Research into psychological distress and mental health issues during crises suggests that the world’s healthcare workers will face challenges through the pandemic and for years afterward.1,2

New data from the Centers for Disease Control and Prevention (CDC) and an online survey revealed that one in 10 respondents seriously considered suicide within the past 30 days, and about one in five essential workers considered the same.3

Frontline professionals, and other healthcare workers to a lesser extent, are witnessing traumatic events that could lead to moral injury. As the authors of one new paper suggest, a big contributor to this problem is their frustration and sense of powerlessness. Nurses and others affected by the pandemic’s trauma need education, coping tools, and therapy to help alleviate the adverse effects.2

The frontline workers in intensive care units (ICUs), caring for dying COVID-19 patients, are tired and swamped and may experience moral injury, says Alexander Tsai, MD, PhD, a psychiatrist at Massachusetts General Hospital, and associate professor of psychiatry at Harvard Medical School.

“‘Moral injury’ is a term coined by a psychiatrist who worked with combat veterans in the Vietnam War,” Tsai explains. “He defined it as being party to the perpetration or not being able to transgress these acts, such as the Vietnam War atrocities.”

People who have experienced moral injury are harmed for years after the event. They can include journalists, chaplains, healthcare workers, and others after large-scale disasters or mass violence, he adds.

Just as Vietnam War soldiers were helpless to prevent atrocities, healthcare workers in all settings have been helpless to prevent COVID-19 deaths. “Moral injury is an important issue that factors into distress among healthcare workers,” Tsai says. “A study of healthcare workers in New York City, at the time of the surge, polled them about occupational hazards, what factors ranked highest in their mental health, and they identified ‘not having control.’”

Other factors were the lack of support and being redeployed to do work outside of their specialty. “Those are the occupational factors. There were other things, like being fearful about being infected with COVID-19 or having to work despite having symptoms and not having personal protective equipment,” Tsai says. “There is a long list of factors associated with mental healthcare in the epidemic, and working long hours is low on the list because they’re used to long hours.”

Burnout, anxiety, and depression among healthcare workers are caused by factors other than hard and long hours of work, he adds.

For all healthcare workers in the pandemic era, a big stressor involves anxiety about contracting the virus. “We saw a lot of stress and anxiety around illness,” says Cynthia Harper, PhD, professor of obstetrics, gynecology, and reproductive sciences, and director of the UCSF-Kaiser Permanente Building Interdisciplinary Research Careers in Women’s Health at the University of California, San Francisco (UCSF).

In a study, Harper and co-investigators found that reproductive health professionals were worried about bringing illness home to their families. They also were worried about finding child care, which was scarce during pandemic surges. “Some were able to do telemedicine and have their shifts remote,” Harper says.

Iconic images of the pandemic show healthcare workers with capes or being saluted by Superman — as an Ohio COVID-19 poster shows — or as masked hospital staff walk down a hallway, Marvel and Justice League superheroes bow to them. (The images can be found here.)

“We see these health workers as heroes who can take on everything,” says Alison B. Comfort, PhD, health economist with the Bixby Center for Global Reproductive Health at UCSF. “They have to show up for work, and we count on them for so much. In San Francisco, we have ads that say, ‘Not all superheroes wear capes,’ and they show healthcare workers.”

But what these tributes to their work during the pandemic miss is the emotional health toll of their struggles during the pandemic. “We depend on them, and yet we’re putting them under so much pressure. They’re human and not sleeping and are constantly stressed and worried about their families,” Comfort says. “We call them superheroes, but they’re going through these very real, challenging situations.”

Comfort says she was compelled, in part, to study this topic because of the tragic examples of physicians taking their own lives after months of caring for COVID-19 patients.

“We need to acknowledge [their difficulties], support them, and not make them do impossible jobs that put them under so much strain,” she says. “They’re not super human; they’re human.”


  1. Comfort AB, Krezanoski PJ, Rao L, et al. Mental health among outpatient reproductive health care providers during the US COVID-19 epidemic. Reprod Health 2021;18:49.
  2. Hossain F, Clatty A. Self-care strategies in response to nurses’ moral injury during COVID-19 pandemic. Nurs Ethics 2021;28:23-32.
  3. Rutgers Robert Wood Johnson Medical School. Staying ahead of the curve: How experts at Rutgers are addressing the pandemic’s impact on mental health and risk for suicide. Newswise. March 9, 2021.