Patterns of Potential Moral Injury in Post-9/11 Combat Veterans and COVID-19 Healthcare Workers

Abstract

Background Moral injury has primarily been studied in combat veterans but might also affect healthcare workers (HCWs) due to the COVID-19 pandemic. Objective To compare patterns of potential moral injury (PMI) between post-9/11 military combat veterans and healthcare workers (HCWs) surveyed during the COVID-19 pandemic. Design Cross-sectional surveys of veterans (2015–2019) and HCWs (2020–2021) in the USA. Participants 618 military veterans who were deployed to a combat zone after September 11, 2001, and 2099 HCWs working in healthcare during the COVID-19 pandemic. Main Measures Other-induced PMI (disturbed by others’ immoral acts) and self-induced PMI (disturbed by having violated own morals) were the primary outcomes. Sociodemographic variables, combat/COVID-19 experience, depression, quality of life, and burnout were measured as correlates. Key Results 46.1% of post-9/11 veterans and 50.7% of HCWs endorsed other-induced PMI, whereas 24.1% of post-9/11 veterans and 18.2% of HCWs endorsed self-induced PMI. Different types of PMI were significantly associated with gender, race, enlisted vs. officer status, and post-battle traumatic experiences among veterans and with age, race, working in a high COVID-19–risk setting, and reported COVID-19 exposure among HCWs. Endorsing either type of PMI was associated with significantly higher depressive symptoms and worse quality of life in both samples and higher burnout among HCWs. Conclusions The potential for moral injury is relatively high among combat veterans and COVID-19 HCWs, with deleterious consequences for mental health and burnout. Demographic characteristics suggestive of less social empowerment may increase risk for moral injury. Longitudinal research among COVID-19 HCWs is needed. Moral injury prevention and intervention efforts for HCWs may benefit from consulting models used with veterans.

Injurious Memories from the COVID-19 Frontline: The Impact of Episodic Memories of Self- and Other-Potentially Morally Injurious Events on Romanian Nurses’ Burnout, Turnover Intentions and Basic Need Satisfaction

“…Self-PMIEs are moral violations perpetrated by the person under perceived environmental constraint, whereas other-PMIEs are moral violations perpetrated by others and passively witnessed by the person. These constructs are best viewed as correlated, but distinctive, because of their different effects on the emotional health of healthcare providers [ 5 , 15 ]. Only exposure to self-PMIEs predicted levels of anxiety, PTSD and burnout above the clinical cutoffs, while also being significantly associated with disengagement [ 5 ].…”

“…Only exposure to self-PMIEs predicted levels of anxiety, PTSD and burnout above the clinical cutoffs, while also being significantly associated with disengagement [ 5 ]. However, both types of PMIE exposure were associated with scores surpassing the clinical cutoff for depression, worse quality of life and burnout in samples including nurses [ 5 , 15 ].…”

When the trauma never ends: (Post)-Traumatic Stress Disorder after COVID-19 amongst trauma and acute care surgeons

“…These data are intriguing and consistent with previous studies measuring PTSD and moral injury amongst surgeons and healthcare workers. 2 , 3 Interestingly, there did not appear to be an increase in self-reported PTSD compared with historical data. This highlights the demanding nature of a surgeon's day-to-day life beyond a pandemic.…”

“It hurts your heart”: frontline healthcare worker experiences of moral injury during the COVID-19 pandemic

“…However, evidence has begun to emerge suggesting experiences of betrayal (a form of other-induced MI) may be of particular concern among HCWs (Zerach & Levi-Belz, 2021), especially perceived betrayal by those in management positions in the NHS (French et al, 2021). Most recently, HCWs were shown to be nearly three times more likely to report ‘other-induced’ PMIEs compared to ‘self-induced’ (Nieuwsma et al, 2022). Consistently, we found experiences of betrayal were most often discussed among HCWs in our sample.…”