Moral Injury Among Frontline Long-Term Care Staff and Management During the COVID-19 Pandemic

Abstract

BackgroundA growing body of research highlights the experiences of moral injury among healthcare professionals during the COVID-19 pandemic. Moral injury (i.e., participating in or witnessing acts that violate one's central moral values), is associated with a host of psychological sequelae and corresponding negative psychosocial impacts. There is a lack of research examining the experiences of moral injury among those working in long-term care settings during the COVID-19 pandemic. Given the drastic impact that the COVID-19 pandemic has had on long-term care facilities in Canada, it is important to understand the experiences of moral injury among those working in long-term care settings to inform the development of effective prevention and intervention strategies.Objectives & MethodThe objectives of this study were to understand the experiences and impact of moral injury among Canadian frontline long-term care workers (staff and management) during the COVID-19 pandemic. Participants (N = 32 long-term care staff and management working in Ottawa and Manitoba) completed in-depth, semi-structured qualitative interviews and clinical diagnostic assessments (Mini International Neuropsychiatric Interviews; MINI; Version 7.0.2) between March 2021-June 2021.FindingsThe core category of our qualitative grounded theory model of moral injury in long-term care exemplified four shared types of morally injurious experiences, paired with cognitive, affective, and physiological symptom domains. Seven associated main themes emerged, contributing to the experiences and impact of moral injury in long-term care: 1) Beliefs about older adults and long-term care; 2) Interpretation of morally injurious experiences; 3) Management of morally injurious experiences; 4) Long-term care pandemic impacts; 5) Personal pandemic impacts; 6) Structural impacts in long-term care; and 7) Mental health needs and supports. Clinical assessments demonstrated anxiety disorders (n = 4) and feeding and eating disorders (n = 3) were among the most frequently classified current psychiatric disorders among long-term care workers.ConclusionsThis is the first Canadian study to examine the experiences and impact of moral injury in long-term care during the COVID-19 pandemic using qualitative and clinical diagnostic methodologies. Implications and insights for screening and intervention are offered.

Canadian Long-Term Residential Care Staff Recommendations for Pandemic Preparedness and Workforce Mental Health

“…The overall need for more mental health support for LTRC workers that we identified aligns with recommendations in a report by The Royal Society of Canada Task Force on COVID-19 (Estabrooks et al, 2020) and provincial reports undertaken in Alberta (Graff-Mcrae, 2021;MNP LLP, 2021), British Columbia (Ernst & Young LLP, 2020;Howegroup, 2020) and Ontario (Marrocco, Coke, & Kitts, 2021). Our participant-identified need for a mix of options to meet LTRC workers' diverse preferences for mental health supports also accords with findings from a study by Reynolds et al (2022), whose 70 staff and management survey participants from central Canadian LTRC facilities reported similarly varied preferences for mental health supports ranging from counseling, online therapy, online discussion groups, peer support discussion groups, additional staff support, and additional workrelated debriefings (Reynolds et al, 2022). An important component of enhancing the capacity, accessibility, and variety of workplace supports to meet pandemicera mental health needs of LTRC workers is evaluating existing mental health supports.…”

“…In a mixed-methods study of the impacts of pandemic management strategies on LTRC staff mental health in British Columbia, Havaei and colleagues identified "a vicious cycle of staffing shortages, heavy workloads, poor mental health and sub-optimal quality of care" (Havaei et al, 2022: p. 83), arising from pandemic management policies related to staffing, sick time, and visitation. A similar characterization of simultaneous and dynamic stressors was reported by Reynolds et al (2022) in a study entailing interviews with 26 staff from a LTRC facility in British Columbia. Participants in Reynolds et al's study described mental health and coping as impacted by combinations of heavy workloads, fear of outbreaks and getting sick, keeping up with shifts in pandemic guidelines, and being confronted with negative public views of LTRC (Reynolds et al, 2022).…”

“…A similar characterization of simultaneous and dynamic stressors was reported by Reynolds et al (2022) in a study entailing interviews with 26 staff from a LTRC facility in British Columbia. Participants in Reynolds et al's study described mental health and coping as impacted by combinations of heavy workloads, fear of outbreaks and getting sick, keeping up with shifts in pandemic guidelines, and being confronted with negative public views of LTRC (Reynolds et al, 2022). Graff-McRae's (2021) report for the Parkland Institute surveyed 370 LTRC workers from Alberta to discover worker perspectives on how job characteristics and working conditions supported their ability to provide care.…”

A pilot study on improvements in attention function in major depressive disorder after 12 weeks of escitalopram monotherapy or combined treatment with agomelatine

“…The inclusion criteria were as follows: (1) met the DSM-5 diagnostic criteria of MDD, (2) age 18–50 years, (3) right-handed, (4) Hamilton Depression Rating Scale−17 items (HAMD-17) score ≥ 22, (4) Hamilton Anxiety Rating Scale (HAMA) score ≥ 14, (5) at least 5 years of education, and (6) the ability to understand and read Mandarin Chinese. The exclusion criteria included: (1) comorbidity with other mental disorders assessed by the Mini-International Neuropsychiatric Interview ( 33 ), English Version 7.0.2 ( 34 ), (2) suicidal ideation (HAMD-17 item 3 score > 2), (3) patients who had received any medical treatment, including traditional Chinese medicine treatment, within 1 month of study enrolment and treatments such as modified electroconvulsive therapy, repeated transcranial magnetic stimulation, or transcranial electrical stimulation within 6 months of study enrollment, (4) current diagnosis with significant sleep disorders except for insomnia, (5) alcohol use within 1 week prior to enrollment or tobacco use of more than five cigarettes per day, and (6) shift work or travel causing jet lag or the presence of social jet lag within 3 months of study enrollment.…”

Mental Health and Well-being of Healthcare Professionals Amid the COVID-19 Pandemic in Canada

“…Research studies conducted in Canada have During the COVID-19 pandemic, moral injury also emerged as a significant challenge faced by 32 frontline long-term care staff. 26 It encompassed various distressing experiences, such as feeling unsupported by management, witnessing residents passing away alone, confronting a lack of preparedness, enduring personal loss or trauma, and dealing with inadequate support following morally injurious events. Each HCP recounted at least one instance of moral injury they had encountered.…”