Exploring Moral Injury in Researchers in a Paediatric Humanitarian Research Setting: A Qualitative study from the Mavrovouni Closed Controlled Access Center, Lesvos, Greece

doi:10.21203/rs.3.rs-4842714/v1

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Exploring Moral Injury in Researchers in a Paediatric Humanitarian Research Setting: A Qualitative study from the Mavrovouni Closed Controlled Access Center, Lesvos, Greece

https://doi.org/10.21203/rs.3.rs-4842714/v1

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Background

Moral injury refers to the emotional distress experienced when an individual's moral or ethical beliefs are violated. This concept has been widely studied in a number of disciplines, but limited attention has been given to the moral injury experienced by researchers in the humanitarian setting. This paper aims to explore the ethical challenges and resulting moral injury faced by paediatric humanitarian researchers in the Mavrovouni Closed Controlled Access Center, Lesvos, Greece.

Methods

Based on a qualitative approach, we conducted three ethics support workshops with 5 to 10 participants each, in which they were invited to discuss the moral dilemmas they were experiencing in their research work. Sessions were audio-recorded and transcribed; transcripts were analysed using reflexive thematic analysis.

Results

Seven main themes were developed: community and system-level considerations, witnessing and moral responsibility, conflicting duties, participant benefit misconception, coping strategies, cultural aspects, and theories of change. These themes highlight the diverse ethical dilemmas researchers face in this field.

Conclusion

Researchers reported feelings pointing to a risk of moral injury if these issues are not adequately addressed. The results of this study will contribute to the development of support systems for researchers working in sensitive data collection and promote a more sustainable and healthy research practice.

Moral injury

ethical support

refugee camps

refugees

asylum seekers

children

paediatric

Researchers from 'The Mavrovouni Migrant Child Health Project', in which nutritional status and the quality of life of children living in one of Europe's biggest refugee camps are assessed, voiced the need for support after experiencing diverse ethical challenges. Although ethical challenges encountered by humanitarian healthcare workers have been described, the challenges experienced specifically by researchers in this context have been little addressed, particularly in the paediatric context. In a systematic review of the ethical challenges of 'field' research in low and middle-income countries, Steinhart and colleagues described the ethical issues reported in the literature, but moral injury, specifically to medical researchers, has rarely been studied or described. It is essential to recognise the vulnerability of the children and families in the refugee centre, especially their ongoing need for basic sustenance and healthcare. The latter cannot always be provided in this setting, and certainly not by researchers in their different roles. Researchers certainly have moral questions about why children and families have been forced into this situation, whether by war or poverty and soon by climate change, none of which they can control, which seems a paradigm set up for moral injury.

Following research abuses, concern for research participants has been the main focus and extensively described, leading to research practices aiming to ensure the protection of all research participants. Additionally, although to a lesser degree, increased attention has been given to the impact of research practices on researchers themselves, with existing research pointing to the need to develop support systems for researchers working in the area of sensitive data collection , especially in qualitative research in sensitive topics or with vulnerable populations. However, the focus has been on researchers' safety, emotional distress, and vulnerability, with less attention to the experience of morally challenging situations and the impact these can have on researchers' well-being and research output. While more extensively described in the healthcare and military fields and described in different disciplines, including psychology, psychiatry, social work, philosophy, religious and spiritual studies, the concepts of moral distress and moral injury in the research field have rarely been explored.

There are no agreed definitions for the concepts of moral distress and moral injury, with these terms often used interchangeably. The concept of moral distress was initially described by Jameton in 1984 in relation to student nurses' experiences of distress when "when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action". Moral injury was initially conceptualised in the military context, referring to the emotional distress and a particular type of trauma that an individual experiences as a consequence of their moral or ethical beliefs being violated when "perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations" . Both terms are now used in healthcare to refer to the impact of morally challenging situations on individuals' psychological and spiritual well-being. For example, the British Medical Association adopted an integrated approach, where moral distress is understood as a feeling of unease arising from situations where institutionally required behaviour does not align with the individual's own ethical principles; moral injury occurs when sustained moral distress leads to impaired function or longer-term psychological harm. Witnessing or participating in potentially morally injurious events has been significantly associated with depression, post-traumatic stress disorder and suicidal ideation. Experiencing moral injury can potentially lead to impaired occupational and social functioning.

A better understanding of the ethical challenges faced by researchers and the potential for moral distress and moral injury they might experience in this setting is important. Ultimately, supporting researchers better to prevent harm to them will ensure more sustainable and healthy research practices.

Objective

To explore the ethical challenges that paediatric humanitarian researchers working in a European refugee camp face and the impact these experiences have on them.

An experiential orientation to qualitative study design was chosen to enable in-depth exploration of participants’ experiences of ethical challenges in their humanitarian research work practice. Research students from four different universities in the Netherlands and Greece with backgrounds in medicine, global health and disaster management involved in 'the Mavrovouni Migrant Child Health Project' in a European refugee camp, were invited to participate in a series of three ethics workshops. Ahead of the workshops, participants were asked "What are ethical dilemmas that you face during your work as a researcher?" and were invited to share the ethical challenges they experienced, either written ahead of each workshop or verbally during the meeting. We did not provide participants with a definition of "ethical challenge" to allow a more comprehensive discussion without pre-established limits around a concept lacking an agreed definition in healthcare research.

Three workshops were hosted online and were facilitated by two experienced members of a Paediatric Bioethics team from a tertiary children's hospital. Participation in the workshop was voluntary and informed consent from each participant was sought prior to each session, reassuring participation was voluntary and ensuring anonymity and confidentiality of the collected data.

All three sessions, with a duration of 45–60 minutes, were audio-recorded and subsequently transcribed verbatim using an online transcription tool and anonymised. Two authors analysed transcripts independently (MD, HB) following a reflexive thematic analysis approach, following a familiarisation with the data, iterative inductive coding and theme development. Initial codes and themes were then discussed within the team and organised into overarching themes and subthemes.

Participants: out of a total of ten researchers invited to participate, between 5–10 researchers joined each session, with some of them participating in more than one. All participants joined the workshops during their research internships. Participants’ included research students with backgrounds in psychology, global health and medicine. Sessions lasted between 45–60 minutes each. Reflexive thematic analysis of the transcripts led to the development of seven major themes with sub-themes (Table 1).

Table 1. Themes and subthemes
Main themes	Subthemes
1. Community and System-Level Considerations
2. Witnessing and Moral Responsibility	i. Injustice ii. Discrimination iii. Power imbalances iv. Guilt
3. Conflicting duties	i. Participant welfare ii. Professional boundaries & rules
4. Informed consent and participants' misconception about potential benefits
5. Coping strategies	i. Emotional support ii. Peer support iii. Privileges and responsibilities
6. Cultural aspects
7. Theory of Change	i. Advocacy ii. Action iii. Giving children a voice

1. Community and system-level considerations

This theme touched upon the ethical considerations related to the impact of their research work. There were reflections about the short versus long-term effects of the research, as well as local versus international impact. One participant described this in the following manner:

"You want to create some sort of transformation, some sort of action, action perspective for the people that you work with for the community. In this case, it would be then the people in the camp, the refugee community. And I have had some sort of conflicting things within myself during the time that I was here that the current research that we are doing is of course going to create hopefully with the, hopefully the impact that we will make, make some change for people in the future, for the people living in the camp later on." - Participant workshop 1

Researchers grappled with the balance between individual and collective interests, as well as the balance between direct and indirect benefits of the research that they are performing:

"Say we're not only studying these detailed elements of well-being but trying to describe the whole picture in a more comprehensive picture of a population in a camp and being bold and really looking to see what can we actually really do." - Participant workshop 1

Participants reflected on how, at times, it felt distressing to know that the research is intended to have long-term benefits but no tangible direct benefit for participants, as illustrated by the following quote:

"Maybe it even feels now sometimes like a burden for the people that are included because we can give them some information but not always the help." - Participant workshop 1

2. Witnessing and moral responsibility

This major theme relates to the moral responsibility and personal impact that researchers felt when witnessing - and feeling unable to change or directly address - the multiple challenges faced by paediatric populations and their caregivers in humanitarian settings. The theme could be further defined into four sub-themes, i.e., different challenges that the researchers witnessed and considered appealed to their own moral responsibility: injustice, discrimination, power imbalances and guilt.

(i) Injustice

This sub-theme delves into the distress researchers encounter when witnessing systemic inequalities and disparities within their research populations, as illustrated by the following quote:

"And then for me, the feeling, but I go into that camp and I, with that, I feel that I contribute to the system, which I do not completely stand behind. And that's the feeling of discomfort that I'm like actually, yeah, or it feels that I'm contributing to a system that doesn't feel right to me in some, yeah, on some levels." - Participant workshop 2

(ii) Discrimination

A second important sub-theme that arose was the fact that researchers witness discrimination, feeling that camp residents received worse treatment than themselves as research team members, as illustrated in the following text:

"So, at the entrance of the camp, we are not searched, but the residents and visitors are. Just based on how I look, I'm already treated differently. I go there every day and it feels like I am contributing to the inequality in treatment. In the first week, I would make a comment about it and try to suggest that they could scan." - Participant workshop 2

Further highlighting that there should be no discrimination:

"We are all humans. Nobody has a stamp that is a refugee, a migrant, or a local, or whatever." - Participant workshop 1

(iii) Power imbalances

Researchers frequently mentioned the fact that being a witness to power imbalances also gave significant distress and spoke to their moral responsibility:

"Within research people have to decide for themselves really if they want to participate, but is that even possible in a setting like this, if there are so many power imbalances and if people, well, might indeed think that if I do not participate will it have any negative consequences on my asylum procedure." - Participant workshop 1

(iv) Guilt

Being a witness to injustice at times brought along a feeling of guilt, questioning their personal opportunities and choices:

"Sometimes I feel a bit guilty when I'm spending money on a coffee, while studying or when I'm going out for dinner, while being aware of the current situation in the camp." - Participant workshop 2

3. Conflicting duties

One prevalent theme revolved around the ethical dilemma of researchers' conflicting duties. Researchers found themselves torn between obligations to the research participants, the broader community, and the scientific community. This overall theme can be subdivided into the following subthemes:

(i) Participant welfare

On the one hand, researchers worried about the potential burden of their research practices on the participants:

"Sometimes it feels like we are extracting so much data from them, without being able to do something for them right now."- Participant workshop 1

On the other hand, researchers felt the obligation to provide medical care even though that was beyond the scope of the research.

"But she was almost five, and she didn't speak. She seemed autistic, and she didn't go to school. And I was talking to her mom and her mom was very concerned about that. It's not the type of chronic disease where she is lacking medication, so she should be urgently transferred to the mainland by using our network of paediatricians. But she is autistic. She has other requirements needed for optimal development." - Participant workshop 3

(ii) Professional boundaries & rules

Researchers sometimes struggled to maintain professional boundaries while maintaining an authentic and genuine human connection in their daily work.

"We're not providing a service, so there's not a dilemma of them giving us payments or

gifts for our service. It's kind of like we're researchers, but we're also humans and think it's perfectly okay to have these kind of connections. It's like we're here and we're in this situation, so I think that as long as we set boundaries..." - Participant workshop 3

Simultaneously, there was a quest for guidance on what was appropriate as a researcher in such a setting.

"But who makes the boundary, right? And that's what you're saying. Is that something as someone who's new to this should you be told what that is? Should you be able to feel what it is? And if you get it wrong, how can that be right? Because if we're asking you to decide on your own values what should happen, well who can tell you what's right or wrong apart from you? That's the problem. So, what is the set rule of this? What is, you know, what is okay? Are there anything in your world where people say this sort of relationship's okay?" - Participant workshop 3

4. Informed consent

and participants' misconception about potential benefits

Another recurrent theme was 'benefit misconception', where researchers were faced with research participants who had the hope that the research provided some sort of benefit for, e.g., their asylum procedure. Researchers, for example, struggled to obtain unbiased informed consent despite efforts to clarify the actual benefits.

"This is another issue, an ethical issue that we have to take in consideration and clarify from the very, very, very beginning that we're not involved in any administrative procedures and nobody's going to take anything off." - Participant workshop 1

Researchers experienced this as bias in their research:

"The other thing is that always how you are going to take this sample, let's say, because most of the time people in the camp believe that if they participate, this is a bias always, that if they participate in our research, they are going to take something as an advantage. They are going to think that the procedures, the bureaucratic procedures, the administrative procedures for their asylum will be easier." - Participant workshop 1

5. Researchers' coping strategies

Coping strategies emerged as a crucial theme, shedding light on different ways that the researchers personally dealt with the ethical challenges in their research work. They discussed the various strategies employed to manage stress, mitigate emotional impact, and maintain resilience in the face of the challenging ethical dilemmas. The sub-themes that arose from this theme were: emotional support, peer support and using privilege for the good.

(i) Emotional support:

Researchers emphasised the need for emotional support as a means to be able to do the work sustainably.

"You have to take care of your students. They must have psychological support, because many times they will feel like they are doing nothing even if they write all these problems and after that what? Nothing. So, give the psychology support. If we go on and we are not disappointed in what we are doing, we will win." - Participant workshop 1

(ii) Peer support:

Much value was placed on having a community to talk about the challenges that were faced, even though they did not bring practical solutions, they did offer some kind of relief:

"The idea that you can have a space where you might have a facilitated discussion with someone who can help you think through the morality of an issue, even if you can't fix things." - Participant workshop 1

This is further supported by another researcher who said:

"I hear how someone who's very experienced deals with that and not just practically or research technically deals with it, but personally deals with it. I think for me that is very important and helps me to not be blocked by an ethical dilemma but to give it a place and to move on." - Participant workshop 1

(iii) Privileges and responsibilities

A repeatedly mentioned coping mechanism for ethical difficulties, especially when it comes to experiencing different opportunities, was to use researchers' own privilege for good.

"How I personally try to see this is really use, recognising your own privilege and then using it for the good. And that's exactly where this sense of, for me personally, the sense of responsibility comes from saying, well, I have these privileges, so I need to, I have a responsibility to use them to create positive change. And use my privilege to my advantage. So, I definitely, I use the fact that I'm a woman to my advantage, I use the fact that I have a Dutch passport." - Participant workshop 2

6. Cultural aspects

Cultural considerations played an important role in shaping the ethical landscape of the research. The transcripts showed the importance of cultural sensitivity, in particular, when, for example, finding the right researcher-participant relationship:

"I also feel that that's professional distance sometimes is the Western point of view me or

maybe not measured Western but also cultural, that there are cultural differences in that." - Participant workshop 3

7. Theory of Change

A last theme that emerged when discussing ethical dilemmas in this research setting was the theme concerning theories of change. Researchers critically examined the potential impact of their work and the most effective ways to contribute positively to the research setting so that the research directly affects the local population. Relevant sub-themes were advocacy, action and giving children a voice, with participants highlighting the need for resources and funding to be in place for these actions.

i. Advocacy

Advocacy was often mentioned as a tool for using the research to truly achieve

systemic change.

"And then if it comes to humanitarian law, I think identifying these issues is very important, to get in contact with a human rights team, following these things up, analysing them, and maybe supporting on individual case level, but also maybe formulating advocacy messages to European and national institutions." - Participant workshop 1

ii. Action

"So don't give up. For humanity, for human beings, we have to go on. If we go on and we are not disappointed in what we are doing, we will win." - Participant workshop 1

iii. Giving children a voice

So I think we have to understand that if these children can answer, of course with the parent inside the room, let them speak. The parents could change their answer because of the asylum procedure. So let these children, even five-year-old children, speak. You have to have your ears open and to catch what this child says to you. - Participant workshop 1

This study aimed to explore the ethical challenges faced by paediatric humanitarian researchers, focusing on the context of a European refugee camp. Through qualitative analysis of ethics support session transcripts, several key themes were identified, which enabled consideration of the ethical landscape of this research field.

The factors contributing to the ethical challenges researchers encounter in the refugee environment are multifaceted: Witnessing injustice, discrimination, and power imbalances within the research population evoke a sense of moral responsibility. Conflicting duties between researchers' professional roles and genuine human connections further intensify the ethical dilemmas. The balance between individual and collective interests, as well as the long-term impact of research versus some perceived, erroneous, immediate benefit for participants, adds another layer of complexity.

Ethical considerations in research with vulnerable populations and the associated challenges with the informed consent process are widely acknowledged and addressed in international research ethics guidelines. The structural disadvantages experienced by refugees and asylum seekers and the unequal power relationships with the researchers are likely to affect participants' voluntariness to consent. In our study, researchers reflected on the misconception regarding the benefit thought to exist by participants in this setting. Research participant's hope for benefit in this environment, essentially benefit misconception, seems to us to be a version of therapeutic misconception well described in clinical trials, where patients' decision to enrol in research appears to be "based on confusion between the nature of research and of ordinary treatment", potentially invalidating the consent given by participants. Rather than a direct therapeutic benefit, participants perceive some kind of beneficial factor in their own asylum procedure or in the care of their child. This persists despite specific information to the contrary and repeated clarification from the research team. Research ethics guidance on protecting refugees and asylum seekers participating in research is needed. Alongside addressing both the group's and individual's vulnerability, learning from the work done in relation to the identification and management of therapeutic misconception might offer an additional layer to protect participants and researchers, ensuring the integrity of the whole research process.

In the clinical field, it is well established that ethical dilemmas in which clinicians must deliver treatment that conflicts with their moral viewpoint are harmful and cause accumulative damage to them and their well-being . Moral distress and moral injury are far less frequently described in the research field, but one could expect the ethical challenges experienced and lack of ability to address the causes to potentially have a negative impact on paediatric humanitarian researchers. While the focus in the research setting has been on researchers' well-being, emotional distress and resilience, we believe that looking at researchers' experiences of ethical challenges through the lenses of the moral distress and moral injury models might offer an opportunity to appropriately investigate, understand, prevent and respond to the problem to ensure both research participants' and researchers' are protected throughout the research process and to avoid harmful consequences to individuals' psychological and physician well being. Focusing on resilience might imply that the failure is on the individuals suffering from moral distress or injury rather than the institutional and structural constraints leading to these experiences.

Consistent with existing literature on ethical challenges experienced by researchers, participants in our study reported role conflicts, power imbalances and feelings of guilt. Guilt and shame have been described, alongside other emotions, as characteristic emotions of moral injury . This suggests that these and other negative emotions should be further explored and addressed as, like healthcare professionals, researchers might be at risk of experiencing moral distress and, if not timely addressed, suffer moral injury if they don't count with appropriate support to address the ethical challenges encountered during fieldwork. Participants acknowledged that existing codes of conduct and guidelines do not address the complexities of their experiences and challenges. Their accounts suggest that peer support and readily available ethics support might offer a more nuanced and contextualised approach to dealing with these issues. Although limited, evidence suggests that clinical ethics support services can decrease healthcare workers' moral distress . Perhaps, together with sound ethical approval and monitoring processes prior to commencing and throughout the research process, researchers working with vulnerable populations or researching sensitive topics should have access to some form of research ethics support to consult when experiencing complex ethical challenges.

Despite arguably the novelty of this paper on moral distress among this type of researcher, our study certainly has limitations. Though diverse in academic background, the sample size does not fully represent the spectrum of experiences in paediatric humanitarian research. Additionally, the findings are context-specific to the European refugee camp setting and may not be generalisable to other contexts.

This analysis of support session transcripts provides an exploration of the ethical challenges in paediatric humanitarian research and their impact on the research team. The identified themes, such as participant benefit misconception and witnessing and moral responsibility, highlight the complexity of ethical decision-making and the need for a thoughtful and context-specific approach to navigate the ethical challenges of this field. Acknowledging these challenges is a crucial step towards building ethical research practices that prioritise the well-being of vulnerable paediatric populations in humanitarian settings, ensuring vital research to improve their health is conducted, and securing the well-being of researchers in this field.

Ethics:

Ethical clearance for this research project was obtained from the Medical Ethics Committee of the Greek National Public Health Organization (EODY). This was provided in December 2022 under Reference No. 23702/06-12-2022. This study was performed in line with the principles of the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study. Confidentiality and anonymity of participants were strictly maintained throughout the research process.

Consent for publication:

Not applicable

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding:

This research was conducted without any external financial support.

Authors’ contributions:

HB conceived the original idea for this project; MD and JB facilitated the workshops, MD and HB analised the data. All authors revised it critically for important intellectual content and approved the final version for publication.

Acknowledgements:

Not applicable

https://home-affairs.ec.europa.eu/news/how-lesvos-refugee-centre-evolved-year-2022-09-09_en
Dittborn M, Micolich C, Rojas D, Salas SP. Ethical Challenges Experienced by Healthcare Workers Delivering Clinical Care during Health Emergencies and Disasters: A Rapid Review of Qualitative Studies and Thematic Synthesis. AJOB Empir Bioeth. 2022 Jul-Sep;13(3):179–195. doi: 10.1080/23294515.2022.2063996. Epub 2022 Apr 25. PMID: 35467462; PMCID: PMC9881594.
Steinert JI, et al. BMJ Global Health 2021;6:e005380. doi:10.1136/bmjgh-2021-005380
Dickson-Swift et al, Doing sensitive research: what challenges do qualitative researchers face? Qualitative Research, August 2007, 283–424
Brierley J, Larcher V. Lest we forget... research ethics in children: perhaps onerous, yet absolutely necessary. Arch Dis Child. 2010 Nov;95(11):863-6. doi: 10.1136/adc.2009.179762.
Johnson et al, Collecting Sensitive Data: The Impact on Researchers, Qualitative Health Research, Volume 13, March 2003, 299–443
Haugstvedt, H. (2020). A Scoping Review of Practitioner Research on Sensitive Topics. Nordic Journal of Social Research, 11(1), 151–174. 10.7577/njsr.3594
Lisa Oakley, Lee-Ann Fenge & Bethan Taylor (2022) ‘I call it the hero complex’ – Critical considerations of power and privilege and seeking to be an agent of change in qualitative researchers’ experiences, Qualitative Research in Psychology, 19:3, 587–610, DOI: 10.1080/14780887.2020.1718813
Lisa Oakley, Lee-Ann Fenge & Bethan Taylor (2022) ‘I call it the hero complex’– Critical considerations of power and privilege and seeking to be an agent of change in qualitative researchers’ experiences, Qualitative Research in Psychology, 19:3, 587–610, DOI: 10.1080/14780887.2020.1718813
Dickson-Swift et al, Doing sensitive research: what challenges do qualitative researchers face? Qualitative Research, August 2007, 283–424
Jameton, A. 2017. What moral distress in nursing history could suggest about the future of health care. AMA Journal of Ethics 19 (6):617–28. doi: 10.1001/journalofethics.2017.19.6.mhst1-1706.
Griffin et al, Moral Injury: an Integrative Review, Journal of Traumatic Stress, June 2019, 32, 350–362
Jan Grimell & Sofia Nilsson (2020) An advanced perspective on moral challenges and their health-related outcomes through an integration of the moral distress and moral injury theories, Military Psychology, 32:6, 380–388, DOI: 10.1080/08995605.2020.1794478
British Medical Association Moral distress and moral injury – recognising and tackling it for UK doctors (2021)
Jan Grimell & Sofia Nilsson (2020) An advanced perspective on moral challenges and their health-related outcomes through an integration of the moral distress and moral injury theories, Military Psychology, 32:6, 380–388, DOI:10.1080/08995605.2020.1794478
BMA
Williamson et al, Occupational moral injury and mental health: Systematic review and meta-analysis. The British Journal of Psychiatry 212(6): 339–346
Braun V, Clarke V. Conceptual and design thinking for thematic analysis. Qualitative Psychology
2022; 9: 3–26.
Schofield G, Dittborn M, Selman LE, Huxtable R. Defining ethical challenge(s) in healthcare research: a rapid review. BMC Med Ethics. 2021 Sep 29;22(1):135. doi: 10.1186/s12910-021-00700-9. PMID: 34587950; PMCID: PMC8479723.
Braun, Virginia, and Victoria Clarke. "Using thematic analysis in psychology." Qualitative research in psychology 3.2 (2006): 77–101.
Davidson, N., Hammarberg, K. & Fisher, J. Ethical Considerations in Research With People From Refugee and Asylum Seeker Backgrounds: A Systematic Review of National and International Ethics Guidelines. Bioethical Inquiry (2023). https://doi.org/10.1007/s11673-023-10297-w
Appelbaum PS, Roth LH, Lidz C. The therapeutic misconception: informed consent in psychiatric research. Int J Law Psychiatry. 1982;5(3–4):319 − 29. doi: 10.1016/0160-2527(82)90026-7. PMID: 6135666.
de Melo-Martín I, Ho A, Beyond informed consent: the therapeutic misconception and trust, Journal of Medical Ethics 2008;34:202–205
Davidson, N., Hammarberg, K. & Fisher, J. Ethical Considerations in Research With People From Refugee and Asylum Seeker Backgrounds: A Systematic Review of National and International Ethics Guidelines. Bioethical Inquiry (2023). https://doi.org/10.1007/s11673-023-10297-w
BMA. Moral distress and moral injury: recognising and tackling it for UK doctors. Jun 2021. https://www.bma.org.uk/media/4209/bma-moral-distress-injury-survey-report-june-2021.pdf#.
Čartolovni A, Stolt M, Scott PA, Suhonen R. Moral injury in healthcare professionals: A scoping review and discussion. Nurs Ethics. 2021 Aug;28(5):590–602. doi: 10.1177/0969733020966776. Epub 2021 Jan 11. PMID: 33427020; PMCID: PMC8366182.
Thibodeau PS, Nash A, Greenfield JC, Bellamy JL. The Association of Moral Injury and Healthcare Clinicians' Wellbeing: A Systematic Review. Int J Environ Res Public Health. 2023 Jul 5;20(13):6300. doi: 10.3390/ijerph20136300. PMID: 37444147; PMCID: PMC10341511.
BMA. Moral distress and moral injury: recognising and tackling it for UK doctors. Jun 2021. https://www.bma.org.uk/media/4209/bma-moral-distress-injury-survey-report-june-2021.pdf#.
Steinert JI, et al. BMJ Global Health 2021;6:e005380. doi:10.1136/bmjgh-2021-005380
Litz BT, Plouffe RA, Nazarov A, Murphy D, Phelps A, Coady A,
Houle SA, Dell L, Frankfurt S, Zerach G, Levi-Belz Y and the Moral Injury Outcome Scale Consortium
(2022) Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium. Front. Psychiatry 13:923928. doi: 10.3389/fpsyt.2022.923928
Jan Grimell & Sofia Nilsson (2020) An advanced perspective on moral challenges and their health-related outcomes through an integration of the moral distress and moral injury theories, Military Psychology, 32:6, 380–388, DOI: 10.1080/08995605.2020.1794478
Crico C, Sanchini V, Casali PG, Pravettoni G. Evaluating the effectiveness of clinical ethics committees: a systematic review. Med Health Care Philos. 2021 Mar;24(1):135–151. doi: 10.1007/s11019-020-09986-9. Epub 2020 Nov 21. PMID: 33219898; PMCID: PMC7910230.
Wocial, L.D., Miller, G., Montz, K. et al. Evaluation of Interventions to Address Moral Distress: A Multi-method Approach. HEC Forum (2023). https://doi.org/10.1007/s10730-023-09508-z

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Exploring Moral Injury in Researchers in a Paediatric Humanitarian Research Setting: A Qualitative study from the Mavrovouni Closed Controlled Access Center, Lesvos, Greece

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Version 1

Abstract

Background

Methods

Results

Conclusion

Background

Objective

Methods

Results

1. Community and system-level considerations

2. Witnessing and moral responsibility

(i) Injustice

(ii) Discrimination

(iii) Power imbalances

(iv) Guilt

3. Conflicting duties

(i) Participant welfare

(ii) Professional boundaries & rules

5. Researchers' coping strategies

(i) Emotional support:

(ii) Peer support:

(iii) Privileges and responsibilities

6. Cultural aspects

7. Theory of Change

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1