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. 2025 Dec;16(1):2512677.
doi: 10.1080/20008066.2025.2512677. Epub 2025 Jun 19.

Moral distress, moral residue, and associations with psychological distress: a cross-sectional study

Martina E Gustavsson  1   2 , Niklas Juth  3   4 , Johan von Schreeb  1 , Filip K Arnberg  5
Affiliations

Moral distress, moral residue, and associations with psychological distress: a cross-sectional study

Martina E Gustavsson et al. Eur J Psychotraumatol. 2025 Dec.

Abstract
in English, Spanish

Background: The consequences of moral challenges among healthcare workers (HCWs) have been increasingly recognized. To date, however, there is limited knowledge about the predictors of and associations between moral distress, moral residue, and other psychological consequences among HCWs working in a pandemic context.Objective: We aimed to assess the levels of, and the associations between HCWs' experiences of moral distress and moral residue with traumatic stress, burnout, and general psychological distress, and evaluate the role of empathic and compassion aspects for these outcomes, while adjusting for demographic and professional factors.Methods: This is a cross-sectional study of 6551 Swedish HCWs participating in a survey during the COVID-19 pandemic, in the autumn of 2020. The survey included questions related to moral challenges, moral distress and residue, and self-report scales for general psychological distress (GHQ-5), traumatic stress (ITQ), compassion satisfaction and fatigue (ProQoL), empathic ability (B-IRI), and burnout (SMBQ).Results: There were strong associations between moral challenges and moral distress and residue. There were also clear associations between moral distress and residue and psychological distress scales. Empathic ability, compassion fatigue, and compassion satisfaction were associated with moral residue whereas compassion satisfaction was not associated with moral distress. Demographic and professional predictors included gender, age, and occupational role. No interactions between moral challenges and empathic ability were found for moral distress or residue.Discussion/conclusion: Moral distress and moral residue share some variance with both general and stress-related psychological distress; however, moral distress and residue are both theoretically and empirically distinct outcomes of moral challenges as compared to other established psychological consequences of occupational stress. Empathic ability was associated with moral distress, but not with moral residue. Moving forward, longitudinal research is needed to better understand the interplay among moral aspects relevant to HCWs.

Antecedentes: Las consecuencias de los desafíos morales entre los trabajadores de la salud (HCWs, por sus siglas en inglés) se reconocen cada vez más. Sin embargo, hasta la fecha, existe un conocimiento limitado sobre los factores predictores y las asociaciones entre el distrés moral, las huellas morales y otras consecuencias psicológicas entre los HCWs que trabajan en un contexto de pandemia.

Objetivo: Nuestro objetivo era evaluar los niveles y las asociaciones entre las experiencias del distrés moral y las huellas morales de los HCWs con el estrés traumático, el burnout y el malestar psicológico general, y evaluar el rol de los aspectos empáticos y de compasión para estos resultados, ajustando los resultados por los factores demográficos y profesionales.

Métodos: Este es un estudio transversal de 6.551 HCWs suecos que participaron en un cuestionario durante la pandemia de la COVID-19, durante el otoño de 2020. El cuestionario incluyó preguntas relacionadas con los desafíos morales, el distrés y las huellas morales, y cuestionarios de auto reporte para medir el malestar psicológico general (GHQ-5), el estrés traumático (ITQ), la satisfacción y la fatiga por compasión (ProQoL), la capacidad empática (B-IRI) y el burnout (SMBQ).

Resultados: Se observaron fuertes asociaciones entre los desafíos morales y el distrés y las huellas morales. También se observaron asociaciones claras entre el distrés moral, las huellas y las escalas de malestar psicológico. La capacidad empática, la fatiga por compasión y la satisfacción por compasión se asociaron con las huellas morales, mientras que la satisfacción por compasión no se asoció con el distrés moral. Los predictores demográficos y profesionales incluyeron el género, la edad y el rol ocupacional. No se observaron interacciones entre los desafíos morales y la capacidad empática en lo que respecta al distrés o las huellas morales.

Discusión/conclusión: El distrés moral y las huellas morales presentan cierta variación con el malestar psicológico general y la relacionada con el estrés; sin embargo, el distrés moral y las huellas morales son resultados, tanto teórica como empíricamente, distintos de los desafíos morales en comparación con otras consecuencias psicológicas establecidas del estrés laboral. La capacidad empática se asoció con el distrés moral, pero no con las huellas morales. En el futuro, se necesitarán investigaciones longitudinales para comprender mejor la interacción entre los aspectos morales relevantes para los trabajadores de la salud.

Keywords: COVID-19; COVID-19 pandemic; Estrés moral; Moral stress; burnout; capacidad empática; desafíos morales; distrés moral; empathic ability; estrés traumático; health care workers; huellas morales; malestar psicológico; moral challenges; moral distress; moral residue; psychological distress; trabajadores de la salud; traumatic stress.

Plain language summary

Moral challenges, moral distress and moral residue were clearly associated with general and stress-related psychological distress.Weak associations were found between moral distress, empathic ability, and compassion satisfaction.Moral distress and moral residue are theoretically and empirically separate from other types of consequences of occupational stress but share variance with both general and stress-related psychological distress.

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Conflict of interest statement

No potential conflict of interest was reported by the author(s).

Figures

Figure 1.
Figure 1.
Illustration of the theoretical concepts related to moral issues and the potential timeline.
Figure 2.
Figure 2.
Distribution of moral distress and moral residue across exposure levels of morally stressful situations.
Figure 3.
Figure 3.
Correlations between moral distress/residue, psychological distress, empathic ability, and compassion satisfaction/fatigue. The left panel shows correlations for participants working in COVID-19 care, and the right panel shows not working in COVID-19 care. BIRI = Brief Interpersonal Reactivity Index, CF = Compassion fatigue, CS = Compassion satisfaction, GHQ5 = General Health Questionnaire, 5 item version, ITQ = International Trauma Questionnaire, MD = Moral distress, MFRQ = Frequency of moral challenges, MR = Moral residue, SMBQ = Shilom-Melamed Burnout Questionnaire.
See this image and copyright information in PMC

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