The prevalence of moral injury, burnout, depression, and anxiety in Brazilian healthcare workers

Context: Moral injury is a significant contributor to healthcare worker distress in the United States, leading to patient and healthcare worker harm. The presence of moral injury among healthcare workers in Brazil has not been studied.

Objective: To identify the extent to which moral injury is a cause of healthcare worker distress in Brazil.

Study Design and Analysis: A cross-sectional survey was conducted to gather data from healthcare professionals on anxiety, depression, burnout and moral injury.

Setting and Population Studied: Physicians at the University of São Paulo (374 faculty, 1,600 residents) were invited via email to complete a voluntary electronic survey.

Intervention/Instrument: Quantitative screening for depression, anxiety, burnout, and moral injury with an open-ended question to provide insights into quantitative responses.

Outcome Measures: The Patient Questionnaire-9 (PHQ-9) is a 9-item tool that screens for depression, with a score of 10 being moderately severe. 1 The Generalized Anxiety Disorder -7 (GAD-7) is a 7-item scale that screens for anxiety, with a score of 10 being moderate anxiety. 2 The Copenhagen Burnout Inventory (CBI) measures personal, work, and patient burnout, with a score of 50-74 indicating moderate burnout.

3 Results: A total of 148 participants completed the survey. The prevalence of at least moderate depression, anxiety, burnout (personal, work, patient), and moral injury were, respectively, 62%, 45%, 45-80%, and 88%. These are higher than recently reported among respondents at a comparable US academic medical center, whose prevalences were 19.5%, 18.7%, 23.8- 42.4%, and 27.6%. 4 Interestingly, only 54% of respondents self-identified moderate or greater moral injury distress. This indicates that 39% of those suffering from moral injury may be unaware of the extent of their impairment. Most concerning, 26% of respondents had suicidal thoughts on several or more days in the preceding two weeks.

Conclusions: Although our low response rate limits generalizability, we are able to report for the first time that moral injury is a cause of distress for at least some healthcare workers in Brazil, and indicates a need for a detailed study of the phenomenon in this population.