Moral Injury in Healthcare Professionals
By: Previous HoneyB pre-licensed clinician
Moral injury occurs when a person’s sense of morality is fractured as a result of acting in a way that is deeply incongruent with their moral code or intrinsic belief system (Carey & Hodgson, 2018). Morally injurious events are the repeated “situations that lead to the violation of deeply held beliefs or moral values (Held et al., 2021, p. 2),” and these morally injurious events experienced by healthcare professionals were frequent at the height of the Covid-19 pandemic.
During the first wave of the pandemic, some likened the situation in hospitals to a battlefield—life and death triage decisions were being made due to the critical shortage of life-saving resources like ventilators, and many healthcare providers on the frontlines were put in high-risk conditions without enough personal protective equipment (PPE) (Giwa et al., 2021). It is estimated that 3,600 frontline workers died in the first year of the pandemic and were three times more likely to be exposed to and contract Covid-19 than the general population, as a direct result of their line of work (Spencer et al., 2021). Among those who did survive, many were forced to choose between conflicting duties to their families and their ethical duty to provide patient care, and when there was scarce information about how the disease was transmitted it meant donning their tattered armor of reused PPE and quarantining themselves from their loved ones (Giwa et al., 2021).
Moral injury impacts the biological, psychological, and emotional domains and if left untreated, the clinical outcomes can include symptoms of posttraumatic stress disorder (PTSD), depression, fatigue, and sleep disturbances (Koenig & Zaben, 2021; Yan, 2016), self-destructive behaviors associated with drug or alcohol use, and especially concerning is an increased risk of suicide (Giwa et al., 2021; Jamieson et al., 2020). This is significant when considering that healthcare providers are already prone to higher rates of suicide than the general population. Death by suicide is two to four times higher amongst physicians (Kingston, 2020; Moutier, 2018), nurses (Davidson et al., 2020; Guille, 2021), first responders, emergency medical technicians and paramedics (Vigil et al., 2019), with workplace stressors presenting as a major contributing risk factor of suicidality among healthcare providers (Moutier, 2018). Among frontline workers who provided direct patient care during the Covid-19 pandemic in China, 70% experienced increased psychological distress with elevated rates of depression, anxiety, and distress (Lai et al., 2020).
Many touted healthcare workers as heroes for their life saving efforts during the pandemic, but the reality is that Covid-19 exacerbated many of the stressors faced by healthcare professionals, and the weight of that work has not come without consequences. The question now becomes, how can we effectively support healthcare workers and their continued functioning amidst the psychological toll inextricably linked to the work they do.
Carey, L. B., & Hodgson, T. J. (2018). Chaplaincy, spiritual care and moral injury: Considerations regarding screening and treatment. Frontiers in Psychiatry, 9, 1–10. https://doi.org/10.3389/fpsyt.2018.00619
Davidson, J. E., Proudfoot, J., Lee, K., Terterian, G., & Zisook, S. (2020). A longitudinal analysis of nurse suicide in the United States (2005–2016) with recommendations for action. Worldviews on Evidence-Based Nursing, 17(1), 6–15. https://doi.org/10.1111/wvn.12419
Giwa, A., Crutchfield, D., Fletcher, D., Gemmill, J., Kindrat, J., Smith, A., & Bayless, P. (2021). Addressing moral injury in emergency medicine. The Journal of Emergency Medicine, 1–7. https://doi.org/10.1016/j.jemermed.2021.07.066
Guille, C. (2021). Rate of suicide among women nurses compared with women in the general population before the COVID-19 Global Pandemic. JAMA Psychiatry, 78(6), 597. https://doi.org/10.1001/jamapsychiatry.2021.0141
Held, P., Klassen, B. J., Steigerwald, V. L., Smith, D. L., Bravo, K., Rozek, D. C., Van Horn, R., & Zalta, A. (2021). Do morally injurious experiences and index events negatively impact intensive PTSD treatment outcomes among combat veterans? European Journal of Psychotraumatology, 12(1), 1–11. https://doi.org/10.1080/20008198.2021.1877026
Jamieson, N., Usher, K., Maple, M., & Ratnarajah, D. (2020). Invisible wounds and suicide: Moral injury and veteran mental health. International Journal of Mental Health Nursing, 29(2), 105–109. https://doi.org/10.1111/inm.12704
Kingston A. M. (2020). Break the Silence: Physician Suicide in the Time of COVID-19. Missouri medicine, 117(5), 426–429. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7723130/#b1-ms117_p426
Koenig, H. G., & Al Zaben, F. (2021). Moral injury: An increasingly recognized and widespread syndrome. Journal of Religion and Health, 60(5), 2989–3011. https://doi.org/10.1007/s10943-021-01328-0
Lai, J., Ma, S., Wang, Y., Cai, Z., Hu, J., Wei, N., Wu, J., Du, H., Chen, T., Li, R., Tan, H., Kang, L., Yao, L., Huang, M., Wang, H., Wang, G., Liu, Z., & Hu, S. (2020). Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Network Open, 3(3), 1–12. https://doi.org/10.1001/jamanetworkopen.2020.3976
Moutier, C. (2018). Physician mental health: An evidence-based approach to change. Journal of Medical Regulation, 104(2), 7-13. https://doi.org/10.30770/2572-1852-104.2.7
Spencer, J., The Guardian, & Jewett, C. (2021, April 8). 12 months of trauma: More than 3,600 US health workers died in Covid’s first year. Kaiser Health News. https://khn.org/news/article/us-health-workers-deaths-covid-lost-on-the-frontline/
Vigil, N. H., Grant, A. R., Perez, O., Blust, R. N., Chikani, V., Vadeboncoeur, T. F., Spaite, D. W., & Bobrow, B. J. (2019). Death by suicide-the EMS profession compared to the general public. Prehospital Emergency Care, 23(3), 340–345. https://doi.org/10.1080/10903127.2018.1514090
Yan, G. W. (2016). The invisible wound: Moral injury and its impact on the health of Operation Enduring Freedom/Operation Iraqi Freedom Veterans. Military Medicine, 181(5), 451–458. https://doi.org/10.7205/milmed-d-15-00103