Moral Distress among Disaster Responders: What is it? Martina E. Gustavsson, RN, MSc; 1 Filip K. Arnberg, Assoc Prof, PhD; 2 Niklas Juth, Assoc Prof, PhD; 3 Johan von Schreeb, Prof, MD, PhD 1 Abstract Introduction: Current research of moral distress is mainly derived from challenges within high-resource health care settings, and there is lack of clarity among the different definitions. Disaster responders are prone to a range of moral challenges during the work, which may give rise to moral distress. Further, organizations have considered increased drop-out rates and sick leaves among disaster responders as consequences of moral distress. Therefore, ini- tiatives have been taken to address and understand the impacts of moral distress and its con- sequences for responders. Since there is unclarity among the different definitions, a first step is to understand the concept of moral distress and its interlinkages within the literature related to disaster responders. Hypothesis/Problem: To examine how disaster responders are affected by moral chal- lenges, systematic knowledge is needed about the concepts related to moral distress. This paper aims to elucidate how the concept of moral distress in disaster response is defined and explained in the literature. Methods: The paper opted to systematically map the existing literature through the meth- ods of a scoping review. The searches derived documents which were screened regarding specific inclusion criteria. The included 16 documents were analyzed and collated according to their definitions of moral distress or according to their descriptions of moral distress. Results: The paper provides clarity among the different concepts and definitions of moral distress within disaster response. Several concepts exist that describe the outcomes of morally challenging situations, centering on situations when individuals are prevented from acting in accordance with their moral values. Their specific differences suggest that to achieve greater clarity in future work, moral stress and moral distress should be distinguished. Conclusion: Based on the findings, a conceptual model of the development of moral dis- tress was developed, which displays a manifestation of moral distress with the interplay between the responder and the context. The overview of the different concepts in this model can facilitate future research and be used to illuminate how the concepts are interrelated. Gustavsson ME, Arnberg FK, Juth N, von Schreeb J. Moral distress among disaster responders: what is it?. Prehosp Disaster Med. 2020;35(2):212–219. Introduction Background Disasters are chaotic events characterized by health needs that exceed existing capacities, requiring outside health care assistance. This assistance can be provided by national and international disaster health care responders. International disaster responders can be deployed by governmental agencies and non-governmental organizations. Their work is characterized by a lack of resources (eg, time, materials, or capacity). Difficult decisions must be made in often dangerous and challenging contexts. Choices must rapidly be made regarding whom to treat first, who must wait, and how to make optimal use of the limited resources available. The morally challenging choices add an additional burden to the work in an already stressful environment filled with risk factors for traumatic stress and burnout. 1 To support responders, there are a range of policies and legislations to guide their work, 2–4 as well as ethical principles and documents on medical ethics in disasters. 5 These documents, however, outline general policies that are difficult to apply in practice. They provide limited guidance for specific situations in choosing the “best solution” for whom to treat and whom to leave. In reality, there are few, if any, specific training programs to support ethically informed decision making in disaster settings. Algorithms for triage within mass-casualty 1. Centre for Research on Healthcare in Disasters, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden 2. National Centre for Disaster Psychiatry, Department of Neuroscience, Uppsala University, Uppsala, Sweden 3. Stockholm Centre for Healthcare Ethics (CHE), Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden Correspondence: Martina Gustavsson, RN, MSc The Centre for Research on Healthcare in Disasters Health Systems and Policy (HSP) Department of Global Public Health Karolinska Institutet Tomtebodavägen 18, 171 77 Stockholm, Sweden E-mail: martina.gustavsson@ki.se Conflicts of interest: none Keywords: disaster ethics; disaster responders; disaster response; moral distress; moral stress Abbreviations: ICRC: International Committee of the Red Cross MSF: Médecins Sans Frontières UREPH: Research Unit on Humanitarian Principles and Practices of MSF Switzerland Received: June 28, 2019 Revised: August 20, 2019 Accepted: September 7, 2019 doi:10.1017/S1049023X20000096 © World Association for Disaster and Emergency Medicine 2020. 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