Abstract
Moral injury in health care professionals (HPs) has worsened over the course of the COVID-19 pandemic. The trauma and burnout associated with moral injury has profound implications for the mental health of HPs. To explore the potential factors associated with moral injury for HPs who were involved in patient care during the COVID-19 pandemic in 2020, prior to the availability of vaccines. In this qualitative study, HPs were actively recruited to participate in a survey via snowball sampling via email and social media in 2 phases of 5 weeks each: April 24 to May 30, 2020 (phase 1), and October 24 to November 30, 2020 (phase 2). Overall, 1831 respondents answered demographic questions and assessments for moral injury, intrinsic religiosity, and burnout. Of those, 1344 responded to the open-ended questions. Responses to open-ended questions were coded iteratively and thematically analyzed within the framework of moral injury. Working in a patient care setting during the COVID-19 pandemic prior to the availability of vaccines. Inductive thematic analysis of open-response survey answers identified dominant emotions and common stressors associated with moral injury. There were 335 individuals (109 [32.6%] aged 35-44 years; 288 [86.0%] women; 294 [87.8%] White) in phase 1 and 1009 individuals (384 [38.1%] aged 35-44 years; 913 [90.5%] women; 945 [93.7%] White) in phase 2. In phase 1, the respondents were predominantly nurses (100 [29.9%]), physicians (78 [23.3%]), advanced practice practitioners (APPs) (70 [20.9%]), and chaplains (55 [16.4%]). In phase 2, the respondents were predominantly nurses (589 [58.4%]), physicians (114 [11.3%]), and APPs (104 [10.3%]). HPs faced numerous stressors, such as fear of contagion, stigmatization, short-staffing, and inadequate personal protective equipment. The emotions experienced were (1) fear in phase 1, then fatigue in phase 2; (2) isolation and alienation; and (3) betrayal. These findings suggest that HPs experienced moral injury during the COVID-19 pandemic. Moral injury was not only experienced after a single moral dilemma but also from working in morally injurious environments. These experiences can serve as potential starting points for organizations to engender and enhance organizational and individual recovery, team building, and trust. System-level solutions that address shortages in staffing and personal protective equipment are needed to promote HP well-being.
Highlights
Moral injury is emotional distress resulting from events or transgressive acts that create dissonance within one’s very being due to a disruption or violation of their existential orientation and values system.[1]
The emotions experienced were (1) fear in phase 1, fatigue in phase 2; (2) isolation and alienation; and (3) betrayal. These findings suggest that health care professionals (HPs) experienced moral injury during the COVID-19 pandemic
Exemplar responses are presented in eAppendices 1 to 3 in the Supplement
Summary
Moral injury is emotional distress resulting from events or transgressive acts that create dissonance within one’s very being due to a disruption or violation of their existential orientation and values system.[1]. Conceived in the context of combat trauma and the experiences of war veterans,[4] moral injury has been theorized and studied in the context of health care professionals (HPs).[5,6,7] Moral injury manifests itself as a double bind: “[d]o we take care of our patient, the hospital, the insurer, the EMR [electronic medical record], the health care system, or our productivity metrics first? Moral injury is strongly associated with medical errors, clinician burnout, and increased suicidal thoughts.[9,10] Prior to the COVID-19 pandemic, nearly 1 in 4 HPs reported at least moderate impairment in family, social, or occupational functioning.[9] Both mental health disorders and burnout are projected to increase among clinicians in the wake of the pandemic[11,12,13]; early evidence suggests that increases in moral injury may be a bellwether of a workforce under tremendous strain.[14]
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