{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T00:45:06Z","timestamp":1790642706859,"version":"4.1.0"},"reference-count":58,"publisher":"BMJ","issue":"7","license":[{"start":{"date-parts":[[2022,7,18]],"date-time":"2022-07-18T00:00:00Z","timestamp":1658102400000},"content-version":"unspecified","delay-in-days":17,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2022,6,1]]},"published-print":{"date-parts":[[2022,7]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>To describe the prevalence and sources of experienced moral stress and anxiety by Swedish frontline healthcare staff in the early phase of COVID-19.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Cross-sectional survey, quantitative and qualitative.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants and setting<\/jats:title>\n                    <jats:p>1074 healthcare professionals (75% nurses) in intensive, ward-based, primary and municipal care in one Swedish county.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Measures<\/jats:title>\n                    <jats:p>A study-specific closed-ended and an open-ended questionnaire about moral stress and the Generalised Anxiety Disorder 7-item scale measuring anxiety, followed by an open question about anxiety.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Findings<\/jats:title>\n                    <jats:p>Moral stress was experienced by 52% of respondents and anxiety by 40%. Moral stress in concern for others attributed to institutional constraints comprised experiences of being deprived of possibilities to respond to humane and professional responsibility. Staff experienced being restricted in fulfilling patients\u2019 and families\u2019 need for closeness and security as well as being compelled to provide substandard and inhumane care. Uncertainty about right and good, without blame, was also described. However, a burdensome guilt also emerged as a moral distress, blaming oneself. This comprised feeling complicit in the spread of COVID-19, inadequacy in care and carrying patients\u2019 suffering. Staff also experienced an exhausting distress as a self-concern in an uncontrollable work situation. This comprised a taxing insecurity by being in limbo, being alone and fear of failing, despair of being deprived control by not being heard; unable to influence; distrusting management; as well as an excessive workload.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>We have not only contributed with knowledge about experiences of being in the frontline of COVID-19, but also with an understanding of a demarcation between moral stress\/distress as a concern for patients and family, and exhausting distress in work situation as self-concern. A lesson for management is that ethics support should first include acknowledgement of self-concern and mitigation of guilt before any structured ethical reflection. Preventive measures for major events should focus on connectedness between all parties concerned, preventing inhumane care and burn-out.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2021-055726","type":"journal-article","created":{"date-parts":[[2022,7,18]],"date-time":"2022-07-18T11:52:16Z","timestamp":1658145136000},"page":"e055726","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":21,"title":["Moral and exhausting distress working in the frontline of COVID-19: a Swedish survey during the first wave in four healthcare settings"],"prefix":"10.1136","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0679-5695","authenticated-orcid":false,"given":"Mia","family":"Svantesson","sequence":"first","affiliation":[{"name":"University Health Care Reserach Center, Faculty of Medicine and Health, \u00d6rebro University, \u00d6rebro, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Linda","family":"Durnell","sequence":"additional","affiliation":[{"name":"University Health Care Reserach Center, Faculty of Medicine and Health, \u00d6rebro University, \u00d6rebro, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erik","family":"Hammarstr\u00f6m","sequence":"additional","affiliation":[{"name":"University Health Care Reserach Center, Faculty of Medicine and Health, \u00d6rebro University, \u00d6rebro, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gustav","family":"Jarl","sequence":"additional","affiliation":[{"name":"University Health Care Reserach Center, Faculty of Medicine and Health, \u00d6rebro University, \u00d6rebro, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lars","family":"Sandman","sequence":"additional","affiliation":[{"name":"Department of Medical and Health Sciences, Link\u00f6ping University, Link\u00f6ping, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2022,7,18]]},"reference":[{"key":"2025121510545218000_12.7.e055726.1","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2020.3976","article-title":"Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019","volume":"3","author":"Lai","year":"2020","journal-title":"JAMA Netw Open"},{"key":"2025121510545218000_12.7.e055726.2","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2020-042555"},{"key":"2025121510545218000_12.7.e055726.3","doi-asserted-by":"publisher","DOI":"10.2196\/24983"},{"key":"2025121510545218000_12.7.e055726.4","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2020.10185","article-title":"Mental health outcomes among frontline and second-line health care workers during the coronavirus disease 2019 (COVID-19) pandemic in Italy","volume":"3","author":"Rossi","year":"2020","journal-title":"JAMA Netw Open"},{"key":"2025121510545218000_12.7.e055726.5","doi-asserted-by":"publisher","DOI":"10.1007\/s11920-020-01166-z"},{"key":"2025121510545218000_12.7.e055726.6","doi-asserted-by":"crossref","DOI":"10.1016\/j.psychres.2020.113360","article-title":"Psychological effects of the COVID 19 pandemic on healthcare workers globally: a systematic review","volume":"292","author":"Sheraton","year":"2020","journal-title":"Psychiatry Res"},{"key":"2025121510545218000_12.7.e055726.7","doi-asserted-by":"publisher","DOI":"10.1186\/s12889-020-09322-z"},{"key":"2025121510545218000_12.7.e055726.8","doi-asserted-by":"crossref","DOI":"10.3390\/ijerph17217857","article-title":"COVID-19-Related mental health effects in the workplace: a narrative review","volume":"17","author":"Giorgi","year":"2020","journal-title":"Int J Environ Res Public Health"},{"key":"2025121510545218000_12.7.e055726.9","doi-asserted-by":"crossref","first-page":"212","DOI":"10.1017\/S1049023X20000096","article-title":"Moral distress among disaster responders: what is it?","volume":"35","author":"Gustavsson","year":"2020","journal-title":"Prehosp Disaster Med"},{"key":"2025121510545218000_12.7.e055726.10","doi-asserted-by":"crossref","first-page":"585","DOI":"10.1016\/j.cnur.2016.07.005","article-title":"Complicated realities: mental health and moral incongruence in Disaster\/Humanitarian response","volume":"51","author":"Boswell","year":"2016","journal-title":"Nurs Clin North Am"},{"key":"2025121510545218000_12.7.e055726.11","doi-asserted-by":"publisher","DOI":"10.1111\/j.1471-8847.2006.00153.x"},{"key":"2025121510545218000_12.7.e055726.12","unstructured":"Jameton A . 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