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Healthcare Workers and COVID-19-Related Moral Injury: An Interpersonally-Focused Approach Informed by PTSD

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Healthcare Workers and COVID-19-Related Moral Injury: An Interpersonally-Focused Approach Informed by PTSD

Abstract

The COVID-19 pandemic has resulted in a still-unfolding series of novel, potentially traumatic moral and ethical challenges that place many healthcare workers at risk of developing moral injury. Moral injury is a type of psychological response that may arise when one transgresses or witnesses another transgress deeply held moral values, or when one feels that an individual or institution that has a duty to provide care has failed to do so. Despite knowledge of this widespread exposure, to date, empirical data are scarce as to how to prevent and, where necessary, treat COVID-19-related moral injury in healthcare workers. Given the relation between moral injury and post-traumatic stress disorder (PTSD), we point here to social and interpersonal factors as critical moderators of PTSD symptomology and consider how this knowledge may translate to interventions for COVID-19-related moral injury. Specifically, we first review alterations in social cognitive functioning observed among individuals with PTSD that may give rise to interpersonal difficulties. Drawing on Nietlisbach and Maercker's 2009 work on interpersonal factors relevant to survivors of trauma with PTSD, we then review the role of perceived social support, social acknowledgment and social exclusion in relation to potential areas of targeted intervention for COVID-19-related moral injury in healthcare workers. Finally, building on existing literature (e.g., Phoenix Australia—Centre for Posttraumatic Mental Health and the Canadian Centre of Excellence—PTSD, 2020) we conclude with individual and organizational considerations to bolster against the development of moral injury in healthcare workers during the pandemic.
REVIEW
published: 14 February 2022
doi: 10.3389/fpsyt.2021.784523
Frontiers in Psychiatry | www.frontiersin.org 1February 2022 | Volume 12 | Article 784523
Edited by:
Rosalba Morese,
University of Italian
Switzerland, Switzerland
Reviewed by:
Agata Benfante,
University of Turin, Italy
Hannah Murray,
University of Oxford, United Kingdom
*Correspondence:
Margaret C. McKinnon
mckinno@mcmaster.ca
Specialty section:
This article was submitted to
Social Cognition,
a section of the journal
Frontiers in Psychiatry
Received: 28 September 2021
Accepted: 29 December 2021
Published: 14 February 2022
Citation:
D’Alessandro AM, Ritchie K,
McCabe RE, Lanius RA, Heber A,
Smith P, Malain A, Schielke H,
O’Connor C, Hosseiny F, Rodrigues S
and McKinnon MC (2022) Healthcare
Workers and COVID-19-Related Moral
Injury: An Interpersonally-Focused
Approach Informed by PTSD.
Front. Psychiatry 12:784523.
doi: 10.3389/fpsyt.2021.784523
Healthcare Workers and
COVID-19-Related Moral Injury: An
Interpersonally-Focused Approach
Informed by PTSD
Andrea M. D’Alessandro 1, Kimberly Ritchie 2, Randi E. McCabe 2,3, Ruth A. Lanius 4, 5,6,7 ,
Alexandra Heber 8,9 , Patrick Smith 10,11, Ann Malain 12 , Hugo Schielke 12,
Charlene O’Connor 12, Fardous Hosseiny 10, 11, Sara Rodrigues 10,11 and
Margaret C. McKinnon 2,5,13
*
1Neuroscience Graduate Program, McMaster University, Hamilton, ON, Canada, 2Department of Psychiatry and Behavioral
Neurosciences, McMaster University, Hamilton, ON, Canada, 3Anxiety Treatment and Research Clinic, St. Joseph’s
Healthcare Hamilton, Hamilton, ON, Canada, 4Department of Psychiatry, University of Western, London, ON, Canada,
5Homewood Research Institute, Guelph, ON, Canada, 6Imaging Division, Lawson Health Research Institute, London, ON,
Canada, 7Department of Neuroscience, Western University, London, ON, Canada, 8Veterans Affairs Canada, Ottawa, ON,
Canada, 9Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada, 10 Centre of Excellence on Post-Traumatic
Stress Disorder, Ottawa, ON, Canada, 11 University of Ottawa Institute of Mental Health Research at the Royal, Ottawa, ON,
Canada, 12 Homewood Health Centre, Guelph, ON, Canada, 13 Mental Health and Addictions Program, St. Joseph’s
Healthcare, Hamilton, ON, Canada
The COVID-19 pandemic has resulted in a still-unfolding series of novel, potentially
traumatic moral and ethical challenges that place many healthcare workers at risk of
developing moral injury. Moral injury is a type of psychological response that may arise
when one transgresses or witnesses another transgress deeply held moral values, or
when one feels that an individual or institution that has a duty to provide care has failed
to do so. Despite knowledge of this widespread exposure, to date, empirical data are
scarce as to how to prevent and, where necessary, treat COVID-19-related moral injury
in healthcare workers. Given the relation between moral injury and post-traumatic stress
disorder (PTSD), we point here to social and interpersonal factors as critical moderators of
PTSD symptomology and consider how this knowledge may translate to interventions for
COVID-19-related moral injury. Specifically, we first review alterations in social cognitive
functioning observed among individuals with PTSD that may give rise to interpersonal
difficulties. Drawing on Nietlisbach and Maercker’s 2009 work on interpersonal factors
relevant to survivors of trauma with PTSD, we then review the role of perceived social
support, social acknowledgment and social exclusion in relation to potential areas of
targeted intervention for COVID-19-related moral injury in healthcare workers. Finally,
building on existing literature (e.g., Phoenix Australia—Centre for Posttraumatic Mental
Health and the Canadian Centre of Excellence—PTSD, 2020) we conclude with individual
and organizational considerations to bolster against the development of moral injury in
healthcare workers during the pandemic.
Keywords: moral injury, post-traumatic stress disorder, healthcare workers, COVID-19, interpersonal factors,
social cognition
D’Alessandro et al. Healthcare Workers and Moral Injury
INTRODUCTION
Healthcare workers around the globe are facing a series of novel,
potentially traumatic moral and ethical challenges during the
COVID-19 pandemic. In interviews with Canadian healthcare
workers that our research group has been conducting throughout
2021, for example, healthcare workers have recounted repeatedly
struggling with how wrong it feels to helplessly witness the
deterioration of human life when caring for critically ill COVID-
positive patients (see Figure 1 for a sample vignette of healthcare
workers’ experiences with moral injury). Exposure to such events
has the potential to place healthcare workers at an elevated risk
for moral injury. Moral injury is a form of psychological response
that may arise when one transgresses, or witnesses another
transgress, deeply held moral values, or when one feels that an
individual or institution that has a duty to provide care has failed
to do so (1,2). Moral injury is associated with negative mental
health outcomes, such as incapacitating feelings of guilt and
shame (3) and elevated symptoms of anxiety (4,5), depression
(68), post-traumatic stress disorder (PTSD) (4,5,912) and
suicidality (1214). Despite widespread exposure during the
COVID-19 pandemic, limited empirical data renders it unclear
at present how best to prevent and, where necessary, treat moral
injury in healthcare workers during the pandemic, particularly
among those who go on to develop full-blown mental illness as a
result of this exposure.
A growing body of literature points to a relation between
moral injury and PTSD (reviewed below), suggesting that
knowledge in the field of PTSD may translate well to prevention
of and intervention for moral injury. Here, an understanding of
alterations in social cognitive functioning (e.g., empathy, moral
reasoning, theory of mind) associated with PTSD (15) may
assist in better elucidating the role of interpersonal factors (e.g.,
social support, acknowledgment and exclusion) in moderating
PTSD symptomology (16). These disruptions are of particular
concern where an overwhelming body of evidence points to
social support as a consistently strong predictor of who develops
PTSD following trauma exposure (1722), such as the exposures
associated with the current pandemic.
Given evidence pointing toward the role of interpersonal
factors in moderating symptoms of PTSD, along with the
relation between PTSD and moral injury, we suggest here
that an interpersonally-focused approach may serve as a useful
starting point for prevention, early intervention, and treatment
strategies for COVID-19-related moral injury in healthcare
workers. Accordingly, the purpose of the present narrative review
is to illustrate the potential utility of an interpersonally-focused
approach focusing on the role of perceived social support,
social acknowledgment and social exclusion as key targets in
understanding and mitigating COVID-19-related moral injury
in healthcare workers. In this synthesis of the relevant literature,
we first review social cognitive impairments previously observed
in PTSD that may be associated with interpersonal difficulties.
We next consider Nietlisbach and Maercker’s (16) landmark
review of the role of social support, social acknowledgment
and social exclusion in the development and maintenance of
PTSD symptoms and consider these factors in relation to
moral injury among healthcare workers during the COVID-19
pandemic. Finally, we summarize individual and organizational
considerations for bolstering against the development of moral
injury among healthcare workers during and after the pandemic.
Moral Injury in Healthcare Workers
Moral Injury and Moral Distress
The potentially traumatic moral and ethical challenges that
healthcare workers face in their occupation were first addressed
in the moral distress literature. Moral distress has been
conceptualized as the psychological distress that arises when
a healthcare worker is prevented, by personal or institutional
constraints, from doing what they believe to be right (e.g.,
witnessing the deterioration of patient care due to institutional
factors or a lack of communication) (23,24). Moral distress is
associated with poor self-esteem, low job satisfaction, burnout
and intention to leave one’s position or profession (2325).
Relatedly, moral injury, as reviewed above, has been defined
as a type of psychological response to trauma that may arise
from exposure to a single or several potentially morally injurious
events (PMIEs): rarely occurring, abnormally stressing, high-
stakes situations with limited time for decision making (3,26).
Although a concrete definition has yet to be established, Litz et al.
(10) contend that PMIEs can take several forms, including acting
in ways that contravene moral values (i.e., acts of commission),
failing to prevent events that transgress moral values (i.e., acts
of omission), or witnessing someone else fail to act in line
with moral values (10). Following this definition, PMIEs may
be discussed as perpetration- and/or betrayal-based, where an
individual holds perceived responsibility for a PMIE (e.g., by
acting or failing to act), or has witnessed/been affected by the
actions or inactions of others, respectively (11). Morally injurious
outcomes will vary on an individual basis according to the
codes of moral conduct in one’s culture and one’s personal
values, yet the sequelae of moral injury, as reported in a
recent integrative review, often include widespread effects in
psychological/behavioral, social, religious/spiritual and biological
domains (11). Following Litz and Kerig’s heuristic continuum of
moral injury (2), moral distress and moral injury may differ in
frequency and event magnitude, where moral distress, although
harmful, is believed to be less severe in degree of psychological
impact when compared to moral injury (2). Due to its origin
in the military literature, empirical research on healthcare
workers’ experiences with moral injury is limited in comparison
to research on moral distress among this population. Indeed,
in a recent scoping review, Cartolovni et al. (27) identified
just seven articles examining moral injury among healthcare
workers. Given the unique moral and ethical challenges present
in the healthcare arena, exacerbated further by the COVID-
19 pandemic, research in this area appears to be accelerating,
with some researchers using moral injury and moral distress
as interchangeable terms in healthcare during the COVID-19
pandemic (28).
COVID-19-Related Moral Injury in Healthcare Workers
Healthcare workers may be at an elevated risk for moral
injury during the COVID-19 pandemic as they are more
likely to be exposed to PMIEs at this time than, for example,
civilians. Possible PMIEs discussed within the healthcare context
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D’Alessandro et al. Healthcare Workers and Moral Injury
FIGURE 1 | In an ongoing study in our research group, healthcare workers from across Canada have described various events which may be experienced as morally
injurious. This vignette provides a summary of the types of events we have heard about from Canadian respiratory therapists early in the Spring of 2021. Participants
recounted instances of having to perform care that was perceived to be futile, feeling helpless when caring for critically-ill COVID-positive patients and being at the
beside of dying COVID-positive patients in place of their family members, who were prohibited from entering the hospital due to COVID restrictions. Additional
stressors compacting upon these potentially morally injurious events included having no time to process events, rushing to change PPE and a high patient caseload.
during COVID-19 include having to take potentially life-saving
resources from one patient in an attempt to save another patient’s
life, exposing individuals to the coronavirus because of failure
in the screening process, witnessing healthcare managers poorly
ration life-saving resources, or witnessing people living life
unbothered outside of the hospital (26,29). Indeed, preliminary
findings from ongoing research in our group have revealed
that Canadian respiratory therapists experienced intubating and
proning patients over 90 years of age and “holding an infant
while he passed away because COVID rules would not allow
his mother in the room” as PMIEs. Critically, as the pandemic
persists, moral injury and other mental health concerns are
expected to remain, if not increase. Hines et al. (30) reported that
healthcare workers in the United States showed stable symptoms
of moral injury across the first 3 months of the pandemic (i.e.,
March to July 2020), occurring at levels similar to reports from
military veterans upon return from deployment (31). Similarly to
military populations, moral injury in healthcare workers during
the pandemic has been associated with anxiety, depression, PTSD
and suicidal ideation (32). Some caution is warranted in the
interpretation of these findings, however, as moral injury is a
relatively recent concept in the healthcare context and, to date,
the clinical and research communities have not identified a
highly-reliable, psychometrically-validated measurement tool for
common use in this population.
Notably, as moral injury has been related to
psychological/behavioral, social, religious/spiritual and biological
harm (11), outcomes of moral injury among healthcare workers
performing their duties during the COVID-19 pandemic may
also vary across these domains. For example, in the case of a
respiratory therapist comforting a dying infant in place of his
mother, the respiratory therapist may experience impairing
moral emotions of guilt, shame, anger or betrayal. The distress
associated with this experience may, in turn, lead the respiratory
therapist to withdraw from others, question prior beliefs of
the world as a just place or experience a spiritual/existential
crisis (11). Exposure to this event may be associated with
physical manifestations such as decreased sensitivity to pain
or stress-related illnesses, such as arthritis and PTSD, as found
in prior research on outcomes of exposure to PMIEs (33,34).
Furthermore, exposure to these types of events may be associated
with a sense of being “dirty” or shameful, thus contributing to
a sense of being undeserving. Relatedly, such feelings of being
“undeserving” have been recounted by healthcare workers in
our research group’s ongoing interviews during the COVID-19
pandemic where healthcare workers have shared that these
feelings have limited their efforts to seek appropriate physical or
mental healthcare and/or take breaks and rest periods from the
healthcare environment.
Moral Injury and PTSD
Moral injury and PTSD are currently thought to be associated
yet distinct concepts based on symptomology and etiology (9,
11). Both moral injury and PTSD are stressor-linked problems
where the outcome is identified after evidence of a prolonged
emotional response from exposure to a potentially traumatic
or morally injurious event (2). To date, whereas PTSD is
considered a mental disorder, moral injury is not (5,35).
There is some evidence to suggest, however, that moral injury
and PTSD are associated by symptomology. Based on research
with military service members, Litz et al. (10) developed a
conceptual model of moral injury that accounts for intersecting
symptoms of PTSD and moral injury. In this model, individuals
who experience distress over a moral transgression and hold
global, internal and stable (i.e., not context dependent, specific
to the individual and enduring) attributions about the event
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D’Alessandro et al. Healthcare Workers and Moral Injury
are posited to experience enduring shame, guilt and anxiety,
which may influence the individual to socially withdraw. With
social withdrawal comes failure to encounter experiences with
important members of one’s community that may otherwise have
provided alternative attributions that cultivate self-forgiveness.
Here, Litz et al. (10) contend that the path following internal
moral conflict, withdrawal and self-condemnation resembles
PTSD symptomology. Indeed, chronic intrusions of the morally
transgressive event, avoidance behaviors, numbing, self-harming
or self-handicapping and demoralization are expected here and,
critically, are also classic experiences indicative of PTSD (10,36).
Conversely, Bryan et al. (12) found evidence of distinct
symptom profiles between moral injury and PTSD in a sample of
American military personnel. In this study, the PTSD symptom
profile included an exaggerated startle reflex, memory loss,
flashbacks, nightmares and insomnia, whereas the moral injury
symptom profile included guilt, shame, anger, anhedonia and
social alienation (12). A distinction between moral injury and
PTSD is further supported by etiology, where PTSD has been
defined as a response after exposure to direct or indirect life
threat or sexual violence (9), but such criteria is not necessary
for PMIEs, which are characterized by moral transgressions or
betrayal from leadership (10). Furthermore, Currier et al. (33)
highlighted how the function of symptoms consistent between
PTSD and moral injury may be related to different motivations
in some cases. For example, whereas some individuals with PTSD
may engage in avoidance behaviors related to fear and safety
concerns, some individuals with moral injury may engage in
avoidance behaviors motivated by shame and a perception that
they may morally contaminate others (33). Although further
research on the relationship between moral injury and PTSD is
needed, they are currently thought of as associated yet distinct
traumatic responses (9,11).
Given the relation between moral injury and PTSD, it has
been suggested that some evidenced-based psychotherapies for
PTSD may prove useful in treating moral injury (9,37). Here, the
majority of research and clinical work centred on the treatment
of moral injury focuses primarily on military populations (38
41). For example, prolonged exposure therapy and cognitive
processing therapy for PTSD have been proposed for treating
moral injury in military samples (35,38,42). Murray and
Ehlers (35), however, recently discussed the use of cognitive
therapy for PTSD (CT-PTSD) for moral injury-related PTSD
(i.e., PTSD related to traumatic events including a PMIE),
providing a case outline and example of the use of CT-PTSD in a
healthcare population. As treatment for moral injury continues
to be explored, it will be essential that PTSD treatments be
strategically adapted to target symptoms specific to moral injury
[e.g., dissonance that arises from the discrepancy between moral
beliefs and perpetrations/witnessed events, impairing guilt and
shame; (10,12)].
Social Cognition and PTSD
Alterations in social cognitive functioning have been
documented among survivors of trauma who went on to develop
a diagnosis of PTSD (1517,4345). Nietlisbach and Maercker
(16) previously reviewed evidence for a relation between
PTSD and impairments in social cognition and associated
interpersonal factors (e.g., social support, acknowledgment and
exclusion). Social cognition has been defined as “the ability to
use, encode and store information about others that we gain
from social interactions” (40). Specifically, social cognition is
the coordination of several modes of cognition (e.g., attention,
perception, interpretation and processing) in a social context
that allows one to perceive and interpret social cues to direct
their behavior (41,46). There are four classic domains of social
cognition, namely, theory of mind (ToM), social perception,
affective empathy and social behavior (15). ToM refers to the
ability to draw on knowledge of how the mind works and of
social rules to understand the mental states and beliefs of others
(15). ToM can be subdivided into a cognitive component (i.e.,
what others are thinking) and an affective component (i.e., what
others are feeling) (15). Social perception is a domain of social
cognition concerned with the ability to recognize and perceive
emotional stimuli such as facial expressions, body language or
prosody, whereas affective empathy refers to one’s emotional
response to social situations (15). Finally, social behavior refers
to the ways in which an individual conducts themselves in a
social context. Alterations in any one of ToM, social perception
or affective empathy may lead to deficits in social behavior where
an individual displays aggression or socially withdraws (15).
A recently published systematic review of social cognition in
PTSD found that social cognition is altered in individuals with
PTSD as they display significant impairments in predicting the
internal states of others, alterations in perceiving basic emotions
and disturbances in empathy (15). In a study investigating
emotion recognition and ToM among military police officers
exposed to trauma, Mazza et al. (17) found that those with
PTSD, in comparison to their counterparts without PTSD,
showed deficits in ToM on a task where they were instructed
to identify the emotions of a protagonist in a short story. Poljac
et al. (44) examined emotion recognition in PTSD patients and
controls when viewing video clips of an individual displaying
basic emotions. The PTSD group displayed reduced accuracy and
sensitivity to facial expressions of fear and sadness in comparison
to controls (44). Relatedly, Parlar et al. (47) examined empathic
responding among women with PTSD related to childhood
trauma. Results of this investigation revealed altered empathic
responding in this population, such that women with PTSD
showed impairments in identifying the perspective of others
when compared to healthy controls (47). Interestingly, however,
women with PTSD in this study reported greater levels of
personal distress than controls when learning about the negative
experiences of others (47). Nazarov et al. (43) examined moral
reasoning among women with PTSD related to chronic abuse
in childhood and found evidence of altered moral reasoning
among these women in comparison to healthy, matched controls.
Participants in this study were presented with complex moral
situations and were asked to provide a response and justification
for their decisions to these dilemmas. The results of this
investigation revealed that women with PTSD related to chronic
childhood abuse were less likely than controls to approve of
utilitarian decisions if the decision involved personally inflicting
direct physical harm driven by concern over feelings of guilt and
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D’Alessandro et al. Healthcare Workers and Moral Injury
shame associated with these actions (43). Finally, Sherman et al.
(45) examined veteran’s perceptions of the impact that PTSD had
on their parenting, on their children and on the parent-child
relationship. More than half of the sample scored above the cut-
off on the reactivity subscale of the Parenting Scale, suggestive of
alterations in social behavior related to PTSD (45). Cumulatively,
the evidence on deficits in key domains of social cognition (i.e.,
ToM, social perception, affective empathy and social behavior)
among individuals with PTSD are related to outcomes of poor
quality of life (15). This evidence warrants, in part, the necessity
of interpersonally-focused interventions for survivors of trauma
with PTSD.
Here, we explore the utility of a social cognitive approach to
understanding, mitigating and treating moral injury in healthcare
workers during the COVID-19 pandemic. While not intended
to be a stand-alone approach to treatment of moral injury in
the healthcare population, this perspective may prove useful
to the development and implementation of prevention, early
intervention and targeted intervention strategies surrounding
moral injury in this vital workforce. In a study investigating the
relation between moral injury and PTSD among a sample of U.S.
National Guard personnel, Bryan et al. (12) noted that a social-
cognitive perspective may be a useful approach to understanding
moral injury. Social cognitive theory accounts for different
types of emotions: natural and manufactured (12,42). Natural
emotions include fear, anxiety and sadness as they are natural
responses to direct trauma exposure. By contrast, manufactured
emotions are those that arise from an individual’s processing
and interpretation of events as opposed to the event itself and
include feelings of guilt and shame (12,42). Targeting healthcare
workers’ interpretation and processing of events during the
pandemic, thus, may be one mechanism through which to buffer
against the deleterious impacts of guilt and shame related to
moral injury. As interpersonal factors such as social support,
acknowledgment and inclusion are mediators of PTSD symptom
development and maintenance (16), we argue further that an
interpersonally-focused approach to moral injury may prove a
useful starting point to address COVID-19-related moral injury
among healthcare workers.
Importantly, evidence-based treatments for PTSD should
always be provided where necessary. The International Society
for Traumatic Stress Studies offers guidelines for the prevention
and treatment of PTSD, including the use of cognitive behavioral
therapy and eye movement desensitization and reprocessing
(48). Beyond evidence-based treatments for PTSD that may
be adapted for moral injury, a social cognitive approach may
be promising, while in need of future study. Notably, this
approach relies heavily on a top-down, cognitively oriented
approach to the treatment of moral injury. We wish to be
clear here that we believe such approaches may, in some
cases, require augmentation with more bottom-up therapies
that target raw emotion and alterations in somatosensory
processes that are also characteristic of PTSD [please see
Harricharan et al. (39) for a recent review] (49). An additional
caveat to the discussion that follows is that the targeted
treatment approach described does not distinguish between
dissociative and non-dissociative presentations of PTSD (5052).
Such work, focusing on neuroscientifically-guided approaches
to restoration of lower-brain based alterations in emotional
processing and somatosensory integration [e.g., deep-brain re-
orienting; (53,54)] as potential augmentative treatments for
moral injury are on-going in our research group, as are
efforts to develop therapeutic approaches for the treatment of
moral injury that distinguish between the dissociative and non-
dissociative presentations of PTSD. Lloyd et al. (83) recently
demonstrated alterations in top-down control of emotional
affect among military and paramilitary personnel with PTSD.
Specifically, participants with PTSD described a “nauseating
and painful, like an internal gnawing sensation (p. 601)” when
recalling morally injurious events, which was thought to be
linked to increased activation of the posterior insula and
its connections to the viscera. The authors postulated that
unpleasant visceral sensations aroused when recalling morally
injurious events may, in turn, lead to increased activation
of modulating brain areas such as the dorsolateral prefrontal
cortex, or the central executive network, in an effort to
control excessive bottom-up activity evoked from recalling
morally injurious events (83). Critically, over-modulation of
excessive bottom-up affect is a pattern of neural activation
consistent with dissociation (82,83). Social support, for
example, may then be an important factor in processing
morally injurious events as treatments focused on bottom-up
affective processes and bodily sensation may encourage pro-
social, attachment-based, interpersonal relationships and in turn
alleviate interfering symptoms, including heightened arousal
and dissociation. Further evidence is required, however, to verify
the veracity of this claim and at present, it is imperative that
healthcare workers receive access to evidence-based approaches
to treat PTSD that, where necessary, may be augmented
by evidence-informed approaches for residual symptoms in
treatment-refractory cases.
An Interpersonally-Focused Approach to
Moral Injury
With limited empirical data on moral injury in healthcare
workers in general and during COVID-19 specifically, we
look here to interpersonal factors known to influence the
development and maintenance of PTSD symptoms (e.g., social
support, acknowledgment and exclusion) as a starting point
for potential prevention and treatment strategies. Notably,
this interpersonally-focused approach to moral injury is in
keeping with evidence from healthcare workers’ experiences
during the SARS crisis (55). Here, social support and social
rejection/isolation were reported to be associated with the
psychological impact that the crisis had on healthcare workers
(55). Marjanovic et al. (56) found that poor organizational
support was associated with avoidance and anger among nurses,
a finding similar to that of Tam et al. (57) who reported that
poor “team spirit” and administrators not hearing healthcare
workers’ feedback were associated with poor mental health (55).
Similarly, Chen et al. (58) found that nurses who reported
greater family support were at a lower risk of mental health
problems (55). Koh et al. (59) reported increased work stress
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D’Alessandro et al. Healthcare Workers and Moral Injury
and workload among healthcare workers on the frontlines of
the SARS crisis in Singapore, with many experiencing social
stigmatization and ostracism from family members due to
their occupation (55). Drawing on this pre-pandemic evidence
in combination with Nietlisbach and Maercker’s (16) work
on interpersonal factors relevant to survivors of trauma with
PTSD, we now provide a review of the role of perceived social
support, social acknowledgment and social exclusion in relation
to potential areas of targeted intervention for COVID-19-related
moral injury in healthcare workers.
Perceived Social Support
Social Support and PTSD
Social support is a psychological construct referring to the
emotional and instrumental care provided by those close in one’s
social circle, such as family or close friends (16). Whereas, seeking
social support to deal with traumatic stress is a protective factor
against PTSD (18), a perceived lack of social support is strongly
associated with increased PTSD symptoms (60). The role of social
support in mediating PTSD has been reported among many
populations, including war veterans (19), survivors of childhood
sexual abuse (20), survivors of violent crime (61) and nurses (21).
Cieslak (19) investigated the role of perceived social support and
self-efficacy in veterans’ adaptations to distress. The results of
this investigation revealed that greater received and perceived
social support predicted high coping self-efficacy, which in turn
predicted lower post-traumatic stress and depression symptom
severity (19). Kerasiotis and Motta (21) investigated PTSD
symptoms among nurses and found that nurses reported high
levels of anxiety but did not reach clinically significant levels
of PTSD, depression and dissociation. Here, social support was
inferred to help nurses cope with work-related stressors (21).
Finally, in a study investigating the specific types of perceived
social support that mediated PTSD development in female
survivors of childhood sexual abuse, self-esteem support was
defined as “others’ communications indicating that the abused
individual is valued” (20) and was the type of social support
that specifically mediated PTSD development in the sample. It
is critical to acknowledge that while social support is a strong
moderator of PTSD symptom development and maintenance,
PTSD characteristically undermines relationships and support
networks (62) as discussed above, making social relationships
a key target for PTSD intervention. Moreover, PTSD is highly
associated with disruptions in childhood attachment (47,63,
64), rendering it potentially more difficult to form and sustain
interpersonal relationships into adulthood.
Social support is thought to influence the cognitive appraisals
of traumatic events in survivors of trauma. Specifically, social
support may influence how one attributes their role in the
traumatic event and their beliefs about the world (65). Cohen
and Wills’ (66) well-cited stress-buffering model posits that social
support is a protective factor against the deleterious effects of
trauma exposure as it increases one’s perceived ability to cope
with trauma and reduces negative appraisals of the traumatic
event (22). In a study investigating social constraints, post-
traumatic cognitions and PTSD among recent survivors of
trauma, those who reported more social constraints (i.e., feeling
unsupported, misunderstood or alienated when seeking support)
reported more negative post-traumatic cognitions (67). Further,
both social constraints and negative post-traumatic cognitions
were related to a greater number of PTSD symptoms in this
sample (67). These findings are in keeping with decades of
research on the role of social support following exposure to
trauma where a lack of social support continues to be a strong
risk factor for developing PTSD (18,22,68). Further, individuals
with strong social support are likely to recover faster than those
who lack support (68). Indeed, in a recent meta-analytic review,
Zalta et al. (22) examined the magnitude of the relation between
social support and PTSD symptom severity, reporting a medium
effect size across 148 cross-sectional studies and 38 longitudinal
studies. The results supported the notion that greater levels of
social support and lower levels of negative social reactions are
related to lower levels of PTSD symptom severity (22).
Though not fully understood, the relation between social
support and resilience documented in neurobiological literature
may represent, in part, the mechanism through which social
support moderates PTSD symptoms. The noradrenergic and
hypothalamic-pituitary-adrenocortical (HPA) systems are
implicated in both stress and resilience. Individuals with PTSD
display dysregulated noradrenergic systems that fail to terminate
the stress response after exposure to stressful stimuli (62).
Individuals who report low social support display physiological
and neuroendocrine responses, such as increased heart rate and
blood pressure, that are indicative of a heightened reactivity to
stress (69). Conversely, stress resilience is associated with the
ability to keep the HPA and noradrenergic systems stable during
exposure to stressful stimuli and terminated when the stimuli
are no longer present (69). Social support is thought to influence
both biological and environmental susceptibility to stress by
acting on the HPA and noradrenergic systems, encouraging
resilience (69,70). As such, on a neurobiological level, social
support may be a key factor in mediating the stress response as it
promotes resilience.
Relatedly, the neurohormone oxytocin also plays a key role
in stress regulation where social contact impacts the HPA axis
to release oxytocin and in turn reduce stress (7177). Indeed,
studies using animal models have demonstrated that social
contact is associated with oxytocin release (7577). Furthermore,
oxytocin release during or just after exposure to stressful
events has been shown to regulate the HPA axis through the
corticotropin-releasing factor (72,78). Oxytocin’s affinity for
reducing PTSD symptoms may be related, in part, to its critical
role in social bonding as oxytocin is known as the neurohormonal
substrate of human affiliations, including parental, romantic
and filial social bonds (79). For example, oxytocin release is
implicated in maternal-infant social bonds such that oxytocin
levels early in pregnancy and postpartum were related to
maternal bonding behaviors such as positive affect, attachment-
related thoughts and frequency of attending to the infant (80).
Indeed, in a study investigating the therapeutic potential of
intranasal oxytocin administration as a preventative measure
for PTSD symptoms, Frijling et al. (81) found that repeated
oxytocin administration reduced the development of PTSD
symptoms among individuals who were recently trauma exposed.
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Furthermore, oxytocin has been shown to cause long-term
depression of the amygdala, regulating the amygdala’s sensitivity
to aversive social stimuli (74). As such, the relation between
social support and PTSD symptom severity may be explained,
in part, due to the release of oxytocin, which is critical for
social bonding and regulates the HPA axis along with subcortical
structures critical to the stress response [see Lanius et al. (82)
for a detailed review of the neurobiology of PTSD, including its
dissociative subtype].
Healthcare Workers and Social Support During
COVID-19
Research on healthcare workers’ perceived social support during
the pandemic is limited yet provides evidence that social
support is critical for mental health and well-being. Indeed,
in a systematic review of quantitative studies investigating
psychological resilience, coping behaviors and social support in
nurses during the pandemic (84), only seven studies explored
the relation between social support and mental health outcomes,
where greater perceived social support yielded a reduction
in burnout (84,85) and explained variance in psychological
distress (84,86). Using qualitative interviews, Brophy et al.
(87) explored Canadian healthcare workers’ experiences during
the initial months of the pandemic, reporting that a perceived
lack of support from employers affected healthcare workers’
sense of well-being (e.g., a co-worker being sent to care for a
suspected COVID-19 patient without PPE). Similarly, Xiao et
al. (88) explored the impact of social support on sleep quality
and functioning in a sample of Chinese healthcare workers
providing medical care during the pandemic. Social support not
only decreased anxiety and stress, but also increased self-efficacy
in this sample (88). Finally, Labrague and De los Santos (89)
examined the role of resilience, social support and organizational
support on COVID-19-related anxiety among nurses working on
the frontlines in the Philippines. Here, whereas social support
was defined as assistance and protection offered by colleagues,
managers, friends and family, organizational support was defined
as the degree to which resources, reinforcement, communication
and encouragement were offered to an individual by their
organization (89). Both social and organizational support
significantly predicted COVID-19-related anxiety among this
sample, such that greater degrees of these supports were
associated with lower degrees of anxiety (89).
In recent surveys of healthcare workers’ needs during the
pandemic, healthcare workers have highlighted their desire for
social support. For example, Shanafelt et al. (90) asked healthcare
workers about their main concerns during the pandemic, their
needs from leaders and their perspectives on tangible supports.
Healthcare workers’ requests were summarized as follows: hear
me, protect me, prepare me, support me and care for me.
Healthcare workers desire clear assurance from their leaders that
they, along with their families, will be supported emotionally,
physically and socially while working on the frontlines on the
pandemic (90). Specifically, healthcare workers shared a desire
for their expert perspectives to be included in decision making,
for their risk of infection to be mitigated, for appropriate training
to treat critically ill patients, for support in dealing with extreme
work hours and distress and for practical support such as food
and childcare aid should they be infected (90). This call for
support was echoed in a recent review by Heber et al. (91) who
reported that public safety personnel (PSP) who, like healthcare
workers, face novel stressors while working during the pandemic
(e.g., greater risk of infection compared to civilians), may benefit
from consistent support offered in the form of specialized mental
health and preparedness training, frequent and transparent
communication, strong leadership and team building, assistance
in navigating quarantine and focus on self-care.
Altogether, social support mediates PTSD symptoms in a
range of populations, perhaps through influencing cognitive
appraisals of events by survivors of trauma (i.e., buffering
patterns of common emotional response to trauma, enhancing
feelings of connectedness) and likely enhancing resiliency
on a neurobiological level [i.e., increasing the availability
of neurohormones associated with stress reduction, in turn,
regulating the HPA axis and critical subcortical structures
associated with trauma and stress; (6365,67,69,70,84). Given
the relation between moral injury and PTSD symptoms and
emerging mental health data suggesting that social support is
important for decreasing healthcare workers’ anxiety and stress
during pandemic situations, targeting perceived social support
is one means by which organizations and individuals may
mediate the morally injurious outcomes for healthcare workers
exposed to PMIEs during the COVID-19 pandemic. This may
be accomplished by creating Communities of Practice where
healthcare workers may gather in person and/or virtually to
discuss shared concerns and coping mechanisms, or by ensuring
that healthcare workers have regular breaks to spend with family
members or creating “buddy systems.” Similarly, the need for
efforts to retain a healthcare workforce that is increasingly
considering leaving the profession given experiences throughout
the pandemic (92,93) combined with our own preliminary
qualitative findings that healthcare workers demonstrate more
concern for team members and family members than themselves,
we suggest that efforts to retain healthcare staff and to promote
workplace wellness focus, to an extent, on teams and team
well-being. Strengthening these connections by highlighting
social cohesion with team members may facilitate retention and
promote post-traumatic growth. These efforts may also focus on
the identity of the healthcare worker as a helping professional and
serve as a reminder of why the healthcare worker entered the field
in the first place.
Perceived Social Acknowledgment
Social Acknowledgment and PTSD
Social acknowledgment involves receiving appreciation and
positive reactions from the wider social environment in
recognition of the difficult situation experienced by individuals
exposed to trauma (16). The social environment may include
colleagues, neighbors, authorities, clergy and the media (94).
Social acknowledgment differs from social support as the
former measures the degree to which one feels recognized and
understood as a survivor of trauma and the latter emphasizes
emotional or instrumental care (95).
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Poor social acknowledgment (i.e., receiving disapproval and
a lack of recognition as a survivor of trauma) is associated
with greater severity of PTSD (95). For example, in a study
examining PTSD symptom trajectories for Red Cross volunteers
in Indonesia who responded to a large earthquake, those in
the chronic PTSD trajectory reported lower perceived social
acknowledgment compared to those in the resilient trajectory
(96). Furthermore, a lack of social acknowledgment predicted
increased PTSD symptomology in a longitudinal study on
predictors of PTSD recovery in survivors of crime (97). In a study
investigating trauma and PTSD symptomatology in German
developmental aid workers, some participants reported that
experiencing general disapproval from others was associated with
more severe intrusive thoughts about the traumatic event and
increased hyperarousal (94). Finally, a study on PTSD symptom
severity, disclosure attitudes and social acknowledgment among
Chinese and German survivors of crime found that, although
PTSD symptom severity differed cross-culturally, disclosure
attitudes and social acknowledgment predicted PTSD severity in
both groups where a reluctance to disclose and a perceived lack
of social acknowledgment predicted greater PTSD severity (97).
One mechanism through which social acknowledgment
may mediate PTSD symptom development and maintenance
is similar to that of social support, namely, post-traumatic
cognitions. Post-traumatic cognitions are recognized as strong
predictors of PTSD (97). Whereas, a strong sense of social
acknowledgment may help survivors of trauma affirm positive
cognitions that a traumatic experience has damaged, poor social
acknowledgment may foster negative self- and other-focused
cognitions (95). Indeed, Mueller et al. (97) found that perceived
social acknowledgment was negatively associated with post-
traumatic cognitions in a sample of 86 survivors of crime.
Here, it is critical to note evidence of altered patterns of
response to emotions among individuals with PTSD that may
pose as a barrier to the reception of social acknowledgment.
For example, Nazarov et al. (98) found evidence for altered
comprehension of affective prosody among women with PTSD
related to chronic child abuse. Women in this study were
asked to recognize angry, fearful, sad and happy emotions on a
computer-based task and also asked to identify if the emotions
portrayed in consecutive excerpts were the same or different.
Nazarov et al. (98) found that women with PTSD took longer
to identify all emotions except for those portraying anger in
comparison to healthy controls. Interestingly, women with PTSD
who experienced dissociative symptoms were more likely to be
less accurate in discriminating between consecutive emotional
presentations (98). Further, greater severity of childhood trauma
was related to poorer accuracy in discrimination as well as slower
recognition of emotions (98). Consistent with the altered patterns
of emotional response demonstrated by Nazarov et al. (98),
alterations in ToM, emotional recognition, empathic reasoning,
moral reasoning and social behavior have been demonstrated
among individuals with PTSD, as described above (15,17,43
45). As such, altered patterns of emotional response in PTSD
must be considered when evaluating interventions targeting
social acknowledgment.
Healthcare Workers and Social Acknowledgment
During COVID-19
Research on healthcare workers’ perceived social
acknowledgment during the pandemic is limited, with the
majority of work instead focused heavily on social support
from familiar others, such as co-workers. A small number of
studies, however, have explored healthcare workers perceptions
surrounding a lack of recognition for their efforts during the
COVID-19 pandemic. For example, some healthcare workers
have described feeling abandoned by political leaders and have
attributed inadequate staffing and PPE during the pandemic
to political leaders’ poor response to their needs during the
crisis (26,99). Relatedly, in a recent systematic review and
meta-synthesis on frontline healthcare workers’ experiences
during pandemics and epidemics (e.g., COVID-19, SARS,
MERS, Ebola), Billings et al. (100) reported that workers felt
abandoned and betrayed by organizations when they did not
received promised financial renumeration for their service
and sacrifice on the frontlines. Kröger (26) stated further
that healthcare workers may perceive an inconsistent world
outside of the hospital when witnessing people carelessly
ignoring safety measures. Despite window decorations in
homes and businesses thanking healthcare workers for their
service, healthcare workers may perceive the non-chalance of
people in their communities as a lack of recognition for their
sacrifice on the frontlines. Finally, Cai et al. (99) investigated
the psychological impact and coping strategies of healthcare
workers in China and found that recognition from management
and the government was associated with psychological benefit.
Preliminary findings from our research groups’ ongoing
interviews with healthcare workers throughout 2021 corroborate
the perceived lack of recognition discussed in the literature where
nurses discussed feeling underappreciated at the beginning of
the pandemic when financial renumeration for their service was
smaller in proportion to that offered to some first responders.
Unsurprisingly, we also heard from some healthcare workers
that they felt abandoned and described a lack of recognition
from the community when protests against masks and vaccines
were held outside the hospital.
As social acknowledgment plays a role in the development
and maintenance of PTSD symptoms in various trauma-exposed
groups, it is imperative that healthcare workers perceive that
they are recognized and understood as survivors of trauma
during the COVID-19 pandemic. This perception may influence
positive post-traumatic cognitions that may ameliorate moral
injury as a response to COVID-19-related-PMIEs. Indeed, in
outlining how healthcare workers desire strong leadership to
support them during the pandemic, Shanafelt et al. (90) note the
critical role of leadership asking healthcare workers about their
concerns and acknowledging their requests. Despite potentially
being constrained from providing answers, leadership must
demonstrate that healthcare workers’ service is acknowledged
and appreciated (90). This call for strong leadership was echoed
by Jetly et al. (1) who discussed key qualities of effective
leadership in the military that may prove useful for leaders
attending to COVID-19-related moral injury in healthcare
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D’Alessandro et al. Healthcare Workers and Moral Injury
workers. Jetly et al. (1) propose that effective leadership listens
to the concerns of subordinates, are positive yet not overly
optimistic, respect their subordinates’ values, recognize that the
risk of COVID-19 infection is not evenly distributed as frontline
workers are the most vulnerable at this time, care about those
whom they lead and accept the blame for team failures while
attributing success to their team members.
Perceived Social Exclusion
Social Exclusion and PTSD
Social exclusion is an act of ostracism related to stigmatization
where one is rejected and isolated from a group (16). Humans
have an inherent need for relationships with others that is
disturbed in situations of social exclusion (101). Social exclusion
may lead to feelings of isolation as if one were no longer viewed
as a part of society (16). When ostracized, survivors of trauma
may perceive themselves as less-human and believe that they are
perceived to be less-human by the perpetrator of their ostracism
(101). Social exclusion or ostracism can lead to physiological
changes, such as cardiovascular issues or increased cortisol levels
and psychological issues, including negative emotions of anger,
sadness and shame (102,103).
Individuals suffering from PTSD and other mental illnesses
are often victims of social exclusion in the form of stereotyping
and stigmatization (104). For example, among East-African
conflict survivors, stigmatization was associated with an
increased likelihood of PTSD after exposure to trauma (105).
Wesselmann et al. (103) investigated the relation between
perceived ostracism (i.e., “being ignored and excluded”) and
post-traumatic stress among military veterans and found
that perceived ostracism was related to post-traumatic stress
symptoms, anxiety and psychological distress. Further, perceived
ostracism explained variance in post-traumatic stress symptoms
apart from theoretically relevant variables (i.e., deployment
stress and social support) (103). In a study investigating the
effects of social exclusion between individuals with PTSD
and control participants, those with PTSD reported greater
perceived social exclusion than control participants in an
experimental manipulation of inclusion and exclusion (106),
perhaps underscoring evidence of impaired social cognition
among individuals with PTSD. Finally, among female adolescents
exposed to war-related trauma, those who experienced sexual
violence reported increased stigmatization (i.e., feeling treated
worse than others, being insulted, rejected and excluded from
family or community) (107). Further, stigmatization explained
symptoms of depression and post-traumatic stress more so than
did the direct impact of sexual violence in this sample (107).
Healthcare Workers and Social Exclusion During
COVID-19
Healthcare workers may perceive themselves to be socially
excluded during the pandemic. In acknowledgment of the
stigmatization that healthcare workers may experience by
their communities during disease outbreaks, Taylor et al.
(108) conducted a North American study evaluating non-
healthcare workers’ attitudes toward healthcare workers serving
during COVID-19 and found that more than one quarter of
respondents believed that healthcare workers should be subject
to severe restrictions, including isolation from communities
and families. Further, one-third of the respondents reported
avoiding healthcare workers due to fear of infection (108).
Indeed, Kröger (26) highlighted how healthcare workers have
been prohibited from certain public spaces including bringing
their children to school and Shimizu and Lin (109) recounted
instances of defamation against healthcare workers in Japan
during the pandemic. Individuals affected by COVID-19 in
Japan have experienced societal rejection, discrimination and
stigmatization and since healthcare workers are at a high risk of
infection due to contact with COVID-19 patients, they are more
likely to suffer from social exclusion (110). Reports indicate that
Japanese healthcare workers have been victims of discrimination
and abuse outside of work as the public treats them as “germs”
(109). Healthcare workers in Japan have also been denied access
to public transportation and their families have fallen victim
to discrimination as well (109). In Canada, a national news
organization reported on two nurses’ experiences of facing
criticism for crossing the border to provide care at a hospital in
Detroit. The nurses described being blamed for bringing COVID
cases into their city as they worked to be a part of the solution
by caring for COVID-19 patients (111). Furthermore, Dye et al.
(112) conducted a survey of healthcare workers’ experiences of
COVID-19-related bullying and stigma with participants from
across 173 countries, reporting that healthcare workers were
experiencing social exclusion during the pandemic, especially in
communities affected by the intersection of racism, violence and
police involvement (112).
In sum, social exclusion violates the inherent human need
for relationships, consequently generating physiological and
psychological disturbances. The effects of social exclusion in the
form of stigmatization have been documented among various
populations such as war veterans (103), survivors of sexual
violence (107) and survivors of conflict (105). Our research group
is currently preparing a scoping review on healthcare workers’
and public safety personnel’s exposure to PMIEs and distressing
experiences during the pandemic. Here, we identified a need
for further investigation of the verbal and physical abuse that
healthcare workers have experienced in order to understand
the context and severity of such exposures globally. As social
exclusion is implicated in the development and maintenance of
PTSD symptoms, targeting healthcare workers’ perceptions of
social exclusion may be an effective strategy to prevent and treat
COVID-19-related moral injury.
DISCUSSION
In Litz et al.’s (10) conceptual model of moral injury, it is clear
that an individual’s social world is expected to mediate their
response to PMIEs. Indeed, this model postulates that the degree
of dissonance an individual initially experiences post-PMIE will
be moderated by others’ reactions. In addition, stable, internal
and global attributions may be countered when an individual
has others in their environment to offer interpretations of
events that lead to self-forgiveness rather than self-condemnation
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D’Alessandro et al. Healthcare Workers and Moral Injury
(10). Targeting perceived social support, acknowledgment and
inclusion may be an opportunity for PMIE-exposed healthcare
workers to reconcile dissonant cognitions of their beliefs about
the world and their experiences. Here, this targeted approach may
aid the individual in processing intense moral emotions and deter
them from social withdrawal, which may otherwise manifest
into symptoms of moral injury such as self-condemnation,
overwhelming shame, guilt, anger, anhedonia and/or PTSD
symptoms. For example, social exclusion may play a critical role
in how healthcare workers evaluate themselves after experiencing
perpetration-based PMIEs during the COVID-19 pandemic. In
interviews our research group has conducted with healthcare
workers throughout 2021, healthcare workers have described
excessive guilt when not able to attend to patients quickly enough
due to changing out of and into PPE. If an individual in this
situation is subsequently ostracized from colleagues or receives
condemning information from close individuals in their life
regarding their actions, these reactions may strengthen beliefs
such as “I am a bad person” and “I am responsible for the patient’s
death”, contributing to the sequalae of moral injury postulated by
Litz et al. (10).
Relatedly, social support and acknowledgment may not only
be factors that mediate morally injurious outcomes among those
who are exposed to PMIEs, but may also inherently constitute
PMIEs for some healthcare workers during the pandemic. For
example, in a recent review of frontline healthcare workers’
perspectives on working during pandemics and epidemics (e.g.,
COVID-19, SARS, Ebola), Billings et al. (100) discussed how
healthcare workers valued support from their organizations and
perceived the organization to have “an institutional duty to
provide staff with sufficient protection to work safely” (pg. 10).
Healthcare workers may feel betrayed by their organization when
they are sent to care for COVID-19 patients without appropriate
PPE (87) or when they feel unheard by leaders (91) who establish
procedures and policy with which workers do not agree. Finally,
actions or inactions that communicate to healthcare workers that
their efforts on the frontlines are not recognized or appreciated
[e.g., lack of inclusion in financial compensation; (100)] may
constitute betrayal-based PMIEs for some healthcare workers.
Thus, healthcare organizations must carefully consider the ways
in which their operations may betray their employees in addition
to recognizing that, as a trusted authority to their healthcare
workers, they have the ability and responsibility to support
workers and mitigate the effects of moral injury through means
of social support and acknowledgment.
An important consideration in translating research on
interpersonal factors in PTSD to moral injury, however, is
that moral injury by definition may involve witnessing morally
transgressive acts and/or an individual enacting the moral
harm themselves. Thus, the utility of addressing social support,
acknowledgment and exclusion in moral injury may need to be
strategically implemented to accommodate for both personally
transgressed and witnessed PMIEs, which has not been explored
in the PTSD literature. This tailored approach will mimic
research that has adapted traditional PTSD treatments to better
suit the experience of those with moral injury (11,35). With this
consideration, it is necessary for future studies to continue to
investigate the boundaries between moral injury and PTSD as
well as the ways in which a social cognitive model can inform
treatment interventions.
An interpersonally-focused approach to understanding and
mitigating moral injury in healthcare workers during COVID-
19 is consistent with a recent call for moral injury treatments
to move beyond psychotherapy and include an affirmative
community effort (11). This approach must include both
individual and organization considerations that take into account
the unqiue indiviudal in their specific social environement.
Indeed, Billings et al. (100) highlighted the importance of the
social environment when reviewing the experiences of frontline
healthcare workers affected by stigma and discrimination
in their communities. Here, healthcare workers reported
feeling supported by their orgnizations at times (e.g., when
communication was clear, when buddy systems were established
between expereinced and new staff) and unsupported at other
times (e.g., when staff safety was not a clear priority, when they
felt coerced to caring for infected paitents). Below, we synthesize
and disucss ciritical considerations for bolstering against the
deliterious imapcts of moral injury in healthcare workers at both
the indiviudal and organizaiton level.
Individual Considerations
In line with the recommendations made in the recent Moral
Injury Guide prepared by the Centre of Excellence on PTSD
(113), we offer the following individual level considerations
to buffer against the deleterious impacts of moral injury for
healthcare workers during the COVID-19 pandemic.
At the individual level, it is important to consider risk and
resilience factors that may affect one’s likelihood of developing
moral injury after exposure to a PMIE. Williamson et al. (114)
highlighted risk factors for moral injury in the military, which
may be pertinent to healthcare workers during the pandemic,
including loss of life to a vulnerable person (e.g., elderly,
children), perception of leaders not taking responsibility for
events or being unsupportive, staff feeling unprepared for the
emotional or psychological impacts of decisions, concurrent
exposure to other traumatic events and a lack of social support
after exposure to a PMIE. Furthermore, our research group
has shown that emotional abuse during childhood (115,116)
and emotional regulation (116) are critical factors related to
moral injury. Battaglia et al. (115) examined the relation between
childhood abuse and moral injury among members of the
Canadian Armed Forces (CAF) and found that emotional abuse
in childhood may increase the likelihood of moral injury among
adults in the CAF (115). Further, Roth and colleagues (116)
demonstrated that exposure to adverse childhood experiences
was associated with both moral injury and trauma-related
symptoms among PSP, but emotion regulation skills buffered
moral injury (116). Thus, whereas healthcare workers who are
survivors of childhood trauma may be at an elevated risk for
moral injury, those with strong emotion regulation skills may
have the necessary resilience to buffer against the development
of moral injury.
Healthcare workers who identify with a minority group (e.g.,
gender, sexual orientation, or racial/ethnic group) may also be
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D’Alessandro et al. Healthcare Workers and Moral Injury
at an elevated risk for moral injury during the pandemic due to
the compacting nature of minority stress (i.e., stress associated
with discrimination or marginalization) with COVID-19-related
stressors. The Centre of Excellence on PTSD’s moral injury
guide (113) highlighted that racialized individuals are at a higher
risk of COVID-19 exposure, infection and severe outcomes due
to racial disparities in income and poverty. Further, racialized
healthcare workers may deal with stressors related to systemic
racism in addition to the stressors associated with providing
care during COVID-19. For example, racialized healthcare
workers may experience racism from patients and colleagues,
may witness colleagues make racist comments about patients,
may feel compelled to protect racialized patients from racism,
may face skepticism about their training and competence, may
experience belittlement of their speech, appearance, religion or
cultural practices and may be called upon to educate others about
systemic racism (113). As a result, racialized healthcare workers
may be at an increased risk of experiencing distress and moral
injury during the pandemic in comparison to their non-racialized
counterparts. It is vital to acknowledge the unique stressors that
healthcare workers who identify with minority groups may face
in relation to discrimination and marginalization and consider
these impacts when developing interventions for COVID-19-
related moral injury.
Based on Heber at al.’s (91) recommendations for PSP to
support themselves during COVID-19, healthcare workers
may benefit from taking time to practice self-care in the form
of healthy coping and seeking connections and help. For
example, frontline workers should prioritize sleep, nutrition,
hydration and exercise, stress management, relaxation,
maintaining/establishing routines, connecting with friends,
family and co-workers and seeking informal and formal supports
as needed (91). These individual recommendations were echoed
in the Centre of Excellence on PTSD’s guide to moral injury
(113), which additionally recommends that healthcare workers
gain education about moral stressors, moral injury, relaxation
therapy and mindfulness or meditation to reduce stress.
Organizational Considerations
Cohen and Wills’ (66) stress-buffering model contends that
a specific match between trauma and the subsequent social
support is necessary for social support to reduce the harmful
psychological responses associated with trauma exposure. Thus,
in the context of COVID-19, healthcare organizations must play
a critical role in supporting healthcare workers to buffer against
moral injury as their workers look to leadership for guidance
in these unprecedent times. In line with the recommendations
made in the recent Moral Injury Guide prepared by the Centre of
Excellence on PTSD (113), we offer the following organizational
level considerations for leaders to consider in an effort to
buffer against the deleterious impacts of PMIE exposure and
moral injury as an outcome for healthcare workers during the
COVID-19 pandemic. Recommendations for organizations to
support healthcare workers include: offering clear, positive yet
realistic information; establishing peer support networks among
healthcare workers where team cohesion is emphasized; time
and space to rest and discuss experiences; encouraging self-
forgiveness and re-integration of moral transgressions into one’s
moral code; honest discussions about the moral requirements
of working during a pandemic; leaders taking responsibility to
ensure that staff are prepared for the emotional consequences of
their work and are aware of vicarious traumatization and relevant
coping strategies; peer support teams to provide psychological
first aid; encouraging staff to utilize employee assistance
programs, chaplaincy, or other levels of support; intentionally
expressing gratitude to frontline workers; offering accessible
professional resources; rotating staff between high and low stress
roles; optimizing the work environment for appropriate breaks;
educating healthcare workers on PMIEs and the possible morally
injurious outcomes that may be experienced after exposure (e.g.,
overwhelming moral emotions of anger, guilt, shame betrayal;
self-condemnation, anhedonia, social withdrawal), encouraging
self-assessments for risks of moral injury and formal screening
for PTSD, as well as receiving evidenced-based treatment, if
required (113,117121). Critically, some healthcare workers
may show signs of distress, yet deny or lack insight into these
difficulties and refuse help (122). Healthcare workers involved in
previous pandemics and epidemics did not fully voice their needs
or seek supports until after the peak of the crisis (100). As such, it
is essential that orgnaizations continiously offer and encourage
staff to prioritize their mental health during and beyond the
COVID-19 pandemic, even in the absence of explicit requests for
this support.
Limitations
While a thorough search of the literature was conducted in
preparing this review, it must be acknowledged that the present
review is limited by its narrative structure, which inherently
is unsystematic and is consequently associated with bias. The
purpose of this review was to synthesize literature on different
topics (e.g., social cognition, PTSD, moral injury) to present
the notion of an interpersonally-focused approach to COVID-
19-related moral injury in healthcare workers. Though it has
limitations, a narrative review was the most appropriate type of
review for this work (123). The present review is additionally
limited by the paucity of empirical research surrounding
moral injury in healthcare workers and a lack of consensus
on moral injury as a clinical phenomenon. As moral injury
has historically been situated in the military context, there
remains a need for research on the types of events that
may be experienced by healthcare workers as PMIEs, as well
as the outcomes associated with these exposures, to better
characterize healthcare workers’ experiences and arrive at a
definition for moral injury in this population. Future research
should consider a systematic review of the literature on moral
injury in healthcare workers as data becomes available to
reduce bias and synthesize knowledge on moral injury in
this population.
CONCLUSION
In summary, many healthcare workers have faced morally
and ethically challenging situations throughout the COVID-19
Frontiers in Psychiatry | www.frontiersin.org 11 February 2022 | Volume 12 | Article 784523
D’Alessandro et al. Healthcare Workers and Moral Injury
pandemic that place them at an elevated risk for moral injury.
The relation between moral injury and PTSD, although not
fully understood, suggests that the two are related yet distinct
responses to trauma. Alterations in social cognitive functioning
that may contribute to interpersonal difficulties in PTSD render
interpersonal factors such as social support, acknowledgment
and exclusion important in moderating PTSD symptomology.
Existing research on the interpersonal factors that moderate
PTSD symptom development and maintenance, then, may prove
to be a useful starting point for preventing and, where necessary,
treating moral injury in healthcare workers during the COVID-
19 pandemic. We urge researchers and clinicians to consider
carefully a social cognitive and interpersonal lens in relation
to ongoing research on moral injury in healthcare workers
during the COVID-19 pandemic and beyond. Healthcare
organizations should follow the available recommendations to
support healthcare workers at this time to bolster against
moral injury.
AUTHOR CONTRIBUTIONS
AD’A: conceptualization, writing (original draft), review, and
editing. KR and RM: conceptualization and review and editing.
RL, AH, PS, AM, HS, CO’C, FH, and SR: review and editing.
MM and RL: conceptualization, writing, review and editing, and
funding acquisition. All authors contributed to the article and
approved the submitted version.
FUNDING
This work was supported by research grants from the Veteran’s
Affairs Canada supported Centre of Excellence on PTSD,
Defense Canada, and the Canadian Institute of Health Research
(grant number: MVP-171647) to MM and RL, along with a
generous donation from Homewood Health Incorporated to
Homewood Research Institute. MM was supported by the
Homewood Chair in Mental Health and Trauma at McMaster
University. RL was supported by the Harris-Woodman
Chair in Psyche and Trauma at Western University
of Canada.
ACKNOWLEDGMENTS
The authors would like to acknowledge that healthcare workers
around the globe have placed themselves and their families at
great risk during this time and also like to thank frontline
healthcare workers and staff for their heroic efforts and
sacrifices in providing care to those in need during the
COVID-19 pandemic.
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Frontiers in Psychiatry | www.frontiersin.org 15 February 2022 | Volume 12 | Article 784523
... Compassion-focused therapeutic approaches (134,135) that directly address developmental attachment trauma may further reduce shame and guilt surrounding MI and assist in its processing, particularly when combined with bottom-up, sensory-driven approaches. Finally, given established patterns of perceived social exclusion, poor social support, and a lack of social acknowledgment among HCWs throughout the COVID-19 pandemic, preventative and early intervention efforts focused on the strengthening of interpersonal relationships and enhancing social support would be expected to also assist in addressing MI among HCWs (136), particularly given that metaanalytic research consistently confirms social support as a strong predictor of the development of PTSD following trauma exposure (137,138). ...
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Healthcare workers (HCWs) and public safety personnel (PSP) across the globe have continued to face ethically and morally challenging situations during the COVID-19 pandemic that increase their risk for the development of moral distress (MD) and moral injury (MI). To date, however, the global circumstances that confer risk for MD and MI in these cohorts have not been systematically explored, nor have the unique circumstances that may exist across countries been explored. Here, we sought to identify and compare, across the globe, potentially morally injurious or distressful events (PMIDEs) in HCWs and PSP during the COVID-19 pandemic. A scoping review was conducted to identify and synthesize global knowledge on PMIDEs in HCWs and select PSP. Six databases were searched, including MEDLINE, EMBASE, Web of Science, PsychInfo, CINAHL, and Global Health. A total of 1,412 articles were retrieved, of which 57 articles were included in this review. These articles collectively described the experiences of samples from 19 different countries, which were comprised almost exclusively of HCWs. Given the lack of PSP data, the following results should not be generalized to PSP populations without further research. Using qualitative content analysis, six themes describing circumstances associated with PMIDEs were identified: (1) Risk of contracting or transmitting COVID-19; (2) Inability to work on the frontlines; (3) Provision of suboptimal care; (4) Care prioritization and resource allocation; (5) Perceived lack of support and unfair treatment by their organization; and (6) Stigma, discrimination, and abuse. HCWs described a range of emotions related to these PMIDEs, including anxiety, fear, guilt, shame, burnout, anger, and helplessness. Most PMIDE themes appeared to be shared globally, particularly the 'Risk of contracting or transmitting COVID-19' and the 'Perceived lack of support and unfair treatment by their organization.' Articles included within the theme of 'Stigma, discrimination, and abuse' represented the smallest global distribution of all PMIDE themes. Overall, the present review provides insight into PMIDEs encountered by HCWs across the globe during COVID-19. Further research is required to differentiate the experience of PSP from HCWs, and to explore the impact of social and cultural factors on the experience of MD and MI.
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Healthcare workers (HCWs) on the frontline of the COVID-19 pandemic exhibit a high prevalence of depression and psychological distress. Moral injury (MI) can lead to such mental health problems. MI occurs when perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations. Since the start of the pandemic, psychosocial stressors at work (PSWs) might have been exacerbated, which might in turn have led to an increased risk of MI in HCWs. However, research into the associations between PSWs and MI is lacking. Considering these stressors are frequent and most of them are modifiable occupational risk factors, they may constitute promising prevention targets. This study aims to evaluate the associations between a set of PSWs and MI in HCWs during the third wave of the COVID-19 pandemic in Quebec, Canada. Furthermore, our study aims to explore potential differences between urban and non-urban regions. The sample of this study consisted of 572 HCWs and leaders from the Quebec province. Prevalence ratios (PR) of MI and their 95% confidence intervals (CI) were modelled using robust Poisson regressions. Several covariates were considered, including age, sex, gender, socio-economic indicators, and lifestyle factors. Results indicated HCWs exposed to PSWs were 2.22–5.58 times more likely to experience MI. Low ethical culture had the strongest association (PR: 5.58, 95% CI: 1.34–23.27), followed by low reward (PR: 4.43, 95% CI: 2.14–9.16) and high emotional demands (PR: 4.32, 95% CI: 1.89–9.88). Identifying predictors of MI could contribute to the reduction of mental health problems and the implementation of targeted interventions in urban and non-urban areas.
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Post-traumatic stress disorder (PTSD) is a severe mental disorder that results in the frequent coexistence of other diseases, lowers patients’ quality of life, and has a high annual cost of treatment. However, despite the variety of therapeutic approaches that exist, some patients still do not achieve the desired results. In addition, we may soon face an increase in the number of new PTSD cases because of the current global situation—both the COVID-19 pandemic and the ongoing armed conflicts. Hence, in recent years, many publications have sought a new, more personalized treatment approach. One such approach is the administration of intranasal oxytocin (INOXT), which, due to its pleiotropic effects, seems to be a promising therapeutic option. However, the current findings suggest that it might only be helpful for a limited, strictly selected group of patients.
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You can heal, recover from trauma, and grow, and this workbook can guide you through this important, meaningful work, step by step, at a pace that feels safe for you. If you’ve experienced trauma, life may sometimes feel hopeless, full of feeling too much or too little. You may feel that the world is a terrifying and dangerous place. You may even feel like you don’t deserve anything positive, especially if you have been hurt by people you needed, loved, or relied on. To escape the pain, you may have been disconnecting from yourself and the world, including in risky or unsafe ways. In this workbook, the expert authors guide you step by step along the path of healing from trauma and offer specific exercises to practice daily that will help you feel safer and develop a grounded, worthy sense of self. This book includes the information sheets and exercises that are the foundation for the Finding Solid Ground program. The companion book, Finding Solid Ground: Overcoming Obstacles in Trauma Treatment, provides the theoretical, clinical, and research rationale for the program. This workbook breaks recovery into practical manageable steps that can be immediately implemented. Participation in the Finding Solid Ground program in the Treatment of Patients with Dissociative Disorder (TOP DD) Network study was associated with increased ability to manage emotions in healthy ways and reduced dissociation, posttraumatic stress symptoms, and self-injury. Join the international community of people who have used this program to find solid ground!
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Background Emerging cross-sectional data indicate that healthcare workers (HCWs) in the COVID-19 era face particular mental health risks. Moral injury – a betrayal of one’s values and beliefs, is a potential concern for HCWs who witness the devastating impact of acute COVID-19 illness while too often feeling helpless to respond. This study longitudinally examined rates of depression, generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), and moral injury among United States HCWs in the COVID-19 era. We anticipated finding high levels of clinical symptoms and moral injury that would remain stable over time. We also expected to find positive correlations between clinical symptoms and moral injury. Methods This three-wave study assessed clinical symptoms and moral injury among 350 HCWs at baseline, 30, and 90 days between September and December 2020. Anxiety, depression, PTSD, and moral injury were measured using the Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Primary Care PTSD Screen (PC-PTSD), and Moral Injury Events Scale (MIES). Results Of the 350 HCWs, 72% reported probable anxiety, depression, and/or PTSD disorders at baseline, 62% at day 30, and 64% at day 90. High level of moral injury was associated with a range of psychopathology including suicidal ideation, especially among healthcare workers self-reporting COVID-19 exposure. Conclusions Findings demonstrate broad, persisting, and diverse mental health consequences of the COVID-19 pandemic among United States HCWs. This study is the first to longitudinally examine the relationships between moral injury and psychopathology among HCWs, emphasizing the need to increase HCWs’ access to mental healthcare.
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Background Healthcare workers across the world have risen to the demands of treating COVID-19 patients, potentially at significant cost to their own health and wellbeing. There has been increasing recognition of the potential mental health impact of COVID-19 on frontline workers and calls to provide psychosocial support for them. However, little attention has so far been paid to understanding the impact of working on a pandemic from healthcare workers’ own perspectives or what their views are about support. Methods We searched key healthcare databases (Medline, PsychINFO and PubMed) from inception to September 28, 2020. We also reviewed relevant grey literature, screened pre-print servers and hand searched reference lists of key texts for all published accounts of healthcare workers’ experiences of working on the frontline and views about support during COVID-19 and previous pandemics/epidemics. We conducted a meta-synthesis of all qualitative results to synthesise findings and develop an overarching set of themes and sub-themes which captured the experiences and views of frontline healthcare workers across the studies. Results This review identified 46 qualitative studies which explored healthcare workers’ experiences and views from pandemics or epidemics including and prior to COVID-19. Meta-synthesis derived eight key themes which largely transcended temporal and geographical boundaries. Participants across all the studies were deeply concerned about their own and/or others’ physical safety. This was greatest in the early phases of pandemics and exacerbated by inadequate Personal Protective Equipment (PPE), insufficient resources, and inconsistent information. Workers struggled with high workloads and long shifts and desired adequate rest and recovery. Many experienced stigma. Healthcare workers’ relationships with families, colleagues, organisations, media and the wider public were complicated and could be experienced concomitantly as sources of support but also sources of stress. Conclusions The experiences of healthcare workers during the COVID-19 pandemic are not unprecedented; the themes that arose from previous pandemics and epidemics were remarkably resonant with what we are hearing about the impact of COVID-19 globally today. We have an opportunity to learn from the lessons of previous crises, mitigate the negative mental health impact of COVID-19 and support the longer-term wellbeing of the healthcare workforce worldwide.
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Objective To address posttraumatic stress disorder (PTSD) predictors with research focused on the coping styles of traumatized individuals. Method A total of 86 crime victims (mean age 46.1, standard deviation 17.6) were assessed at 5 and 11 months post-crime. Disclosure of trauma, social acknowledgement, dysfunctional posttraumatic cognitions, and PTSD symptom severity were assessed by self-reports. Results Dysfunctional posttraumatic cognitions, disclosure attitudes, and social disapproval correlated positively with PTSD severity. Hierarchical regression analyses revealed the particular value of disclosure attitudes and perceived social disapproval in predicting PTSD symptom severity at 11 months post-crime. Conclusions In addition to known predictors of PTSD, disclosure attitudes and social acknowledgement should also be considered. Future research should focus on broader concepts such as the victim's perception of, and interaction with, their social environment, and on the objective factors of social interaction, in addition to intrapersonal processes of posttraumatic recovery.
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LAY SUMMARY Moral injury (MI) refers to the distress experienced when people do, or do not, do something that goes against their morals or values. It can also occur when people perceive that their values have been betrayed. MI is associated with several mental health conditions, including posttraumatic stress disorder (PTSD), depression, and anxiety. A potential risk factor for MI may include difficulties with emotion regulation (ER). Difficulties with ER refers to the ability to manage emotions. It is associated with the same mental health conditions linked to MI, including PTSD. The purpose of this study was to examine whether difficulties with ER were associated with MI in a Canadian military personnel and Veteran sample. Participants completed several questionnaires assessing for MI, difficulties with ER, and other mental health symptoms, such as PTSD, while they were inpatients at a psychiatric hospital. It was found that MI and perceived betrayals were associated with symptoms of PTSD. Symptoms of PTSD, depression, and anxiety were also associated with one another. Difficulties with ER were also associated with symptoms of PTSD, depression, and anxiety but were not related to MI. The findings serve as a first step in examining potential risk factors of MI.
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Post-traumatic stress disorder (PTSD) is triggered by an individual experiencing or witnessing a traumatic event, often precipitating persistent flashbacks and severe anxiety that are associated with a fearful and hypervigilant presentation. Approximately 14-30% of traumatized individuals present with the dissociative subtype of PTSD, which is often associated with repeated or childhood trauma. This presentation includes symptoms of depersonalization and derealization, where individuals may feel as if the world or self is "dream-like" and not real and/or describe "out-of-body" experiences. Here, we review putative neural alterations that may underlie how sensations are experienced among traumatized individuals with PTSD and its dissociative subtype, including those from the outside world (e.g., touch, auditory, and visual sensations) and the internal world of the body (e.g., visceral sensations, physical sensations associated with feeling states). We postulate that alterations in the neural pathways important for the processing of sensations originating in the outer and inner worlds may have cascading effects on the performance of higher-order cognitive functions, including emotion regulation, social cognition, and goal-oriented action, thereby shaping the perception of and engagement with the world. Finally, we introduce a theoretical neurobiological framework to account for altered sensory processing among traumatized individuals with and without the dissociative subtype of PTSD.
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Aim To appraise and synthesize studies examining resilience, coping behaviours, and social support among healthcare workers during the coronavirus pandemic. Background A wide range of evidence has shown that healthcare workers, currently on the frontlines in the fight against COVID‐19, are not spared from the psychological and mental health‐related consequences of the pandemic. Studies synthesizing the role of coping behaviours, resilience, and social support in safeguarding the mental health of healthcare workers during the pandemic is largely unknown. Evaluation This is a systematic review with a narrative synthesis. A total of 31 articles were included in the review. Key Issues Healthcare workers utilized both problem‐centred and emotion‐centred coping to manage the stress‐associated with the coronavirus pandemic. Coping behaviours, resilience, and social support were associated with positive mental and psychological health outcomes. Conclusion Substantial evidence supports the effectiveness of coping behaviours, resilience, and social support to preserve psychological and mental health among healthcare workers during the COVID‐19 pandemic. Implications for Nursing Management In order to safeguard the mental health of healthcare workers during the pandemic, hospital and nursing administrators should implement proactive measures to sustain resilience in HCWs, build coping skills, and implement creative ways to foster social support in healthcare workers through theory‐based interventions, supportive leadership, and fostering a resilient work environment.
Book
Even seasoned clinicians can feel deskilled when trying to help to highly traumatized and dissociative patients. Together, this book and its accompanying workbook for patients (The Finding Solid Ground Program Workbook: Overcoming Obstacles in Trauma Recovery) provide an evidence-informed, pragmatic, and compassionate approach to the stabilization and treatment of complex trauma and dissociation. These books will help clinicians immediately implement ways to assess and treat traumatized individuals with a comprehensive therapeutic program that includes session-by-session information sheets and exercises developed through the process of synthesizing decades of clinical experience, the results of the TOP DD (Treatment of Patients with Dissociative Disorders) studies, and feedback from individuals living with trauma-related disorders. Traumatized individuals who participated in the program as part of the TOP DD Network study were better able to manage emotions in healthy ways, and reduced their levels of dissociation, posttraumatic stress symptoms, and self-injury. This book provides guidance on how to use the program in individual and group contexts, as well as expert recommendations for assessing dissociation and clinical vignettes that focus on how to overcome common obstacles in trauma treatment. The companion book, Finding Solid Ground: Overcoming Obstacles in Trauma Recovery includes the patient-facing Information Sheets and Exercises that are the foundation for the Finding Solid Ground program. Together, these books present a coherent, comprehensive approach to trauma treatment that rests upon a clearly articulated understanding of the neurobiological impacts of trauma. Clinicians of all levels of experience will find these books inspiring, informative, and accessible.
Article
Background Adverse Childhood Experiences (ACEs) increase risk for negative mental health outcomes in adulthood; however, the mechanisms through which ACEs exert their influence on adult mental health are poorly understood. This is particularly true for Public Safety Personnel (PSP; e.g., police, firefighters, paramedics, etc.), a group with unique vulnerability to negative psychiatric sequalae given their chronic exposure to potentially traumatic, work-related events. Objectives To examine the role of moral injury (MI) and emotion regulation in the relation between ACEs and adult mental health symptoms in adulthood. Participants and setting Participants (N = 294) included a community sample of Canadian and American PSP members aged 22 to 65. Methods The current study uses cross-sectional data collection via retrospective self-report questionnaires administered between November, 2018 and November, 2019 to assess level of ACEs (ACE-Q), emotion regulation difficulties (DERS) and symptoms of post-traumatic stress (PCL-5), dissociation (MDI), depression, stress, and anxiety (DASS-21). Additionally, participants completed the Moral Injury Assessment for Public Safety Personnel, the first measure of MI developed specifically for PSP. Results Path analysis revealed that ACEs significantly predicted adverse mental health symptoms in adulthood; this effect was mediated by symptoms of MI and moderated by difficulties with emotion regulation. Conclusions This study is the first to identify MI as a mechanism involved in the relation between ACEs and adult psychopathology and highlights the protective role of emotion regulation skills. These findings can inform the development of future research and clinical interventions in PSP populations.
Article
Aims and objectives: This study aimed to determine the relationship between nurses' exposure to violence and their professional commitment during the COVID-19 pandemic. Background: Violence against nurses is a common problem that persists worldwide. Design: This was a descriptive cross-sectional study. Methods: An online questionnaire form and the Nursing Professional Commitment Scale were used to collect the data. The study was carried out online during the COVID-19 pandemic between October-December 2020. A total of 263 nurses agreed to participate in the study. The STROBE checklist was followed for observational studies. Results: During the COVID-19 pandemic, 8.4% of the nurses stated that they were exposed to physical violence, 57.8% to verbal violence, 0.8% to sexual violence and 61.6% to mobbing. 52.1% of the nurses stated that they thought of quitting the profession during the COVID-19 pandemic. The mean total Nursing Professional Commitment Scale score was 71.33 ± 15.05. Conclusions: This study revealed that nurses' exposure to physical, verbal and sexual violence during the COVID-19 pandemic decreased compared to before the pandemic. Nurses' exposure to mobbing during the pandemic was found to increase. A statistically significant difference was found between the status of the nurses' exposure to physical violence, verbal violence, and mobbing, working hours, number of patients given care, and their thoughts of quitting the profession. It was found that the status of exposure to physical violence, thinking of quitting the profession and working hours decreased professional commitment. Relevance to clinical practice: In the light of these results, it is recommended that measures to prevent violence should be addressed in a multifaceted way. In managing the pandemic process, the decisions and practices should not be left to the managers' initiative to prevent mobbing. Initiatives that will increase nurses' professional commitment during the pandemic process should be planned and implemented.