COVID-19 and Moral Injury: a Mental Health Pandemic for Frontline Health Care Workers

COVID-19 and Moral Injury: a Mental Health Pandemic for Frontline Health Care Workers

More than 2 years ago, the alarm and first warnings of a global pandemic sounded. Now with over 830,000 deaths caused by COVID-19 in the US, there looms on the horizon a second underlying curve with equally serious long-term consequences: a mental health pandemic.

The mental health fallout from the COVID-19 pandemic demands recognition, intervention, and mitigation strategies. Among the many at-risk populations are frontline health care workers who have been at the epicenter of the global pandemic, working long shifts with at times a tenuous safety net and limited support, and caring for COVID-19 patients with limited resources, mixed messaging, and uncertainty with regards to an end to the crisis. The psychological effects in some health care providers are akin to the moral trauma or moral injury that is recognized in combat veterans with post-traumatic stress disorder (PTSD).

Mental health professionals and other health care providers caring for frontline health care workers who present with insomnia, depression, anxiety, panic attacks, PTSD, and suicidal thoughts should recognize and validate their experiences and moral injury. Intervention strategies including health promotion, resilience training, and ongoing multilevel support will play an important role in flattening the moral injury curve.

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Resilient Professionals

As a rule, the frontline health care workforce is considered capable, competent, resilient, professional, and persevering in the face of adversity. However, COVID-19 presented as an unprecedented crisis unlike any other unforeseen disaster, eliciting fear, uncertainty, and anxiety, coupled with grief and loss, both personally and professionally.1 As noted by Warren D. Taylor, MD, MHSc, and Jennifer Urbano Blackford, PhD1:

The pandemic created anxiety and fear in health care providers, from physicians and nurses to allied health professionals and first-line responders. We fear for the safety of our families and patients. We grieve for those who have died. We feel guilt for not being able to save all our patients, for getting sick ourselves, and for abandoning our families. Many adopted the phrase, “we will get through this together but none of us will survive unscathed.”

At the outset, the shortage of equipment and resources, changing practice guidelines, and unpredictability of the workload rendered health care workers with a sense of powerlessness and loss of control of the conditions under which they were able to deliver care. The emotional distress and social isolation from family and friends exacted an immeasurable toll on the physical health and emotional well-being of the workforce, setting the stage for the inevitable moral injury.2

Moral Injury Defined

Moral injury is a term that has been applied to veterans of combat. Moral injury or moral distress as experienced by frontline health care providers occurs when health care providers are forced to make decisions that transgress their professional commitment to patient comfort and care, and forcibly shift their moral compass. They are not able to meet the physical, emotional, and end-of-life needs of patients.3

Watson et al noted that moral injury in health care workers “can occur when someone engages in, fails to prevent, or witnesses acts that conflict with their values or beliefs.”4 Moral injuries may result from the following, according to Watson et al4:

Making decisions that affect the survival of others or where all options will lead to a negative outcome;Engaging in something that goes against your beliefs (an act of commission);Failing to do something in line with your beliefs (an act of omission);Witnessing or learning about such an act; orExperiencing betrayal by trusted colleagues

The consequences of such experiences may include feelings of rage, guilt, shame, and anger and moral injury is the “lasting psychological, spiritual, behavioral or social impact that may result from these experiences.”4 The number of acutely ill COVID-19 patients and high death rate coupled with lack of resources and at times rationing of limited resources such as personal protective equipment (PPE) and ventilators added to the dilemma that frontline health care workers faced.

In a study of 448 Jordanian nurses during the COVID-19 pandemic, the majority of nurses (64%) reported experiencing acute stress disorder (ASD) and 41% reported significant psychological distress, with a predilection for younger nurses compared to older nurses.5 However, coping self-efficacy was a protective factor with the potential to mitigate the severity of psychological distress.5 An online survey of non-health care providers (N=976) found that individuals with previous trauma were at highest risk for increased symptoms of anxiety, depression, and PTSD related to COVID-19 compared with individuals with no previous history of trauma.6

Long-Term Effects of Moral Injury

The long-term mental health consequences of moral injury for frontline health care workers have important implications for workforce survivability and durability; however, research on this topic is lacking. In one of the few published studies on moral injury among health care providers, investigators looked at the thematic content of experiences reported by nurses following incidents meeting the contextual definition of moral injury (ie, events with unintended consequences, potentially causing patient harm or putting patients at risk for serious injury). The investigators found nurses reported experiencing “guilt, shame, spiritual–existential crisis, and loss of trust.”7

COVID-19 has presented difficult and untenable working conditions beyond the scope of the challenges frontline health care workers are prepared for professionally. Frontline health care workers have experienced conflict and distress over prioritizing patient care vs their own safety, protecting family members from infection, and the reality that the supplies, medications, and equipment needed to save a life were not always available or were being rationed. Because of high infectivity, morbidity, and mortality associated with the spread of the virus, frontline health care workers were often in the position to be the only person at the bedside at the end of life with patients who were separated from their families. This is not how families should experience the loss of a loved one.4

There is a body of research regarding the long-term effects of moral injury among combat soldiers.3 It is reasonable to expect that feelings of guilt, shame, anger, and self-recrimination stemming from moral injury in these soldiers may be similar to feelings experienced by frontline health care workers during the COVID-19 pandemic and that their experiences increase the risk for acute stress reactions with long-term consequences including increased incidence of depression, anxiety, substance abuse, PTSD, and suicide.4,8 Behavior changes including intrusive memories, avoidance of situations that are reminders of prior events, self-isolation, and potential triggers of traumatic memories are common in individuals suffering from acute stress disorder or PTSD. Additional responses to stress, trauma, and moral injury include disturbed sleep, emotional changes such as numbing, desensitization, depersonalization, and a decreased capacity for empathy and compassion. For some individuals, the consequences of moral injury may be an opportunity for reflection and reprioritization of values and an existential inner process of reflecting on what is important in life.4

Given the consequences of moral injury, it is important for mental health professionals and health care providers treating frontline health care providers to recognize and identify those experiences that have the potential for promoting resilience.9

Strategies for Promoting Resilience

An analysis of data from 2579 frontline health care workers in New York City early on in the pandemic showed that key factors predictive of psychological resilience were positive emotions, self-efficacy, purpose in life, strong social support, and not engaging in maladaptive coping strategies (eg, substance abuse).9 Psychological resilience was described by the authors as, “the capacity to adapt and thrive while facing adversity or challenging circumstances,” leading to the question of how can institutions promote psychological resilience in frontline health care workers?9

Initiativespromoting psychological resilience are critical.10,11 Interventions identifying those at high risk for moral injury and in need of support in the form of psychological first-aid and psychotherapy have the potential of improving resilience. Kameno et al administered the short-form of the Kessler Psychological Distress Scale with 4 additional questions, 2 regarding sleep, 1 on appetite changes, and 1 on alcohol misuse, in health care workers during the pandemic.12 The researchers found that women and nurses had higher rates of affective symptoms compared to men and other medical staff, respectively. The researchers noted that early identification and psychotherapy may improve psychological resilience and reduce psychological distress in nurses at high risk for maladaptive coping.12

The need for institutional support, leadership support, education, and training is equally important. Leadership and management are challenged to identify those practices that address the needs of their respective health care workers.10 Survey findings on the expectations and needs of health care workers (physicians, nurses, advanced practice clinicians, residents, and fellows; N=69) during the first week of the pandemic at a single hospital identified the following 5 requests of their organization: hear me, protect me, prepare me, support me, and care for me.13 Management and leadership have the opportunity to promote resilience and show visible support for the health care workforce with unique initiatives to help reduce and mitigate the long-term consequences of moral injury and acute stress response.


Similar to triage protocols and models to meet emergent health care systems demands from unexpected disasters, there is a need for a multilayered mental health care response for frontline workers. Self-care and wellness initiatives have the potential to reduce the long-term consequences of moral injury. Ongoing support, skills training, psychoeducation, and wellness education regarding strategies to address and process the experiences of frontline health care workers are critical for healing the wounds of moral injury. Empathic sensitivity on the part of mental health providers and primary care providers is essential. Listening to “the story” and having the opportunity to process and reflect on the self-talk related to the experience of moral injury can lay the groundwork for healing.

Self-care needs should include the opportunity to seek out and have available a support system of peers and colleagues. All too often the experience of shame, guilt, and self-condemnation are obstacles to seeking self-help and lead to self-isolation. If allowed to process and reflect on those experiences, health care workers may be provided an opportunity for experiential growth and a redefinition of priorities personally and professionally.

Leaders in health care have the opportunity to create and foster a culture of open, nonjudgmental communication. In the face of unpredictable events such as the COVID-19 pandemic, natural disasters, and social and political unrest that impact health care delivery, strategies are available to promote mental health recovery and return to stability and wellness among frontline health care workers.

Catherine R. Judd, MS, PA-C, CAQ-Psy, DFAAPA, is an assistant clinical professor in the Department of Physician Assistant Studies at the School of Health Professions, The University of Texas Southwestern Medical Center, Dallas, Texas.


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2. Hossain F, Clatty A. Self-care strategies in response to nurses’ moral injury during COVID-19 pandemic. Nurs Ethics. 2021;28(1):23-32. doi:10.1177/0969733020961825

3. Borges LM, Barnes SM, Farnsworth JK, Bahraini NH, Brenner LA. A commentary on moral injury among health care providers during the COVID-19 pandemic. Psychol Trauma. 2020;12(S1):S138-S140. doi:10.1037/tra0000698

4. Watson P, Norman SB, Maguen S, Hamblen J. Moral injury in health care workers. Accessed January 4, 2021.

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8. Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. Brain Behav Immun. 2020;88:901-907. doi:10.1016/j.bbi.2020.05.026

9. Pietrzak RH, Feingold JH, Feder A, Charney DS, Peccoralo L, Southwick SM, Ripp J. Psychological resilience in frontline health care workers during the acute phase of the COVID-19 pandemic in New York City. J Clin Psychiatry. 2020;82(1):20l13749. doi:10.4088/JCP.20l13749

10. Krystal JH, Alvarado J, Ball SA, et al. Mobilizing an institutional supportive response for healthcare workers and other staff in the context of COVID-19: the Yale experience. Gen Hosp Psychiatry. 2021;68:12-18. doi:10.1016/j.genhosppsych.2020.11.005

11. Park ER, Sylvia LG, Streck JM, et al. Launching a resiliency group program to assist frontline clinicians in meeting the challenges of the COVID-19 pandemic: results of a hospital-based systems trial. Gen Hosp Psychiatry. 2021;68:111-112. doi:10.1016/j.genhosppsych.2020.10.005

12. Kameno Y, Hanada A, Asai D, et al. Individual psychotherapy using psychological first aid for frontline nurses at high risk of psychological distress during the COVID-19 pandemic. Psychiatry Clin Neurosci. 2021;75(1):25-27. doi:10.1111/pcn.13170.

13. Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA. 2020;323(21):2133-2134. doi:10.1001/jama.2020.5893

This article originally appeared on Clinical Advisor

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