Healthcare Workers and COVID-19-Related Moral Injury: An Interpersonally-Focused Approach Informed by PTSD

Abstract

The COVID-19 pandemic has resulted in a still-unfolding series of novel, potentially traumatic moral and ethical challenges that place many healthcare workers at risk of developing moral injury. Moral injury is a type of psychological response that may arise when one transgresses or witnesses another transgress deeply held moral values, or when one feels that an individual or institution that has a duty to provide care has failed to do so. Despite knowledge of this widespread exposure, to date, empirical data are scarce as to how to prevent and, where necessary, treat COVID-19-related moral injury in healthcare workers. Given the relation between moral injury and post-traumatic stress disorder (PTSD), we point here to social and interpersonal factors as critical moderators of PTSD symptomology and consider how this knowledge may translate to interventions for COVID-19-related moral injury. Specifically, we first review alterations in social cognitive functioning observed among individuals with PTSD that may give rise to interpersonal difficulties. Drawing on Nietlisbach and Maercker's 2009 work on interpersonal factors relevant to survivors of trauma with PTSD, we then review the role of perceived social support, social acknowledgment and social exclusion in relation to potential areas of targeted intervention for COVID-19-related moral injury in healthcare workers. Finally, building on existing literature (e.g., Phoenix Australia—Centre for Posttraumatic Mental Health and the Canadian Centre of Excellence—PTSD, 2020) we conclude with individual and organizational considerations to bolster against the development of moral injury in healthcare workers during the pandemic.

Potential Circumstances Associated With Moral Injury and Moral Distress in Healthcare Workers and Public Safety Personnel Across the Globe During COVID-19: A Scoping Review

“…Compassion-focused therapeutic approaches ( 134 , 135 ) that directly address developmental attachment trauma may further reduce shame and guilt surrounding MI and assist in its processing, particularly when combined with bottom-up, sensory-driven approaches. Finally, given established patterns of perceived social exclusion, poor social support, and a lack of social acknowledgment among HCWs throughout the COVID-19 pandemic, preventative and early intervention efforts focused on the strengthening of interpersonal relationships and enhancing social support would be expected to also assist in addressing MI among HCWs ( 136 ), particularly given that meta-analytic research consistently confirms social support as a strong predictor of the development of PTSD following trauma exposure ( 137 , 138 ).…”

Examining the prevalence and health impairment associated with subthreshold PTSD symptoms (PTSS) among frontline healthcare workers during the COVID-19 pandemic

“…A growing body of research indicates that this PTSD risk stems from a complex set of pandemic-related experiences. HCWs have served at the frontlines delivering care to critically ill patients, bringing them into repeated contact with human death ( D'Alessandro et al, 2022 ). This work has often occurred in the context of disrupted sleep, inadequate recovery time ( Zhang et al, 2021 ), and social isolation, contributing to feelings of loneliness ( Stubbs and Achat, 2022 ).…”

Post-traumatic stress disorder in doctors: Origins, approach and Eye Movement Desensitisation and Reprocessing therapy

“…Drawing from the COVID-19 pandemic experience, an interview series with Canadian HCWs indicated that they repeatedly struggled with how wrong it felt to witness the deterioration of critically-ill COVID patients leading to moral injury. 9 Their strong sense of responsibility, ownership and morality may be conceptualised as morally transgressive trauma, as commonly seen in military services personnel. 10 Chronic intrusive thoughts and images, avoidance behaviours, withdrawal, self-blame and physiological activation can arise following internal moral conflict and injury, resembling PTSD symptomology.…”