Moral injury and mental health among health-care workers during the COVID-19 pandemic: meta-analysis

Figures & data

Figure 1. Flow diagram of the systematic search.

Table 1. Selected characteristics of studies examining the association between moral injury and mental health problems.

Study	N	Mean age (SD)	Females (%)	Profession (with % of physicians and nurses)	Years of practice (mean)	MI measure	Providing care for patients with COVID-19 (%)	Psychiatric measures	Location	Quality ratings
Amsalem et al. (2021)	350	34.8 (11.5)	74	Physicians (15), nurses (68), pharmacists, physical therapists, other	NR	MIES	NR	PTSD (PC-PTSD), depression (PHQ-9), anxiety (GAD-7), suicidal ideation (PHQ-9)	US	7
Dale et al. (2021)	265	37.62 (11.08)	81.9	NR	NR	MIES (reduced)	NR	PTSD (PCL-5), depression (PHQ-9), anxiety (GAD), PFI (burnout)	US	6
de Groot (2021)	33	28.9 (11.2)^++	93.9^++	NR	NR	MIAS	100	PTSD (PCL-5)	Netherlands	4
Dias et al. (2021)	86	40.6 (11.7)	65.1	Physicians (25.6), nurses (47.7), other	NR	MISS-SF	100	PTSD (PCL-5), burnout (PFI)	US	4
Litam and Balkin (2021)	109	35.5 (NR)	76	Physicians (36.7), nurses (56.88)	12.30	MIES	NR	PTSD (PROQOL), burnout (PROQOL)	US	6
Mantri et al. (2021)	1831	NR	90	Physicians (15.4), nurses (50.4), APP	NR	MISS-HP	NR	Burnout (MBI)	US	7
Rodríguez et al. (2021)	169	36.04 (10.46)	76.33	Physicians (86.39), nurses (13.61)	8.84	MISS-HP	NR	Depression (PHQ-9), anxiety (GAD-7), suicidal ideation (PHQ-9)	Honduras	7
Zerach & Levi-Belz (2021)	296	40.28 (10.83)	77.6	Physicians (36.3), nurses (43.4), social workers, other	12.67	MISS-HP	31.75	PTSD (ITQ), depression (PHQ-9), anxiety (GAD-7), suicidal ideation (PHQ-9)	Israel	8
Chandrabhatla et al. (2022)	37	NR	54	Physicians (100)	6.8	MIES	NR	Burnout (Mini Z Burnout Survey)	US	4
Chug & Babasa (2022)	129	35.77 (8.5)	52.7	Physicians (100)	NR	MISS-HP	100^++	Depression (K10), anxiety (K10), burnout (MBI)	Philippines	4
Gherman et al. (2022)	614	38.1 (8.6)	85.3	Nurses (100)	12.7	MIES	NR	Burnout (MBI)	Romania	7
Hagerty & Williams (2022)	1122	39.29 (NR)	88.8	Physicians (5), nurses (60.4), physician assistants, respiratory therapists	NR	MIES	NR	PTSD (PCL-5), suicidal ideation (PHQ-9)	US	7
Jovarauskaite et al. (2022)^+	206	42.34 (11.68)	97.1	Nurses (100)	NR	MIOS	NR	PTSD (ITQ)	Lithuania	7
Ma et al. (2022)	3465	35.8 (8.3)	75.4	Physicians (55.3), nurses (44.3)	12.8	MISS-HP	13.3	PTSD (PCL-5-SF)	China	8
Malakoutikhah et al. (2022)	455	33.39 (7.07)^++	83.1	Nurses (73.6)^++, other	NR	MISS-HP	NR	PTSD (IES)	Iran	5
Morris (2022)*	322	NR	70.8^++	Forensic mental HCWs	NR	MIESS-C	0	PTSD (PCL-5), depression (PHQ-9), anxiety (GAD-7), burnout (PROQOL)	UK	4
Morris et al. (2022)	237	NR	65.8	Physicians (.8), nurses (72.9), psychologists, occupational therapists, other	NR	MIES	0	PTSD (PROQOL), burnout (PROQOL)	UK	8
Nieuwsma et al. (2022)	1088^++	NR	NR	Physicians, nurses	NR	MIES (reduced)	NR	Depression (PROMIS Emotional Distress-Depression Scale), burnout (one six-Likert item)	US	5
Sert-Ozen & Kalaycioglu (2022)	201	40.43 (8.57)^++	41.8	Physicians (100)	NR	MIES (reduced)	NR	Burnout (six items)	Turkey	5
Testoni et al. (2022)	270	44.54 (12.23)	70.0	Physicians (65.19), nurses (20.7), physiotherapists, health technicians, other	NR	MIES	78.0	PTSD (PTSD-8), depression (PHQ-9), burnout (one Likert item), suicidal ideation (PHQ-9)	Italy	7
Ulusoy & Çelik (2022)	124	33.3 (6.37)	74.2	Physicians (67.7), nurses (21.8), other	NR	MIES	100	Depression (DASS-21), anxiety (DASS-21), burnout (MBI)	Turkey	7
Üstün (2022)	125	31.93 (8.2)	79.2	Nurses (100)	NR	MISS-HP	NR	PTSD (CF-SS), Burnout (CF-SS)	Turkey	6
Wang et al. (2022)	3006	35.4 (8.1)	65.01	Physicians (80.6), nurses (19.4)	11.6	MISS-HP	22.2	Depression (PHQ-9), anxiety (GAD-7), burnout (MBI), suicidal ideation (PHQ-9)	China	8
Dumarkaite et al. (2023)^+	206	42.34 (11.68)	97.1	Nurses (100)	NR	MIOS	NR	Depression (PHQ-4), anxiety (PHQ-4)	Lithuania	7
Behnampour et al. (2023)	333	NR	58.6	Physicians (67.9), nurses (32.1)	NR	MISS-HP	NR	Depression (DASS-21), anxiety (DASS-21)	Iran	4
Cooper-Bribiesca et al. (2023)	108	30.4 (4.9)	57.4	Physicians (100)	NR	MIES	100	PTSD (EGS-R), Depression (HADS), Anxiety (HADS), Burnout (BMS)	Mexico	7
Greene et al. (2023)	1056	41.7 (.2)	92.6	Health and social care workers	NR	MIES	NR	PTSD (ITQ)	UK	7
Kimble (2023)	41	NR	70	Clinical social workers, psychologists	NR	MISS	NR	Burnout (CBI)	US	4
Lennon et al. (2023)	1323^++	NR	76.9^++	Physicians (23.6), nurses (26.3)	NR	MISS-HP	NR	Depression (PHQ-9), anxiety (GAD-7), burnout (CBI), suicidal ideation (PHQ-9)	US	7
Norman et al. (2023)	356	49.8^++	83.4^++	Physicians (7), nurses (45.8), other	NR	MIDS	NR	PTSD (PCL-5), depression (PHQ), suicidal ideation (PHQ-9)	US	7
Sharma & Cousins (2023)	235	NR	89.4	NR	NR	MISS-HP	100	Burnout (2-item inventory)	UK	6
Thomas et al. (2023)*	382 / 324	33.17/35.17^++	75.39/71.91^++	Physicians (13.08), nurses (26.43), other / Physicians (11.11), nurses (25.92), other	NR / NR	OMIS	NR / NR	PTSD (PCL-5), depression (PHQ-9), burnout (PROQOL), suicidal ideation (PHQ-9)	Several countries	8
Williamson et al. (2023)	12965	44.0 (12)	77.0	Physicians (7), nurses (27), other	NR	MIES	NR	PTSD (PCL-6), depression (PHQ-9), anxiety (GAD-7), burnout (BAT-12)	UK	8

Note: APP: advanced practice provider; BAT-12: Burnout Assessment Tool; BMS: Burnout Measure – Short Version; CBI: Copenhagen Burnout Inventory; DASS-21: Depression Anxiety and Stress Scale; EGS-R: The Posttraumatic Stress Disorder Symptom Severity Scale-Revised; GAD: General Anxiety Disorder-7; HADS: The Posttraumatic Stress Disorder Symptom Severity Scale-Revised; IES: Impact of event scale; ITQ: International Trauma Questionnaire; K10: Kessler Psychological Distress Scale; MBI: Maslach Burnout Inventory; MI: Moral injury; MIAS: The Moral Injury Appraisals Scale; MIES: Moral Injury Events Scale; MIESS-C: Moral Injury Exposure and Symptom Scale-Civilian; MIDS: Moral Injury and Distress Scale; MIOS: Moral Injury Outcome Scale; MISS-HP: Moral Injury Symptom Scale-Health Professional; MISS-SF: Moral Injury Symptom Scale – Short Form; NR: not reported; OMIS: Occupational Moral Injury Scale; PC-PTSD: Primary Care PTSD Screen; PCL-5: PTSD Checklist for DSM-5; PCL-5-SF: PTSD Checklist for DSM-5 Short Form; PCL-6: Abbreviated PTSD Checklist; PFI: Professional Fulfillment Index; PHQ-4: Patient Health Questionnaire – four items; PHQ-9: Patient Health Questionnaire – nine items; PROQOL: Professional Quality of Life Scale. * Thomas et al. contains two studies with separate samples (study I contains the effect sizes for PTSD and burnout). ⁺Jovarauskaite et al and Dumarkaite et al. used the same sample. ⁺⁺ Data provided by the authors.

Table 2. Effect sizes (Pearson’s r with level of significance) for the relationship between moral injury and mental health problems.

Study	PTSD	Anxiety	Depression	Burnout	Suicidal Ideation
Amsalem et al. (2021)	.42***	.56***	.59***		.44***
Dale et al. (2021)	.30***^+	.22***^+	.27***^+	.37***^+
de Groot (2021)	.77***^+
Dias et al. (2021)	.60**^+			.54**^+
Litam & Balkin (2021)	.49***			.41**
Mantri et al. (2021)				−.43***
Rodríguez et al. (2021)		.46***	.48***		.40**^+
Zerach & Levi-Belz (2021)	.40***	.41***	.42***		.35**^+
Chandrabhatla et al. (2022)				.48**
Chug & Babasa (2022)		.33**^+	.28**^+	.29**^+
Gherman et al. (2022)				.44***^+
Hagerty & Williams (2022)	.49^NR				.24^NR
Jovarauskaite et al. (2022)	.29***
Ma et al. (2022)	.43*
Malakoutikhah et al. (2022)	.40***
Morris (2022)	.29***^+	.41***^+	.35***^+	.51***^+
Morris et al. (2022)	.46***			.54***
Nieuwsma et al. (2022)			.24^NR+	.20^NR+
Sert-Ozen & Kalaycioglu (2022)				.37**
Üstün (2022)	.34***^+			.33***^+
Testoni et al. (2022)	.20**		.26***	.20***	.18*^+
Ulusoy & Çelik (2022)		.30***^+	.31***^+	.26*
Wang et al. (2022)		.41***	.44***	.41***	.30***^+
Dumarkaite et al. (2023)		.54***^+	.54***^+
Behnampour et al. (2023)		.43***	.47***
Cooper-Bribiesca et al. (2023)	.20*^+	.12^+	.13^+	.22*^+
Greene et al. (2023)	.35 ^+ NR
Kimble (2023)				.65***^+
Lennon et al. (2023)		.19***^+	.16***^+	.23***^+	.12***^+
Norman et al. (2023)	.64***^+		.60***^+		.49***^+
Sharma & Cousins (2023)				.38***
Thomas et al. (2023)	.33***^+		.35***^+	.50***^+	.21***^+
Williamson et al. (2023)	.30***	.27***^+	.28***^+	.30***

Note: * p < .05; **p < .01; ***p < .001; ⁺Effect size provided by the author(s); ^NR Level of significance not reported.

Figure 2. Adjusted funnel plot for missing studies (k = 2) with Pearson’s correlation coefficient (r) between moral injury and PSTD symptoms.

Table 3. Effect of moral injury on mental health and moderation analysis.

PTSD symptoms	k	Pearson’s r	95% CI	p-value
Overall outcome (n = 22,188)	19	.41	.35–.46	<.0001
Moderation Analyses
Mean age	17	−.0007	−.014–.13	.92
Sex	19	.004	−.003–.01	.25
Quality	19	−.034	−.08–.012	.14
Nurses	16	.001	−.0009–.003	.27
Physicians	15	−.001	−.004–.0008	.20
Direct care	8	.001	−.002–.004	.55
Years of practice	3	−.08	−.36–.20	.57
MI measure	19	.012	−.14–.17	.88
PTSD vs secondary trauma	19	.031	−.15–.21	.74
Location (Europe vs other)	19	.06	−.06–.19	.32
Location (US vs other)	19	.12	.002–.25	.04
Anxiety symptoms	k	Pearson’s r	95% CI	p-value
Overall outcome (n = 19,596)	13	.36	.30–.43	<.0001
Moderation Analyses
Mean age	10	.007	−.016–.03	.54
Sex	13	.003	−.003–.01	.33
Quality	13	−.005	−.06–.04	.85
Nurses	11	.003	.0008–.005	.007
Physicians	11	−.001	−.003–.001	.44
Direct care	6	−.002	−.003 to −.0005	.006
Years of practice	4	−.04	−.12–.04	.36
MI measure	13	−.01	−.16–.13	.86
Location (Europe vs other)	13	−.02	−.18–.14	.77
Location (US vs other)	13	−.05	−.22–.11	.56
Depressive symptoms	k	Pearson’s r	95% CI	p-value
Overall outcome (n = 21,604)	17	.37	.30–.43	<.0001
Moderation Analyses
Mean age	13	.009	−.006–.02	.26
Sex	16	.005	−.001–.012	.12
Quality	17	.007	−.046–.06	.79
Nurses	14	.004	.001–.006	.004
Physicians	14	−.001	.004–.0009	.23
Direct care	7	−.002	−.003 to −.0003	.01
Years of practice	4	−.05	−.15–.06	.37
MI measure	17	−.01	−.16–.13	.87
Location (Europe vs other)	17	.03	−.12–.18	.72
Location (US vs other)	17	.006	−.14–.16	.93
Burnout	k	Pearson’s r	95% CI	p-value
Overall outcome (n = 23,508)	21	.34	.22–.46	<.0001
Moderation Analyses
Mean age	13	−.003	−.017–.01	.68
Sex	19	−.0001	−.005–.005	.97
Quality	21	−.03	−.10–.04	.46
Nurses	17	−.0001	−.004–.004	.94
Physicians	17	−.0004	−.003–.003	.79
Direct care	9	−.002	−.003–.0001	.07
Years of practice	5	−.02	−.08–.04	.49
MI measure	21	−.13	−.33–.07	.21
Location (Europe vs other)	21	.08	−.12–.27	.44
Location (US vs other)	21	.07	−.13–.28	.46
Suicidal ideation	k	Pearson’s r	95% CI	p-value
Overall outcome (n = 7,186)	9	.30	.24–.37	<.0001
Moderation Analyses
Mean age	8	.004	−.01–.02	.57
Sex	9	.004	−.008–.02	.42
Quality	9	−.02	−.2–.2	.82
Nurses	9	.002	−.002–.007	.26
Physicians	9	.001	−.003–.002	.95
Direct care	3	−.02	−.005–.0005	.10
Years of practice	4	−.04	−.12–.04	.32
MI measure	9	−.03	−.02–.15	.75
Location (US vs other)	9	−.03	−.2–.14	.73

Note: Mean age, sex (percentage of female-identifying individuals), quality assessment, nurses (percentage of nurses), physicians (percentage of physicians), direct care (percentage of individuals providing care for patients with COVID-19), and years of practice were continuous variables. Location and MI measure were categorical variables.

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Data availability statement

The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.