Skip to main content
SpringerLink
Log in

Healing the Healers: Addressing Moral Injury in Healthcare Workers During COVID-19

  • Chapter
  • First Online:
Integrity of Scientific Research

  • 759 Accesses

Abstract

Moral injury (MI) describes the intense feelings of shame, guilt, anger, and betrayal that individuals may experience after violating their own moral codes or witnessing the moral transgressions of others. While MI is not a diagnosable mental health disorder, it has been associated with elevated symptoms of depression and anxiety, suicidal ideation, and substance misuse. MI overlaps with some of the diagnostic properties of posttraumatic stress disorder (PTSD) but has been proposed as a distinct phenomenon. Originally identified in military contexts, moral injuries have also been observed in civilian populations. Healthcare workers (HCWs) are at risk of encountering potentially morally injurious events (PMIEs) in the workplace. During the COVID-19 crisis, HCWs forced to provide care with limited resources reported self-blame after losing patients and while fearful of infecting loved ones. As vaccine roll-out continues, it is essential that we encourage healing among the very population that serviced the ill in their time of need.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 129.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 169.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

References

  1. Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, Maguen S (2009) Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev 29:695–706

    Article  PubMed  Google Scholar 

  2. Currier JM, McCormick W, Drescher KD (2015) How do morally injurious events occur? A qualitative analysis of perspectives of veterans with PTSD. Traumatology 21:106–116

    Article  Google Scholar 

  3. Litz BT, Kerig PK (2019) Introduction to the special issue on moral injury: conceptual challenges, methodological issues, and clinical applications. J Trauma Stress 32:341–349

    Article  PubMed  Google Scholar 

  4. Shay J (2014) Moral injury. Psychoanal Psychol 31:182–191

    Article  Google Scholar 

  5. Jordan AH, Eisen E, Bolton E, Nash WP, Litz BT (2017) Distinguishing war-related PTSD resulting from perpetration- and betrayal-based morally injurious events. Psychol Trauma Theory Res Pract Policy 9:627–634

    Article  Google Scholar 

  6. Nash WP, Carper TLM, Mills MA, Au T, Goldsmith A, Litz BT (2013) Psychometric evaluation of the moral injury events scale. Mil Med 178:646–652

    Article  PubMed  Google Scholar 

  7. Nash WP, Litz BT (2013) Moral injury: a mechanism for war-related psychological trauma in military family members. Clin Child Fam Psychol Rev 16:365–375

    Article  PubMed  Google Scholar 

  8. Neria Y, Pickover A (2019) Commentary on the special issue on moral injury: advances, gaps in literature, and future directions. J Trauma Stress 32:459–464

    Article  PubMed  Google Scholar 

  9. Williamson V, Murphy D, Phelps A, Forbes D, Greenberg N (2021) Moral injury: the effect on mental health and implications for treatment. Lancet Psychiat 8(6):453–455

    Article  Google Scholar 

  10. Farnsworth JK, Drescher KD, Evans W, Walser RD (2017) A functional approach to understanding and treating military-related moral injury. J Contextual Behav Sci 6:391–397

    Article  Google Scholar 

  11. Wisco BE, Marx BP, May CL, Martini B, Krystal JH, Southwick SM, Pietrzak RH (2017) Moral injury in U.S. combat veterans: results from the national health and resilience in veterans study. Depress Anxiety. https://doi.org/10.1002/da.22614

  12. Levi-Belz Y, Greene T, Zerach G (2020) Associations between moral injury, PTSD clusters, and depression among Israeli veterans: a network approach. Eur J Psychotraumatol 11(1):1736411

    Article  PubMed  PubMed Central  Google Scholar 

  13. Killgore WDS, Cotting DI, Thomas JL, Cox AL, McGurk D, Vo AH, Castro CA, Hoge CW (2008) Post-combat invincibility: violent combat experiences are associated with increased risk-taking propensity following deployment. J Psychiatr Res 42:1112–1121

    Article  PubMed  Google Scholar 

  14. Griffin BJ, Purcell N, Burkman K, Litz BT, Bryan CJ, Schmitz M, Villierme C, Walsh J, Maguen S (2019) Moral injury: an integrative review. J Trauma Stress 32:350–362

    Article  PubMed  Google Scholar 

  15. Currier JM, McDermott RC, Farnsworth JK, Borges LM (2019) Temporal associations between moral injury and posttraumatic stress disorder symptom clusters in military veterans. J Trauma Stress 32:382–392

    Article  PubMed  Google Scholar 

  16. Currier JM, Foster JD, Isaak SL (2019) Moral injury and spiritual struggles in military veterans: a latent profile analysis. J Trauma Stress 32:393–404

    Article  PubMed  Google Scholar 

  17. Litz BT, Contractor AA, Rhodes C et al (2018) Distinct trauma types in military service members seeking treatment for posttraumatic stress disorder. J Trauma Stress 31:286–295

    Article  PubMed  Google Scholar 

  18. Bryan CJ, Bryan AO, Roberge E, Leifker FR, Rozek DC (2018) Moral injury, posttraumatic stress disorder, and suicidal behavior among National Guard personnel. Psychol Trauma Theory Res Pract Policy 10:36–45

    Article  Google Scholar 

  19. Maguen S, Metzler TJ, Bosch J, Marmar CR, Knight SJ, Neylan TC (2012) Killing in combat may be independently associated with suicidal ideation. Depress Anxiety 29:918–923

    Article  PubMed  PubMed Central  Google Scholar 

  20. Bryan CJ (2011) The clinical utility of a brief measure of perceived burdensomeness and thwarted belongingness for the detection of suicidal military personnel. J Clin Psychol 67:981–992

    Article  PubMed  Google Scholar 

  21. American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. https://doi.org/10.1176/appi.books.9780890425596

    Book  Google Scholar 

  22. Held P, Klassen BJ, Brennan MB, Zalta AK (2018) Using prolonged exposure and cognitive processing therapy to treat veterans with moral injury-based PTSD: two case examples. Cogn Behav Pract 25:377–390

    Article  PubMed  Google Scholar 

  23. Stein NR, Mills MA, Arditte K, Mendoza C, Borah AM, Resick PA, Litz BT (2012) A scheme for categorizing traumatic military events. Behav Modif 36:787–807

    Article  PubMed  Google Scholar 

  24. Barnes HA, Hurley RA, Taber KH (2019) Moral injury and PTSD: often co-occurring yet mechanistically different. J Neuropsychiatry Clin Neurosci 31:A4-103

    Article  PubMed  Google Scholar 

  25. Lancaster SL (2018) Negative outcomes after morally injurious experiences: a replication and extension. Psychol Trauma Theory Res Pract Policy 10:456–462

    Article  Google Scholar 

  26. Gray MJ, Schorr Y, Nash W, Lebowitz L, Amidon A, Lansing A, Maglione M, Lang AJ, Litz BT (2012) Adaptive disclosure: an open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries. Behav Ther 43:407–415

    Article  PubMed  Google Scholar 

  27. Affairs O of P and I VA releases 2020 National Veteran Suicide Prevention annual report. va.gov/opa/pressrel/pressrelease.cfm?id=5565. Accessed 25 May 2021

  28. Bryan CJ, Cukrowicz KC (2011) Associations between types of combat violence and the acquired capability for suicide. Suicide Life Threat Behav 41:126–136

    Article  PubMed  Google Scholar 

  29. Rice TR, Sher L (2013) Killing in combat and suicide risk. Eur Psychiatry 28:261–261

    Article  CAS  PubMed  Google Scholar 

  30. Hoge CW, Castro CA, Messer SC, Mcgurk D, Cotting DI, Koffman RL (2004) Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 351:13–22

    Article  CAS  PubMed  Google Scholar 

  31. Yeterian JD, Berke DS, Carney JR, McIntyre-Smith A, St Cyr K, King L, Kline NK, Phelps A, Litz BT, Members of the Moral Injury Outcomes Project Consortium (2019) Defining and measuring moral injury: rationale, design, and preliminary findings from the Moral Injury Outcome Scale Consortium. J Trauma Stress 32:363–372

    Article  PubMed  Google Scholar 

  32. Maguen S, Metzler TJ, Litz BT, Seal KH, Knight SJ, Marmar CR (2009) The impact of killing in war on mental health symptoms and related functioning. J Trauma Stress 22:435–443

    Article  PubMed  Google Scholar 

  33. Purcell N, Koenig CJ, Bosch J, Maguen S (2016) Veterans’ perspectives on the psychosocial impact of killing in war. Couns Psychol 44:1062–1099

    Article  Google Scholar 

  34. Stotz SJ, Elbert T, Müller V, Schauer M (2015) The relationship between trauma, shame, and guilt: findings from a community-based study of refugee minors in Germany. Eur J Psychotraumatol 6:25863

    Article  PubMed  Google Scholar 

  35. Hoffman J, Liddell B, Bryant RA, Nickerson A (2018) The relationship between moral injury appraisals, trauma exposure, and mental health in refugees. Depress Anxiety 35:1030–1039

    Article  PubMed  Google Scholar 

  36. Feinstein A, Pavisian B, Storm H (2018) Journalists covering the refugee and migration crisis are affected by moral injury not PTSD. JRSM Open 9:2054270418759010

    Article  PubMed  PubMed Central  Google Scholar 

  37. Weiss DS, Brunet A, Best SR, Metzler TJ, Liberman A, Pole N, Fagan JA, Marmar CR (2010) Frequency and severity approaches to indexing exposure to trauma: the critical incident history questionnaire for police officers. J Trauma Stress 23:734–743

    Article  PubMed  PubMed Central  Google Scholar 

  38. Komarovskaya I, Maguen S, McCaslin SE, Metzler TJ, Madan A, Brown AD, Galatzer-Levy IR, Henn-Haase C, Marmar CR (2011) The impact of killing and injuring others on mental health symptoms among police officers. J Psychiatr Res 45:1332–1336

    Article  PubMed  PubMed Central  Google Scholar 

  39. Papazoglou K, Blumberg DM, Chiongbian VB, Tuttle BM, Kamkar K, Chopko B, Milliard B, Aukhojee P, Koskelainen M (2020) The role of moral injury in PTSD among law enforcement officers: a brief report. Front Psychol 11:310

    Article  PubMed  PubMed Central  Google Scholar 

  40. Haight W (2017) Moral injury among Child Protection Professionals – implications for the ethical treatment and retention of workers. Child Youth Serv Rev 82:27–41

    Article  Google Scholar 

  41. Haight W, Sugrue E, Calhoun M, Black J (2017) Everyday coping with moral injury: the perspectives of professionals and parents involved with child protection services. Child Youth Serv Rev 82:108–121

    Article  Google Scholar 

  42. Haight W, Sugrue E, Calhoun M, Black J (2017) “Basically, I look at it like combat”: reflections on moral injury by parents involved with child protection services. Child Youth Serv Rev 82:477–489

    Article  Google Scholar 

  43. Levinson M (2015) Moral injury and the ethics of educational injustice. Harv Educ Rev 85:203–228

    Article  Google Scholar 

  44. Keefe-Perry LC (2018) Called into crucible: vocation and moral injury in U.S. public school teachers. Relig Educ 113:489–500

    Article  Google Scholar 

  45. Sugrue EP (2020) Moral injury among professionals in K–12 education. Am Educ Res J 57:43–68

    Article  Google Scholar 

  46. WHO Coronavirus (COVID-19) dashboard. covid19.who.int. Accessed 13 May 2021

    Google Scholar 

  47. Amsalem D, Dixon LB, Neria Y (2021) The coronavirus disease 2019 (COVID-19) outbreak and mental health: current risks and recommended actions. JAMA Psychiat 78:9

    Article  Google Scholar 

  48. Gao J, Zheng P, Jia Y, Chen H, Mao Y, Chen S, Wang Y, Fu H, Dai J (2020) Mental health problems and social media exposure during COVID-19 outbreak. PLoS One 15:e0231924

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  49. Watkins A, Rothfeld M, Rashbaum WK, Rosenthal BM (2020) Top E.R. doctor who treated virus patients dies by suicide. nytimes.com/2020/04/27/nyregion/new-york-city-doctor-suicide-coronavirus.html. Accessed 13 May 2021

  50. Tan BYQ, Chew NWS, Lee GKH et al (2020) Psychological impact of the COVID-19 pandemic on health care workers in Singapore. Ann Intern Med 173(4):317–320

    Article  PubMed  Google Scholar 

  51. Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P (2020) Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. Brain Behav Immun 88:901–907

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  52. Smith GB, Hukill E (1996) Nurses impaired by emotional and psychological dysfunction. J Am Psychiatr Nurses Assoc 2:192–200

    Article  Google Scholar 

  53. Brooks SK, Chalder T, Gerada C (2011) Doctors vulnerable to psychological distress and addictions: treatment from the Practitioner Health Programme. J Ment Health Abingdon Engl 20:157–164

    Article  Google Scholar 

  54. Sanchez M, Simon A, Ford D (2019) PTSD in Tx ICU nurses. J Heart Lung Transplant 38:S93–S94

    Article  Google Scholar 

  55. Lo D, Wu F, Chan M, Chu R, Li D (2018) A systematic review of burnout among doctors in China: a cultural perspective. Asia Pac Fam Med 17:3

    Article  PubMed  PubMed Central  Google Scholar 

  56. Chan AOM, Huak CY (2004) Psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in Singapore. Occup Med 54:190–196

    Article  Google Scholar 

  57. Matsuishi K, Kawazoe A, Imai H et al (2012) Psychological impact of the pandemic (H1N1) 2009 on general hospital workers in Kobe. Psychiatry Clin Neurosci 66:353–360

    Article  PubMed  Google Scholar 

  58. Maunder RG, Lancee WJ, Balderson KE et al (2006) Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerg Infect Dis 12:1924–1932

    Article  PubMed  PubMed Central  Google Scholar 

  59. Dean W, Talbot S, Dean A (2019) Reframing clinician distress: moral injury not burnout. Fed Pract 36:400–402

    PubMed  PubMed Central  Google Scholar 

  60. Borges LM, Barnes SM, Farnsworth JK, Bahraini NH, Brenner LA (2020) A commentary on moral injury among health care providers during the COVID-19 pandemic. Psychol Trauma Theory Res Pract Policy 12:S138–S140

    Article  Google Scholar 

  61. Shortland N, McGarry P, Merizalde J (2020) Moral medical decision-making: colliding sacred values in response to COVID-19 pandemic. Psychol Trauma Theory Res Pract Policy 12:S128–S130

    Article  Google Scholar 

  62. Young KP, Kolcz DL, O’Sullivan DM, Ferrand J, Fried J, Robinson K (2020) Health care workers’ mental health and quality of life during COVID-19: results from a mid-pandemic, national survey. Psychiatr Serv 72:122–128

    Article  PubMed  Google Scholar 

  63. Maguen S, Price MA (2020) Moral injury in the wake of coronavirus: attending to the psychological impact of the pandemic. Psychol Trauma Theory Res Pract Policy 12:S131–S132

    Article  Google Scholar 

  64. Horsch A, Lalor J, Downe S (2020) Moral and mental health challenges faced by maternity staff during the COVID-19 pandemic. Psychol Trauma Theory Res Pract Policy 12:S141–S142

    Article  Google Scholar 

  65. Greenberg N, Docherty M, Gnanapragasam S, Wessely S (2020) Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ 368:m1211

    Article  PubMed  Google Scholar 

  66. Stovall M, Hansen L, van Ryn M (2020) A critical review: moral injury in nurses in the aftermath of a patient safety incident. J Nurs Scholarsh Off Publ Sigma Theta Tau Int Honor Soc Nurs 52:320–328

    Google Scholar 

  67. Gibbons SW, Shafer M, Hickling EJ, Ramsey G (2013) How do deployed health care providers experience moral injury? Narrat Inq Bioeth 3:247–259

    Article  PubMed  Google Scholar 

  68. Amsalem D, Lazarov A, Markowitz JC, Naiman A, Thomas ES, Lisa BD, Neria Y (2021) Psychiatric symptoms and moral injury among US healthcare workers in the COVID-19 era. BMC Psychiatry:1–8

    Google Scholar 

  69. Williamson V, Murphy D, Greenberg N (2020) COVID-19 and experiences of moral injury in front-line key workers. Occup Med 70:317–319

    Article  Google Scholar 

  70. Amsalem D, Lazarov A, Markowitz JC, Smith TE, Dixon LB, Neria Y (2021) Video intervention to increase treatment-seeking by healthcare workers during the COVID-19 pandemic: randomised controlled trial. Br J Psychiatry:1–7

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Psychiatry and New York State Psychiatric Institute, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA

    Aliza Naiman, Doron Amsalem, Maja Bergman & Yuval Neria

  2. Department of Epidemiology, Columbia University Irving Medical Center, New York, NY, USA

    Yuval Neria

Authors
  1. Aliza Naiman
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Doron Amsalem
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Maja Bergman
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Yuval Neria
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Yuval Neria .

Editor information

Editors and Affiliations

  1. Hospital das Clinicas, University of Sao Paulo, Sao Paulo, São Paulo, Brazil

    Joel Faintuch

  2. Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA

    Salomão Faintuch

Rights and permissions

Reprints and permissions

Copyright information

© 2022 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Naiman, A., Amsalem, D., Bergman, M., Neria, Y. (2022). Healing the Healers: Addressing Moral Injury in Healthcare Workers During COVID-19. In: Faintuch, J., Faintuch, S. (eds) Integrity of Scientific Research. Springer, Cham. https://doi.org/10.1007/978-3-030-99680-2_29

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-99680-2_29

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-99679-6

  • Online ISBN: 978-3-030-99680-2

  • eBook Packages: Social SciencesSocial Sciences (R0)

Publish with us

Policies and ethics

Search

Navigation