Combat veterans, COVID-19 healthcare workers experience similar rates of 'moral injury,' study finds

The potential for "moral injury" among COVID-19 healthcare workers is like rates among military veterans deployed to a combat zone after Sept. 11, 2001, according to a study published online April 5 in the Journal of General Internal Medicine.

"Moral injuries can happen when healthcare workers' values and beliefs conflict with their actions or the ways they witness others acting," lead author Jason Nieuwsma, PhD, a researcher with the Veterans Health Administration and the Department of Psychiatry and Behavioral Sciences at Duke University School of Medicine, said in a news release.

"While 'burnout' is often used to describe the effects of ongoing stress in the workplace, moral injury is used to describe the damage done to the conscience or identity of people who might witness, cause or fail to prevent acts that go against their own moral standards," Dr. Nieuwsma said. "For example, with healthcare workers, this might entail them making choices or being part of situations that stray from their genuine commitment to healing."

The study — a collaboration between Durham, N.C.-based Duke University, Nashville, Tenn.-based Vanderbilt University and the Department of Veterans Affairs — is based on data from the VA Mid-Atlantic Mental Illness Research, Education and Clinical Center and findings from the Healthcare Worker Exposure Response and Outcomes registry. Researchers compared data from 618 post-9/11 veterans and a survey of 2,099 people working in healthcare during the COVID-19 pandemic in the U.S.

Researchers found that 46.1 percent of post-9/11 veterans and 50.7 percent of healthcare workers reported other-induced potential moral injury (disturbed by immoral acts of others), while 24.1 percent of post-9/11 veterans and 18.2 percent of healthcare workers reported self-induced potential moral injury (disturbed by having violated own morals). 

Healthcare workers who experienced incidents of potential moral injury conflicting with their moral values said they saw the public's disregard for preventing transmission of the virus, saw people dying, endured staffing shortages, rationed care and personal protective equipment, and enforced policies prohibiting visitors from seeing dying patients, according to the release.

Researchers also found that experiencing incidents of either type of potential moral injury was linked to significantly higher symptoms of depression and worse quality of life among veterans and healthcare workers and higher burnout among healthcare workers.

"The potential for moral injury is relatively high among combat veterans and COVID-19 [healthcare workers], with deleterious consequences for mental health and burnout," the study authors concluded. "Demographic characteristics suggestive of less social empowerment may increase risk for moral injury. Longitudinal research among COVID-19 [healthcare workers] is needed. Moral injury prevention and intervention efforts for [healthcare workers] may benefit from consulting models used with veterans."

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