Professionals)
Article
The Moral Impact of the COVID-19 Pandemic on Nurses’ Burnout, Work Satisfaction and Adaptive Work Performance: The Role of Autobiographical Memories of Potentially Morally Injurious Events and Basic Psychological Needs
Int. J. Environ. Res. Public Health 2022, 19(13), 7645; https://doi.org/10.3390/ijerph19137645 - 22 Jun 2022
Cited by 1 | Viewed by 470
Abstract
The COVID-19 pandemic resulted in unprecedented exposure to Potentially Morally Injurious Events (PMIEs) for nurses, in which they were both moral transgressors and moral victims, with deleterious consequences on their psycho-social health and functioning. Our experimental design compared memories of PMIEs with memories [...] Read more.
The COVID-19 pandemic resulted in unprecedented exposure to Potentially Morally Injurious Events (PMIEs) for nurses, in which they were both moral transgressors and moral victims, with deleterious consequences on their psycho-social health and functioning. Our experimental design compared memories of PMIEs with memories of severe moral transgressions (SMTs), in which participants were only moral transgressors. Drawing from Self-Determination Theory and research on moral auto-biographical episodic memories, we assessed a conceptual model describing the impact of recalling a single PMIE or SMT event on nurses’ burnout, work satisfaction and adaptive performance. Our convenience sample comprised 614 Romanian nurses, and data was analyzed with path analysis, general linear modelling, and t-tests. Findings showed that memories of PMIEs, compared to SMTs, were more autonomy thwarting, being associated with more controlled work motivation, less moral learning, higher burnout, less work satisfaction, and adaptive performance. Burnout, moral learning, and work satisfaction were significant mediators of the relationships between PMIE and SMT recall and, respectively, adaptive performance. Our results highlight the urgency for organizational practices of moral repair for nurses after the pandemic, along with interventions meant to increase their autonomy and self-determined work motivation. Full article
(This article belongs to the Special Issue Moral Distress and Mental Health among Healthcare Professionals)
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Article
Moral Distress in Healthcare Providers Who Take Care of Critical Pediatric Patients throughout Italy—Cultural Adaptation and Validation of the Italian Pediatric Instrument
Int. J. Environ. Res. Public Health 2022, 19(7), 3880; https://doi.org/10.3390/ijerph19073880 - 24 Mar 2022
Cited by 2 | Viewed by 833
Abstract
Background: Although Moral Distress (MD) is a matter of concern within the Pediatric Intensive Care Unit (PICU), there is no validated Italian instrument for measuring the phenomenon in nurses and physicians who care for pediatric patients in Intensive Care. The authors of the [...] Read more.
Background: Although Moral Distress (MD) is a matter of concern within the Pediatric Intensive Care Unit (PICU), there is no validated Italian instrument for measuring the phenomenon in nurses and physicians who care for pediatric patients in Intensive Care. The authors of the Italian Moral Distress Scale-Revised (Italian MDS-R), validated for the adult setting, in 2017, invited further research to evaluate the generalizability of the scale to clinicians working in other fields. Our study aims to reduce this knowledge gap by developing and validating the pediatric version of the Italian MDS-R. Methods: We evaluated the new instrument for construct validity, then we administered it in a multicenter, web-based survey that involved healthcare providers of three PICUs and three adult ICUs admitting children in northern, central, and southern Italy. Finally, we tested it for internal consistency, confirmatory factorial validity, convergent validity, and differences between groups analysis. Results: The 14-item, three-factor model best fit the data. The scale showed good reliability (a = 0.87). Still, it did not correlate with the Emotional Exhaustion and Depersonalization sub-scales of the Maslach Burnout Inventory (MBI) or with the 2-item Connor-Davidson Resilience Scale (CD-RISC 2) or the Satisfaction with Life Scale (SWLS). A mild correlation was found between the Italian Pediatric MDS-R score and intention to resign from the job. No correlation was found between MD and years of experience. Females, nurses, and clinicians who cared for COVID-19 patients had a higher MD score. Conclusions: The Italian Pediatric MDS-R is a valid and reliable instrument for measuring MD among Italian health workers who care for critically ill children. Further research would be helpful in better investigating its applicability to the heterogeneous scenario of Italian Pediatric Critical Care Medicine. Full article
(This article belongs to the Special Issue Moral Distress and Mental Health among Healthcare Professionals)
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Article
How Supportive Ethical Relationships Are Negatively Related to Palliative Care Professionals’ Negative Affectivity and Moral Distress: A Portuguese Sample
Int. J. Environ. Res. Public Health 2022, 19(7), 3863; https://doi.org/10.3390/ijerph19073863 - 24 Mar 2022
Cited by 1 | Viewed by 522
Abstract
In the modern healthcare landscape, moral distress has become an increasingly common phenomenon among healthcare professionals. This condition is particularly prevalent among palliative care professionals who are confronted with bioethical issues in their daily practice. Although some studies described the effects of poor [...] Read more.
In the modern healthcare landscape, moral distress has become an increasingly common phenomenon among healthcare professionals. This condition is particularly prevalent among palliative care professionals who are confronted with bioethical issues in their daily practice. Although some studies described the effects of poor ethical climate and negative affectivity on moral distress, how these variables could be incorporated into a single model is still unclear. Thus, this study aims to investigate whether ethical relationships with the hospital could be related to the intensity and frequency of moral distress, both directly and as mediated by professionals’ negative affectivity. Sixty-one Portuguese palliative care professionals completed web-based self-report questionnaires. After exploring descriptive statistics, mediation analyses were performed using the partial least squares method. The results indicated that the presence of positive relationships with the hospital reduced the professionals’ negative affectivity levels. This, in turn, led palliative care professionals to experience a lower frequency and intensity of moral distress. Being a physician was positively associated with negative affectivity but not with the frequency of moral distress. Considering the protective role of ethical relationships with hospitals, health organizations could consider implementing interventions to improve hospitals’ ethical climate and provide staff with ethics training programs. Full article
(This article belongs to the Special Issue Moral Distress and Mental Health among Healthcare Professionals)
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Article
Impact of Nurse–Physician Collaboration, Moral Distress, and Professional Autonomy on Job Satisfaction among Nurses Acting as Physician Assistants
Int. J. Environ. Res. Public Health 2022, 19(2), 661; https://doi.org/10.3390/ijerph19020661 - 07 Jan 2022
Viewed by 808
Abstract
Although there is considerable literature on job satisfaction among nurses in various settings, there is little research about contributing factors, including moral distress to job satisfaction among a certain group of nurses, such as nurses acting as physician assistants. The purpose of this [...] Read more.
Although there is considerable literature on job satisfaction among nurses in various settings, there is little research about contributing factors, including moral distress to job satisfaction among a certain group of nurses, such as nurses acting as physician assistants. The purpose of this study was to verify the impact of nurse–physician collaboration, moral distress, and professional autonomy on job satisfaction among nurses acting as physician assistants. Descriptive and correlational research was conducted on a convenience sample of 130 nurses from five general hospitals in South Korea. In the final regression model, the adjusted R square was significant, explaining 38.2% of the variance of job satisfaction (F = 8.303, p < 0.001), where ‘cooperativeness’ (β = 0.469, p = 0.001) from nurse–physician collaboration, ‘institutional and contextual factor’ from moral distress (β = −0.292, p = 0.014), and professional autonomy (β = 0.247, p = 0.015) were included. In hospital environments, a more cooperative inter-professional relationship between nurses and physicians led to less moral distress caused by organisational constraints. A higher level of professional autonomy among nurses acting as physician assistants is required to increase their job satisfaction. Full article
(This article belongs to the Special Issue Moral Distress and Mental Health among Healthcare Professionals)
Article
Moral Distress Trajectories of Physicians 1 Year after the COVID-19 Outbreak: A Grounded Theory Study
Int. J. Environ. Res. Public Health 2021, 18(24), 13367; https://doi.org/10.3390/ijerph182413367 - 19 Dec 2021
Cited by 4 | Viewed by 1131
Abstract
The COVID-19 pandemic has confronted emergency and critical care physicians with unprecedented ethically challenging situations. The aim of this paper was to explore physicians’ experience of moral distress during the pandemic. A qualitative multicenter study was conducted using grounded theory. We recruited 15 [...] Read more.
The COVID-19 pandemic has confronted emergency and critical care physicians with unprecedented ethically challenging situations. The aim of this paper was to explore physicians’ experience of moral distress during the pandemic. A qualitative multicenter study was conducted using grounded theory. We recruited 15 emergency and critical care physicians who worked in six hospitals from the Lombardy region of Italy. Semi-structured interviews about their professional experience of moral distress were conducted from November 2020–February 2021 (1 year after the pandemic outbreak). The transcripts were qualitatively analyzed following open, axial, and selective coding. A model of moral distress was generated around the core category of Being a Good Doctor. Several Pandemic Stressors threatened the sense of Being a Good Doctor, causing moral distress. Pandemic Stressors included limited healthcare resources, intensified patient triage, changeable selection criteria, limited therapeutic/clinical knowledge, and patient isolation. Emotions of Moral Distress included powerlessness, frustration/anger, and sadness. Physicians presented different Individual Responses to cope with moral distress, such as avoidance, acquiescence, reinterpretation, and resistance. These Individual Responses generated different Moral Outcomes, such as moral residue, disengagement, or moral integrity. The Working Environment, especially the team and organizational culture, was instrumental in restoring or disrupting moral integrity. In order for physicians to manage moral distress successfully, it was important to use reinterpretation, that is, to find new ways of enacting their own values by reframing morally distressing situations, and to perceive a cooperative and supportive Working Environment. Full article
(This article belongs to the Special Issue Moral Distress and Mental Health among Healthcare Professionals)
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Article
Morally Distressing Experiences, Moral Injury, and Burnout in Florida Healthcare Providers during the COVID-19 Pandemic
Int. J. Environ. Res. Public Health 2021, 18(23), 12319; https://doi.org/10.3390/ijerph182312319 - 24 Nov 2021
Cited by 6 | Viewed by 1347
Abstract
Because healthcare providers may be experiencing moral injury (MI), we inquired about their healthcare morally distressing experiences (HMDEs), MI perpetrated by self (Self MI) or others (Others MI), and burnout during the COVID-19 pandemic. Participants were 265 healthcare providers in North Central Florida [...] Read more.
Because healthcare providers may be experiencing moral injury (MI), we inquired about their healthcare morally distressing experiences (HMDEs), MI perpetrated by self (Self MI) or others (Others MI), and burnout during the COVID-19 pandemic. Participants were 265 healthcare providers in North Central Florida (81.9% female, Mage = 37.62) recruited via flyers and emailed brochures that completed online surveys monthly for four months. Logistic regression analyses investigated whether MI was associated with specific HMDEs, risk factors (demographic characteristics, prior mental/medical health adversity, COVID-19 protection concern, health worry, and work impact), protective factors (personal resilience and leadership support), and psychiatric symptomatology (depression, anxiety, and PTSD). Linear regression analyses explored how Self/Others MI, psychiatric symptomatology, and the risk/protective factors related to burnout. We found consistently high rates of MI and burnout, and that both Self and Others MI were associated with specific HMDEs, COVID-19 work impact, COVID-19 protection concern, and leadership support. Others MI was also related to prior adversity, nurse role, COVID-19 health worry, and COVID-19 diagnosis. Predictors of burnout included Self MI, depression symptoms, COVID-19 work impact, and leadership support. Hospital administrators/supervisors should recognize the importance of supporting the HCPs they supervise, particularly those at greatest risk of MI and burnout. Full article
(This article belongs to the Special Issue Moral Distress and Mental Health among Healthcare Professionals)
Article
Ethical Conflict and Its Psychological Correlates among Hospital Nurses in the Pandemic: A Cross-Sectional Study within Swiss COVID-19 and Non-COVID-19 Wards
Int. J. Environ. Res. Public Health 2021, 18(22), 12012; https://doi.org/10.3390/ijerph182212012 - 16 Nov 2021
Cited by 2 | Viewed by 944
Abstract
Background: During the Covid-19 pandemic, nurses experienced increased pressure. Consequently, ethical concerns and psychological distress emerged. This study aimed to assess nurses’ ethical conflict, resilience and psychological impact, and compare these variables between nurses who worked in Covid-19 wards and nurses who did [...] Read more.
Background: During the Covid-19 pandemic, nurses experienced increased pressure. Consequently, ethical concerns and psychological distress emerged. This study aimed to assess nurses’ ethical conflict, resilience and psychological impact, and compare these variables between nurses who worked in Covid-19 wards and nurses who did not. Methods: Design—Multicentre online survey. Setting—Multi-site public hospital; all nursing staff were invited to participate. The survey included validated tools and a novel instrument to assess ethical conflict. Spearman’s rho coefficient was used to assess correlations between ethical conflict and psychological distress, logistic regressions to evaluate relationships between nurses’ characteristics and outcome variables, and the Mann–Whitney/t-test to compare groups. Results: 548 questionnaires out of 2039 were returned (275 = Covid-19; 273 = non-Covid-19). We found a low–moderate level of ethical conflict (median = 111.5 [76–152]), which emerged mostly for seeing patients dying alone. A moderate and significant positive correlation emerged between ethical conflict and psychological distress rs (546) = 0.453, p < 0.001. Nurses working in Covid-19-ICUs (OR = 7.18; 95%CI = 3.96–13.01; p < 0.001) and Covid-19 wards (OR = 5.85; 95%CI = 3.56–9.6; p < 0.001) showed higher ethical conflict. Resilience was a protective factor for ethical conflict. Conclusions: Ethical conflict was significantly linked to psychological distress, while a higher level of resilience was found to be a protective factor. These results can be informative for nursing management in future similar crises. Full article
(This article belongs to the Special Issue Moral Distress and Mental Health among Healthcare Professionals)
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Article
Moral Distress and Perceived Community Views Are Associated with Mental Health Symptoms in Frontline Health Workers during the COVID-19 Pandemic
Int. J. Environ. Res. Public Health 2021, 18(16), 8723; https://doi.org/10.3390/ijerph18168723 - 18 Aug 2021
Cited by 19 | Viewed by 4318
Abstract
Background: Sudden changes in clinical practice and the altered ability to care for patients due to the COVID-19 pandemic have been associated with moral distress and mental health concerns in healthcare workers internationally. This study aimed to investigate the severity, prevalence, and predictors [...] Read more.
Background: Sudden changes in clinical practice and the altered ability to care for patients due to the COVID-19 pandemic have been associated with moral distress and mental health concerns in healthcare workers internationally. This study aimed to investigate the severity, prevalence, and predictors of moral distress experienced by Australian healthcare workers during the COVID-19 pandemic. Methods: A nationwide, voluntary, anonymous, single time-point, online survey of self-identified frontline healthcare workers was conducted between 27th August and 23rd October 2020. Participants were recruited through health organisations, professional associations, or colleges, universities, government contacts, and national media. Results: 7846 complete responses were received from nurses (39.4%), doctors (31.1%), allied health staff (16.7%), or other roles (6.7%). Many participants reported moral distress related to resource scarcity (58.3%), wearing PPE (31.7%) limiting their ability to care for patients, exclusion of family going against their values (60.2%), and fear of letting co-workers down if they were infected (55.0%). Many personal and workplace predictors of moral distress were identified, with those working in certain frontline areas, metropolitan locations, and with prior mental health diagnoses at particular risk of distress. Moral distress was associated with increased risk of anxiety, depression, post-traumatic stress disorder, and burnout. Conversely, feeling appreciated by the community protected against these risks in healthcare workers. Conclusions: Safeguarding healthcare workforces during crises is important for both patient safety and workforce longevity. Targeted interventions are required to prevent or minimise moral distress and associated mental health concerns in healthcare workers during COVID-19 and other crises. Full article
(This article belongs to the Special Issue Moral Distress and Mental Health among Healthcare Professionals)

Review

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Review
A Scoping Review of Moral Stressors, Moral Distress and Moral Injury in Healthcare Workers during COVID-19
Int. J. Environ. Res. Public Health 2022, 19(3), 1666; https://doi.org/10.3390/ijerph19031666 - 01 Feb 2022
Cited by 8 | Viewed by 1790
Abstract
Ethical dilemmas for healthcare workers (HCWs) during pandemics highlight the centrality of moral stressors and moral distress (MD) as well as potentially morally injurious events (PMIEs) and moral injury (MI). These constructs offer a novel approach to understanding workplace stressors in healthcare settings, [...] Read more.
Ethical dilemmas for healthcare workers (HCWs) during pandemics highlight the centrality of moral stressors and moral distress (MD) as well as potentially morally injurious events (PMIEs) and moral injury (MI). These constructs offer a novel approach to understanding workplace stressors in healthcare settings, especially in the demanding times of COVID-19, but they so far lack clear identification of causes and consequences. A scoping review of moral stressors, moral distress, PMIEs, and MI of healthcare workers during COVID-19 was conducted using the databases Web of Science Core Collection and PsycINFO based on articles published up to October 2021. Studies were selected based on the following inclusion criteria: (1) the measurement of either moral stress, MD, PMIEs, or MI among HCWs; (2) original research using qualitative or quantitative methods; and (3) the availability of the peer-reviewed original article in English or German. The initial search revealed n = 149,394 studies from Web of Science and n = 34 studies from EBSCOhost. Nineteen studies were included in the review. Conditions representing moral stressors and PMIEs as well as MD and MI as their potential outcomes in healthcare contexts during COVID-19 are presented and discussed. Highlighting MD and MI in HCWs during COVID-19 brings attention to the need for conceptualizing the impact of moral stressors of any degree. Therefore, the development of a common, theoretically founded model of MD and MI is desirable. Full article
(This article belongs to the Special Issue Moral Distress and Mental Health among Healthcare Professionals)
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Review
Ethical Problems and Moral Distress in Primary Care: A Scoping Review
Int. J. Environ. Res. Public Health 2021, 18(14), 7565; https://doi.org/10.3390/ijerph18147565 - 16 Jul 2021
Cited by 4 | Viewed by 2043
Abstract
Background: Since 1997, nursing ethics research has focused on solving ethical dilemmas, enhancing decision-making strategies, and introducing professional education. Few studies describe the triggers of ethical dilemmas among primary care nurses. The aim of this study was to explore the moral distress and [...] Read more.
Background: Since 1997, nursing ethics research has focused on solving ethical dilemmas, enhancing decision-making strategies, and introducing professional education. Few studies describe the triggers of ethical dilemmas among primary care nurses. The aim of this study was to explore the moral distress and ethical dilemmas among primary care nurses. Methods: A scoping review was performed following Arskey and O’Malley’s framework. PubMed, CINAHL, PsycINFO, Embase, and Scopus were searched systematically to retrieve relevant titles and abstracts. A temporal filter was applied to focus on the most recent literature (years of 2010–2020). The research was completed on 17 November 2020. Results: Of 184 articles retrieved, 15 were included in the review. Some (n = 7) studies had a qualitative design, and the most productive country was Brazil (n = 7). The total number of nurses involved in quantitative studies was 1137 (range: 36–433); the total number of nurses involved in qualitative studies was 144 (range: 7–73). Three main focus areas were identified: (a) frequent ethical conflicts and moral distress episodes among nurses working in primary care settings; (b) frequent moral distress measures here employed; (c) coping strategies here adopted to prevent or manage moral distress. Conclusion: Further research is needed to examine the differences between moral distress triggers and sources of ethical dilemmas among the different care environments, such as primary care and acute care settings. Full article
(This article belongs to the Special Issue Moral Distress and Mental Health among Healthcare Professionals)
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Review
Psychological Support Interventions for Healthcare Providers and Informal Caregivers during the COVID-19 Pandemic: A Systematic Review of the Literature
Int. J. Environ. Res. Public Health 2021, 18(13), 6939; https://doi.org/10.3390/ijerph18136939 - 28 Jun 2021
Cited by 12 | Viewed by 2638
Abstract
Background: During the COVID-19 pandemic, healthcare providers and informal caregivers were at an increased risk of adverse mental health effects. This systematic review provides a summary of the available evidence on the content and efficacy of the psychological support interventions in increasing mental [...] Read more.
Background: During the COVID-19 pandemic, healthcare providers and informal caregivers were at an increased risk of adverse mental health effects. This systematic review provides a summary of the available evidence on the content and efficacy of the psychological support interventions in increasing mental health among healthcare providers and informal caregivers during the COVID-19 pandemic. Methods: PubMed, Google Scholar, PsychINFO, and Scopus databases were systematically searched for relevant articles, and the methodological quality of selected articles was assessed using the Quality Assessment Tool for Quantitative Studies. Results: A search of electronic databases identified five reports based on inclusion and exclusion criteria. All psychological support interventions for caregivers were delivered digitally. Despite the large heterogeneity of the selected studies, the findings support the efficacy of mental health interventions in reducing distress and burnout, while promoting self-efficacy and well-being in both healthcare providers and informal caregivers. Conclusion: Since mental health problems are expected to increase during, and as a result of, the COVID-19 pandemic, and digital tools might offer a range of mental health treatments to meet the unique and immediate needs of people, further research is needed to test the cost-effectiveness of digital psychological interventions. Full article
(This article belongs to the Special Issue Moral Distress and Mental Health among Healthcare Professionals)
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