Moral Injury and Distress in Health Care Professionals During Infectious Disease Crises

 

Verity Williams

Rafey Faruqui 

Rhian Bradley

Julie Anderson

Abstract

Healthcare crises create challenges for all professional workforces. In this context, healthcare workers in particular may experience distress when their actions or experiences conflict with their ethical values.  Moral injury is a concept which emerged in military contexts to describe the specific distress experienced by individuals exposed to potentially morally injurious events (PMIES) which violate or conflict with their moral beliefs. This paper discusses the concept of moral injury as experienced in the healthcare workforce during infection epidemics and pandemics, with reference to the COVID-19 pandemic. We describe a systematic review of the extent, and clinical and socio-demographic correlates, of moral injury in healthcare professionals during the COVID-19 pandemic.

Introduction

The phenomenon of moral injury (MI) within professional workforces in the context of mass scale disaster events, such as wars and infectious disease, refers to distress resulting from perceived challenges to a person’s profound moral and ethical values. Whilst the term ‘moral injury’ originated in relation to the military, the deontological basis of medical practice, which directs a doctor’s duty to the individual patient rather than to society’s wider needs, may place doctors at risk of moral injury when this duty is perceived to have been breached. In a crisis such as the COVID-19 pandemic, healthcare professionals may be more exposed to potentially morally injurious events (PMIES), such as participating in decisions to withdraw care due to resource shortages, for example.

An aspect of moral injury debated in the military literature concerns what should constitute a ‘transgressive act’ predisposing to MI. To be transgressive, the act must violate accepted rules of behaviour, and it has been suggested that transgressive acts should be defined as those falling outside the ‘rules of engagement’ (in a military context) [1] In a healthcare setting, the COVID pandemic presents a situation out of the ordinary, where resource shortages and other limitations may lead to situations that fall outside the normal ‘rules of engagement’, thus leading to an increased likelihood of resultant moral injury. The socio-cultural context in which healthcare professionals work may be expected to influence which events are conceptualised as ‘potentially morally injurious’, and to what extent. A review of evidence for moral injury in past pandemics or infectious may help to define circumstances that could predispose to moral injury.

In the light of expanding discussion of this rapidly developing area, we conducted a systematic review of the medical literature to understand the extent and clinical and socio-demographic correlates of moral injury during the COVID-19 pandemic. In this paper, we discuss the extent and associations of moral injury in healthcare workers during COVID-19, as well as features of distress recorded in studies from previous infection epidemics, with a view to developing strategies for improved disaster-preparedness in the workforce.

Systematic review

We conducted a systematic review of reports on online databases in February 2021, using the following search terms: “moral injury” AND “covid” OR “coronavirus” OR “pandemic”, supplemented by reference searching (see Appendix). Our search identified 502 records; after screening articles and removing duplicates, four reports met our protocol requirements.

The papers reported outcomes from 3334 subjects in total, with a higher proportion of female subjects. The largest study [2] reported MI in 41.3% of their sample. Other papers did not use a cut-off value for the moral injury scales, and therefore did not provide prevalence data. The study characteristics and results are presented in Table 1, below.

Table 1

Study characteristics and results

Hines SE, Chin KH, Glick DR, Wickwire EM. 2021. Trends in Moral Injury, Distress, and Resilience Factors among Healthcare Workers at the Beginning of the COVID-19 Pandemic. Hines SE, Chin KH, Levine AR, Wickwire EM. 2020. Initiation of a survey of healthcare worker distress and moral injury at the onset of the COVID‐19 surge. Litam S, Balkin R; 2020. Moral Injury In Health-Care Workers during Covid-19 PandemicWang Z, Koenig HG, Tong Y, Wen J, Sui M, Liu H, Al Zaben F, Liu G. 2020. Moral injury in Chinese health professionals during COVID-19 pandemic.
Publication status:PublishedPublishedAdvance online publicationPreprint
Location: USAUSAUSAMainland China
Date of study:March -July 202020th March – 7th April 2020May-July 2020March-April 2020
Aims/ target populationHealthcare workers during first 3 months of COVID pandemic response in USA.
Hypothesis that experience of moral injury would increase over the course of the pandemic and vary with resiliency factors
Reported initial measurements of self-reported distress and moral injury among healthcare workers at the onset of the COVID-19 surge in a large academic medical centre in Baltimore.Understanding the extent to which physicians, nurses, and other healthcare workers experience moral injury whilst working in a pandemic. To examine the prevalence and correlates of MI among physicians and nurses in mainland China during the pandemic
Study designLongitudinal observational study. Convenience sample of staff members via emailObservational, cross-sectional online survey. Convenience sample of staff members via emailCross-sectional survey, online. Convenience sample recruited online. Observational, cross-sectional online survey. Convenience sample.
Sample size962191093006
Demographics:Male 49%
Mean age 40.6
Physicians: 89.7%. Other (nurses and allied healthcare professionals) 10.3%
Ethnicity not specified
Female 57%; male 43%, nonbinary/no answer 1%
Age mean 39.10
85% physicians, 15% other
Ethnicity not specified
76% female.
40 physicians, 62 nurses, 7 other professionals.
75.2% White,
17.4% Asian/Asian American, 2.8% African American/Black.
2.7% Hispanic. 0.9% Native Hawaiian/Pacific
Male 34.9%
Average age 35.4 583 nurses, 2423 physicians.
22% had direct contact with COVID patients.
Findings: Moral Injury Events Scale (MIES) scores did not significantly change between baseline and month one or between month one and month three.

A supportive workplace environment was related to lower moral injury.
Average MIES score 16.15

Higher proportion of inpatient time and sleep troubles associated with higher MIES score
Mean MIES score higher for physicians compared to nurses.
Study uses a modified version of the MIES, using 6 items of the 9-item scale, with lower scores indicative of higher levels of moral injury.

No MIES cut-off used, so no prevalence data.
Used Moral Injury Symptoms Scale-Health Professional (MISS-HP).

Due to the lack of a ‘gold-standard’, the cut-off value of MISS-HP was determined based on self-reported functional impairment.

Prevalence of MI – 41.3% (96% CI 393.3-43%).

MI significantly less likely in married participants. MI significantly more likely in Buddhists/Taoist and those providing direct care to COVID patients.
MI strongly and significantly correlated with depression, anxiety and burnout.
Older HCPS less likely to experience MI than those <30 years. Higher MI in females.

Discussion

Our systematic review provided evidence that healthcare professionals working during the COVID-19 pandemic experienced moral injury.  Correlates to moral injury in healthcare professionals during the COVID-19 pandemic included providing direct care to COVID-19 patients and a higher proportion of inpatient time. Demographic associations included being unmarried, being under 30 years old, being female, and being of Buddhist/Taoist faith background. Sleep troubles were also associated with greater moral injury. Healthcare role may be a significant factor, as nurses reported greater severity than physicians. There appeared to be a marked correlation between moral injury and experience of anxiety, depression and burnout.

The longitudinal study reported that more stressful and less supportive work environments predicted greater MI at 3 months follow-up. This accords with previous suggestions that inadequate support compounds moral distress following exposure to a potentially morally injurious event [3]. Workplace interventions that enhance support to healthcare professionals may therefore have a useful role in reducing the risk of moral injury.

At the time of our review, most studies contained data from early in the pandemic. Whilst the longitudinal study did not show a significant increase in moral injury over the 3-month period measured, all the studies used data from the pandemic’s initial stages.  Later data might indicate moral injury increase with hypothesised increased burnout, or conversely that acclimatisation to the pandemic leads to the development of new workplace norms and ‘rules of engagement’ that thus tend to modify the effect of exposure to potentially morally injurious events.

Most of the papers included in this review did not provide data on the prevalence of moral injury in their sample, due to the lack of a ‘gold-standard’ cut-off in the symptom scales used. This review demonstrates a need for further studies using a moral injury scale which has been validated for use in healthcare professionals. It should also be noted that MI is not a mental illness diagnosis, although it may contribute to other mental health diagnoses such as PTSD.

Having established the existence of moral injury in healthcare professionals during the pandemic, some possible targets for interventions begin to emerge, including social and workplace support structures, disaster preparedness, burnout prevention and occupational health strategies to address mental illness in healthcare workers. In military and other non-healthcare occupations, exposure to potentially morally injurious experiences has been found to associate significantly with post-traumatic stress disorder, depression and suicidal ideation, and to have highlighted the importance of interventions such as community support [1,4,5]. Considering the experiences of healthcare workers in other recent infectious outbreaks may provide evidence of the factors influencing workforce distress and suggest areas for targeted intervention. Whilst these studies do not all address the concept of moral injury specifically, as opposed to more general distress and impact on healthcare workers’ lives, they may highlight recurring factors which influence distress and resilience in healthcare workers during crises and may assist in developing strategies as part of onward workforce preparedness.

There is little public record of healthcare workers’ views from epidemics prior to the 21st century [6]. Throughout history there have been regular outbreaks of infectious disease causing epidemics and pandemics, including plague, cholera, flu, MERS and SARS prior to the COVID-19 pandemic. With increased global trade and cross-continental travel, changing land usage and increased human population, greater encroachment on natural habitats may spur more frequent pathogen transmission from animals to humans. There may also be threats related to climate change expanding the habitats of vectors of disease, drug resistance, insecticide tolerance, or even bioweapons [7]. Regardless of the recent experience of the COVID-19 pandemic, therefore, workforce preparedness for pandemics and other disasters is a necessity. 

Studies of healthcare workers during infectious outbreaks have also identified loss of professional distance while providing care as a factor which may increase exposure to PMIES [8]. Providing direct care to patients where professional duties take on personal resonance (for example, caring for those dying alone, or mediating between family and patient), as may have occurred during treatment for patients with COVID, could lead to such loss of professional distance. The association observed in our systematic review that nurses experienced greater moral injury than physicians could be explained by a greater role in such activities. Workforce preparedness strategies which acknowledge the potential of such experiences, promote adaptive coping, and encourage peer support, may be required.

Reports of personal fears such as risk of contagion and concern for the health of family, friends and neighbours were documented among Ebola outbreak workers [9]. Healthcare professionals during the COVID-19 pandemic also described fears of being infected and spreading infection to their families [8]. Rankin (2006) describes the effect of the SARS crisis on nurses in Canada as transforming their view of the profession as being relatively safe, as it had appeared throughout the later part of the 20th century, to one which was potentially life-threatening. Fears of exhaustion, spreading infection, disruption to home life and isolation were relevant features [6]. Nurses caring for SARS patients in Hong Kong expressed similar anxieties about fear of infection and the effect on their families [10].

A study of healthcare workers during the Ebola outbreak in Sierra Leone (2014-16) identified factors related to institutions, public health bodies, and uncertainty of knowledge as markers of distress. Lack of knowledge and misconceptions about the illness, absence of trust and support in the system, as well as insufficient risk information provision were involved in increased distress [9]. A study by Kreh et al (2021) on the psychosocial effects of COVID-19, during the early months of the pandemic in Italy and Austria, reported a loss of trust amongst healthcare professionals in hospitals, combined with uncertainty of information and lack, or anticipated lack, of resources. The study found evidence of moral injury regarding triage and PPE shortage [8].  Nurses caring for SARS patients in Hong Kong also reported feelings of powerlessness, unfamiliarity, and frustration [10]. Uncertainty with regard to information and resources, and fears of institutional failings, seem therefore to increase risk of distress in healthcare workers. Supportive workplaces and institutions that provide appropriate training and supervision, maintain equipment and infrastructure and ensure adequate communication regarding resources and health information may be strategically helpful.

Relevant factors may also exist in public attitudes towards healthcare workers. During the Ebola outbreak, stigma, quarantine and interpersonal isolation were found to be concerns for healthcare workers [9].  Uncertainty concerning means of transmission and public fear about the consequences of infection may affect interpersonal relationships and so reduce sources of social support for healthcare workers. Providing sufficient and accurate public information combined with offering support services to staff may constitute important intervention. Mechanisms to support staff could include building on existing peer networks and developing links with the community to increase trust.

Key areas for health system preparedness emerge from these prior infection experiences: these include adequate supply of equipment, provision of relevant knowledge, ensuring trust in the healthcare system, and better communication concerning risks to rationalise public concerns about spread of disease by health workers and fear of infection from patients [9]. In the case of the Sierra Leone Ebola outbreak, organisational interventions such as a risk allowance (due to economic impact of the outbreak, including increased cost of living), training and supply of equipment, and psychosocial support were developed [9]. Individual and social strategies identified as supporting resilience for staff included inculcating a sense of duty and service, peer and family support, support on social media, and religious beliefs [9].  During COVID, factors identified as supporting resilience have included organisational leadership, supportive environments, and provision of psychosocial and mental health support [8].

Conclusions

It is becoming clear that some healthcare professionals have experienced moral injury whilst working in the COVID-19 pandemic. It is important that we are able to address moral injury awareness training as part of workforce preparedness and burnout prevention not only during the COVID-19 pandemic but when responding to other crises. Reviewing healthcare- worker experiences in previous infectious epidemics and pandemics may suggest factors that aid resilience or which conversely increase risk of healthcare-worker distress, with implications for developing interventions. Recognition of moral injury is important for the development of strategies to limit the impact of distress on the healthcare workforce. Such strategies include response preparedness, promoting adaptive coping and encouraging peer support.

Appendix

We conducted a systematic review of reports included in Medline, PsycINFO, BNI, CINAHL, EMBASE, EMCARE and HMIC databases using the following search terms: “moral injury” AND “covid” OR “coronavirus” OR “pandemic”.  We also searched Google Scholar and Ovid Database and conducted reference searching. Our search was carried out in February 2021, and this was a rapidly developing area in the context of the COVID-19 pandemic. Therefore, we also searched for published quantitative primary research, advance online publications and pre-print research. We reported findings in line with Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA). We excluded studies which did not offer new data, if data was collected outside the time period of the COVID-19 pandemic (prior to February 2020), or which did not report data on moral injury in healthcare professionals. We did not include studies which included data solely on PTSD symptoms, moral distress or ‘burnout’ rather than moral injury. Our search identified 502 records; after screening articles and removing duplicates, 4 reports met our protocol requirements. Two authors independently assessed the included studies’ methodological quality using a seven-item checklist (as used by Williamson et al, 2018). There was strong agreement between the authors’ ratings.

Three papers used cross-sectional designs. One paper reported longitudinal outcomes of their sample [11], with initial results already described in one of the other three papers [12]. Only one study [2] used a MI scoring system validated for healthcare professionals. The Moral Injury Symptoms Scale – Health Professional (MISS-HP) is a ten-item scale including data of betrayal, guilt, shame, moral concerns, loss of trust, loss of meaning, difficulty forgiving, self-condemnation, faith struggle, and loss of faith. The original scale was designed for military personnel but was modified for applicability to health professionals. It was administered to the Chinese sample following translation.  The other papers used the Moral Injury Events Scale scoring system, which has been validated for use in military populations. One of the papers [13] appeared to use a modified version of the MIES, using 6 items of the 9-item scale. It was not clear which items had been omitted and no comment was made regarding the impact of this on validity.

Systematic Review References

  1. Hines SE, Chin KH, Glick DR, Wickwire EM. Trends in Moral Injury, Distress, and Resilience Factors among Healthcare Workers at the Beginning of the COVID-19 Pandemic (2021) International Journal of Environmental Research and Public Health. Jan;18(2):488.
  2. Hines S.E., Chin K.H., Levine A.R., Wickwire E.M. (2020) Initiation of a survey of healthcare worker distress and moral injury at the onset of the COVID‐19 surge. American Journal of Industrial Medicine; 63(9):830-833
  3. Litam, S. D. A., & Balkin, R. S. (2021). Moral injury in health-care workers during COVID-19 Pandemic. Traumatology, 27 (1), 14-19
  4. Wang Z., Koenig H. G., Tong Y., Wen J., Sui M., Liu H., Al Zaben F., Liu G. (2020) Moral injury in Chinese health professionals during COVID-19 pandemic. [Preprint]. Available at SSRN: https://ssrn.com/abstract=3606455     (Accessed 09/02/2021)

Full References

[1] Frankfurt S & Frazier P (2016) A Review of Research on Moral Injury in Combat Veterans, Military Psychology, 28:5, 318-330

[2] Wang Z., Koenig H. G., Tong Y., Wen J., Sui M., Liu H., Al Zaben F., Liu G. (2020) Moral injury in Chinese health professionals during COVID-19 pandemic. [Preprint]. Available at SSRN: https://ssrn.com/abstract=3606455     (Accessed 09/02/2021)

[3] Williamson V, Murphy D, Stevelink SAM, Allen S, Jones E, Greenberg N, 2020. The impact of trauma exposure and moral injury on UK military veterans: a qualitative study. European Journal Psychotraumatology, 2020; 11(1)

[4] Bryan, AO, Bryan, CJ, Morrow, CE, Etienne, N., & Ray-Sannerud, B. (2014). Moral injury, suicidal ideation, and suicide attempts in a military sample. Traumatology, 20(3), 154–160.

[5] Williamson V, Stevelink SA, Greenberg N. Occupational moral injury and mental health: systematic review and meta-analysis. The British Journal of Psychiatry. 2018 Jun;212(6):339-46.

[6] Rankin, J. 2006. Godzilla in the corridor: The Ontario SARS crisis in historical perspective. Intensive Crit Care Nurs, 22, 130-7.

[7] Piret, J. & Boivin, G. 2021. Pandemics Throughout History. Frontiers in Microbiology, 11.

[8] Kreh, A., Bracaleoni, R., Magalini, S. C. Chieffo, D. P. R., Flad, B., Ellebrecht, N. Juen, B. 2021. Ethical and psychosocial considerations for hospital personnel in the Covid-19 crisis: Moral injury and resilience. PLOS ONE, 16, e0249609.

[9] Raven, J., Wurie, H. & Witter, S. 2018. Health workers’ experiences of coping with the Ebola epidemic in Sierra Leone’s health system: a qualitative study. BMC Health Services Research, 18, 251.

[10] Chung, B. P., Wong, T. K., Suen, E. S. & Chung, J. W. 2005. SARS: caring for patients in Hong Kong. J Clin Nurs, 14, 510-7.

[11] Hines SE, Chin KH, Glick DR, Wickwire EM. Trends in Moral Injury, Distress, and Resilience Factors among Healthcare Workers at the Beginning of the COVID-19 Pandemic (2021) International Journal of Environmental Research and Public Health. Jan;18(2):488.

[12] Hines S.E., Chin K.H., Levine A.R., Wickwire E.M. (2020) Initiation of a survey of healthcare worker distress and moral injury at the onset of the COVID‐19 surge. American Journal of Industrial Medicine; 63(9):830-833

[13] Litam, S. D. A., & Balkin, R. S. (2021). Moral injury in health-care workers during COVID-19 Pandemic.

About the authors

Verity Williams is a higher trainee (ST6) in general adult psychiatry working in Kent and Medway NHS Trust (KMPT).

Prof Rafey Faruqui is Chair of South Eastern Division of Royal College of Psychiatrists (RCPsych) and represents English Divisions at the RCPsych Board of Trustees. He is a Consultant Neuropsychiatrist at Kent & Medway Partnership Trust and Honorary Professor at CHSS, University of Kent. He has previously served as Chair of Neuropsychiatry Faculty and is an Editor of recently published Oxford Textbook of Neuropsychiatry.

Dr Rhian Bradley is a higher trainee (ST6) in general adult psychiatry working in Kent and Medway NHS Trust (KMPT). Dr Bradley has an interest in rehabilitation psychiatry, and is currently in post as the trainee representative for the Royal College of Psychiatry’s Rehabilitation faculty. Dr Bradley is actively involved in medical education within the trust, Kent and Medway Medical School, and Canterbury Christchurch University.

Julie Anderson is a Professor of Modern History and Faculty Director of Medical Humanities at the University of Kent.