Coronavirus Pandemic Inflicts Moral Injury on Healthcare Professionals, Study Says

In 2020, the primary feelings healthcare professionals reported about the coronavirus pandemic shifted from fear to fatigue.

A new research article shows healthcare professionals (HPs) on the frontlines of the coronavirus pandemic in 2020 experienced significant levels of moral injury.

"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," the co-authors of the research article wrote. Moral injury has been associated with clinician burnout, medical errors, and suicidal thoughts.

The research article, which was published by JAMA Network Open, is based on survey data collected from more than 1,300 healthcare professionals in 2020 before vaccinations for COVID-19 were available. The surveys were conducted in two phases from April 24 to May 30, 2020, and Oct. 24 to Nov. 30, 2020. The surveys included a half-dozen open-ended questions such as, "What has been your greatest source of fear during the pandemic?" Survey respondents included nurses, physicians, advanced practice practitioners, and chaplains.

The research article features several key findings.

• Stressors during the first year of the pandemic included fear of contagion, stigmatization, short-staffing, and inadequate personal protective equipment
   
• Fear was the primary emotion experienced in phase 1 of the study
   
• Fatigue was the primary emotion experienced in phase 2 of the study
   
• Survey respondents reported feeling isolated from non-healthcare professionals
   
• Survey respondents reported feeling alienated from patients
   
• Survey respondents reported feeling betrayed by coworkers, administrators, and the public

"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," the research article's co-authors wrote.

Shifting from fear to fatigue

The primary emotions that HPs experienced shifted from phase 1 to phase 2 of the study.

"In phase 1, most participants expressed fear and uncertainty about the virus itself and its societal consequences. Fears were predominantly associated with 'catching the virus' and becoming ill and/or 'spreading it' to friends, family, and patients. Some referenced fear of COVID-19 transmission to higher risk people, such as pregnant people, older people, and/or those with other medical comorbidities," the co-authors wrote.

The availability and effectiveness of personal protective equipment (PPE) was another source of fear during phase 1 of the study. "We just all assume that we will get sick or have asymptomatic COVID at some point," one survey respondent wrote.

Fatigue supplanted fear in phase 2 of the study.

"In phase 2, most participants stated that as there was more knowledge about COVID-19, there was a decrease in fear: they were 'over it' and experiencing 'COVID fatigue.' There was also resignation around adapting to 'the new normal,'" the co-authors wrote.

By phase 2 of the study, fear associated with PPE dissipated, the co-authors wrote. "In phase 2, many respondents stated that as their PPE became more available with better protocols in place, their fear is gone and replaced with exhaustion."

Isolation and alienation

In both phases of the study, survey respondents reported feeling distrustful and afraid of others such as patients and coworkers. "I don't know that others are taking it as seriously as I am," one survey respondent wrote.

Some survey respondents wrote that family, friends, and community members had become afraid of healthcare workers, with one survey respondent writing that conducting errands while wearing scrubs had to be avoided because of the stigma associated with being a healthcare worker.

Isolation and withdrawal were reported by several survey respondents. "Some people isolated and withdrew physically from others 'for fear of infecting them or exposing them to this as every day I feel that I am a carrier' (respondent 8). They also withdrew emotionally, often assuming other people did not know what they were going through. People felt isolated from their community due to politicized discourses circulating on social media on social distancing protocols, such as wearing masks, especially after having 'dealt with death or even just the difficulty of caring for these patients' (respondent 9)," the co-authors wrote.

Survey respondents reported feeling isolated from patients. "The use of PPE and social distancing measures in patient care contributed to isolation from patients, with HPs feeling as if they were providing suboptimal care. As essentialized by one respondent, 'We can't build a connection with our patients because we can't spend the time to really care for them the way they deserve to be cared for' at the bedside (respondent 14). Many lamented the use of telehealth in clinics and loss of 'the true connection,' finding telehealth to be 'dehumanizing and disjointed' (respondent 15)," the co-authors wrote.

Feelings of betrayal

In phase 1 of the study, the lack of PPE fed a sense of betrayal among some survey respondents. "I felt like our lives were more disposable than our PPE was," one survey respondent wrote.

Some survey respondents still felt betrayed over PPE in phase 2 of the study. "We've just gotten better at protecting ourselves. Our hospital doesn't do a lot for us," one survey respondent wrote.

The feeling of betrayal came from several sources, the co-authors wrote. "HPs felt betrayed and unsupported by management, administrators, institutions, the healthcare system more broadly, and the government. Many pointed to a disconnect between leadership and 'those of us in there doing the hard work.'"