Discussion

Most of the participants had mild-moderate Moral Distress scores. Physicians had moderate MD, while nurses and EMS workers had mild MD. This finding differs from previous studies in which MD intensity was higher in nurses due to the belief that physicians had decision-making control over patients and less direct contact. ^{Reference Epstein, Whitehead and Prompahakul13,Reference Whitehead, Herbertson and Hamric22} Physicians in the Bahamas have longer and more direct patient interactions than in some other systems, as they are required to perform most bedside procedures such as foley catheter insertion, intravenous cannula insertion, blood collection, and wound care, which are often performed by other staff like phlebotomists or Emergency Room technicians in many settings. ^{Reference Epstein, Whitehead and Prompahakul13,Reference Whitehead, Herbertson and Hamric22,Reference Hamric and Blackhall23} Physicians’ scores may also be elevated due to their rating of lack of resources as “severely distressing,” a finding also seen in the 2019 Epstein et al. study.

Most of the participants that worked immediately after the passing of Hurricane Dorian had moderate MD. In contrast, those that worked during the storm or at both times had mild MD. A study of healthcare workers that worked during Typhoon Haiyan in 2013 found that persons who were inside the hospital experienced a protective “bubble” that isolated them from the external events of the storm, which led them to be able to block out negative thoughts. ^{Reference Hugelius, Adolfsson and Örtenwall6} This phenomenon may have occurred with participants that worked in the hospital during Hurricane Dorian. Crisis situations require a heightened focus on the immediate tasks at hand and lead to increased teamwork among hospital staff. The shared goal of managing the disaster can create a supportive environment and provide a sense of protection within the team. Participants that were outside the hospital during the storm, but worked immediately after, were more exposed to the destruction, and had a higher potential to suffer alone, through personal traumatic events that may have been left unresolved prior to reporting to duty, such as property damage, and loss. This group also struggled with the consequences of the aftermath of the storm such as resource shortages, limited clinical space, increased patient load, and a prolonged recovery phase which may have made their MD worse.

Many who worked during the COVID-19 pandemic had mild-moderate MD. Participants may have developed a level of moral resilience over time as this study occurred 3 years after the start of the COVID-19 pandemic, and healthcare workers had adapted during this time. ^{Reference Kreh, Brancaleoni and Magalini24} Moral resilience is defined as the ability to sustain or restore one’s integrity in the face of moral challenges and has been shown to occur with support from employers and coworkers. ^{Reference Spilg, Rushton and Phillips18,Reference Rushton25,Reference Rushton26} More than 50% of the responders thought the lack of resources and staffing challenges were moderately distressing. This finding is in line with a study on MD in Swedish healthcare workers that found lack of resources created great moral stress for staff. ^{Reference Gustavsson, Juth and Schreeb16} In 2023, Gustavsson et al. included staff in lack of resources. This study separated staffing challenges and included limited staffing numbers and competency levels in this category. More than 50% of the nurses rated staffing challenges as moderately distressing; however, physicians found staffing challenges to be mildly distressing. In December 2022, it was reported that the public healthcare system in Grand Bahama lost 19 nurses in 2021 and 14 in 2022 through resignations. ^{Reference Thompson-Evariste27} Prior to 2019, the rate of nursing loss from resignation was less than 10 per year, and prolonged working hours to cover staffing deficits were noted to be a cause. ^{Reference Thompson-Evariste27} The aftermath of Dorian and the pandemic appears to be an impetus in the nursing resignation rate doubling 2 years later. There are over 200 nurses currently in the system on Grand Bahama to support a population of under 48 000. ^{Reference Gibson28} In contrast, 2 physicians in the A&E resigned before the COVID-19 pandemic.

Nearly 50% of the physicians found the lack of resources severely distressing, while nurses were even across severity levels of MD. In developing the measure of Moral Distress for healthcare professions in 2019, Epstein et al. found that “lack of resources” was rated as 1 of the top 5 causes of MD in physicians in their study. ^{Reference Epstein, Whitehead and Prompahakul13} In the aftermath of Dorian, the A&E department at RMH was severely impacted with limited bed space due to the destruction of the rest of the hospital, and experienced extreme overcrowding that persisted, and worsened during the COVID-19 pandemic. The pandemic also introduced challenges of supplying PPE to hospital staff due to supply-chain shortages and shipping delays. This made evaluating and managing patients difficult for physicians, which may have led to their rating of lack of resources as “severely distressing” All professionals thought ethical challenges and pressure from external forces were mildly distressing. Gustavsson et al.’s 2023 study also noted that moral dilemmas were not the main cause of MD, but lack of resources was. ^{Reference Gustavsson, Juth and Schreeb16} Most participants were between 40 – 50 years old with 20 – 30 years of work experience, and therefore had years of dealing with ethical challenges before the pandemic, which may have provided some level of moral resilience compared to previous studies. ^{Reference Gustavsson, Juth and Arnberg15}

Participants who suffered from multiple negative experiences from COVID-19 had higher MD scores. These people had experienced a combination of being infected with the virus, requiring quarantine due to contact with a positive case, and/ or losing a loved one. These were also considered stressors in previous Covid -19 studies. ^{Reference Kreh, Brancaleoni and Magalini24,Reference Dai, Hu and Xiong29} The concern for their safety and that of their loved ones may have contributed to higher Moral Distress scores in the study group. ^{Reference Kreh, Brancaleoni and Magalini24} However, the loss of a loved one due to COVID-19 alone was associated with lower scores. The type of death, prior end-of-life actions, and the relationship with the deceased have already been described as impacting the level of grief experienced. ^{Reference Rabow, Huang and White-Hammond9} It is possible that the death of a loved one from COVID-19 may have strengthened the study group’s resolve to combat the pandemic, leading to lower MD scores. Previous studies of grief and psychological stressors in healthcare workers during the pandemic identified self-isolation from friends and relatives for fear of infecting them as a contributory factor. ^{Reference Rabow, Huang and White-Hammond9,Reference Kreh, Brancaleoni and Magalini24,Reference Ansari30,Reference Eftekhar, Naserbakht and Bernstein31} In those studies, when death of a loved one occurred, they were unable to mourn properly and may have experienced what Rabow et al. described as “disenfranchised grief,” which occurs when one cannot openly acknowledge or publicly mourn their loss due to shame or guilt of causing the illness, or not being present when they died, and therefore, grieve alone. ^{Reference Rabow, Huang and White-Hammond9} In our study, the participants had support from family and friends, and only quarantined when they had contact with a positive case, or isolated when tested positive. It is possible that this support was used after the death of a loved one and may have lessened the MD experience.

Conversely, those who lost a loved one during Hurricane Dorian had higher MD scores. It is well known that unexpected death is linked to the development of post-traumatic stress disorder. ^{Reference Atwoli, Stein and King32} These deaths occurred suddenly, with no time to mentally prepare for the loss, thus increasing trauma to those left behind. ^{Reference Hugelius, Adolfsson and Örtenwall6,Reference Gesi, Carmassi and Cerveri33,Reference Kristensen, Weisaeth and Bereavement34} This group includes those who’s loved one went missing and was not found dead, so they may also suffer from the stress and grief of “ambiguous loss,” which differs from confirmed death due to the lack of closure the loved one’s experience. ^{Reference Boss and Yeats35} The survey asked about losing a loved one but did not specify only death. There are currently still over 200 persons missing after Hurricane Dorian, some of whom are likely relatives of healthcare workers.

Daily exercise decreases MD significantly and improves moral resilience when used as a part of self-care regimens. ^{Reference Rabow, Huang and White-Hammond9,Reference Rushton, Christine Westphal and Campbell36} Family and friends were the most utilized means of support, aligning with previous studies. ^{Reference Gustavsson, Arnberg and Juth8,Reference Gustavsson, Juth and Schreeb16} Support tools that required a level of self-reflection and discussion were associated with decreased scores of MD. ^{Reference Gustavsson, Juth and Arnberg15} Those who took time off, however, had increased MD scores. These people may have needed time off due to their increased levels of distress. While time off may improve employee well-being by giving the individual time to regroup and recharge, MD may end up unchanged or worsen upon return if the patient care challenges which prompted the time off remained unchanged. Gustavsson et al., in 2023 noted that moral stress could not be improved unless the underlying factors were addressed, which require adequate peer support, and effective leadership. ^{Reference Gustavsson, Juth and Schreeb16} Due to the differences in how individuals handle and process stressful situations, psycho-social interventions may also need to be tailored to individual needs to ensure beneficial outcomes. ^{Reference Eftekhar, Naserbakht and Bernstein31}