Healthcare Workers Experiencing Moral Injury Similar to Combat Veterans

Researchers compared moral injury experienced by combat veterans after Sept. 11, 2001, and healthcare workers during the coronavirus pandemic.

During in the coronavirus pandemic, healthcare workers have experienced moral injury at levels comparable to combat veterans, a new research article found.

The pandemic has put tremendous pressure on healthcare workers. Prior to the pandemic, healthcare workers burnout rates averaged in the range of 30% to 50%; now, average burnout rates range from 40% to 70%, a healthcare worker well-being expert recently told HealthLeaders.

The new research article, which was published by the Journal of General Internal Medicine, is based on information gathered from 618 veterans who served in a combat zone after Sept. 11, 2001, and 2,099 healthcare workers who have provided care during the pandemic.

Moral injury has been defined as the "psychological, biological, spiritual, behavioral and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations." The new research article examined two kinds of potential moral injury: other-induced potential moral injury, which involves being disturbed by the immoral acts of others, and self-induced potential moral injury, which involves being disturbed by violating your own morals.

The study includes several key data points.

• 46.1% of combat veterans and 50.7% of healthcare workers reported other-induced potential moral injury
   
• 24.1% of combat veterans and 18.2% of healthcare workers reported self-induced potential moral injury
   
• For healthcare workers, other-induced potential moral injury was linked to younger age and COVID-19 exposure
   
• For healthcare workers, self-induced potential moral injury was linked to younger age, nonwhite race, working in a high-risk setting, and COVID-19 exposure
   
• Healthcare workers who reported other-induced potential moral injury had higher levels of depression and lower quality of life compared to healthcare workers who did not report other-induced potential moral injury
   
• Healthcare workers who reported self-induced potential moral injury had higher levels of depression and lower quality of life compared to healthcare workers who did not report self-induced potential moral injury
   
• Healthcare workers who reported other-induced or self-induced potential moral injury experienced significantly higher levels of burnout compared to healthcare workers who did not report other-induced or self-induced potential moral injury

"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's co-authors wrote.

Interpreting the data

The time of reported events is an important difference between the combat veterans and the healthcare workers, the lead author of the study told HealthLeaders.

"Veterans in our sample were reporting on experiences from their military service. While they were all combat veterans, those we interviewed about morally injurious experiences reported on both combat-related events and non-combat related experiences. Healthcare workers were reporting on experiences that were more recent in most cases. This is an important difference, and it will be important to monitor healthcare workers over time," said Jason Nieuwsma, PhD, an associate professor at Duke University Medical Center in Durham, North Carolina.

There are other key differences between the combat veterans and the healthcare workers, he said.

"There are also of course differences between serving in the military during a deployment, where you don't go home at night and don't really have the option to quit or take leave, and in healthcare during a pandemic, where you do go home at night and can make decisions about quitting or leaving. These differences can cut both ways in terms of the stress involved. While there is clear potential for intense pressure and stress in a deployment situation that one can't escape, I've also known many service members and veterans who would rather not have easy contact with their families during deployments because switching between those mindsets can be difficult and jarring—something healthcare workers reported in juxtaposing their experiences in hospitals with how upon leaving the hospital outside parts of society seemed ambivalent at times," Nieuwsma said.

Among healthcare workers, younger age was associated with both other-induced and self-induced potential moral injury. He said demographic characteristics like this may be associated with lower social status or empowerment.

"Jonathan Shay, a psychiatrist who did a lot of earlier work on moral injury among Vietnam War era veterans, defined moral injury as a betrayal by a legitimate authority in a high-stakes situation. Among healthcare workers, we heard anecdotes from persons who felt betrayed by leadership and/or felt like they were in situations with no good options, sometimes leading to providing lower quality patient care and associated feelings of guilt about that. Younger persons are more likely to be earlier in their careers and potentially finding themselves in these kinds of situations more often," Nieuwsma said.

For healthcare workers, the relationship between burnout and potential moral injury can go in both directions, he said.

"When people feel exhausted and burned out, we know that we as humans make worse decisions. This includes our ability to make moral decisions. To cite Shay again, he talked about how important sleep was for service members in combat because sleep deprived combatants are more likely to make worse decisions, again including morally consequential decisions. For example, firing on a vehicle that you think is an enemy combatant but turns out to be civilians. We heard similar things from healthcare workers, who said that they felt so exhausted and burned out that they ended up at higher risk for violating their own values and standards of patient care. Conversely, those who felt they had experienced a potential moral injury also reported feeling further demotivated and burned out, so, it can be a cycle," Nieuwsma said.

Related: Coronavirus Pandemic Inflicts Moral Injury on Healthcare Professionals, Study Says