How moral injury is affecting health care workers amid COVID

Pandemic has pushed nurses and doctors to the brink, clinical psychologist tells COS

How moral injury is affecting health care workers amid COVID

Mental health is more essential than ever before in the OHS sector. The pandemic has shone a light on the importance of worker wellbeing, and the role that employers play in keeping their employees psychologically safe.

Exposure to traumatic events – like a pandemic – may be exposing workers across Canada to moral injury. Due to the demanding nature of their work, health care workers are particularly vulnerable.

Though moral injury itself isn’t a mental health disorder, it is a significant mental health issue which can create lasting emotional and psychological damage.

Internal conflict

So what exactly is moral injury?

Moral injury occurs “any time we might question our decision making, our ability to prevent what happened in our line of work or any time we might believe we did not do enough or did not do the right thing,” says Dr. Katy Kamkar, clinical psychologist based in Toronto and Assistant Professor, Department of Psychiatry, University of Toronto.

Moral injury can also occur when a worker feels like any event, action or lack of action may have transgressed their moral or ethical beliefs, or expectations or standards.

It can include adverse life events or traumatic events that may impact a person’s moral beliefs. This can, for example, be unintentional errors that could lead to death, or witnessing or failing to prevent harm or death.

This can “create an internal tension or internal conflict,” she says, “when we feel we might have been prevented from doing what we felt was morally right.”

All of these factors can set the stage for moral distress, moral suffering and moral injury.

“Organizational stressors might also increase the risk for moral suffering or moral distress. So at times when you might feel [you] are experiencing systemic failure or organizational injustice, or tasked with heavy workloads that [a person] feels is increasingly becoming difficult to manage,” says Dr. Kamkar.

This, she says, is also especially true for those involved in a human care profession or a human service profession.

And this is why there are certain sectors where workers are more prone to moral injury: military veterans, police and first responders, and health care workers.

As mentioned before, the question of moral injury has come up a lot over recent months specifically with regards to health care workers.

The COVID-19 pandemic has had a huge impact on the health care sector. A number of reports have come out since the start of the pandemic about the increased violence and mental health issues that health care workers may be facing such as anxiety, PTSD, burnout, and moral injury.

Problems like staffing shortages or lack of access to medical equipment such as PPE have affected those in the sector.

There have also been concerns around “changes to communications with patients and families, and witnessing all the pain and the suffering and wanting to provide more help and more services,” says Dr. Kamkar. “All of those changes have invited room for moral suffering, or can increase the risk for moral suffering.”

Guilt and shame

What are the symptoms of moral injury?

Dr. Kamkar says that the symptoms of moral injury can be similar to those of PTSD. These include:

  • Negative emotions including guilt, shame, embarrassment and anxiety
  • Negative beliefs about oneself and/or others
  • Behavioural responses such as avoidance, withdrawal, self-isolation and emotional numbness.

Experiencing moral injury may lead individuals to feel emotionally distant from others, creating relationship problems or leading to reduced empathy and even perhaps and increase in substance abuse.

As mentioned before, organizational stressors can also increase the risk of moral injury such as heavy workloads, role ambiguity and conflict and poorly defined demands or responsibilities.

System approach

So how can employers and organizations support workers who are suffering from moral injury, or may be at risk?

Dr. Kamkar says that employers wishing to handle moral injury among employees should take a system approach to proactive and preventative strategies.

“A lot of times when we talk about a system approach we’re talking about having budget decisions which include mental health, capacity and staffing,” she says.

It also means finding ways to boost organizational engagement and making sure that there is balance between work demands and the level of work control, meaning a balance between the demands of work duties and resources, training, staffing, support and education as well as leadership training and support.

“We also need to manage fatigue as well to reduce exhaustion and burnout,” says Dr. Kamkar. “Having people-focused leadership, a supportive workplace environment, empathy in the workplace and trust in leadership.”

Realistic communication about work tasks and duties is also important. As is education and support for moral distress:

“To know where to seek support and help resources, and access to care,” she says.

This approach should be done at an organizational level but also at the individual level as well: Training and education for employees as well as leadership, self-care, peer support, access to treatment and professional help, and also self-compassion and building self-efficacy.