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Background: The consequences of moral challenges among healthcare workers (HCWs) have been increasingly recognized. To date, however, there is limited knowledge about the predictors of and associations between moral distress, moral residue, and other psychological consequences among HCWs working in a pandemic context.

Objective: We aimed to assess the levels of, and the associations between HCWs’ experiences of moral distress and moral residue with traumatic stress, burnout, and general psychological distress, and evaluate the role of empathic and compassion aspects for these outcomes, while adjusting for demographic and professional factors.

Methods: This is a cross-sectional study of 6551 Swedish HCWs participating in a survey during the COVID-19 pandemic, in the autumn of 2020. The survey included questions related to moral challenges, moral distress and residue, and self-report scales for general psychological distress (GHQ-5), traumatic stress (ITQ), compassion satisfaction and fatigue (ProQoL), empathic ability (B-IRI), and burnout (SMBQ).

Results: There were strong associations between moral challenges and moral distress and residue. There were also clear associations between moral distress and residue and psychological distress scales. Empathic ability, compassion fatigue, and compassion satisfaction were associated with moral residue whereas compassion satisfaction was not associated with moral distress. Demographic and professional predictors included gender, age, and occupational role. No interactions between moral challenges and empathic ability were found for moral distress or residue.

Discussion/conclusion: Moral distress and moral residue share some variance with both general and stress-related psychological distress; however, moral distress and residue are both theoretically and empirically distinct outcomes of moral challenges as compared to other established psychological consequences of occupational stress. Empathic ability was associated with moral distress, but not with moral residue. Moving forward, longitudinal research is needed to better understand the interplay among moral aspects relevant to HCWs.