Moral Distress, COVID-19, and Healthcare Workers, a Systematic Review and Meta-Synthesis: Solutions by JUMS Clinical Decision-making Scheme

Background: Although studies are conducted on moral distress during the COVID-19 period, those being conducted by using various methods of moral distress assessment, the majority of which were developed for moral distress conditions befor the arrival of the pandemic, and qualitative studies are better suited to the COVID-19-driven moral and ethical dilemma. For COVID-19 era, we aimed at reviewing qualitative studies on moral distress. Methods: Based on the PRISMA-P and COREQ criteria, a comprehensive evaluation of qualitative studies looking at moral distress in Hrealthcare workers (HCWs) working with COVID-19 patients was conducted. A combination of relevant terms was searched in the MEDLINE and PsycINFO, EMBASE, SCOPUS, and Web of Science databases. The CASP checklist was used to evaluate the research quality. To synthesize the data, a meta-aggregation method was employed in conjunction with the ConQual methodology. ‎‎ Results: Nine studies with 644 participants were evaluated. 4 studies were about physicians in Emergency departments or acute care centers, 2 studies were about nursing students, and 3 studies were about the nursing staff. A total number of 11 subthemes were found in cases of moral distress experienced in the emergency department. All themes and subthemes were summarized in 3 themes adapting to categories: of resource constraints, scientific limitation, and personal variables. Conclusion: New ethical dilemmas have been emerging during the COVID-19 pandemic and we sought systematically categorize these moral distress cases and evaluate compliance of our decision-making rules with such circumstances. Our proposed model of decision-making based on the available protocols of legitimate and acceptable authorities is a way to avoid moral distress in facing limited science in practice.