The COVID-19 pandemic has led to an unprecedented demand for already limited and quickly dwindling healthcare resources. Healthcare workers are being asked to make extremely difficult decisions about who receives care while also attempting to manage their own mental and physical well-being.
The increased pressure, the moral weight of these decisions, and stress concerning their health may lead to moral injury, increased burnout, and fatigue. In light of these circumstances, initiatives are needed to provide support to the healthcare workers that are placing themselves at risk daily to provide care to those in need.
Researchers, led by Neil Greenberg, Professor of Defence Mental Health at King’s College in London, and member of the National Institute for Health Research’s (NIHR) Health Protection Research Unit in Emergency Preparedness and Response, warn that healthcare workers may experience moral injury as a result of the unparalleled circumstances with which they are currently faced. They explain:
“Moral injury, a term that originated in the military, can be defined as the psychological distress that results from actions, or the lack of them which violate someone’s moral or ethical code.”
Moral injury is not meant to be a ‘diagnosis’ that pathologizes normative responses to harrowing circumstances. On the contrary, some have argued that moral injury better captures the experience of professionals facing systemic barriers to helping their patients in the context of for-profit healthcare systems. In the context of the COVID-19 pandemic, some health care workers have used the term moral injury to discuss how they feel “betrayed by their employers, the health care system, and the government, all of which were woefully unprepared for a pandemic and then chose to ignore their warnings.”
Moral injuries have been associated with intense feelings of guilt, shame, or disgust, as well as disparaging thoughts about themselves or others. This experience can parallel the symptoms associated with ‘post-traumatic stress disorder’ and ‘depression’ and has been connected to an increase in suicidal thoughts. For example, past research identifies mental health workers as being more susceptible to long-term emotional distress following quarantine. However, adversities such as moral dilemmas or trauma can lead to post-traumatic growth, or resilience or positive changes following the adverse event or events.
The authors argue that how one is affected by challenging or traumatic events is “influenced by the way that they are supported before, during, and after a challenging incident.” They suggest that to prevent adverse effects of the challenges healthcare workers will face in the fight against COVID-19, we need to prepare better to support our healthcare workers.
The researchers identify several steps that can be taken to ensure that support is provided to healthcare workers early on, which can foster resilience and growth, as opposed to waiting until after the fact, which can have detrimental effects on mental health. They suggest that healthcare workers need to be made explicitly aware of and prepared for the ethical dilemmas that they will experience during the pandemic – rather than dancing around or avoiding the topic.
As situations worsen, team leaders serve a vital role in supporting staff. The authors suggest that team leaders assist staff with processing and making sense of the morally ambiguous decisions facing healthcare workers. They offer Schwarz rounds discussions as a model, as they provide a safe space for healthcare workers to address the emotional and social challenges of caring for patients.
Team leaders also need to be alert to their staff engaging in avoidance. The authors emphasize that team leaders should attend and reach out to staff who repeatedly avoid attending discussions related to the emotional toll of the work. They highlight how the team leader or peers can offer support to individuals who are persistently avoiding meetings or are becoming increasingly distressed. The authors suggest that a referral to psychotherapy can be facilitated if the staff member’s level of distress is severe.
In addition to the opportunity for reflection and discussion, support should also incorporate psychoeducation on moral injuries so that healthcare workers know what to be aware of in themselves and others. The authors highlight how although, during normative times, individual healthcare workers may be experienced in and feel competent dealing with challenging situations, repeatedly having to face breaking bad news to relatives, or treating those who remind them of loved ones, may lead to moral injury, burnout, and emotional distress.
Supporting healthcare workers extends beyond the present crisis, as workers will require continued help in processing the impacts of what they experienced during the pandemic. Greenberg and his colleagues emphasize the importance of helping workers reflect on and make meaning out of their experiences, rather than attempting to avoid addressing any feelings of guilt or shame.
The authors provide us with an understanding of how to best support those who are placing themselves at risk in the service of caring for others during this pandemic. We must provide our healthcare workers with all of the resources we have to help them to cope with the psychological and physical strain of treating patients during the pandemic.
Greenberg, N., Docherty, M., Gnanapragasam, S., & Wessely, S. (2020). Managing mental health challenges faced by healthcare workers during the COVID-19 pandemic. BMJ, 368, (1211). (Link)