Moral injury in Chinese health professionals during the COVID-19 pandemic.

Abstract

Objective: Caring for patients during the COVID-19 pandemic has placed considerable stress on health care professionals (HCPs), increasing their risk of moral injury (MI) and clinician burnout. The present study sought to examine the prevalence and correlates of MI among physicians and nurses in mainland China during the pandemic. Method: A cross-sectional study was performed via an online survey conducted from March 27, 2020 to April 26, 2020. The 10-item Moral Injury Symptoms Scale-Health Professional version (MISS-HP) was administered along with measures of clinician mental health and burnout. A total of 3,006 physicians and nurses who completed the questionnaire were included in the final analysis. Unconditional logistic regression modeling was performed to determine the associations, including that between COVID-19 patient exposure and the risk of moral injury. Results: MISS-HP scores strongly and positively correlated with depression, anxiety, low well-being, and burnout symptoms. The estimated prevalence of MI in the total sample was 41.3%, 95% confidence interval (CI) [39.3%, 43.0%]. HCPs providing medical care to COVID-19 patients experienced a 28% greater risk of MI than those providing medical care to patients without the coronavirus (odds ratio = 1.28, 95% CI [1.05, 1.56], p = .01). Conclusions: A significant proportion of HCPs in mainland China are at risk for significant MI symptoms as well as mental health problems and burnout during the COVID-19 pandemic. MI symptoms are strongly correlated with higher clinician burnout, greater psychological distress, and lower level of subjective well-being. Effective strategies are needed to address MI and other mental health problems in frontline health care workers treating those with and without COVID-19 disease. Clinical Impact StatementMoral injury (MI) symptoms are correlated with higher clinician burnout, greater psychological distress, and lower level of subjective well-being. Strategies shown to be effective for MI in former military personnel might be used to address burnout and mental health problems in frontline health care workers tasked with treating those with and without COVID-19 disease. Our findings provide a profile of HCPs who are at risk for MI symptoms and may help to identify those at risk of downstream effects in terms of psychological health and patient safety.

Moral Injury: An Increasingly Recognized and Widespread Syndrome

“…When HCPs experience "burnout," as is so common today, MI may be the actual underlying cause (Kopacz et al, 2019;Talbot & Dean, 2018). Furthermore, MI has been associated with increased medical errors among HCPs during the COVID-19 pandemic (Mantri et al, 2021a;Wang et al, 2021). It may be difficult, however, to determine whether such medical errors are the result of MI or its cause (Curlin 2005;Stovall et al, 2020).…”

“…There are also several personal, behavioral, and situational factors that characterize the presence of MI in healthcare professionals. These include younger age (Mantri et al, 2021b;Wang et al, 2021), female gender (Wang et al, 2021), the unmarried (Wang et al, 2021), the divorced (Mantri et al, 2021b), those with lower religiosity (Mantri et al, 2021a(Mantri et al, , 2021b, Buddhist or Taoist religion (vs. no religion) (Wang et al, 2021), involvement in the care of COVID-19 patients (Mantri et al, 2021b;Wang et al, 2021), nurses (vs. physicians) (Mantri et al, 2021b), higher levels of burnout or emotional exhaustion (Mantri et al, 2021a(Mantri et al, , 2021bWang et al, 2020Wang et al, , 2021, and exposure to workplace violence (Wang et al, 2020(Wang et al, , 2021. As in studies of military personnel, depression and anxiety symptoms have been significantly correlated with MI in each of the studies above (except when controlling for HCP burnout).…”

A longitudinal analysis of the role of potentially morally injurious events on COVID-19-related psychosocial functioning among healthcare providers

“…While research is still limited, the mental health consequences of healthcare providers' exposure to PMIEs and moral distress in the context of the COVID-19 pandemic are beginning to be investigated. Several cross-sectional studies with samples of individuals from different countries (China, Spain, and the United States [US]), have shown a relationship between exposure to PMIEs and greater risk for anxiety, depression, posttraumatic stress disorder (PTSD), burnout, sleep difficulties, and suicidal ideation and self-directed violence [13][14][15].…”

Brief Eclectic Psychotherapy for Moral Trauma (BEP-MT): treatment protocol description and a case study

“…Whereas refugees are at risk, moral trauma can also affect, among others, law enforcement personnel or journalists (Feinstein et al, 2018;Papazoglou et al, 2020). In the recent COVID-19 pandemic moral trauma can also affect health care professionals (Wang et al, 2021;Kopacz et al, 2019;Lu et al, 2020). As the distress and moral emotions that are provoked by such a trauma may be comparable for people from different backgrounds, it could be worthwhile to examine if the current protocol could be similarly helpful for others who have been exposed to moral trauma, but currently this is not known.…”

“…Also, amongst law enforcement officers MI is observed and was an important predictor of PTSD symptoms (Papazoglou et al, 2020). The current COVID-19 pandemic has posed serious moral dilemmas to health care professionals and studies refer to mental health consequences, but also to MI (Kopacz, Ames, & Koenig, 2019;Lu et al, 2020;Lu, Wang, Lin, & Li, 2020;Wang et al, 2021). A population at high risk for MI are refugees.…”