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Clinical Research Article

The independent and combined impact of moral injury and moral distress on post-traumatic stress disorder symptoms among healthcare workers during the COVID-19 pandemic

El impacto independiente y combinado del daño moral y angustia moral en los síntomas del trastorno de estrés postraumático entre los trabajadores sanitarios durante la pandemia COVID-19

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Article: 2299661 | Received 13 Apr 2023, Accepted 04 Dec 2023, Published online: 09 Feb 2024

References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://dsm.psychiatryonline.org/doi/book/10.1176appi.books.9780890425596
  • Amsalem, D., Lazarov, A., Markowitz, J. C., Naiman, A., Smith, T. E., Dixon, L. B., & Neria, Y. (2021). Psychiatric symptoms and moral injury among US healthcare workers in the COVID-19 era. BMC Psychiatry, 21(1), 546. https://doi.org/10.1186/s12888-021-03565-9
  • Andhavarapu, S., Yardi, I., Bzhilyanskaya, V., Lurie, T., Bhinder, M., Patel, P., Pourmand, A., & Tran, Q. K. (2022). Post-traumatic stress in healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Psychiatry Reseasrch, 317, 114890. https://doi.org/10.1016/j.psychres.2022.114890
  • Barnes, H. A., Hurley, R. A., & Taber, K. H. (2019). Moral Injury and PTSD: Often Co-occurring yet mechanistically different. Journal of Neuropsychiatry and Clinical Neurosciences, 31(2), A4–A103. https://doi.org/10.1176/appi.neuropsych.19020036
  • Battaglia, A. M., Protopopescu, A., Boyd, J. E., Lloyd, C., Jetly, R., O’Connor, C., Hood, H. K., Nazarov, A., Rhind, S. G., Lanius, R. A., & McKinnon, M. C. (2019). The relation between adverse childhood experiences and moral injury in the Canadian Armed Forces. European Journal of Psychotraumatology, 10(1), 1546084. https://doi.org/10.1080/20008198.2018.1546084
  • Benfante, A., Di Tella, M., Romeo, A., & Castelli, L. (2020). Traumatic stress in healthcare workers during covid-19 pandemic: A review of the immediate impact. Frontiers in Psychology, 11, 569935. https://doi.org/10.3389/fpsyg.2020.569935
  • Billings, J., Ching, B. C. F., Gkofa, V., Greene, T., & Bloomfield, M. (2021). Experiences of frontline healthcare workers and their views about support during COVID-19 and previous pandemics: A systematic review and qualitative meta-synthesis. BMC Health Services Research, 21(1), 923. https://doi.org/10.1186/s12913-021-06917-z
  • Boyd, J. E., Protopopescu, A., O’Connor, C., Neufeld, R. W. J., Jetly, R., Hood, H. K., Lanius, R. A., & McKinnon, M. C. (2018). Dissociative symptoms mediate the relation between PTSD symptoms and functional impairment in a sample of military members, veterans, and first responders with PTSD. European Journal of Psychotraumatology, 9(1), 1463794. https://doi.org/10.1080/20008198.2018.1463794
  • Briere, J., Weathers, F. W., & Runtz, M. (2005). Is dissociation a multidimensional construct? Data from the multiscale dissociation inventory. Journal of Traumatic Stress, 18(3), 221–231. https://doi.org/10.1002/jts.20024
  • Brophy, J. T., Keith, M. M., Hurley, M., & McArthur, J. E. (2021). Sacrificed: Ontario healthcare workers in the time of COVID-19. New Solutions, 30(4), 267–281. https://doi.org/10.1177/1048291120974358
  • Bryan, A. O., Bryan, C. J., Morrow, C. E., Etienne, N., & Ray-Sannerud, B. (2014). Moral injury, suicidal ideation, and suicide attempts in a military sample. Traumatology, 20(3), 154–160. https://doi.org/10.1037/h0099852
  • Bryan, C. J., Bryan, A. O., Roberge, E., Leifker, F. R., & Rozek, D. C. (2018). Moral injury, posttraumatic stress disorder, and suicidal behavior among National Guard personnel. Psychological Trauma: Theory, Research, Practice And Policy, 10(1), 36–45. https://doi.org/10.1037/tra0000290
  • Čartolovni, A., Stolt, M., Scott, P. A., & Suhonen, R. (2021). Moral injury in healthcare professionals: A scoping review and discussion. Nursing Ethics, 28(5), 590–602. https://doi.org/10.1177/0969733020966776
  • CIPSRT Glossary of Terms. (2019).
  • Curran, P. J., West, S. G., & Finch, J. F. (1996). The robustness of test statistics to nonnormality and specification error in confirmatory factor analysis. Psychological Methods, 1(1), 16–29. https://doi.org/10.1037/1082-989X.1.1.16
  • Currier, J. M., Farnsworth, J. K., Drescher, K. D., McDermott, R. C., Sims, B. M., & Albright, D. L. (2018). Development and evaluation of the expressions of moral injury scale-military version. Clinical Psychology & Psychotherapy, 25(3), 474–488. https://doi.org/10.1002/cpp.2170
  • Currier, J. M., Holland, J. M., & Malott, J. (2015). Moral injury, meaning making, and mental health in returning veterans. Journal of Clinical Psychology, 71(3), 229–240. https://doi.org/10.1002/jclp.22134
  • D'Alessandro, A. M., Ritchie, K., McCabe, R. E., Lanius, R. A., Heber, A., Smith, P., Malain, A., Schielke, H., O'Connor, C., Hosseiny, F., Rodrigues, S., & McKinnon, M. C. (2022). Healthcare workers and COVID-19-related moral injury: An interpersonally-focused approach informed by PTSD. Frontiers in psychiatry, 12, 784523. https://doi.org/10.3389/fpsyt.2021.784523
  • Dash, G., & Paul, J. (2021). CB-SEM vs PLS-SEM methods for research in social sciences and technology forecasting. Technological Forecasting and Social Change, 173, 121092. https://doi.org/10.1016/j.techfore.2021.121092
  • Dean, W., Talbot, S., & Dean, A. (2019). Reframing clinician distress: Moral injury not burnout. Federal practitioner: For the Health Care Professionals of the VA, DoD, and PHS, 36(9), 400–402.
  • D’ettorre, G., Ceccarelli, G., Santinelli, L., Vassalini, P., Innocenti, G. P., Alessandri, F., Koukopoulos, A. E., Russo, A., d’Ettorre, G., & Tarsitani, L. (2021). Post-traumatic stress symptoms in healthcare workers dealing with the covid-19 pandemic: A systematic review. International Journal of Environmental Research and Public Health, 18(2), 601. https://doi.org/10.3390/ijerph18020601
  • Easterbrook, B., Plouffe, R. A., Houle, S. A., Liu, A., McKinnon, M. C., Ashbaugh, A. R., Mota, N., Afifi, T. O., Enns, M. W., Richardson, J. D., & Nazarov, A. (2023). Moral injury associated with increased odds of past-year mental health disorders: A Canadian Armed Forces examination. European Journal of Psychotraumatology, 14(1), 2192622. https://doi.org/10.1080/20008066.2023.2192622
  • Epstein, E. G., & Hamric, A. B. (2009). Moral distress, moral residue, and the crescendo effect. Journal of Clinical Ethics, 20(4), 330–342. https://doi.org/10.1086/JCE200920406
  • Epstein, E. G., Whitehead, P. B., Prompahakul, C., Thacker, L. R., & Hamric, A. B. (2019). Enhancing understanding of moral distress: The measure of moral distress for health care professionals. AJOB Empirical Bioethics, 10(2), 113–124. https://doi.org/10.1080/23294515.2019.1586008
  • Frewen, P., Zhu, J., & Lanius, R. (2019). Lifetime traumatic stressors and adverse childhood experiences uniquely predict concurrent PTSD, complex PTSD, and dissociative subtype of PTSD symptoms whereas recent adult non-traumatic stressors do not: Results from an online survey study. European Journal of Psychotraumatology, 10(1), 1606625. https://doi.org/10.1080/20008198.2019.1606625
  • Grimell, J., & Nilsson, S. (2020). An advanced perspective on moral challenges and their health-related outcomes through an integration of the moral distress and moral injury theories. Military Psychology, 32(6), 380–388. https://doi.org/10.1080/08995605.2020.1794478
  • Harris, P. A., Taylor, R., Minor, B. L., Elliott, V., Fernandez, M., O'Neal, L., McLeod, L., Delacqua, G., Delacqua, F., Kirby, J., Duda, S. N., & REDCap Consortium. (2019). The REDCap consortium: Building an international community of software platform partners. Journal of Biomedical Informatics, 95, 103208. https://doi.org/10.1016/j.jbi.2019.103208
  • Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research Electronic Data Capture (REDCap)--A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381. https://doi.org/10.1016/j.jbi.2008.08.010
  • Hegarty, S., Lamb, D., Stevelink, S. A. M., Bhundia, R., Raine, R., Doherty, M. J., Scott, H. R., Marie Rafferty, A., Williamson, V., Dorrington, S., Hotopf, M., Razavi, R., Greenberg, N., & Wessely, S. (2022). ‘It hurts your heart’: Frontline healthcare worker experiences of moral injury during the COVID-19 pandemic. European Journal of Psychotraumatology, 13(2), 2128028. https://doi.org/10.1080/20008066.2022.2128028
  • Hines, S. E., Chin, K. H., Glick, D. R., & Wickwire, E. M. (2021). Trends in moral injury, distress, and resilience factors among healthcare workers at the beginning of the covid-19 pandemic. International Journal of Environmental Research and Public Health, 18(2), 488. https://doi.org/10.3390/ijerph18020488
  • Hu, L. T., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal, 6(1), 1–55. https://doi.org/10.1080/10705519909540118
  • Jinkerson, J. D. (2016). Defining and assessing moral injury: A syndrome perspective. Traumatology, 22(2), 122–130. https://doi.org/10.1037/trm0000069
  • Koenig, H. G., Ames, D., Youssef, N. A., Oliver, J. P., Volk, F., Teng, E. J., Haynes, K., Erickson, Z. D., Arnold, I., O’Garo, K., & Pearce, M. (2018). The moral injury symptom scale-military version. Journal of Religion and Health, 57(1), 249–265. https://doi.org/10.1007/s10943-017-0531-9
  • Levi-Belz, Y., Greene, T., & Zerach, G. (2020). Associations between moral injury, PTSD clusters, and depression among Israeli veterans: A network approach. European Journal of Psychotraumatology, 11(1), 1736411. https://doi.org/10.1080/20008198.2020.1736411
  • Litam, S. D. A., & Balkin, R. S. (2021). Moral injury in health-care workers during COVID-19 pandemic. Traumatology, 27(1), 14–19. https://doi.org/10.1037/trm0000290
  • Litz, B. T., & Kerig, P. K. (2019). Introduction to the special issue on moral injury: Conceptual challenges, methodological issues, and clinical applications. Journal of Traumatic Stress, 32(3), 341–349. https://doi.org/10.1002/jts.22405
  • Litz, B. T., Plouffe, R. A., Nazarov, A., Murphy, D., Phelps, A., Coady, A., Houle, S. A., Dell, L., Frankfurt, S., Zerach, G., Levi-Belz, Y., & Moral Injury Outcome Scale Consortium. (2022). Defining and assessing the syndrome of moral injury: Initial findings of the moral injury outcome scale consortium. Frontiers in Psychiatry, 13, 923928. https://doi.org/10.3389/fpsyt.2022.923928
  • Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695–706. https://doi.org/10.1016/j.cpr.2009.07.003
  • Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the depression anxiety stress scales. Sydney Psychology Foundation.
  • Maftei, A., & Holman, A. C. (2021). The prevalence of exposure to potentially morally injurious events among physicians during the COVID-19 pandemic. European Journal of Psychotraumatology, 12(1), 1898791. https://doi.org/10.1080/20008198.2021.1898791
  • Maguen, S., & Griffin, B. J. (2022). Research gaps and recommendations to guide research on assessment, prevention, and treatment of moral injury among healthcare workers. Frontiers in psychiatry, 13, 874729. https://doi.org/10.3389/fpsyt.2022.874729
  • Maguen, S., Griffin, B. J., Copeland, L. A., Perkins, D. F., Richardson, C. B., Finley, E. P., & Vogt, D. (2022). Trajectories of functioning in a population-based sample of veterans: Contributions of moral injury, PTSD, and depression. Psychological Medicine, 52(12), 2332–2341. https://doi.org/10.1017/S0033291720004249
  • Mantri, S., Lawson, J. M., Wang, Z., & Koenig, H. G. (2020). Identifying moral injury in healthcare professionals: The moral injury symptom scale-HP. Journal of Religion and Health, 59(5), 2323–2340. https://doi.org/10.1007/s10943-020-01065-w
  • Marvaldi, M., Mallet, J., Dubertret, C., Moro, M. R., & Guessoum, S. B. (2021). Anxiety, depression, trauma-related, and sleep disorders among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Neuroscience and Biobehavioral Reviews, 126, 252–264. https://doi.org/10.1016/j.neubiorev.2021.03.024
  • Merrick, M. T., Ports, K. A., Ford, D. C., Afifi, T. O., Gershoff, E. T., & Grogan-Kaylor, A. (2017). Unpacking the impact of adverse childhood experiences on adult mental health. Child Abuse & Neglect, 69, 10–19. https://doi.org/10.1016/j.chiabu.2017.03.016
  • Muthén, L. K., & Muthén, B. O. (1998–2012). Mplus user's guide (7th ed.). Muthén & Muthén.
  • Nash, W. P., Marino Carper, T. L., Mills, M. A., Au, T., Goldsmith, A., & Litz, B. T. (2013). Psychometric evaluation of the moral injury events scale. Military Medicine, 178(6), 646–652. https://doi.org/10.7205/MILMED-D-13-00017
  • Ouyang, H., Geng, S., Zhou, Y., Wang, J., Zhan, J., Shang, Z., Jia, Y., Yan, W., Zhang, Y., Li, X., & Liu, W. (2022). The increase of PTSD in front-line health care workers during the COVID-19 pandemic and the mediating role of risk perception: A one-year follow-up study. Translational Psychiatry, 12(1), 180. https://doi.org/10.1038/s41398-022-01953-7
  • Park, A. H., Protopopescu, A., Pogue, M. E., Boyd, J. E., O’Connor, C., Lanius, R. A., & McKinnon, M. C. (2021). Dissociative symptoms predict severe illness presentation in Canadian public safety personnel with presumptive post-traumatic stress disorder (PTSD). European Journal of Psychotraumatology, 12(1), 1953789. https://doi.org/10.1080/20008198.2021.1953789
  • Patel, H., Easterbrook, B., D’Alessandro-Lowe, A. M., Andrews, K., Ritchie, K., Hosseiny, F., Rodrigues, S., Malain, A., O’Connor, C., Schielke, H., McCabe, R. E., Nicholson, A. A., Lanius, R., & McKinnon, M. C. (2023). Associations between trauma and substance use among healthcare workers and public safety personnel during the SARS-CoV-2 (COVID-19) pandemic: The mediating roles of dissociation and emotion dysregulation. European journal of Psychotraumatology, 14(1), 2180706. https://doi.org/10.1080/20008066.2023.2180706
  • Patel, H., Holshausen, K., Oshri, A., Andrews, K., Penta, S., Raymond, H., McKinnon, M., Brasch, J., MacKillop, J., & Amlung, M. (2021). Posttraumatic stress disorder symptomatology and substance use in an outpatient concurrent disorders sample. Canadian Journal of Psychiatry, 66(9), 788–797. https://doi.org/10.1177/07067437211011851
  • Patel, H., O’Connor, C., Andrews, K., Amlung, M., Lanius, R., & McKinnon, M. C. (2022). Dissociative symptomatology mediates the relation between posttraumatic stress disorder severity and alcohol-related problems. Alcoholism: Clinical and Experimental Research, 46(2), 289–299. https://doi.org/10.1111/acer.14764
  • Plouffe, R. A., Nazarov, A., Forchuk, C. A., Gargala, D., Deda, E., Le, T., Bourret-Gheysen, J., Jackson, B., Soares, V., Hosseiny, F., Smith, P., Roth, M., MacDougall, A. G., Marlborough, M., Jetly, R., Heber, A., Albuquerque, J., Lanius, R., Balderson, K., … Richardson, J. D. (2021). Impacts of morally distressing experiences on the mental health of Canadian health care workers during the COVID-19 pandemic. European Journal of Psychotraumatology, 12(1), 1984667. https://doi.org/10.1080/20008198.2021.1984667
  • Price, M., & van Stolk-Cooke, K. (2015). Examination of the interrelations between the factors of PTSD, major depression, and generalized anxiety disorder in a heterogeneous trauma-exposed sample using DSM 5 criteria. Journal of Affective Disorders, 186, 149–155. https://doi.org/10.1016/j.jad.2015.06.012
  • Protopopescu, A., Boyd, J. E., O’Connor, C., Rhind, S. G., Jetly, R., Lanius, R. A., & McKinnon, M. C. (2021). Examining the associations among moral injury, difficulties with emotion regulation, and symptoms of PTSD, depression, anxiety, and stress among Canadian military members and Veterans: A preliminary study. Journal of Military, Veteran and Family Health, 7(2), 71–80. https://doi.org/10.3138/jmvfh-2020-0036
  • Riedel, P. L., Kreh, A., Kulcar, V., Lieber, A., & Juen, B. (2022). A scoping review of moral stressors, moral distress and moral injury in healthcare workers during COVID-19. International Journal of Environmental Research and Public Health, 19(3), 1666. https://doi.org/10.3390/ijerph19031666
  • Ritchie, K., D’Alessandro-Lowe, A. M., Brown, A., Millman, H., Pichtikova, M., Xue, Y., Altman, M., Beech, I., Karram, M., Hosseiny, F., Rodrigues, S., O'Connor, C., Schielke, H., Malain, A., McCabe, R. E., Heber, A., Lanius, R. A., & McKinnon, M. C. (2023). The hidden crisis: Understanding potentially morally injurious events experienced by healthcare providers during COVID-19 in Canada. International Journal of Environmental Research and Public Health, 20(6), 4813. https://doi.org/10.3390/ijerph20064813
  • Rosen, A., Cahill, J. M., & Dugdale, L. S. (2022). Moral injury in health care: Identification and repair in the COVID-19 era. Journal of General Internal Medicine, 37(14), 3739–3743. https://doi.org/10.1007/s11606-022-07761-5
  • Roth, S. L., Andrews, K., Protopopescu, A., Lloyd, C., O'Connor, C., Losier, B. J., Lanius, R. A., & McKinnon, M. C. (2022). Mental health symptoms in public safety personnel: Examining the effects of adverse childhood experiences and moral injury. Child Abuse & Neglect, 123, 105394. https://doi.org/10.1016/j.chiabu.2021.105394
  • Schreiber, J. B., Nora, A., Stage, F. K., Barlow, E. A., & King, J. (2006). Reporting structural equation modeling and confirmatory factor analysis results: A review. Journal of Educational Research, 99(6), 323–338. https://doi.org/10.3200/JOER.99.6.323-338
  • Shaukat, N., Ali, D. M., & Razzak, J. (2020). Physical and mental health impacts of COVID-19 on healthcare workers: A scoping review. International Journal of Emergency Medicine, 13(1), 40. https://doi.org/10.1186/s12245-020-00299-5
  • Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182–191. https://doi.org/10.1037/a0036090
  • Spiegel, D. (2012). Divided consciousness: Dissociation in DSM-5. Depression and Anxiety, 29(8), 667–670. https://doi.org/10.1002/da.21984
  • Stein, D. J., Koenen, K. C., Friedman, M. J., Hill, E., McLaughlin, K. A., Petukhova, M., Ruscio, A. M., Shahly, V., Spiegel, D., Borges, G., Bunting, B., Caldas-de-Almeida, J. M., de Girolamo, G., Demyttenaere, K., Florescu, S., Haro, J. M., Karam, E. G., Kovess-Masfety, V., Lee, S., … Kessler, R. C. (2013). Dissociation in posttraumatic stress disorder: Evidence from the world mental health surveys. Biological Psychiatry, 73(4), 302–312. https://doi.org/10.1016/j.biopsych.2012.08.022
  • Talbot, S. G., & Dean, W. (2018). Physicians aren’t “burning out.” They’re suffering from moral injury. STAT News. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/
  • Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013). The PTSD checklist for DSM–5 (PCL-5). National Center for PTSD.
  • White, W. F., Burgess, A., Dalgleish, T., Halligan, S., Hiller, R., Oxley, A., Smith, P., & Meiser-Stedman, R. (2022). Prevalence of the dissociative subtype of post-traumatic stress disorder: A systematic review and meta-analysis. Psychological Medicine, 52(9), 1629–1644. https://doi.org/10.1017/S0033291722001647
  • Xue, Y., Lopes, J., Ritchie, K., D'Alessandro, A. M., Banfield, L., McCabe, R. E., Heber, A., Lanius, R. A., & McKinnon, M. C. (2022). Potential circumstances associated with moral injury and moral distress in healthcare workers and public safety personnel across the globe during COVID-19: A scoping review. Frontiers in Psychiatry, 13, 863232. https://doi.org/10.3389/fpsyt.2022.863232
  • Yehuda, R., Halligan, S. L., & Grossman, R. (2001). Childhood trauma and risk for PTSD: Relationship to intergenerational effects of trauma, parental PTSD, and cortisol excretion. Development and Psychopathology, 13(3), 733–753. https://doi.org/10.1017/S0954579401003170
  • Yeterian, J. D., Berke, D. S., Carney, J. R., McIntyre-Smith, A., St Cyr, K., King, L., Kline, N. K., Phelps, A., Litz, B. T., & Members of the Moral Injury Outcomes Project Consortium. (2019). Defining and measuring moral injury: Rationale, design, and preliminary findings from the moral injury outcome scale consortium. Journal of Traumatic Stress, 32(3), 363–372. https://doi.org/10.1002/jts.22380
  • Zerach, G., & Levi-Belz, Y. (2021). Moral injury and mental health outcomes among Israeli health and social care workers during the COVID-19 pandemic: A latent class analysis approach. European Journal of Psychotraumatology, 12(1), 1945749. https://doi.org/10.1080/20008198.2021.1945749