COVID-19 and Moral Injury: a Mental Health Pandemic for Frontline Health Care Workers

Intervention strategies for health care workers experiencing COVID-19-related moral injury include health promotion, resilience training, and ongoing multilevel support.

More than 2 years ago, the alarm and first warnings of a global pandemic sounded. Now with over 830,000 deaths caused by COVID-19 in the US, there looms on the horizon a second underlying curve with equally serious long-term consequences: a mental health pandemic.

The mental health fallout from the COVID-19 pandemic demands recognition, intervention, and mitigation strategies. Among the many at-risk populations are frontline health care workers who have been at the epicenter of the global pandemic, working long shifts with at times a tenuous safety net and limited support, and caring for COVID-19 patients with limited resources, mixed messaging, and uncertainty with regards to an end to the crisis. The psychological effects in some health care providers are akin to the moral trauma or moral injury that is recognized in combat veterans with post-traumatic stress disorder (PTSD).

Mental health professionals and other health care providers caring for frontline health care workers who present with insomnia, depression, anxiety, panic attacks, PTSD, and suicidal thoughts should recognize and validate their experiences and moral injury. Intervention strategies including health promotion, resilience training, and ongoing multilevel support will play an important role in flattening the moral injury curve.

Resilient Professionals

As a rule, the frontline health care workforce is considered capable, competent, resilient, professional, and persevering in the face of adversity. However, COVID-19 presented as an unprecedented crisis unlike any other unforeseen disaster, eliciting fear, uncertainty, and anxiety, coupled with grief and loss, both personally and professionally.1 As noted by Warren D. Taylor, MD, MHSc, and Jennifer Urbano Blackford, PhD1:

The pandemic created anxiety and fear in health care providers, from physicians and nurses to allied health professionals and first-line responders. We fear for the safety of our families and patients. We grieve for those who have died. We feel guilt for not being able to save all our patients, for getting sick ourselves, and for abandoning our families. Many adopted the phrase, “we will get through this together but none of us will survive unscathed.”

At the outset, the shortage of equipment and resources, changing practice guidelines, and unpredictability of the workload rendered health care workers with a sense of powerlessness and loss of control of the conditions under which they were able to deliver care. The emotional distress and social isolation from family and friends exacted an immeasurable toll on the physical health and emotional well-being of the workforce, setting the stage for the inevitable moral injury.2

Moral Injury Defined

Moral injury is a term that has been applied to veterans of combat. Moral injury or moral distress as experienced by frontline health care providers occurs when health care providers are forced to make decisions that transgress their professional commitment to patient comfort and care, and forcibly shift their moral compass. They are not able to meet the physical, emotional, and end-of-life needs of patients.3

Watson et al noted that moral injury in health care workers “can occur when someone engages in, fails to prevent, or witnesses acts that conflict with their values or beliefs.”4 Moral injuries may result from the following, according to Watson et al4:

  • Making decisions that affect the survival of others or where all options will lead to a negative outcome;
  • Engaging in something that goes against your beliefs (an act of commission);
  • Failing to do something in line with your beliefs (an act of omission);
  • Witnessing or learning about such an act; or
  • Experiencing betrayal by trusted colleagues

The consequences of such experiences may include feelings of rage, guilt, shame, and anger and moral injury is the “lasting psychological, spiritual, behavioral or social impact that may result from these experiences.”4 The number of acutely ill COVID-19 patients and high death rate coupled with lack of resources and at times rationing of limited resources such as personal protective equipment (PPE) and ventilators added to the dilemma that frontline health care workers faced.

In a study of 448 Jordanian nurses during the COVID-19 pandemic, the majority of nurses (64%) reported experiencing acute stress disorder (ASD) and 41% reported significant psychological distress, with a predilection for younger nurses compared to older nurses.5 However, coping self-efficacy was a protective factor with the potential to mitigate the severity of psychological distress.5 An online survey of non-health care providers (N=976) found that individuals with previous trauma were at highest risk for increased symptoms of anxiety, depression, and PTSD related to COVID-19 compared with individuals with no previous history of trauma.6

Long-Term Effects of Moral Injury

The long-term mental health consequences of moral injury for frontline health care workers have important implications for workforce survivability and durability; however, research on this topic is lacking. In one of the few published studies on moral injury among health care providers, investigators looked at the thematic content of experiences reported by nurses following incidents meeting the contextual definition of moral injury (ie, events with unintended consequences, potentially causing patient harm or putting patients at risk for serious injury). The investigators found nurses reported experiencing “guilt, shame, spiritual–existential crisis, and loss of trust.”7

COVID-19 has presented difficult and untenable working conditions beyond the scope of the challenges frontline health care workers are prepared for professionally. Frontline health care workers have experienced conflict and distress over prioritizing patient care vs their own safety, protecting family members from infection, and the reality that the supplies, medications, and equipment needed to save a life were not always available or were being rationed. Because of high infectivity, morbidity, and mortality associated with the spread of the virus, frontline health care workers were often in the position to be the only person at the bedside at the end of life with patients who were separated from their families. This is not how families should experience the loss of a loved one.4

There is a body of research regarding the long-term effects of moral injury among combat soldiers.3 It is reasonable to expect that feelings of guilt, shame, anger, and self-recrimination stemming from moral injury in these soldiers may be similar to feelings experienced by frontline health care workers during the COVID-19 pandemic and that their experiences increase the risk for acute stress reactions with long-term consequences including increased incidence of depression, anxiety, substance abuse, PTSD, and suicide.4,8 Behavior changes including intrusive memories, avoidance of situations that are reminders of prior events, self-isolation, and potential triggers of traumatic memories are common in individuals suffering from acute stress disorder or PTSD. Additional responses to stress, trauma, and moral injury include disturbed sleep, emotional changes such as numbing, desensitization, depersonalization, and a decreased capacity for empathy and compassion. For some individuals, the consequences of moral injury may be an opportunity for reflection and reprioritization of values and an existential inner process of reflecting on what is important in life.4

Given the consequences of moral injury, it is important for mental health professionals and health care providers treating frontline health care providers to recognize and identify those experiences that have the potential for promoting resilience.9

This article originally appeared on Clinical Advisor