The Psychoneuroimmunological Model of Moral Distress and Health in Healthcare Workers: Toward Individual and System-Level Solutions

Abstract

Healthcare is presently experiencing a global workforce crisis, marked by the inability of hospitals to retain qualified healthcare workers. Indeed, poor working conditions and staff shortages have contributed to structural collapse and placed a heavy toll on healthcare workers' (HCWs) well-being, with many suffering from stress, exhaustion, demoralization, and burnout. An additional factor driving qualified HCWs away is the repeated experience of moral distress, or the inability to act according to internally held moral values and perceived ethical obligations due to internal and external constraints. Despite general awareness of this crisis, we currently lack an organized understanding of how stress leads to poor health, wellbeing, and performance in healthcare workers. To address this critical issue, we first review the literature on moral distress, stress, and health in HCWs. Second, we summarize the biobehavioral pathways linking occupational and interpersonal stressors to health in this population, focusing on neuroendocrine, immune, genetic, and epigenetic processes. Third, we propose a novel Psychoneuroimmunological Model of Moral Distress and Health in HCWs based on this literature. Finally, we discuss evidence-based individual- and system-level interventions for preventing stress and promoting resilience at work. Throughout this review, we underscore that stress levels in HCWs are a major public health concern, and that a combination of system-level and individual-level interventions are necessary to address preventable health care harm and foster resilience in this population, including new health policies, mental health initiatives, and additional translational research.

Keywords: Epigenetics; Frontline healthcare workers; Genetics; Mental and physical health; Moral distress; Occupational stress; Psychoneuroimmunology; Resilience.

Fig. 1

Example of a Job Demands-Resources Health Model in Healthcare The model links job demands and job resources through a pathogenic and a salutogenic path to both positive and negative health outcomes and motivational processes. Job demands and job resources interact and determine HCWs' well-being. The combination of high job demands and low job resources is a risk factor for exhaustion and burnout, whereas the combination of high job demands and high job resources promotes a heightened level of motivation, task enjoyment, and commitment.

Fig. 2

Psychoneuroimmunological Model of Moral Distress and Health The stress response is mediated, in part, by three bidirectional pathways that enable the brain to communicate with the peripheral immune system and vice versa. These signaling pathways include the (a) hypothalamic-pituitary-adrenal (HPA) axis, (b) sympathetic nervous system (SNS), and (c) vagus nerve. Exposure to a stressor activates the HPA axis and the SNS, which in turn triggers the release of hormones that modulate immune functions, including catecholamines (epinephrine and norepinephrine), glucocorticoids, and pro-inflammatory cytokines (interleukin-1β, IL-1β; interleukin-6, IL-6; tumor necrosis factor-α, TNF-α). During acute stress, the release of these neuroendocrine modulators enhances immune function, and thus is an adaptive psychophysiological mechanism that confers immune protection in response to an infection or an injury and aims to restore homeostasis. Conversely, exposure to chronic or prolonged stress results in upregulated autonomic, neuroendocrine, and inflammatory pathways and, by doing so, increases inflammation and induces immune dysregulation that may alter immune defense mechanisms and elevate someone's susceptibility to certain diseases and mental illnesses.

Fig. 3

Interventions for promoting resilience and moral repair.