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.

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A Scoping Review of Moral Stressors, Moral Distress and Moral Injury in Healthcare Workers during COVID-19

Background: The mental health impact of the COVID-19 crisis may differ from previously studied stressful events in terms of psychological reactions, specific risk factors, and symptom severity across geographic regions worldwide. Objective: To assess the impact of COVID-19 on a wide range of mental health symptoms, to identify relevant risk factors, to identify the effect of COVID-19 country impact on mental health, and to evaluate regional differences in psychological responses to COVID-19 compared to other stressful events. Method: 7034 respondents (74% female) participated in the worldwide Global Psychotrauma Screen - Cross-Cultural responses to COVID-19 study (GPS-CCC), reporting on mental health symptoms related to COVID-19 (n = 1838) or other stressful events (n = 5196) from April to November 2020. Results: Events related to COVID-19 were associated with more mental health symptoms compared to other stressful events, especially symptoms of PTSD, anxiety, depression, insomnia, and dissociation. Lack of social support, psychiatric history, childhood trauma, additional stressful events in the past month, and low resilience predicted more mental health problems for COVID-19 and other stressful events. Higher COVID-19 country impact was associated with increased mental health impact of both COVID-19 and other stressful events. Analysis of differences across geographic regions revealed that in Latin America more mental health symptoms were reported for COVID-19 related events versus other stressful events, while the opposite pattern was seen in North America. Conclusions: The mental health impact of COVID-19-related stressors covers a wide range of symptoms and is more severe than that of other stressful events. This difference was especially apparent in Latin America. The findings underscore the need for global screening for a wide range of mental health problems as part of a public health approach, allowing for targeted prevention and intervention programs.

https://www.tandfonline.com/doi/pdf/10.1080/20008198.2021.1929754

Mental health responses to COVID-19 around the world.

Moral injury has primarily been studied in combat veterans but might also affect healthcare workers (HCWs) due to the COVID-19 pandemic.To compare patterns of potential moral injury (PMI) between post-9/11 military combat veterans and healthcare workers (HCWs) surveyed during the COVID-19 pandemic.Cross-sectional surveys of veterans (2015-2019) and HCWs (2020-2021) in the USA.618 military veterans who were deployed to a combat zone after September 11, 2001, and 2099 HCWs working in healthcare during the COVID-19 pandemic.Other-induced PMI (disturbed by others' immoral acts) and self-induced PMI (disturbed by having violated own morals) were the primary outcomes. Sociodemographic variables, combat/COVID-19 experience, depression, quality of life, and burnout were measured as correlates.46.1% of post-9/11 veterans and 50.7% of HCWs endorsed other-induced PMI, whereas 24.1% of post-9/11 veterans and 18.2% of HCWs endorsed self-induced PMI. Different types of PMI were significantly associated with gender, race, enlisted vs. officer status, and post-battle traumatic experiences among veterans and with age, race, working in a high COVID-19-risk setting, and reported COVID-19 exposure among HCWs. Endorsing either type of PMI was associated with significantly higher depressive symptoms and worse quality of life in both samples and higher burnout among HCWs.The potential for moral injury is relatively high among combat veterans and COVID-19 HCWs, with deleterious consequences for mental health and burnout. Demographic characteristics suggestive of less social empowerment may increase risk for moral injury. Longitudinal research among COVID-19 HCWs is needed. Moral injury prevention and intervention efforts for HCWs may benefit from consulting models used with veterans. 

/pdf/patterns-of-potential-moral-injury-in-post-9-11-combat-1dvqgr7j.pdf

Patterns of Potential Moral Injury in Post-9/11 Combat Veterans and COVID-19 Healthcare Workers

Medical leaders have warned of the potential public health burden of a "parallel pandemic" faced by healthcare workers during the COVID-19 pandemic. These individuals may have experienced scenarios in which their moral code was violated resulting in potentially morally injurious events (PMIEs). In the present study, hierarchical linear modeling was utilized to examine the role of PMIEs on COVID-19 pandemic-related difficulties in psychosocial functioning among 211 healthcare providers (83% female, 89% White, and an average of 11.30 years in their healthcare profession [9.31]) over a 10-month span (May 2020 -March 2021). Reported exposure to PMIEs was associated with statistically significant poorer self-reported psychosocial functioning at baseline and over the course of 10-months of data collection. Within exploratory examinations of PMIE type, perceptions of transgressions by self or others (e.g., "I acted in ways that violated my own moral code or values"), but not perceived betrayal (e.g., "I feel betrayed by leaders who I once trusted"), was associated with poorer COVID-19 related psychosocial functioning (e.g., feeling connected to others, relationship with spouse or partner). Findings from this study speak to the importance of investing in intervention and prevention efforts to mitigate the consequences of exposure to PMIEs among healthcare providers. Interventions for healthcare providers targeting psychosocial functioning in the context of moral injury is an important area for future research.

A longitudinal analysis of the role of potentially morally injurious events on COVID-19-related psychosocial functioning among healthcare providers

Cyberbullying is a global problem with significant negative implications, especially among more vulnerable populations, such as adolescents. Previous research suggested that cyberbullying is significantly associated with depression, and anxiety seems to partially or fully mediate this relationship. We aimed to investigate the prevalence and the relationships between cyberbullying status (i.e., cyberbully, cyber victim, double role, or non-cyber), gender, and age. We also explored the mediating roles of state and trait anxiety on the relationship between adolescents' cyberbullying victimization, cyber-aggressiveness, and depression. Our sample consisted of 501 middle adolescents aged from 12 to 15 years (M = 14.00; SD = 0.80; 51.1% males). The results suggested no significant associations between participants' status, gender, or age. Mediation analyses suggested that the relationship between cyber-victimization, cyber-aggressiveness, and depression was mediated by state anxiety and not trait anxiety. We discuss the implications of the current findings in understanding cyberbullying's psychological consequences and their relevant practical implications for prevention and intervention programs.

https://www.mdpi.com/2227-9067/7/11/240/pdf

Exploring the Mediating Roles of State and Trait Anxiety on the Relationship between Middle Adolescents' Cyberbullying and Depression.

Background: Given the profound psychological distress caused by the Covid-19 pandemic, healthcare workers are at high risk of being exposed to potentially morally injurious events (PMIEs).Objective...

https://www.tandfonline.com/doi/pdf/10.1080/20008198.2021.1898791

The prevalence of exposure to potentially morally injurious events among physicians during the COVID-19 pandemic

Does your child think you’re happy? Exploring the associations between children’s happiness and parenting styles

Using fake news as means of cyber-bullying: The link with compulsive internet use and online moral disengagement

Previous research on adults’ moral licensing and cleansing suggested the moderating role of psychological distance: psychologically close actions generate behavior opposite in valence that would restore moral balance, while distant actions motivate similar behaviors, as they are abstractly conceptualized as identity features. We adapted an experimental paradigm previously used in this area, that of recalling past moral and immoral behaviors, and used it in two studies on children (N = 285) aged 7 to 10 years. In each, we varied the temporal distance (recent vs. distant) to and valence (moral, immoral, and neutral) of the recalled behavior, and then we measured children’s altruism. In the second study, we also explored the mediating role of present versus retrospective guilt within the relationships between recalling immoral behavior and present altruism. In contradiction with the general results of research conducted among adults, our results only highlighted a moral cleansing effect of recalling immoral behavior from the distant past, a condition in which children in both studies behaved more altruistically compared to most of the other conditions. Additionally, the guilt experienced in the present towards the recalled behavior was a potential mediator of this cleansing effect. A potential explanation of this difference from the results on adults could reside in children’s lower abstraction abilities and the differences in the intensity of guilt associated with distant and recent behaviors.

Children’s altruism after recalling recent and distant morally-valenced behavior and the mediating role of guilt

Though not having children is no longer as unusual as it once was, voluntary childlessness is still a controversial choice that might generate moral outrage against people who choose not to have children. The current study explored the associated factors related to the attitudes towards voluntary childlessness in a sample of 418 adults aged 18 to 82 (M = 28.94, SD = 12.63, 76.1% females). Specifically, we investigated the links between participants’ attitudes toward benevolent and hostile sexism, religiosity, and a series of demographic variables (i.e., age, gender, education, relationship status, and parental status). Based on previous related literature, we hypothesized that sexism would mediate the relationship between religiosity and voluntary childlessness. Results suggested that older and married participants with children had more negative attitudes related to voluntary childlessness. Additionally, overall sexism and its two dimensions (hostile and benevolent sexism) partially mediated the relationship between religiosity and attitudes towards voluntary childlessness. The practical implications of these results are discussed in light of Romania’s cultural and socio-economic context, a post-communist country and the most religious state in Europe.

Andrei-Corneliu Holman

Papers

The prevalence of exposure to potentially morally injurious events among physicians during the COVID-19 pandemic

Does your child think you’re happy? Exploring the associations between children’s happiness and parenting styles

Using fake news as means of cyber-bullying: The link with compulsive internet use and online moral disengagement

Children’s altruism after recalling recent and distant morally-valenced behavior and the mediating role of guilt

Choosing a life with no children. The role of sexism on the relationship between religiosity and the attitudes toward voluntary childlessness