Moral injury among healthcare professionals during the COVID-19 pandemic

Prior work examining moral injury centers around military veterans, but the psychological phenomenon has more recently been investigated in healthcare professionals working during the COVID-19 global pandemic [10,12]. Work broadly represents an important social determinant of health, which can yield benefits but also potentially health and social costs [16]. PMIEs within the healthcare sector can involve a variety of high stakes situations, including: caring for COVID-19 patients who are dying without contact with family members, witnessing COVID-19 related unethical healthcare practices and not intervening, and triaging or discharging due to lack of institutional resources COVID-19 patients who need a high level of care [10]. Exposure to PMIEs has been associated with poorer psychosocial functioning, psychological distress, and suicidal ideation [10,17]. Healthcare professionals during the COVID-19 pandemic are especially at risk of being exposed to PMIEs and experiencing moral distress (a precursor to moral injury; [18], which has been previously associated with COVID-19 related posttraumatic stress symptoms, burnout, work stress, and interpersonal difficulties [11]. Certain work-related factors, such as organizational support (the perceived degree to which the organization cares about the worker’s satisfaction, well-being, and contributions), safety standards, and perceived fairness of wage reductions may help ameliorate the negative effects of PMIE exposure [19,20]. It is possible that healthcare workers who regularly interact with COVID-19 patients or work in acute care settings may face higher exposure to PMIEs as a result of acuity and resource rationing within their workplace setting. Working conditions may contribute to worker stress and conflict around their professional role, arising from incongruent expectations around work tasks, role, and evaluations [21]. Literature on moral injury among healthcare workers in this context is limited but growing, with most research focused on a single work context (rather than comparing multiple work settings and conditions) and not necessarily accounting for the lived experience of healthcare workers- as both workers and people with lives outside of the workplace.

Theoretical framework

We applied the Total Worker Health^® framework to our analyses. Total Worker Health^® is a comprehensive framework for evaluating how contextual factors (such as social, political, and economic policies, events, and environments); worker characteristics and homelife; policies, practices, and programs developed within the organization; and working conditions affect worker health and wellbeing as well as organizational outcomes [17,22]. The ecological levels of this framework, modified from Sorensen et al.’s social contextual model is available in Fig 1 [17].

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Fig 1. General relationship between Total Worker Health^® constructs and ecological levels modified from Sorensen et al. (2021) [16] conceptual model.

https://doi.org/10.1371/journal.pone.0304620.g001

To date, the phenomenon of moral injury has not been analyzed from a Total Worker Health^® perspective, although the framework has been applied to health and social service settings [23,24]. However, this framework is particularly suited to explore contributors to moral injury in healthcare settings given the potential for conflicting priorities between patient, workers, and healthcare organizations. In the context of the pandemic, rapidly changing policies, health care resource allocation needs, and organizational finances within a hierarchical work environment could all be implicated in the moral injury of healthcare workers during this time of collective stress. Analysis from a Total Worker Health^® perspective may also help illustrate the potential implications for organizational outcomes, which may include patient outcomes, insurance reimbursements, staff turnover, staffing shortages, and profits and revenue.

Present study

The present study expands current knowledge about moral injury among healthcare workers during a unique and historic time—the COVID-19 global pandemic. Using a Total Worker Health^® theoretical framework as a guide, we utilize both quantitative and qualitative data to examine factors that may contribute to moral injury across multiple ecological levels. Data were analyzed using a sequential mixed methods design [25], where both quantitative and qualitative data were collected at the same time, but analysis of the qualitative data was used to provide context and inform quantitative regression models and their interpretation. Qualitative analyses of open survey responses were exploratory and guided by the following questions: 1) what are the occupational situations in which healthcare workers incur moral injury? 2) what contextual or individual factors contribute to moral injury? and 3) how does moral injury impact healthcare organizations? In our analysis of quantitative survey data, we hypothesized that 1) working conditions which placed workers at greater risk of exposure to COVID-19 (e.g. working with COVID+ patients and not being provided adequate PPE) or 2) created internal conflict about one’s professional role, and 3) settings with more acuity (e.g. inpatient and group care), would be associated with higher moral injury.

Study design and population

The current study consisted of participants from three prospective cohorts: The Nurses’ Health Study II (NHS II), the Nurses’ Health Study 3 (NHS3), and the Growing Up Today Study (GUTS). NHS II is an ongoing cohort study of women, which enrolled 116,429 registered nurses aged 24–42 years residing in 14 US states in 1989. GUTS participants are offspring of NHS II participants and were between 9 and 17 years of age at recruitment in 1996 (N = 27,793), a subset of whom became healthcare workers. NHS3 is a currently recruiting cohort established in 2010 and originally enrolled female registered nurses, licensed practical/vocational nurses, or nursing students born on or after January 1, 1965, who were living in the US or Canada. Between April-August 2020, participants from these three cohorts who had completed the most recent cohort questionnaire were invited to complete an online COVID-19 mixed-method survey designed to examine experiences of participants (at time of survey not all participants worked in healthcare) during the pandemic [26,27]. Following this initial survey, respondents completed a series of follow-up questionnaires with the last quarterly questionnaire completed between March-October 2021. Our analytic sample was restricted to active healthcare workers (defined as professionals working in healthcare facilities where patients are being seen, including home health workers traveling to patient homes to see patients) who had answered the question about moral injury in the Month 1 survey. Although two of the cohorts enrolled registered nurses initially, not all participants continued to work as nurses, and there were several different types of healthcare provider roles represented among active healthcare workers. Our final quantitative analytic sample included 14,516 participants (53.4% (n = 7744) from NHSII, 41.2% (n = 5977) from NHS3, and 5.5% (795) from GUTS). The study protocols were approved by the Institutional Review Boards of the Brigham Women’s Hospital and Harvard Medical School and participant return of questionnaires implied informed consent, but written or verbal consent was not documented or witnessed. Please see S1 Fig for more detail on participant derivation for this study. Authors do not have permission to share data, which is managed by Channing Division of Network Medicine.

Qualitative data were extracted from an unprompted open comment box that appeared at the end of the section of survey questions focused on work (role conflict scale items, moral injury item). We randomly selected 100 participants who endorsed having experienced moral injury on the quantitative scale in the Month 1 survey and made a comment in the comment box to analyze. Five individuals were excluded because the content of their comment was not relevant to the current study (ex. comment included only a period). The qualitative analytic sample included 95 female participants.

Quantitative measurement

Quantitative analysis

To address our quantitative aims, we used multivariable logistic regression models with generalized estimating equations (GEE) to estimate the association between identified exposures and sociodemographic characteristics with reported moral injury. GEE is appropriate for non-normal data with binary outcomes and provides robust error variance. We first fitted unadjusted bivariate models and next fitted 3 models to identify the independent contributions of different work-related factors adjusted for age, sex, and racial identity: Model 1 assessed the effect of workplace setting; Model 2 assessed the effect of caring for COVID+ patients; Model 3 assessed the effect of adequate PPE. After qualitatively identifying the centrality of role conflict in PMIEs, we developed a fourth model with a modified role conflict score exposure. Our final fifth model included all four main exposure variables and adjusted for covariates. All analyses were conducted using SAS 9.4 with an α significance level p<0.05.

Qualitative analysis

Using open coding of a sample of written survey responses (n = 95) and a priori conceptualization of moral injury based upon common definitions in the literature [1,2,6], we developed a code book that contains codes pertaining to 1) descriptions of a potentially morally injurious event (PMIE) and 2) health and interpersonal consequences of PMIE. Codes for exposure to PMIEs included experiencing or witnessing the disturbing actions or inaction of the healthcare professional, healthcare leadership, patients, and people in participants’ larger social environments. Codes for consequences of PMIE exposure included mental health distress symptoms, health behavior changes, and physical health symptoms. All written responses were entered into NVivo12 (QSR International Pty Ltd.). Two trained qualitative researchers independently coded all 95 written records. Inter-rater reliability (IRR) was calculated after the first 25 records were independently double coded; Cohen’s kappa = 0.85 (considered excellent agreement; [36]). Following IRR evaluations, the coders made nominal adjustments to the codebook and continued coding the final 70 records. A third researcher then grouped and summarized data within and between codes to structure an immersion-crystallization approach [37] to identify themes and subthemes through which to understand moral injury experiences and consequences. A Total Worker Health^® theoretical framework was employed in this analysis phase to identify how factors both within and outside of the workplace shaped participants’ moral injury experiences [16,22].

Quantitative findings

Our full quantitative sample consisted of 14,516 individuals who had complete data on the moral injury question. Most identified as female (98.9%), with a mean (SD) age of 51.7 (12.7) years. Most participants identified as non-Hispanic White (96.1%). 50.0% reported working in an inpatient setting, 83.4% reported adequate PPE, and 9.9% reported experiencing moral injury at work since March 1, 2020. A summary of sociodemographic characteristics and work-related factors in our analytic sample is available in Table 1. Of note, at the final COVID-19 survey (approximately one year later) 42.2% of participants who reported moral injury in Month 1 (N = 1043) had quit or seriously considered quitting their job, compared to 21.0% of those who had not reported moral injury at Month 1.

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Table 1. Summary of sociodemographic and work-related factors in quantitative and qualitative samples.

https://doi.org/10.1371/journal.pone.0304620.t001

9.9% of participants reported experiencing moral injury. We conducted five multiple regression models. In each of our first four models, we focused on a specific work-related exposure and adjusted for potential confounders: age, racial identity, and sex. Our fifth and final model fully adjusted for all work-related exposures and covariates (see Table 2 for a summary). In our first multiple regression model (Model 1 in Table 2) we examined the relationship between workplace setting and moral injury. Compared to participants working in an inpatient hospital setting (50.0% of the sample), participants working in a group care setting had 41% higher odds of reporting moral injury (OR = 1.41 [95% CI 1.13, 1.76]). Participants working in an outpatient (OR = 0.63 [95% CI 0.56, 0.71]), school clinic (OR = 0.32 [95% CI 0.17, 0.58]) or home health setting (OR = 0.64 [95% CI 0.47, 0.88]) had significantly lower odds of reporting moral injury compared with participants working inpatient. In our second model (Model 2 in Table 2), we examined contact with COVID-19 positive patients as our main exposure. Working with confirmed COVID-19 (OR = 1.76 [95% CI 1.46, 2.11]) and presumed COVID patients (OR = 1.94 [95% CI 1.67, 2.25]), compared to not working with COVID+ patients, was associated with significantly higher odds of moral injury. In our third model (Model 3 in Table 2), we examined reported PPE adequacy. Participants with inadequate PPE were 2.5 times more likely to report moral injury (OR = 2.53 [95% CI 2.11, 3.03]). In Models 1–3 sex and racial identity were not associated with moral injury, but a protective effect was observed for older age; for every decade increase in age, the odds of moral injury decreased 16% (e.g. Model 1 OR = 0.84 [95% CI 0.80, 0.88]). In our fourth model participants with higher role conflict scores were at increased odds of reporting moral injury (OR = 1.60 [95% CI 1.56, 1.65]). In this model participants who identified as Black were at increased odds of reporting moral injury compared to white participants (OR = 1.91 [95% CI 1.16, 3.16]). The wide confidence interval for this odds ratio suggests a lack of precision, likely due to the small number of participants who identified as Black in the sample (1.1%, n = 163). Older age continued to have a protective effect, but it attenuated compared with previous models (OR = 0.91 [95% CI 0.87, 0.95]).

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Table 2. Summary of cross-sectional moral injury regression model results.

https://doi.org/10.1371/journal.pone.0304620.t002

Our final model (Model 5 in Table 2) adjusted for all four work-related exposures, and all four remained significantly associated with moral injury. Odds ratios attenuated for most exposures but remained statistically significant (Group Care Setting OR = 1.37 [1.07, 1.74], Outpatient Setting OR = 0.75 [0.65, 0.86], School Clinic Setting OR = 0.38 [0.19, 0.76], Confirmed COVID+ contact OR = 1.27 [1.04, 1.55], Presumed COVID+ contact OR = 1.25 [1.06, 1.48], PPE inadequacy OR = 1.55 [1.28, 1.88], Role Conflict OR = 1.58 [1.53, 1.62]). Home health setting, as compared to inpatient work setting was no longer associated with less risk of moral injury. Again, in this model we observed increased odds of moral injury among Black-identified participants compared to white counterparts (OR = 1.84 [95% CI 1.10, 3.09]) and a small protective effect of older age (OR = 0.93 [95% CI 0.89, 0.98] per decade).

To further assess the influence of the role conflict score, we conducted a supplementary analysis of individual items from the Role Conflict subscale of the Role Stressor Scale [29]. These items were significantly correlated with moral injury in descriptive analyses (see S1 Table). Endorsement of all four occupational conflict items were significantly associated with moral injury in a fully adjusted model. The results of this model are summarized in S2 Table.

Qualitative findings

The mean age of respondents in our qualitative sample was comparable to our quantitative sample: 52 years (SD = 11.3, range = 25–70 years). About half were from the NHSII cohort (56.8%; n = 54); 43.2% (n = 41) were from the NHS3 cohort. All identified as female and nearly all identified as non-Hispanic White (97.9%). Qualitative respondents more frequently reported working in an inpatient hospital setting (61.1% vs. 48.8%), worked with more presumed COVID+ patients (23.2% vs. 11.3%), and reported higher occupational role conflict scores (5.8 vs 3.3). Since the qualitative sample was identified based on high moral injury scores and these factors were related to moral injury in qualitative analysis, the high proportions observed in this subsample is expected.

Throughout written survey responses, participants with high moral injury quantitative scores described a variety of contributors to their experiences of work-related moral injury during the COVID-19 pandemic. Some of these contributors occurred externally to the workplace while others originated within the workplace. These contributors have been organized according to Total Worker Health^® constructs (socio-political contextual factors, workers’ life outside of work, workplace policies and practices, and working conditions) in Table 3 and evidenced with illustrative quotes.

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Table 3. Mapping total worker health^® constructs to moral injury themes.

https://doi.org/10.1371/journal.pone.0304620.t003

Many participants described how social and political contextual factors originating outside of the workplace interfaced with personal work experiences or sense of professional self to contribute to moral injury. Describing their efforts to combat COVID-19 at work while simultaneously witnessing nonchalance among the public, one participant wrote: “It’s a moral struggle to be trying to prevent illness at work and then sense all that work being undone when few people are wearing masks or distancing in the stores, and food service workers aren’t wearing masks when we pick up food.” Another participant noted the distress they experienced when an elected official contradicted public health experts: “I feel very stressed when our president does not defer to the educated experienced professionals who should be at the forefront of this pandemic.”

Participants also described how their homelife interacted with work responsibilities to contribute to internal conflict, conflicting demands, and moral injury. A number of participants described fears of accidentally exposing a loved-one to the virus as a result of their caring for COVID-19-positive patients at work. As one participant stated: “I deal with risking possible exposure and then coming home to my mom who is a high-risk individual.” Others described a sense of conflicting responsibility as a healthcare provider during a public health crisis and as a person with family responsibilities. One participant explained this internal conflict: “When I spoke of feeling the need to volunteer, they [children] were distraught, so I chose my children’s well-being over my guilt.”

Within the workplace, conflict between new COVID-related policies and practices, implementation and communication of these policies and practices, and prioritization of institutional finances over patient and worker health and wellbeing produced a variety of PMIEs for participants. Eight workplace policy and practice themes that contributed to participants’ experience of moral injury emerged in analyses (Table 3). Some participants reacted to what they perceived as poor decision-making by leadership, which appeared to prioritize financial gain over or patient and worker safety (e.g. “I have had unnecessary patient exposure due to financial interests of the hospital.”). Other participants wrestled with enforcing effective COVID-19 containment policies at the expense of their patients’ emotional wellbeing. For example, one participant shared: “It is necessary but terrible that we cannot have visitors with patients, that patients are suffering and dying without them.” Participants described feelings of distrust, neglect, and abandonment by organizational leaders during the pandemic and limited support for workers permeated many of workplace policy and practice themes. Participants often described how their employers minimized their needs as workers, reportedly “lied at times about the safety of [their] workplace,” or felt that leadership did not care about the emotional and physical hardship they experienced “beyond getting photo-ops and a happy blurb in the news about how amazing they’re being for their staff.” Several participants explicitly described fear of retaliation by leadership if they were to advocate for the health and safety of patients and workers. As one participant disclosed: “I almost filed an OSHA complaint, but I worry about the repercussions.”

Both material and psychosocial working conditions surfaced as contributors to morally injurious experiences. Numerous participants described staffing shortages driven by hiring and financial decisions of their organizations (not workforce shortages) and how this affected their ability to provide care. One participant succinctly stated: “They will not hire enough nurses to care for patients. They have actual beds.” Participants also noted that limited availability of clean and high-quality PPE affected their sense of safety. Similar to the workplace policy and practice themes, participants also reported feeling conflicted about how the implementation of COVID-19 safety precautions were often at odds with responding to patient needs. As one participant wrote: “I am forced to try to do psych assessments while at the med window. No quality care at all.” Participants also identified a variety of psychosocial working conditions that contributed to their moral injury, particularly witnessing or experiencing discrimination and unequal treatment of staff (e.g. “I saw first-hand also that physicians, nurses, technologists, housekeeping were treated differently.”); bullying by supervisors (e.g. “Our current and fairly new nursing supervisor is ex-army, a bully, who has threatened the nurses, and never lifts a finger to help out, even in an emergency or when short a nurse.”); and unrealistic expectations by superiors (e.g. “My level of burnout is more from lack of support and realistic expectation of my supervisor.”) Many of these working conditions can be described as PMIEs.

A Total Worker Health^® approach postulates that contextual factors, worker characteristics, worker health and well-being, workplace policy and practices, and working conditions coalesce to influence organizational outcomes, such as worker engagement, staffing turnover, and patient care (Fig 1). Analysis of participant responses yielded four themes indicating the impact of moral injury on worker engagement and staff turnover: 1) demoralization of workers who could not meet their own patient care standards; 2) emotional and physical exhaustion of workers contributed to an inability to complete tasks or be fully engaged; 3) workers choosing to leave their current jobs; and 4) workers choosing to leave direct patient care or healthcare workforce. Participants also described additional moral injury and emotional distress from witnessing or participating in what they considered to be poor or unethical patient care. That is, patient-related organizational outcomes seemed to contribute to additional moral injury. For example, one participant disclosed how they experienced “a lot of emotional distress relating to inequities in care that were deepened or laid bare by changes.” Three primary themes surfaced through analysis of patient care and outcomes statements: 1) perceived inability to intervene when witnessing poor care; 2) witnessing or participating in avoidable patient death; and 3) witnessing inequities in patient care. Additional illustrative quotes for each of these themes can be found in Table 4.

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Table 4. Bidirectional influence of organizational outcome themes and moral injury.

https://doi.org/10.1371/journal.pone.0304620.t004

Implications for future research and practice

Our qualitative findings provide an important reminder that healthcare workers have personal lives that cannot be divorced from their professional selves. While perhaps more pronounced during a global pandemic, healthcare is influenced by local and national social, political, and economic factors [40,41]. Our findings emphasize the importance of accounting for these extra-organizational factors when seeking to understand how moral injury—which would not have been observable using the available quantitative data by itself. Healthcare organizations must consider their workers as whole people and understand how personal lives intersect with work. It is in employers’ best interest to be concerned about and take steps to prevent moral injury among workers because it negatively impacts their organizational outcomes, including potentially reducing their workforce.

Strengths and limitations

The sequential mixed-method design of this study is a strength, as it brings together data from a large, well characterized cohort of healthcare workers into dialogue with a subset of these participants’ experiences shared in their own words during a critical period—the early months of the COVID-19 pandemic. Analyzed from a Total Worker Health^® perspective, our qualitative contextualization illustrated the interplay between factors external to the workplace and internal organizational factors on moral injury and also helped to inform and refine quantitative analytic models to investigate the specific contribution of role conflict. These data come from the beginning of the COVID-19 global pandemic, which provides insight into healthcare workers’ experiences at the onset of a public health crisis.

Our study also has several limitations to consider. While our sample was large, it was predominately white and female, and may not generalize to the experiences of all healthcare workers. Similarly, prior literature has revealed sex differences in moral injury and so our findings may not generalize to male healthcare workers [34]. Our quantitative analyses were cross-sectional, and so we were not able to assess the temporality of relationships between factors associated with moral injury. The unprompted comment box from which qualitative data were extracted appeared immediately following the quantitative survey questions about work conflict and moral injury. As we were interested in factors contributing to moral injury, we examined comments made by participants who had reported moral injury on the survey. However, this limits our insight into factors that may have been supportive or protective against moral injury at work. Additionally, analyzing qualitative comments from an unprompted comment box likely yielded different responses than more structured qualitative inquiries would, such as interviews or focus groups on these topics. Future work should consider comparing perspectives of workers with and without moral injury to identify potentially protective factors.