Participants and Procedure
Complete details on enrollment of participants have been described elsewhere 18. In brief, 4,003 healthcare professionals were recruited from mainland China using a snowball sampling technique. An online survey was conducted between March 27 and April 26, 2020, about one month after the COVID-19 pandemic peak in China. A total of 3,975 participants agreed to complete the survey. Of those, 968 questionnaires were excluded during the data cleaning process for several reasons, including being in practice for less than two years, having two or more items with missing value on study measures, or giving the same or similar answer across all items (indicating lack of thoughtfulness when answering the questions). As a result, 3,006 participants were included in the final analysis.
Inclusion criteria were 1) being a physician or nurse, and 2) length of time in practice at least two years. Exclusion criteria were (1) history of six months or more of an extended break from practice for any reason during the past two years; (2) inability to use the internet or other mobile device due to vision or other disability preventing the completion of an online questionnaire; and (3) not formally licensed to practice medicine or nursing in China. The survey was designed as anonymous, and online consent was obtained from all participants before proceeding. The study approved by the institutional review board of Ningxia Medical University (approval #2020-112).
Measures
Information on sociodemographic characteristics was collected, including age, gender, marital status, educational attainment, ethnicity (Chinese Han, or minorities), area of specialty, work area, and length in practice.
MI was assessed using the 10-item Moral Injury Symptoms Scale-Health Professional (MISS-HP) developed by Mantri and colleagues (2020) 19. 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 ranges from 1 to 10 indicating agreement or disagreement, resulting in a total score from 10 to 100, with higher scores indicating greater MI20. The MISS-HP was translated into Chinese followed a standard procedure 21. The Cronbach’s alpha in the present sample was 0.71 in nurses and 0.70 in physicians.
The assessment of mental health included measures of depressive and anxiety symptoms using the 9-item Patient Health Questionnaire (PHQ-9) and 7-item Generalized Anxiety Disorder (GAD-7), respectively. Both PHQ-9 and GAD-7 are rated on a 4-point Likert scale from 0 (not at all) to 3 (nearly every day) 22,23. Higher scores indicate more severe depressive and anxiety symptoms. Chinese versions of the PHQ-9 and GAD-7 have been shown to have solid internal and test-retest reliability as well as construct and factor analytic validity in medical patients and the general population24,25. Cronbach’s alphas for the present sample were 0.91 for the PHQ-9 and 0.94 for the GAD-7.
Religiosity/spirituality (R/S) was assessed by a single question asking about the importance of religion. This question is a commonly used to assess religiosity in secular societies and has been strongly associated with psychological well-being in many studies 26. In the present study, importance of religion was measured using a Visual Analogue Scale (VAS) scale from 0 (not at all important) to 100 (very important) after asking the question: “In general, how important religious or spiritual beliefs in your daily life are?” Religious affiliation was also determined by asking the question: “What is your religion?” Religious affiliation was categorized for analysis into four groups: 1 = none, 2 = Chinese religion (i.e., Buddhist, Daoist, etc.), 3=Western religion (i.e., Christian), and 4=Muslim.
Statistical Analyses
Descriptive statistics were used to determine average scores with standard deviations (SD) and ranges for continuous variables and numbers and percentages for categorical variables. Bivariate analyses were conducted using Pearson’s r for continuous variables and Student’s t-test or ANOVA for comparing continuous variable scores across categorical variable responses.
Hierarchical linear regression modeling was used to examine the moderating effect of MI on the relationship between R/S and mental health variables (depression and anxiety), controlling for demographic variables. First, associations between R/S and mental health (depression and anxiety separately) were determined after controlling for demographic variables (Model 1); this was followed by adding MI to the model (Model 2). Finally, an interaction term between moral injury and R/S was added to model 2 (Model 3) to determine if MI moderated the relationship between R/S and mental health states.
Bootstrap methods of the PROCESS procedure in SPSS designed by Hayes27 were employed to examine the mediating effect of moral injury in the relationship between R/S and mental health depression/anxiety. The IBM SPSS 23.0 version was used to perform all analyses. Alpha level was set at 0.05 for statistical significance and was not adjusted for multiple comparisons due to the exploratory nature of these analyses.