Moral Injury in HCWs at Level of Combat Vets
Experiences of guilt, shame, loss of identity
Moral injury is a fairly well-established syndrome in combat soldiers, but researchers1 found healthcare workers suffered a comparable level of mental turmoil and ethical conflict during the first two years of the pandemic.
The researchers compared the occurrence of “potential moral injury” (PMI) between post-9/11 military combat veterans and healthcare workers surveyed during the COVID-19 pandemic. Surveys of the combat veterans were conducted from 2015 through 2019; healthcare workers were assessed for signs of PMI in 2020 and 2021. The comparative groups included 618 veterans deployed to a combat zone after 9/11 and 2,099 staff working in healthcare during the early months of the pandemic.
Researchers looked for two common triggers of moral injury: “Other-induced” — disturbed by others’ immoral acts — and “self-induced,” harm caused by violating one’s own code of ethics and morality. The results revealed 46% of post-9/11 combat veterans and 51% of healthcare workers experienced other-induced PMI. Self-induced moral injury was reported by 24% of the soldiers and 18% of the healthcare workers.
“Endorsing either type of PMI was associated with significantly higher depressive symptoms, worse quality of life in both samples, and higher burnout among healthcare workers,” the authors concluded. “Demographic characteristics suggestive of less social empowerment may increase risk for moral injury.”
Hospital Employee Health sought further comment from lead author Jason Nieuwsma PhD, a clinical psychologist at Duke University. This transcript has been lightly edited for length and clarity.
HEH: Can you clarify the difference between moral injury and burnout?
Nieuwsma: Before the pandemic, moral injury was something that we had been looking at in veterans [because] post-traumatic stress disorder was not fully encapsulating their experiences. It is distinct from burnout. Burnout is something that has been looked at a fair amount among healthcare workers preceding the pandemic, and then certainly during the pandemic. It tends to describe a feeling of exhaustion and depletion. Moral injury certainly involves some of those feelings, but it is defined or described more by a sense of either participating in something that went against your moral conscience or witnessing something that went against what you thought was right. There is perhaps even a feeling like you felt betrayed or that you saw somebody else do something that went against what you feel like is right.
HEH: One of strongest triggers for moral injury is the killing of non-combatants. Could you speak to this sense of betrayal in healthcare workers?
Nieuwsma: We collected qualitative written responses from healthcare workers in our sample, asking about what they felt this morally injurious experience was. We heard lots of different things with respect to this topic of betrayal. It ranged from feeling like it was from either co-workers or leadership, and that could have been somebody who was leading that unit, or a doctor. [It went] all the way up to the director of a healthcare facility, then extending beyond that to government leaders during the pandemic, and even to society. There were lots of different experiences that were noted by healthcare workers [regarding betrayal]. Some specific things that we heard were rationing of care or the feeling that policies were cruel. For example, some healthcare workers felt very disturbed by having to enforce policies of visitors not being allowed to see their loved ones as they were dying. Then, also, kind of this disconnect where healthcare workers would be in a hospital and seeing people dying or close to death, and then leaving and going out and seeing folks wandering around supermarkets not masking when mask mandates were in place. There was this feeling of “What’s going on here?”
HEH: Were you surprised that healthcare worker other-induced moral injury levels exceeded that of veterans in one of the categories?
Nieuwsma: It’s important to keep in mind two important caveats about this research. In the article, we were careful to label it “potential” moral injury. That was in part because there is no agreed-upon threshold or cutoff for what is or is not moral injury. That doesn’t exist at present. The other important caveat is we collected those data on healthcare workers in March of 2021, at a point when the pandemic was going pretty strong. Our veterans, by contrast, had completed these items on moral injury potentially years after their combat experiences. One of the things that we’ll continue to monitor is the persistence of some of these experiences of healthcare workers. Certainly, it was a high percentage, and concerning. It is something that we want to monitor over time.
HEH: Does your work with military veterans sort of predict or suggest what the long-term outcomes might be for moral injury in healthcare workers?
Nieuwsma: Among our military veterans, we looked at the degree to which moral injury was correlated with depression and quality of life. In the healthcare sample, we looked for burnout. In our research and others’ research looking at moral injury, you routinely see moral injury in veterans correlated with higher levels of depression, suicidality, substance abuse, and a variety of other mental health problems.
One of the things that we see among veterans is, regardless of whether your moral injury is induced by another, a result of a betrayal, or self-induced — where you feel like “I did something wrong” — it can lead to isolation and cutting off from other people. This is either because you feel like other people can’t be trusted, or because you feel like you’re a bad person and don’t deserve to be around other people. Isolation is one of those behaviors that can then exacerbate lots of different mental health problems, and I think is something that in our work with veterans is frequently targeted by different interventions for moral injury. I think that’s one thing we would really want to look at among healthcare workers over the long term — the extent to which healthcare workers feel like they can’t trust others is having an influence on isolation and their continued community with other individuals, whether at work or outside of work.
HEH: Is there a direct line between PMI and PTSD?
Nieuwsma: The two are absolutely correlated. Moral injury was developed as a construct largely because PTSD focused a lot on symptoms of anxiety and fear in the last version of the DSM [Diagnostic and Statistical Manual of Mental Disorders]. PTSD used to be categorized as an anxiety disorder, so a lot of treatments really focused on it that way. Things like exposure therapies — exposing you to fear and anxiety with the hope of reducing those things. A lot of medications for PTSD focused on that as well.
Whereas what we might call symptoms or experiences of moral injury tend to be less related to fear and anxiety, more related to experiences of guilt or shame or loss of identity, which are not as much related to anxiety. An experience that a veteran has can produce both of those things — if you contribute to the death of a civilian in combat, you can end up having both those things, so they’re correlated. But the idea really came out of this recognition that a lot of what we were doing for PTSD was focusing heavily on fear and anxiety — the DSM-4 is where it was categorized in the anxiety disorder section. In DSM-5, there’s now a separate section for trauma and stress-related disorders.
HEH: In self-induced moral injury, can this be a feeling of violating your own values — say, you went along with something that ultimately caused you great distress?
Nieuwsma: Yes, absolutely. It’s kind of a transgression or failing to prevent something. We’ve done some research looking at this. For example, [the feeling is] “I could have stopped something but didn’t, or I did something that I feel like was wrong.” In both cases, you feel like you have the agency, so it’s self-induced, though they are somewhat different.
- Nieuwsma JA, O’Brien EC, Xu H, et al. Patterns of potential moral injury in post-9/11 combat veterans and COVID-19 healthcare workers. J Gen Intern Med 2022;37:2033-2040.
Moral injury is a fairly well-established syndrome in combat soldiers, but researchers found healthcare workers suffered a comparable level of mental turmoil and ethical conflict during the first two years of the pandemic.
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