The extent and nature of stress of conscience among healthcare workers: A scoping review

Background: Healthcare workers experience morally stressful situations during delivery of care which may trouble their conscience. Literature emerging in the context of global pandemics suggest increased frequency of morally stressful situations in healthcare and a link with negative outcomes such as attrition and burnout. Little is known about the emerging concept of stress of conscience which could provide a meaningful way to highlight and address these morally stressful situations in healthcare.

Aim: The aim of this scoping review was to provide an overview of the literature on, (i) the extent, (ii) the factors associated, and (iii) the interventions to prevent or mitigate stress of conscience among healthcare workers.

Design: The study was guided by the framework provided by Arksey and O'Malley in 2005 and the PRISMA Guidelines. Relevant healthcare databases were searched in November 2020 to identify relevant studies.

Results: The search identified 24 studies for inclusion in the analysis, 19 of these were from Nordic countries, particularly Sweden. Across those studies, stress of conscience was prevalent among healthcare workers and the levels varied with demographic factors, individual personalities, perceptions of belonging and the workplace culture and environment. Stress of conscience was associated with negative outcomes such as burnout, moral burden, workplace stress, and low quality of care. Although there were few quality interventions studies, facilitating healthcare workers to provide person-centred care appears to be a promising intervention.

Conclusions: The concept of stress of conscience provides a contemporary framework to assess, highlight and discuss the degree of the negative impact of perceived violations of professional and personal values in healthcare. However, the limited studies suggest that exploring stress of conscience, including trials of potential interventions, particularly beyond Nordic countries is essential to fill the gaps in the literature.