Impacts of morally distressing experiences on the mental health of Canadian health care workers during the COVID-19 pandemic

Plouffe, Rachel A.; Nazarov, Anthony; Forchuk, Callista; Gargala, Dominic; Deda, Erisa; Le, Tri; Bourret-Gheysen, Jesse; Jackson, Brittni; Soares, Vanessa Ferry de Oliveira; Hosseiny, Fardous; Smith, Patrick; Roth, Maya; MacDougall, Arlene; Marlborough, Michelle; Jetly, Rakesh; Heber, Alexandra; Albuquerque, Joy; Lanius, Ruth A.; Balderson, Ken; Dupuis, Gabrielle; Mehta, Viraj; Richardson, J. Don

doi:10.1080/20008198.2021.1984667

Cited by 43 publications

(45 citation statements)

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“…MI scores in these HCPs were also strongly and positively correlated with depression, anxiety, low well-being, and burnout symptoms ( 22 ). Similar results were found in a Canadian study where, again, moral distress significantly and positively predicted symptoms of depression, anxiety, PTSD, and burnout in HCPs ( 23 ). Universally, research is reporting that HCPs are at an increased risk for stress, burnout, and depression during the ongoing COVID-19 pandemic ( 24 ).…”

Section: Introductionsupporting

confidence: 87%

Companions in the Abyss: A Feasibility and Acceptability Study of an Online Therapy Group for Healthcare Providers Working During the COVID-19 Pandemic

et al. 2022

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Introduction:In the context of the global pandemic of the SARS-CoV-2 coronavirus (COVID-19), healthcare providers (HCPs) have experienced difficult moral and ethical dilemmas. Research is highlighting the importance of moral injury (MI)–a trauma syndrome related to transgressing personal morals and values–in understanding the psychological harm and occupational impairment experienced by HCPs. To date, MI treatments have largely been developed for military personnel and veterans and rely on in-person one-on-one psychotherapy.Purpose:This project aims to explore the feasibility and acceptability of an evidence-informed online Acceptance and Commitment Therapy-based group therapy for MI in HCPs called “Accepting Moral Pain and Suffering for Healthcare Providers” (AMPS-HCP).Method:This feasibility and acceptability study included three separate phases with the first two phases focused on the development of the psychotherapeutic intervention and the third phase focused on the evaluation of the psychotherapeutic intervention. Eight participants (including registered nurses, practical nurses and respiratory therapists) completed seven 90-min sessions in an online group format. The focus of these sessions included ACT and MI psychoeducation and experientials. Qualitative semi-structured interview data was thematically analyzed while demographic and quantitative self-reported outcome data underwent descriptive analysis and non-parametric testing.Results:Results show that the intervention was highly feasible and acceptable to healthcare providers who worked on the frontline during COVID-19. Feasibility (referrals, eligibility, retention, participation engagement) was strong (8 out of 10 participants; 80% vs. desired >70% eligibility) and overall, 80% of participants completed 71% of the intervention. Data further supported the applicability and acceptability of the intervention. Preliminary data suggests that AMPS-HCP may supports HCPs to address MI.Discussion:This study is the first to report on the development and evaluation of an online MI group intervention for registered nurses, registered practical nurses, and respiratory therapists working during COVID-19. Results showed the use of both the online and group components of the intervention were acceptable and feasible during the third wave of COVID-19.

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Section: Introductionsupporting

confidence: 87%

Companions in the Abyss: A Feasibility and Acceptability Study of an Online Therapy Group for Healthcare Providers Working During the COVID-19 Pandemic

et al. 2022

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“…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.…”

Section: Introductionmentioning

confidence: 99%

“…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.…”

Section: Introductionmentioning

confidence: 99%

“…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.…”

Section: Introductionmentioning

confidence: 99%

“…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.…”

Section: Introductionmentioning

confidence: 99%

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

2022

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Background There have been no studies to date of moral distress during the COVID-19 pandemic in national samples of U.S. health workers. The purpose of this study was to determine, in a national sample of internal medicine physicians (internists) in the U.S.: 1) the intensity of moral distress; 2) the predictors of moral distress; 3) the outcomes of moral distress. Methods We conducted a national survey with an online panel of internists, representative of the membership of the American College of Physicians, the largest specialty organization of physicians in the United States, between September 21 and October 8, 2020. Moral distress was measured with the Moral Distress Thermometer, a one-item scale with a range of 0 (“none”) to 10 (“worst possible”). Outcomes were measured with short screening scales. Results The response rate was 37.8% (N = 810). Moral distress intensity was low (mean score = 2.4, 95% CI, 2.2–2.6); however, 13.3% (95% CI, 12.1% - 14.5%) had a moral distress score greater than or equal to 6 (“distressing”). In multiple linear regression models, perceived risk of death if infected with COVID-19 was the strongest predictor of higher moral distress (β (standardized regression coefficient) = 0.26, p < .001), and higher perceived organizational support (respondent belief that their health organization valued them) was most strongly associated with lower moral distress (β = -0.22, p < .001). Controlling for other factors, high levels of moral distress, but not low levels, were strongly associated (adjusted odds ratios 3.0 to 11.5) with screening positive for anxiety, depression, posttraumatic stress disorder, burnout, and intention to leave patient care. Conclusions The intensity of moral distress among U.S. internists was low overall. However, the 13% with high levels of moral distress had very high odds of adverse mental health outcomes. Organizational support may lower moral distress and thereby prevent adverse mental health outcomes.

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Predictors of negative moral appraisals and their association with symptoms of post‐traumatic stress and depression in the context of COVID‐19 related stressors

Houle

Ashbaugh

2023

Stress and Health

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Research on moral injury (MI) suggests that negative moral appraisals of stressful events can impact mental health in high‐stakes occupational contexts (e.g., military). Few studies have examined these associations in the general population, limiting the generalisability of findings. Furthermore, factors that may predispose an individual to adverse outcomes in the context of moral stressors remain largely unknown. The objectives of this study were to (1) explore the applicability of the MI construct to stressors experienced by the general public during the COVID‐19 pandemic; (2) explore how trait differences in sense of duty, religiosity/spirituality, anxiety sensitivity, and guilt, shame, and anger, predict negative moral appraisals of COVID‐19 stressors. Participants (n = 355) completed an online survey assessing exposure to and appraisals of COVID‐19 stressors, mental health symptoms, and dispositional characteristics (i.e., trait emotions, anxiety sensitivity, sense of duty, religiosity/spirituality). Path analysis revealed specific indirect associations between self‐based moral appraisals and posttraumatic stress disorder (PTSD) and depression through guilt, and between both self‐ and other‐based moral appraisals and PTSD and depression through anger. Number of COVID‐19 stressors had no influence on associations. Sense of duty, reparative guilt, and anxiety sensitivity best predicted negative moral appraisals. Findings partially support the applicability of the MI construct outside the occupational context.

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Impacts of morally distressing experiences on the mental health of Canadian health care workers during the COVID-19 pandemic

Cited by 43 publications

References 53 publications

Companions in the Abyss: A Feasibility and Acceptability Study of an Online Therapy Group for Healthcare Providers Working During the COVID-19 Pandemic

Companions in the Abyss: A Feasibility and Acceptability Study of an Online Therapy Group for Healthcare Providers Working During the COVID-19 Pandemic

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

Predictors of negative moral appraisals and their association with symptoms of post‐traumatic stress and depression in the context of COVID‐19 related stressors

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