Moral Injury and Moral Resilience in Health Care Workers during COVID-19 Pandemic

Abstract

Background: The 2019 coronavirus (COVID-19) pandemic placed unprecedented strains on the U.S. health care system, putting health care workers (HCWs) at increased risk for experiencing moral injury (MI). Moral resilience (MR), the ability to preserve or restore integrity, has been proposed as a resource to mitigate the detrimental effects of MI among HCWs. Objectives: The objectives of this study were to investigate the prevalence of MI among HCWs, to identify the relationship among factors that predict MI, and to determine whether MR can act as buffer against it. Design: Web-based exploratory survey. Setting/Subjects: HCWs from a research network in the U.S. mid-Atlantic region. Measurements: Survey items included: our outcome, Moral Injury Symptoms Scale–Health Professional (MISS-HP), and predictors including demographics, items derived from the Rushton Moral Resilience Scale (RMRS), and ethical concerns index (ECI). Results: Sixty-five percent of 595 respondents provided COVID-19 care. The overall prevalence of clinically significant MI in HCWs was 32.4%; nurses reporting the highest occurrence. Higher scores on each of the ECI items were significantly positively associated with higher MI symptoms ( p < 0.05). MI among HCWs was significantly related to the following: MR score, ECI score, religious affiliation, and having ≥20 years in their profession. MR was a moderator of the effect of years of experience on MI. Conclusions: HCWs are experiencing MI during the pandemic. MR offers a promising individual resource to buffer the detrimental impact of MI. Further research is needed to understand how to cultivate MR, reduce ECI, and understand other systems level factors to prevent MI symptoms in U.S. HCWs.

Perceived organizational effectiveness, moral injury, and moral resilience among nurses during the COVID-19 pandemic

“…This negative correlation between MR and MI is consistent with the overall group of interdisciplinary HCWs from the original study sample. 4 A similar pattern was demonstrated in a study exploring the relationship of MR, moral distress, and mental health outcomes among HCWs. 7 Increased MR scores were associated with lower moral distress, depression, stress, and anxiety.…”

“…This has left little room or energy for critical reflection or connection to their greater purpose. 4 …”

“…Characteristics of the full dataset are described in a separate paper. 4 For this analysis, data were limited to nurses from the original sample (N = 344). The Johns Hopkins Clinical Research Network, a network of academic and community-based medical centers in Maryland, Pennsylvania, and the District of Columbia, distributed the survey invitation and a web-based link to complete it.…”

“…Items were dichotomized by the two highest and three lowest choices on the scale (0 = not at all/slightly/moderately effective, 1 = very/extremely effective), as in previous analysis. 4 …”

“… 1 - 3 Those at the point of care are experiencing significant moral injury (MI)–defined as a profound threat or violation of one's moral foundation and conscience–which occurs in response to severe personal, collective, organizational, or leadership transgressions or betrayals. 4 , 5 It can lead to erosion of one's moral identity and ignite feelings of guilt, shame, or unworthiness. 4 Nurses providing care to patients with COVID-19 have faced undue moral burden, while concurrently navigating substantial resource shortages, taking on additional responsibilities, and in some cases, feeling left in the dark by their organizations and leaders.…”