COVID-19 pandemic moral injury in healthcare professionals: a systematic review

Abstract

AimsMoral injury (MI) refers to psychological distress resulting from witnessing or participating in events which violate an individual's moral code. Originating from military experiences, the phenomenon also has relevance for healthcare professionals dealing with wars, natural disasters and infectious diseases. The deontological basis of medicine prioritises duty to the individual patient over duty to wider society. These values may place healthcare professionals at increased risk of moral injury, particularly in crisis contexts where they may be party to decisions to withdraw or divert care based on resource availability.We conducted a systematic review of medical literature to understand the extent and clinical and socio-demographic correlates of moral injury during the COVID-19 pandemic.MethodWe conducted a systematic review of reports included in MEDLINE, PsycINFO, BNI, CINAHL, EMBASE, EMCARE and HMIC databases using search terms: “moral injury” AND “covid” OR “coronavirus” OR “pandemic”. We also searched Google Scholar and Ovid Database and conducted reference searching. We searched for published quantitative primary research as well as advance online publications and pre-print research. Findings are reported in line with Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA). Two authors independently assessed the included studies’ methodological quality using a seven-item checklist.ResultOur databases search identified 498 records and other sources identified 4 records. We screened 391 records after removing duplicates. 4 reports met our protocol requirements.Three papers used cross-sectional designs. One reported longitudinal outcomes of their sample already described in one of the three papers. Only one study used a MI scoring system validated for healthcare professionals. Others used scoring validated in military populations. These papers reported outcomes from 3334 subjects, with a higher proportion of females. The largest study (3006 subjects) reported MI in 41.3% of their sample. Overall, factors associated with greater MI included: providing direct care to COVID-19 patients; sleep troubles; being unmarried; aged <30 years; female gender; and Buddhist/Taoist faith. Nurses reported a greater severity of MI than physicians. MI significantly correlated with anxiety, depression and burnout. The longitudinal study reported that more stressful and less supportive work environments predicted greater MI at 3 months follow-up.The average quality assessment score of these studies was 4/7.ConclusionIt is important that we are able to address moral injury awareness training as part of workforce preparedness and burnout prevention during the COVID-19 pandemic and other disaster responses across the globe.

Moral Injury, Nurse Well-being, and Resilience Among Nurses Practicing During the COVID-19 Pandemic

“…Their resilience scores were relatively positive, suggesting that despite their low well-being and high MI, they are resilient. Not surprisingly, MI was moderately negatively associated with well-being, consistent with the findings of prior studies, 6,14 and negatively associated with resilience. These findings are important for nurse administrators who can work with staff to create environmental and system solutions/resources.…”

“…Future studies could be implemented to address circumstances that lead to MI at a system level 32,33 . This could include regular manager rounds to acknowledge the struggles and risk of MI 32 and promote coping, connectedness, self-efficacy, hope calm, and safety 14 and team meetings to discuss concerns and truly listening to staff 34 . In addition, consultations with ethics experts can help nurses and nurse leaders manage MI and address what is unacceptable in challenging clinical situations 28 .…”

“…12,13 Reports from nurses working during COVID-19 point to ethical issues and dilemmas linked to both MI and moral distress. 14 Nurses have felt constrained from doing the right thing for many reasons. 15 They have reported being treated like they are expendable.…”

“…The concept of MI has only recently been applied in healthcare, and much remains unclear about its precise nature 12,13 . Reports from nurses working during COVID-19 point to ethical issues and dilemmas linked to both MI and moral distress 14 . Nurses have felt constrained from doing the right thing for many reasons 15 .…”

Understanding Moral Injury in Frontline Health Care Professionals 2 Years After the Onset of COVID-19

“…A qualitative study of the lived experiences of 18 nurses from eight European countries including the United Kingdom described emotional and ethical challenges during the first wave of the pandemic (Melnikov et al, 2022). There is also a succinct report of a systematic review that yielded four articles that examined moral injury in HPs, which concluded that moral injury awareness training is required to prepare the workforce for working in the context of COVID-19 and other disasters (Williams et al, 2021). This suggests that there is a need to understand predictors of moral injury in HPs working on the frontline to be able to provide targeted interventions in due course.…”