Moral conflicts in health crises : Swedish health care workers’ experiences and management of moral stress

Background: In health crises, elevated patient needs, and scarce resources may pose moral challenges for healthcare workers (HCWs), as they must prioritize and make complex professional decisions regarding the provision of patient care. Moral stress, distinct from occupational stress, may trigger a negative stress reaction, moral distress, and potential psychological outcomes. Consequently, HCWs may resign or take sick leave, where a lack of HCWs can affect both patient care and emergency preparedness. Understanding HCWs' experiences and management of moral stress is crucial for providing support and preventing negative consequences. The overall aim of this thesis was to investigate and describe experiences and management of moral stress and moral distress among Swedish HCWs in health crises.

Methods: The four interdisciplinary studies employed various methods to explore HCWs' experiences. Study I involved content analysis of focus group discussions with Swedish HCWs experienced in international disaster healthcare. Study II was a crosssectional survey during the COVID-19 pandemic, quantifying HCWs’ moral stress experiences among 16,044 participants. In Study III, associations between moral distress and moral residue, and stress-related and general psychological distress were assessed among 6,551 Swedish HCWs from the cross-sectional survey. Study IV used content analysis and conceptual analysis to map and analyze 643 free-text responses describing morally challenging situations from the survey.

Results: In Study I, HCWs’ wellbeing was influenced by the type and length of their response involvement and the severity, repetitiveness, and duration of morally challenging situations. HCWs had to be creative in resolving situations and finding support. Study II revealed common moral stress, especially among those in direct COVID-19 care, primarily due to resource shortages and visiting restrictions. Informal support was deemed most useful. Study III found strong associations between moral challenges, moral distress, and moral residue, and with general psychological distress. In Study IV, themes aligned with the main theme "Being prevented from providing good care,". These were discussed in relation to definitions and assessed through conceptual analysis, and a refined definition of moral stress was presented.

Conclusion: The study results indicate that participating HCWs commonly experienced moral stress when encountering obstacles and feeling inadequate in delivering patient care, despite striving to do their best. Hence, these moral challenges were generally due to the context of resource scarcity in combination with a lack of support. For the participating HCWs, informal support played a crucial role in managing moral stress, though formal support was also valuable if aligned with HCWs’ experiences. The study results also indicate that moral distress and moral residue seem to capture specific issues related to moral values, which cannot fully be explained as psychological distress.

List of scientific papers

I. Gustavsson, M.E., Juth, N., Arnberg, F.K., von Schreeb J. Dealing with difficult choices: a qualitative study of experiences and consequences of moral challenges among disaster healthcare responders. Confl Health. 2022;16(24).
https://doi.org/10.1186/s13031-022-00456-y

II. Gustavsson, M.E., Juth, N., von Schreeb, J., Arnberg F.K. Moral Stress among Swedish Health Care Workers During the COVID-19 Pandemic: A Cross-Sectional Study. Scandinavian Journal of Work and Organizational Psychology. 2023;8(1): 2, 1–13.
https://doi.org/10.16993/sjwop.170

III. Gustavsson, M.E., Juth, N., von Schreeb, J., Arnberg F.K. Associations Between Moral Distress, Moral Residue, and Stress-Related and General Psychological Distress: A Cross Sectional Study of Swedish Healthcare Workers During the COVID-19 Pandemic. [Submitted]

IV. Gustavsson, M.E., von Schreeb, J., Arnberg, F.K., Juth, N. “Being prevented from providing good care: a conceptual analysis of moral stress among health care workers during the COVID-19 pandemic”. BMC Med Ethics. 2023;24(1):110.
https://doi.org/10.1186/s12910-023-00993-y