Participants and Procedure
Health professionals (physicians and nurses) who had at least two years of hospital work experience in mainland China were eligible to participate. The exclusion criteria were: (1) having a six month or longer break in work duties due to any reason in the past two years; (2) unable to access the internet or other mobile device due to the vision or other disability that prevented completion of the online questionnaire; and (3) those without a current active license (in primary health care offices, some physicians may not have yet passed the medical qualifications exam for licensure).
Due to the risk of infection, traditional face-to-face interviews were not employed (even though the pandemic was largely under control). The questionnaire was administered via an online survey platform (WenJuanXing, https://www.wjx.cn/app/survey.aspx) from March 27th to April 26th, 2021. A draft version of the questionnaire was first administrated to 11 physicians from two hospitals for pre-testing. These physicians were asked to send comments about the ease of access to the online questionnaire, clarity of wording, and time burden. Necessary changes in language and technical settings were then made based on the consensus of researchers to arrive at the final version of the electronic questionnaire.
A letter with a link to the online questionnaire was sent to potential participants through social media (includes WeChat, QQ, and email list) inviting them to complete the survey; those who responded to the invitation were encouraged to forward the invitation letter to their colleagues and post it on their social media networks. A small amount of money (approximately one US dollar) was offered for their time. The survey was available in both Smartphone and Windows applications and was developed following guidelines from the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) .
As shown in Fig. 1, there were a total of 15,976 potential participants (documented based on an automated record from the survey platform) who were invited to participate. Of those individuals, 4,025 responded to the invitation (25.2%) and completed the online questionnaire; of those, 4,017 completed the questionnaire. Finally, 552 participants met the exclusion criteria resulting in a final sample of 3,465 participants.
Information was collected on age, gender, marital status, educational attainment, ethnicity (Chinese Han vs. minority ethnicity), work area (general medical ward, ICU/emergency room), physician or nurse status, length in practice, and exposure to patients with COVID-19.
MI was assessed using the 10-item Chinese version of the Moral Injury Symptoms Scale-Health Professional (MISS-HP). This measure assesses ten dimensions of MI: betrayal, guilt, shame, moral concerns, loss of trust, loss of meaning, difficulty forgiving, self-condemnation, faith struggle, and loss of faith. Response options for each of the ten items range from 1 to 10, indicating agreement or disagreement, resulting in a total score ranging from 10 to 100, with higher scores indicating more severe MI symptoms. The Chinese version of MISS-HP is a well-validated instrument applicable to health professionals with a Cronbach’s alpha of 0.71; a test-retest coefficient of 0.77; and a cutoff value of 50 that is indicative of significant MI symptoms. The Cronbach’s alpha in the present sample was 0.72.
The 4-item Suicidal Behaviors Questionnaire-Revised (SBQ-R) was used to assess four different aspects of suicidal behavior: lifetime suicide ideation and suicide attempts; frequency of suicide ideation over the past twelve months; threats of a suicide attempt; and the likelihood of suicidal behavior in the future. The total score ranges from 3 to 18, with a recommended cut-off score of ≥ 7 for high risk of suicide. The Chinese version of the SBQ-R has been shown to have acceptable psychometric properties . In this study, the Cronbach alpha for the SBQ-R was 0.80.
A short-form PTSD Checklist for DSM-5 (PCL‐5-SF) was used to assess the symptoms of PTSD. The four-item version of the scale has acceptable convergent and discriminant validity compared with the full 20-item PCL‐5. Each item is scored from 0 to 4 (not at all, a little bit, moderately, quite a bit, extremely) resulting in a total score ranging from 0 to 16; a cut-off score of 6 is indicative of clinically significant PTSD symptoms. The Chinese version of the PCL-5-SF has acceptable psychometric properties . In this study, the Cronbach alpha of the PCL-5-SF was 0.90.
Descriptive statistics were performed by calculating means, standard deviations (SD), and proportions. The correlation between moral injury, PTSD, and suicidal behaviors was examined using Pearson’s correlation. The chi-square test was used to test the prevalence of clinically significant PTSD and suicidal behavior, and their association with the categorical variables of gender, final academical degree, etc. Unconditional logistic regression model was employed to test the association after controlling for covariates. Odds ratios (OR) with 95% confidence intervals (95% CIs) were calculated under the IBM SPSS 23.0. The alpha level for statistical significant was set at 0.05.