Triggers and factors associated with moral distress and moral injury in health and social care workers: A systematic review of qualitative studies.

OBJECTIVE: At some point in their career, many healthcare workers will experience psychological distress associated with being unable to take morally or ethically correct action, as it aligns with their own values; a phenomenon known as moral distress. Similarly, there are increasing reports of healthcare workers experiencing long-term mental and psychological pain, alongside internal dissonance, known as moral injury. This review examined the triggers and factors associated with moral distress and injury in Health and Social Care Workers (HSCW) employed across a range of clinical settings with the aim of understanding how to mitigate the effects of moral distress and identify potential preventative interventions. METHODS: A systematic review was conducted and reported according to recommendations from Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches were conducted and updated regularly until January 2024 on 2 main databases (CENTRAL, PubMed) and three specialist databases (Scopus, CINAHL, PsycArticles), alongside hand searches of study registration databases and other systematic reviews reference lists. Eligible studies included a HSCW sample, explored moral distress/injury as a main aim, and were written in English or Italian. Verbatim quotes were extracted, and article quality was assessed via the CASP toolkit. Thematic analysis was conducted to identify patterns and arrange codes into themes. Specific factors like culture and diversity were explored, and the effects of exceptional circumstances like the pandemic. RESULTS: Fifty-one reports of 49 studies were included in the review. Causes and triggers were categorised under three domains: individual, social, and organisational. At the individual level, patients' care options, professionals' beliefs, locus of control, task planning, and the ability to make decisions based on experience, were indicated as elements that can cause or trigger moral distress. In addition, and relevant to the CoVID-19 pandemic, was use/access to personal protection resources. The social or relational factors were linked to the responsibility for advocating for and communication with patients and families, and professionals own support network. At organisational levels, hierarchy, regulations, support, workload, culture, and resources (staff and equipment) were identified as elements that can affect professionals' moral comfort. Patients' care, morals/beliefs/standards, advocacy role and culture of context were the most referenced elements. Data on cultural differences and diversity were not sufficient to make assumptions. Lack of resources and rapid policy changes have emerged as key triggers related to the pandemic. This suggests that those responsible for policy decisions should be mindful of the potential impact on staff of sudden and top-down change. CONCLUSION: This review indicates that causes and triggers of moral injury are multifactorial and largely influenced by the context and constraints within which professionals work. Moral distress is linked to the duty and responsibility of care, and professionals' disposition to prioritise the wellbeing of patients. If the organisational values and regulations are in contrast with individuals' beliefs, repercussions on professionals' wellbeing and retention are to be expected. Organisational strategies to mitigate against moral distress, or the longer-term sequalae of moral injury, should address the individual, social, and organisational elements identified in this review.

Development and validation of the Body Compassion Questionnaire.

BACKGROUND: The associations between compassion, self-compassion, and body image are well established. However, there is not yet a compassion-informed measure of body compassion that can be applied to any aspect of one's body. METHOD: Items for The Body Compassion Questionnaire (BCQ) were derived from an earlier expressive writing study on self-compassion in body image. In study 1, the BCQ was completed by 728 men and women; with factor analysis, Rasch analysis, content and concurrent validation and reliability assessed. Study 2 compared BCQ scores with investigator-based ratings of spontaneous expressions of body compassion through writing in female undergraduates as well as an existing measure of body compassion. Study 3 examined the associations between BCQ scores, and the emotions expressed in a structured body image writing task. It also examined the relative predictive ability of the BCQ versus self-compassion in predicting eating pathology. RESULTS: A bi-factor structure was identified, with an overall BCQ score and three subscales: body kindness, common humanity, and motivated action. The BCQ and its subscales had good validity and reliability and Rasch analysis showed the item fit was invariant across a range of demographic characteristics. Spontaneous expressions of body compassion showed positive associations with body kindness. Overall BCQ scores and body kindness were also inversely related to negative emotions expressed in relation to body image. The BCQ was a better predictor of eating disorder symptoms than was self-compassion. CONCLUSIONS: The BCQ is the first measure of body compassion that is aligned with theoretical aspects of self-compassion, and which includes aspects of both the first and second psychologies of compassion. It also highlights its potential use as a process measure of body compassion in models of eating disorder symptomology, mood and wellbeing as well as an outcome measure for compassion-based interventions in eating disorders and body image.