Moral Injury: Pandemic's Fallout for Healthcare Workers

Kathleen Doheny

February 02, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

In his 17 years as a doctor, Matthew Heinz, MD, had never gotten a telephone call like the one from his hospital in Tucson, Arizona. Late one night in December, a hospital supervisor called to tell him that five COVID patients were in distress. All of them needed a higher level of care, four of them urgently. But only one bed was available for the level of care they needed. "You pick," she told Heinz.

"It's something I have never anticipated having to do," he says in retrospect. "I was never, ever called upon to make such an important decision so quickly. I was frustrated, and it's heartbreaking. But you don't have time to dwell on that. I had to sit there and think about...who would be first, second.... No, I thought, this is not what I signed up for."

While burnout is often used to describe the effects of all this ongoing stress among healthcare workers battling the pandemic, mental health experts have recently begun to say that a better description is moral trauma — and that this moral trauma is so long-lasting and pervasive, it actually becomes moral injury.

Originally used to describe what soldiers experience in wartime, moral injury in healthcare began to be applied to healthcare even before the pandemic, says Wendy Dean, MD, a psychiatrist and the president and co-founder of Moral Injury of Healthcare, a nonprofit devoted to reframing clinician distress as moral injury — and to work to improve the source of it, which she and others say is the healthcare system itself.

"We came onto the pandemic already with distress, and the pandemic hit on top — an acute layer of distress," Dean says.

Consuelo Vargas can relate. A registered nurse for 15 years, she works in the emergency room at the John H. Stroger Jr Hospital of Cook County in Chicago, Illinois. Early on in the pandemic, when there wasn't enough protective personal equipment (PPE) for staff, she walked by a room in the ER and saw a colleague doing compressions on a man thought to have COVID and in cardiac arrest.

Her co-worker did not have on enough PPE. "I am very diligent about my PPE,'' she says. "I had mine on, so I went in and took over and started yelling [to her colleague and others who had joined in] to get out. The hardest part is, we know what we are supposed to do as far as caring for our patients. We know how to do it as nurses, but we are not given the tools and support to do it."

Tassia Trink, a registered nurse in Southern California, says the pandemic numbers have risen so much recently that patients sometimes are in her hospital's emergency room waiting room for up to 18 hours. Decisions must be made about who goes first.

Recently, Trink says, a couple came in with COVID symptoms, one with a 70% oxygen saturation and the other with 78%; both exceptionally low. At first, since the hospital had a shortage of beds, she had to pick just one, so she picked the one with the lower percentage. Eventually, they both got an ER bed, she says, but "we are constantly having to pick and choose. It's going against our whole moral code as nurses."

As Cases Rise, So Do Mental Health Issues and Moral Injury

As the pandemic continues, healthcare providers are being asked not only to work extra shifts as colleagues fall ill with the virus, but also to make decisions about who's first in line for a bed or for care.

The pandemic has affected them in other ways as well, including shifting their career-long focus from patient-centered care and ethics to public health ethics. The focus is now on the common good — the risks and benefits to society as a whole, rather than on a single patient. An intensive care unit nurse used to caring for one or two patients may need to take on another one, because it's a public health crisis.

From June to September, Mental Health America polled more than 1100 healthcare workers about COVID-19, finding that 93% reported stress, 86% anxiety, 77% frustration, 76% exhaustion and burnout, and 75% said they were overwhelmed.

Burnout vs Moral Injury

There's a critical difference, Dean says, between burnout and moral injury. Moral injury occurs when healthcare providers are "repeatedly expected, in the course of providing care, to make choices that transgress their long-standing, deeply held commitment to healing," Dean says. The moral injury happens because they're frustrated and can't provide the care they trained for and promised to give.

Healthcare workers generally expect to work hard and have ideals about providing the best care possible, says Dean, who formerly worked as an ER doctor and says she's had her own struggles with moral injury. In general, they love their patients and love taking care of them. But the constraints and lack of supplies and staff, among other pandemic shortfalls, translate to healthcare providers not able to meet patients' needs, and that adversely affects their well-being, Dean says.

Moral trauma is different than the trauma, for instance, from a car accident, says William A. Haseltine, PhD, chair and president of ACCESS Health International, a global health think tank. "Moral trauma is seeing something that's wrong. Moral trauma has a special dimension. It affects your sense of right and wrong."

When healthcare providers have to launch a "crisis standard" of care, deciding on how to distribute healthcare resources based on things like how many productive years a patient likely has left, or the extent of sickness, "that's deeply traumatic," he says. "That could happen in an earthquake, a tidal wave." But having to make these decisions during the COVID pandemic is even worse, he says, than during natural disasters because "COVID was preventable by government action."

Making those standard-of-care decisions in natural disasters doesn't lead to moral injury for healthcare providers, Haseltine says. But "moral injury comes from knowing you are making that decision in a situation where it didn't have to happen. That is deeply traumatic."

Looking at Ethical Dilemmas

Some research has focused on the ethical dilemmas and challenges facing healthcare workers during the pandemic that can lead to moral injury. One is the shift away from patient-centered ethics, says Fahmida Hossain, a PhD candidate and bioethicist at Duquesne University in Pittsburgh in Pennsylvania, who published a report on nurses' moral injury during COVID. Now, she says, "It's a public health issue, it is no longer about an individual patient."

With hospitals sometimes not letting patients' families visit so as not to contract the virus, nurses and others are called on to be surrogate family members, which adds another source of stress, say Hossain and her co-researcher, Ariel Clatty, PhD, a medical ethicist at the University of Pittsburgh Medical Center. Scenarios are played out daily where a healthcare worker holds a cellphone up to the patient to communicate, often for the last time, with their loved ones. "It used to be a caregiving atmosphere," Clatty says. "Now we have taken away the human interacting."

In their report, the Pittsburgh researchers quote one nurse as saying, "That's a tough thing to watch every single day, to watch somebody die without their family there."

Making the Tough Decisions Less So

Heinz, the Tucson doctor, took a stand when he heard there was one available bed and four more needed for his COVID patients. "I said, 'That is unacceptable.'" Next, he went to the hospital, saw all five patients "because they were that sick," and then got to work. "Given that all four were in an equally terrible place, I put in the transfer order that all these needed to be transferred" to another hospital.

It took hours, but he eventually got all transferred by shifting some other patients who were able to be moved and by getting more staff. One patient got transferred within an hour and all by the next morning. Still, Heinz knows, this isn't always possible.

Fixing Moral Injury

As the term moral injury is applied more and more to healthcare workers, experts agree it is a serious issue but don't agree on the fixes.

In their report in the nursing journal, Hossain and Clatty talk about encouraging healthcare providers to follow self-care strategies such as learning to calm themselves with mindful breathing before taking on a new patient and building moral resilience. Vargas, the Chicago nurse, says self-care does help her. "Every morning, I do a yoga routine, and at nighttime, meditation. Nothing can take the place of that time." She also has puppy therapy, she says, enjoying her son's new puppy.

On a recent night after a 12-hour shift, Trink, the Southern California ER nurse, was also walking her dog.

But while such self-care can be useful, Dean says it is not enough to fix the problem. "No amount of mindfulness, meditation, salmon salad, or running is going to help you get your patient the care you need," she says. And most healthcare providers don't need to boost resilience, she says. They have plenty.

The resilience shows as healthcare providers, like Trink, vow to keep showing up. Because, well, it's their job and mission. "People say, 'You are a hero,' but I certainly don't feel like one," Trink says. "I show up to my job. I feel like I am doing what I am supposed to be doing."

Burnout may be an individual problem, Dean says, but moral injury is a systemic problem. What needs to be fixed is not a healthcare provider's ability to stay calm and focused, but the healthcare system itself, she says.

What's needed is to change the institution patterns that inflict the moral injuries, she says. In a recent article, she and her co-founder, Simon G. Talbot, MD, a reconstructive plastic surgeon at Brigham and Women's Hospital and an associate professor at Harvard Medical School, proposed some changes, including a truly free market of insurers and providers (without financial obligations pushed to providers) and the realization that leaders who care for their healthcare providers will also boost compassionate care for their patients.

In a viewpoint published last year, Haseltine proposed this solution to aid the recovery from the pandemic's moral trauma: "We need collective action to return our government to a disciplined plan based on science to control the pandemic. We know with certainty it can be done with the tools at hand." No miracle is needed, he stresses, but "only resolve, that of our government to do what is right, and if not, by we the people to make sure they do!"

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