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How did health care workers experience moral injury during the COVID-19 pandemic before the availability of vaccines?
In this qualitative study of 1344 health care professionals in 2020, respondents reported significant changes in their personal and professional lives during the course of the pandemic. Common themes were feeling isolated from non–health care professionals, alienated from patients, and betrayed by coworkers, administrators, and the public.
Moral injury can result from chronic stressors in morally injurious environments; leadership must identify and address these stressors to effectively support health care professionals as COVID-19 continues to strain staff’s physical, mental, and emotional resources.
Moral injury in health care professionals (HPs) has worsened over the course of the COVID-19 pandemic. The trauma and burnout associated with moral injury has profound implications for the mental health of HPs.
To explore the potential factors associated with moral injury for HPs who were involved in patient care during the COVID-19 pandemic in 2020, prior to the availability of vaccines.
Design, Setting, and Participants
In this qualitative study, HPs were actively recruited to participate in a survey via snowball sampling via email and social media in 2 phases of 5 weeks each: April 24 to May 30, 2020 (phase 1), and October 24 to November 30, 2020 (phase 2). Overall, 1831 respondents answered demographic questions and assessments for moral injury, intrinsic religiosity, and burnout. Of those, 1344 responded to the open-ended questions. Responses to open-ended questions were coded iteratively and thematically analyzed within the framework of moral injury.
Working in a patient care setting during the COVID-19 pandemic prior to the availability of vaccines.
Main Outcomes and Measures
Inductive thematic analysis of open-response survey answers identified dominant emotions and common stressors associated with moral injury.
There were 335 individuals (109 [32.6%] aged 35-44 years; 288 [86.0%] women; 294 [87.8%] White) in phase 1 and 1009 individuals (384 [38.1%] aged 35-44 years; 913 [90.5%] women; 945 [93.7%] White) in phase 2. In phase 1, the respondents were predominantly nurses (100 [29.9%]), physicians (78 [23.3%]), advanced practice practitioners (APPs) (70 [20.9%]), and chaplains (55 [16.4%]). In phase 2, the respondents were predominantly nurses (589 [58.4%]), physicians (114 [11.3%]), and APPs (104 [10.3%]). HPs faced numerous stressors, such as fear of contagion, stigmatization, short-staffing, and inadequate personal protective equipment. The emotions experienced were (1) fear in phase 1, then fatigue in phase 2; (2) isolation and alienation; and (3) betrayal.
Conclusions and Relevance
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.
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Accepted for Publication: September 13, 2021.
Published: November 24, 2021. doi:10.1001/jamanetworkopen.2021.36150
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Song YK et al. JAMA Network Open.
Corresponding Author: Ye Kyung Song, MD, PhD, Department of Psychiatry and Behavioral Sciences, Duke University Medical Century, 3643 N Roxboro St, Durham, NC 27704 (firstname.lastname@example.org).
Author Contributions: Dr Song had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Mantri, Lawson, Berger, Koenig.
Acquisition, analysis, or interpretation of data: Song, Berger, Koenig.
Drafting of the manuscript: Song, Koenig.
Critical revision of the manuscript for important intellectual content: Mantri, Lawson, Berger, Koenig.
Statistical analysis: Song.
Administrative, technical, or material support: Mantri, Koenig.
Supervision: Mantri, Koenig.
Conflict of Interest Disclosures: Ms Berger reported receiving personal fees from Kansas City University outside the submitted work and being a speaker-consultant, an advanced practice board certified chaplain, and a narrative medicine specialist whose work is directed to spiritual health (meaning, purpose, and connectedness), clinician well-being, and the connection to patient care, which is inherently related to the areas of moral injury and burnout in healthcare. No other disclosures were reported.
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