How should we cope with our moral injuries?
As healthcare professionals working during the COVID-19 pandemic, we are at high risk of being affected by moral injuries, whether we deal directly with patients infected by the coronavirus or not.
That is a simple and indisputable fact.
There are many situations that create moral injury during this pandemic. Telling family members that they cannot visit critically ill loved ones. Delaying code activities, even momentarily, to get fully protected with PPE. Seeing patients who have delayed their necessary or preventive care. Using video rather than touch to reassure people.
Knowing that we are following CDC guidelines, does not stop our feelings of guilt. The longer this pandemic goes on the more likely it is that these situations will begin to take a toll on us. At least we can be grateful that UC Davis Health has been much better prepared and resourced than so many other systems we see around the country on the nightly news.
For most of us, being exposed to so many moral injuries is new. Moral injuries have historically been associated with wartime experiences, although some have said that they are contributors to burnout. Whatever the history, moral injuries affect most of us, and our colleagues and families, during this unusual, painful and difficult time.
A time when our lives are altered significantly, and for many have been completely turned upside down.
When many are making enormous sacrifices. And suffering tragic losses.
When we observe others daily on the news ignoring the reality of the pandemic.
But what do I mean by a moral injury?
Most of us have felt the symptoms. Frustration. Anger. Disgust. Guilt.
This injury is very real. It is the psychological, social and spiritual impact of events, such as the pandemic, which leads to the betrayal or transgression of our own deeply held moral beliefs and values in high stakes situations.
In COVID-19, there are three levels of examples described in detail in
Moral Stress Amongst Healthcare Workers During COVID-19: A Guide to Moral Injury:
- Severe moral stressors – such as the denial of treatment to a COVID-19 patient due to lack of resources (as occurred in Italy), the inability to provide optimal care to non-COVID-19 patients for many reasons, and concerns about passing COVID-19 to loved ones.
- Moderate moral stressors – such as preventing visitors, especially to dying patients, triaging patients for healthcare services with inadequate information, and trying to solve the tension between the need for self-preservation and the need for treatment.
- Lower level but common moral challenges, especially in the community – seeing others not protecting the community by hoarding food, partying, not social distancing or not wearing masks. Such stressors lead to frustration and contempt, especially from those who are making personal sacrifices such as healthcare workers.
Every one of us is affected by these stressors.
I certainly am.
So, what are the outcomes?
We know that moral injuries are a risk factor for the development of mental health problems and burnout, and not surprisingly we know that mental health problems, suicidality and substance use disorders have increased markedly during COVID-19 as detailed by the Centers for Disease Control and Prevention (CDC)
Morbidity and Mortality Weekly Report (MMWR) dated August 14, 2020.
Common emotions that occur in response to moral injuries are:
- feelings of guilt, shame, anger, sadness, anxiety and disgust.
- intrapersonal outcomes including lowered self-esteem, high self-criticism, beliefs about being bad, damaged, unworthy, failing or weak.
- interpersonal outcomes including loss of faith in people, avoidance of intimacy and lack of trust in authority figures.
- existential and spiritual outcomes including loss of faith in previous religious beliefs, and no longer believing in a just world.
This issue affects us all, as healthcare workers.
But there are things we can do.
We are not helpless. I suggest:
- Acknowledge that you, like me, are affected by these stressors. This is not a secret and you should not be ashamed of your feelings.
- Talk with your colleagues, your loved ones and your friends about how you, and they, are affected. You are not alone. Encourage others to share their thoughts, stories and feelings.
- Put this topic on your meeting and departmental agendas and discuss these moral issues openly with your colleagues. Allow sufficient time to engage in open dialogue.
- Work out ways of assisting those who are in high risk situations, especially for the severe and moderate level injuries. Be supportive towards those affected.
- Modify policies and change rosters and rotate staff between high and low stress roles. Protect and support at risk colleagues.
- Think about difficult ethical decisions in advance so they can be made by groups, not individuals, and certainly not “on the fly.”
- Keep everyone constantly informed, especially of impending staff or equipment shortages.
- Maintain your inherent self-care and resilience with rest, good nutrition, sleep, exercise, love, caring, socialization and work-life balance
- Access the many professional and peer support services available at the UC Davis Health Clinician Health and Well being website; if you are intensely distressed or if the above suggestions are not enough.
Remember, we are in this together and will find strength in each other. This too will pass.