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Indications of Moral Injury Similar between Combat Veterans and COVID-19 Health Care Workers

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DURHAM, N.C. -- COVID-19 health care workers experienced high rates of potential moral injury that are comparable to rates among military veterans, according to a collaborative study between Duke University, Vanderbilt University, and the Department of Veterans Affairs (VA).

The study, published online April 5 in the Journal of General Internal Medicine, builds on a decade of research into moral injury among veterans by comparing data from VA with findings from the Healthcare Worker Exposure Response and Outcomes (HERO) registry.

“Moral injuries can happen when health care workers’ values and beliefs conflict with their actions or the ways they witness others acting,” said lead author Jason Nieuwsma, Ph.D., a researcher with VA and the Department of Psychiatry and Behavioral Sciences at Duke University School of Medicine.

“While ‘burnout’ is often used to describe the effects of ongoing stress in the workplace, moral injury is used to describe the damage done to the conscience or identity of people who might witness, cause, or fail to prevent acts that go against their own moral standards,” Nieuwsma said. “For example, with health care workers, this might entail them making choices or being part of situations that stray from their genuine commitment to healing.”

The researchers relied on data from a study of 618 post-9/11 combat veterans and a separate survey of 2,099 people working in health care during the COVID-19 pandemic. The health care workers were among those enrolled in the HERO registry -- a research registry supported by the Patient-Centered Outcomes Research Institute that includes over 55,000 health care workers and their families. Among those on the registry are nurses, therapists, physicians, emergency responders, and environmental service workers.

Veterans were asked about moral experiences in the context of their military service. The health care workers were asked about their experiences during COVID-19.

The study authors found that 46% of veterans and 51% of health care workers indicated being troubled by others’ immoral behavior, whereas 24% of veterans and 18% of health care workers indicated being troubled by violating their own morals and values.

Among the experiences that conflicted with their moral values, health care workers said they witnessed the public’s disregard for preventing COVID-19 transmission, saw people dying, endured staffing shortages, rationed care and personal protective equipment, and enforced policies disallowing visitors to see dying patients.

“It is sobering to see how many health care workers are troubled at a moral level because of their work experiences during the pandemic. This may help us to understand some of the current challenges facing health care systems across the country,” Nieuwsma said.

The researchers found that those who experienced incidents of potential moral injury suffered from more depression and lower quality of life, a finding that held both among veterans and health care workers. Among health care workers, those who acknowledged experiences of moral injury also reported higher levels of burnout.

“Health care workers have weathered a great deal of adversity during this pandemic and from many different directions,” said Emily O’Brien, Ph.D., associate professor in Duke’s Department of Population Health Sciences and the lead for the HERO registry arm of this study. “Burnout is often discussed, and it is real. For many, though, I suspect moral injury is a more accurate description of their experience, and that has implications for what we do now and in the future.”

“There may be lessons to learn from how we are approaching moral injury at Veterans Affairs,” said senior author Keith Meador, M.D., professor in the departments of Psychiatry, Religion and Health Policy at Vanderbilt. “Our study is suggestive with respect to the importance of workplace culture and leadership for moral injury in health care. I think the role of the community, whether that be at work or elsewhere, is truly central.”

In both the veteran sample and health care worker sample, the study found associations between potential moral injury and different demographic characteristics, some of which the authors note as being potentially suggestive of less social empowerment (e.g., being enlisted vs. officer in the military).

This is consistent with understandings of moral injury that emphasize its potential to develop because of perceived betrayals by authorities.

“It is still early,” Nieuwsma said. “We have been able to study how moral injury affects veterans for years after their separation from the military. While we can learn things from comparing veterans and health care workers, the two populations are also different in many important ways, and it remains to be seen how pervasive moral injury proves to be in health care contexts over time.”

In addition to Nieuwsma, O’Brien and Meador, study authors include Haolin Xu, and Melissa Smigelsky.

The research received funding support from the Department of Veterans Affairs and the Patient-Centered Outcomes Research Institute (PCORI). Researchers report no conflicts of interest.

Learn more about the HERO registry at https://HeroesResearch.org/

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