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Morally Injurious Experiences and Emotions of Health Care Professionals During the COVID-19 Pandemic Before Vaccine Availability

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  How did health care workers experience moral injury during the COVID-19 pandemic before the availability of vaccines?

Findings  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.

Meaning  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.


Importance  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.

Objective  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.

Exposures  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.

Results  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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Article Information

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 (yekyung.song@duke.edu).

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.

Litz  BT , Stein  N , Delaney  E ,  et al.  Moral injury and moral repair in war veterans: a preliminary model and intervention strategy.   Clin Psychol Rev. 2009;29(8):695-706. doi:10.1016/j.cpr.2009.07.003PubMedGoogle ScholarCrossref
Shay  J .  Casualties.   Daedalus. 2011;140(3):179-188. doi:10.1162/DAED_a_00107PubMedGoogle ScholarCrossref
Wiinikka-Lydon  J .  Moral injury as inherent political critique: the prophetic possibilities of a new term.   Polit Theology. 2017;18(3):219-232. doi:10.1080/1462317X.2015.1104205Google ScholarCrossref
Kinghorn  W .  Challenging the hegemony of the symptom: reclaiming context in PTSD and moral injury.   J Med Philos. 2020;45(6):644-662. doi:10.1093/jmp/jhaa023PubMedGoogle ScholarCrossref
Griffin  BJ , Purcell  N , Burkman  K ,  et al.  Moral injury: an integrative review.   J Trauma Stress. 2019;32(3):350-362. doi:10.1002/jts.22362PubMedGoogle ScholarCrossref
Campbell  SM , Ulrich  CM , Grady  C .  A broader understanding of moral distress.   Am J Bioeth. 2016;16(12):2-9. doi:10.1080/15265161.2016.1239782PubMedGoogle ScholarCrossref
McAninch  A .  Moral distress, moral injury, and moral luck.   Am J Bioeth. 2016;16(12):29-31. doi:10.1080/15265161.2016.1239790PubMedGoogle ScholarCrossref
Dean  W , Talbot  S , Dean  A .  Reframing clinician distress: moral injury not burnout.   Fed Pract. 2019;36(9):400-402.PubMedGoogle Scholar
Mantri  S , Lawson  JM , Wang  Z , Koenig  HG .  Prevalence and predictors of moral injury symptoms in health care professionals.   J Nerv Ment Dis. 2021;209(3):174-180. doi:10.1097/NMD.0000000000001277PubMedGoogle ScholarCrossref
Mantri  S , Lawson  JM , Wang  Z , Koenig  HG .  Identifying moral injury in healthcare professionals: The Moral Injury Symptom Scale–HP.   J Relig Health. 2020;59(5):2323-2340. doi:10.1007/s10943-020-01065-wPubMedGoogle ScholarCrossref
Carmassi  C , Foghi  C , Dell’Oste  V ,  et al.  PTSD symptoms in healthcare workers facing the three coronavirus outbreaks: what can we expect after the COVID-19 pandemic.   Psychiatry Res. 2020;292:113312. doi:10.1016/j.psychres.2020.113312PubMedGoogle Scholar
Restauri  N , Sheridan  AD .  Burnout and posttraumatic stress disorder in the coronavirus disease 2019 (COVID-19) pandemic: intersection, impact, and interventions.   J Am Coll Radiol. 2020;17(7):921-926. doi:10.1016/j.jacr.2020.05.021PubMedGoogle ScholarCrossref
Heitzman  J .  Impact of COVID-19 pandemic on mental health.  Article in Polish.  Psychiatr Pol. 2020;54(2):187-198. doi:10.12740/PP/120373PubMedGoogle ScholarCrossref
Mantri  S , Song  YK , Lawson  JM , Berger  EJ , Koenig  HG .  Moral injury and burnout in health care professionals during the COVID-19 pandemic.   J Nerv Ment Dis. 2021;209(10):720-726. doi:10.1097/NMD.0000000000001367PubMedGoogle ScholarCrossref
Maunder  R , Hunter  J , Vincent  L ,  et al.  The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital.   CMAJ. 2003;168(10):1245-1251.PubMedGoogle Scholar
Nickell  LA , Crighton  EJ , Tracy  CS ,  et al.  Psychosocial effects of SARS on hospital staff: survey of a large tertiary care institution.   CMAJ. 2004;170(5):793-798. doi:10.1503/cmaj.1031077PubMedGoogle ScholarCrossref
Pothiawala  S .  Psychological impact of the COVID-19 on health care workers in the emergency department.   Front Emerg Med. 2020;4(2S):e58.Google Scholar
Dreifuss  BA . I’m a health care worker. You need to know how close we are to breaking. The New York Times. June 25, 2020. Accessed February 12, 2021. https://www.nytimes.com/2020/06/26/opinion/coronavirus-arizona-hospitals.html?searchResultPosition=4
Shanafelt  T , Ripp  J , Trockel  M .  Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic.   JAMA. 2020;323(21):2133-2134. doi:10.1001/jama.2020.5893PubMedGoogle ScholarCrossref
Hasan  Z , Narasimhan  M .  Preparing for the COVID-19 pandemic: our experience in New York.   Chest. 2020;157(6):1420-1422. doi:10.1016/j.chest.2020.03.027PubMedGoogle ScholarCrossref
Walton  M , Murray  E , Christian  MD .  Mental health care for medical staff and affiliated healthcare workers during the COVID-19 pandemic.   Eur Heart J Acute Cardiovasc Care. 2020;9(3):241-247. doi:10.1177/2048872620922795PubMedGoogle ScholarCrossref
Liu  Q , Luo  D , Haase  JE ,  et al.  The experiences of health-care providers during the COVID-19 crisis in China: a qualitative study.   Lancet Glob Health. 2020;8(6):e790-e798. doi:10.1016/S2214-109X(20)30204-7PubMedGoogle ScholarCrossref
Hines  SE , Chin  KH , Glick  DR , Wickwire  EM .  Trends in moral injury, distress, and resilience factors among healthcare workers at the beginning of the COVID-19 pandemic.   Int J Environ Res Public Health. 2021;18(2):488. doi:10.3390/ijerph18020488PubMedGoogle ScholarCrossref
Charmaz  K , Belgrave  LL . Grounded Theory. In:  The Blackwell Encyclopedia of Sociology. John Wiley & Sons, Ltd; 2015. doi:10.1002/9781405165518.wbeosg070.pub2
Tong  A , Sainsbury  P , Craig  J .  Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups.   Int J Qual Health Care. 2007;19(6):349-357. doi:10.1093/intqhc/mzm042PubMedGoogle ScholarCrossref
Kurotschka  PK , Serafini  A , Demontis  M ,  et al.  General practitioners’ experiences during the first phase of the COVID-19 pandemic in Italy: a critical incident technique study.   Front Public Health. 2021;9:623904. doi:10.3389/fpubh.2021.623904PubMedGoogle Scholar
Kuliukas  L , Hauck  Y , Sweet  L ,  et al.  A cross sectional study of midwifery students’ experiences of COVID-19: uncertainty and expendability.   Nurse Educ Pract. 2021;51:102988. doi:10.1016/j.nepr.2021.102988PubMedGoogle Scholar
Koenig  HG , Al Zaben  F .  Moral injury: an increasingly recognized and widespread syndrome.   J Relig Health. 2021;60(5):2989-3011. doi:10.1007/S10943-021-01328-0PubMedGoogle ScholarCrossref
Hlubocky  FJ , Symington  BE , McFarland  DC ,  et al.  Impact of the COVID-19 pandemic on oncologist burnout, emotional well-being, and moral distress: considerations for the cancer organization’s response for readiness, mitigation, and resilience.   JCO Oncol Pract. 2021;17(7):365-374. doi:10.1200/op.20.00937PubMedGoogle ScholarCrossref
Stahl  R .  Why we “support the troops”: rhetorical evolutions.   Rhetoric & Public Affairs. 2009;12(4). doi:10.1353/rap.0.0121Google Scholar
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