Moral Distress In COVID-19 Front Line Health Care Workers: A Protocol of Systematic Review and Meta-Synthesis of Qualitative Studies

Abstract

Background: Literature shows that during the present Covid-19 pandemic, the sense of moral distress among health care workers (HCWs) may be amplified. Moral distress is known as a state of having enough knowledge and skills to manage patients; whilst not being able to properly act due to mental or actual limitations.
Rationale: Even though several investigations have been conducted on moral distress in the COVID-19 period, studies are being conducted with various methods of moral distress assessment, the majority of which are created for moral distress conditions prior to the pandemic's arrival and qualitative studies are better fitting the COVID-19 driven moral and ethical dilemma.
Objective: We aimed at developing a protocol for the review of the qualitative studies about moral distress in the COVID-19 era.

Study design: Protocol of systematic review and meta-synthesis.
Methods: A systematic review of qualitative researches that looks at moral distress in HCWs involved with patients with COVID-19 would be performed based on the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) and Consolidated Criteria for Reporting Qualitative Studies (COREQ) criteria. MEDLINE and PsycINFO, EMBASE, SCOPUS, and Web of Science databases would be searched with a combination of relevant keywords. CASP checklist would be used to assess the quality of qualitative research. The meta-aggregation method would be used with the ConQual approach to synthesis the data.
Results and conclusion: Results of this study would be published in a peer-reviewed journal.

Declarations: 

Research funding: None.

Author contributions: MHM and LD conceptualized the study question. MT, NK, and NH conducted the primary searches. MHM, MT, NK, NH, and LD‎ contributed to protocol development and writing the manuscript. 

Competing interests: None. 

Data availability: ‎ No data are available for current protocol. ‎

Acknowledgments: We would like to thank the Clinical Research Development Unit of Peymanieh Educational and Research and Therapeutic Center of Jahrom University of Medical Sciences for editing manuscript

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Full Text

Methods

‎ We will perform a comprehensive review of qualitative research that looks at‏ ‏moral distress in HCWs ‎involved with patients with COVID-19.  The Preferred Reporting Items for Systematic Reviews and ‎Meta-Analyses Protocols (PRISMA-P) criteria will be followed in this protocol along with criteria of ‎comprehensive reporting of qualitative studies Consolidated criteria for reporting qualitative research ‎‎(COREQ) (15).‎ The searches were started on 3 December 2021 and primary search was completed on 17 December 2021. ‎

Formulating Study Question ‎

This step includes determining the purpose with a research question and a theoretical framework. The ‎scope of the research should be such that it fully covers the dimensions of the phenomenon under study ‎and is sufficiently specific. The chosen topic for meta-synthesis should have sufficient scientific value ‎and applications for knowledge and theory development or performance improvement. ‎

Among the available search tools for study question conceptualization, PICO, PICOS and SPIDER were ‎available that SPIDER was best fitting with our study (16). SPIDER provides a methodical approach to ‎finding qualitative and mixed-methods researches. The SPIDER tool, which is based on the same ‎concepts as the PICO tool, aids rigor in research by outlining important features of non-quantitative ‎research questions (17). The PICO tool has been modified into the SPIDER tool with following ‎questions: ‎

Sample (S): HCWs of Emergency Department (ED), including physicians, nurses, emergency medical ‎personnel, and students at ED, during COVID-19 pandemic. ‎

Phenomenon of Interest (PI): Moral Distress in HCW of ED during the COVID-19 pandemic.‎

Design (D): Systematic review of qualitative research.‎

Evaluation (E): All outcomes of interest related to bioethical issues, moral status, moral injury, moral ‎distress assessed by qualitative researches and mixed method studies would be included. ‎

Research Type (R): qualitative and mixed method studies. ‎

Eligibility criteria: ‎

Research studies would be considered whether they are qualitative studies involving HCWs of ED who ‎handle COVID-19 patients and have been using qualitative methods for data collection and analysis. ‎Mixed method studies would be qualified if the qualitative and quantitative data are analyzed separately. ‎All included studies will be characterizing the different aspects of the moral distress in COVID-19 ‎management. Studies at settings of ICU or COVID-19 wards would not be included to centralize study ‎focus on ED. non-English articles would not be considered. Letters, Commentaries, Narrative Review ‎studies, Systematic review studies, and quantitative studies would not be included. ‎

Sources:‎

MEDLINE and PsycINFO, EMBASE, SCOPUS, and Web of Science databases would be quarried. ‎Up until 2019, the search will be conducted using explosions and combinations of key search terms ‎of [moral distress OR moral injury OR ethic] AND [COVID-19 OR SARS-COV-2 OR pandemic] AND [emergency department OR nurse OR physician OR students].  A PRISMA flow chart would be utilized to ‎visualize the study selection process. ‎The findings would be transferred to an excel spreadsheet. Following removing duplicated search ‎results, two researchers (NK,NH) would independently perform initial title screening. After that, titles ‎and abstracts of remaining records would be evaluated for collection of potentially relevant studies. ‎Then, full-text review would be conducted to find papers that meet eligibility criteria. Final results of the ‎independent researchers would be merged based on their discussions and if an agreement cannot be ‎established, a debate with a third reviewer would be performed to address the issue (LD). ‎

Quality assessment: ‎

The Critical Appraisal Skills Programme (CASP) checklist is a tool commonly used to assess the ‎quality of early qualitative research studies (18). CAPS is a 10-item tool that helps the researcher ‎determine the accuracy, validity, and importance of qualitative research studies. These questions focus ‎on the following: 1. Research objectives, Research objectives, sampling method, Data collection, ‎Reflexivity (including the relationship between the researcher and the participants), Ethical ‎considerations, Accuracy of data analysis, clear expression of the findings, the value of research. ‎

Data extraction

A checklist based on the COREQ [Personal characteristics of the research team: interviewer, ‎credentials, occupation, experience, and training; Relationship with participants (establishing a ‎relationship, participant familiarity of the interviewer, and interviewer traits); Grounded theory, discourse ‎analysis, ethnography, phenomenology, and content analysis are examples of theoretical frameworks. ‎Methods of participant selection; Data collection settings; Data collection techniques (includes inquiries ‎related to the interview guide, repeat interviews, sound recording, field notes, length, data saturation, ‎and returned transcripts); and questions of findings and analysis] would be used along with all themes, ‎subthemes and supplemented quotations. ‎The completed data extraction forms will be checked for consistency and integrity. Each published ‎report's themes and subthemes will be extracted, independently checked by the pairs of reviewers, and ‎uploaded to an Excel spreadsheet. To eliminate ambiguity, the items will be grouped together and ‎duplicates will be removed.‎

Risk of bias

Our checklist of CASP checklist would also be implicated for bias assessment (19).‎

Data synthesis

Combining qualitative evidence to examine research questions is being conducted by precise ‎qualitative methods to combine existing qualitative studies to create more meaning through an ‎interpretive process (20,21). The main goal of a qualitative meta-analysis is knowledge production. ‎From this perspective, goals for qualitative meta-analysis research are proposed to be: 1) theory ‎construction, 2) Theory description, and 3) theory development According to Sherry et al., qualitative ‎meta-synthesis should be used to construct more abstract theories, to describe theories more ‎accurately (theory explanation), and to provide a more general overview of a theory development field) ‎‎(21, 22).‎

Synthesis is a collective set of qualitative or ethnographic researches to identify common themes or to ‎compare and contrast different groups on a general theme, providing deeper insights that may be ‎available in a single study.  The qualitative hybrid approach is not only important for recognizing ‎multiple research studies, but also has the ability to identify gaps and inefficiencies in research content ‎and can add depth of dimension and interpretation to qualitative studies (20-23). ‎

We choose aggregative methodologies to attempt to uncover practice and policy applications. the ‎aggregative method tends to use realist or pragmatist epistemological frameworks in order to provide a ‎complete summary of previous work in a descriptive way. There is no re-interpretation of data (23).‎

Meta-aggregation method

In this method, the Dependability and Credibility of each subtheme would be evaluated to establish a ‎‎ConQual score, as shown in table 1.

0

The synthesized finding is graded based on the aggregated degree ‎of dependability when the five criteria for dependability are not fulfilled throughout the included research. ‎ Downgrading may occur if not all of the findings included in a synthesized finding are judged ‎unambiguous (24).‎ Based on similar previous study by Arnold, we predict about 10 studies to make reliable evidence available in meta-synthesis (25).

Dissemination plan of study

We would report our systematic review progress at PROSPERO registry, planned to submit in ‎January 2022.‎

Results: ‎

We will report the results of the systematic review and submit the work to a peer-reviewed journal.