Moral Injury Among COVID-19 Health Care Professionals

Source: Christoph Kröger, used with permission

Health care professionals have been bearing the brunt of COVID-19 stress as they continue to report to high-stress work environments around infected patients. The strain on their social identity and risk for moral injury play a large part in the mental health issues these frontline responders face. In this interview, Dr. Christoph Kröger shares about the experiences of his own family and the research behind health care professionals' COVID-19 stresses.

Professor Christoph Kröger, PhD is Department of Clinical Psychology at the University of Hildesheim, Germany. His area of specialization is clinical psychology and psychotherapy. His recent publications include articles in Peace and Conflict: Journal of Peace Psychology and European Journal of Health Economics.

JA: How did you first get interested in this topic?

CK: My wife is a general practitioner and was the first one in our region to conduct testing on potentially infected COVID-19 patients. We were therefore one of the first families who had to discuss how we would handle the situation with the “grandmothers.” My two sons had visited their grandmothers’ practically every day before COVID-19, and now they could only see them from a distance. Our children took care of the grocery shopping and delivered them to their grandmothers’ basement so they would not expose them to a possible infection. All of us were very sad. When the risk of infection became publicly known, some of our neighbors avoided us altogether or only spoke to us from a great distance as they feared we would be contagious. We were something special, weird even—the family with the medical practitioner—and were therefore classified as “more dangerous.”

JA: What was the focus of your study?

CK: The article assesses the effects of extreme situations experienced by health care professionals (HCPs) in the context of the global COVID-19 pandemic. HCPs are characterized by high professional expertise and high mental resilience, which form their social identity. Both aspects of the social identity might be shattered due to experiences in the COVID-19 pandemic, as intensive medical care requires special skills and is emotionally exhausting. Additionally, the violation of medical-ethical norms (such as “First, do no harm”) and social-ethical norms may be shattered in these extreme situations, leading to moral injury. Moral injuries result from events that contradict the individual’s personal moral beliefs.

JA: What did you discover in your study?

CK: A key aspect of intensive-care HCPs’ social identity is professional expertise and an ability to bear intense emotional-cognitive demands. Both aspects of social identity come into question when HCPs care for patients with COVID-19. For example, intensive medical care for COVID-19 patients requires special technical equipment and skills regarding respiratory methods (e.g., extracorporeal membrane oxygenation). Even when performing all measures correctly, a high rate of death among patients must be expected. Thus, HCPs had to change the routine and technical equipment knowing most of their patients will still die. This leads to the other important issue—moral injuries. During triage situations, for example, HCPs must potentially do harm by making life-and-death decisions when pressed for time and facing limited resources (e.g., lack of protective gear).

JA: Is there anything that surprised you in your findings, or that you weren't fully expecting?

CK: Research in the context of the military has shown that moral injuries are a result of shock, especially with regards to professional ethics and social norms. I was surprised to see how similar experiences are in both the military realm and the health care sector. Hence, research about moral injuries should be extended to other professions who met the assignment for protection and security (e.g., police officers, rescue workers).

JA: How might readers apply what you found to their lives during COVID-19?

CK: In team meetings or in a one-on-one consultation, the various burdening work conditions can be used for an analysis of critical situations. The following questions may be helpful:

• Were traumatic incidents according to the Diagnostic and Statistical Manual of Mental Disorders (5^th edition) experienced during a job-related operation?
• Did the rescue squad meet their professional limits? Or were material resources not sufficient? Did other people suffer from injuries or did they even experience the death of another individual?
• Did one member of the rescue squad loose emotional or behavioral control, so that he or she was not acting according to his or her professional role? Was she or he unable to work in this situation or was she or he incapable of work in the long term?
• Did one member of the rescue squad disagree with decisions made or want to leave the team implicitly or explicitly?
• Did a violation of professional-ethical standards and norms occur?
• Are other violations of standards and norms relevant (e.g., labor-legislation policies, social-solidarity norms)?

JA: How can readers use what you found to help others amidst this pandemic?

CK: Professional and ethical decisions regarding the workplace should be defined and should be accounted for. An external moderator may even be consulted for ethical questions. A key aspect is to ensure a constructive atmosphere in the HCP team. Especially in situations with higher work-related distress, the shift should end with a short daily debriefing. Amongst all the difficulties and burdening situations, good coping strategies and constructive reciprocal support should be emphasized. Additionally, HCPs should be supported in a special way during the pandemic in their private everyday life and social discrimination should consciously be counteracted.

For example, neighborhood initiatives could ensure that grocery shopping is organized for HCPs so they can recover after coming home after working long hours. Their kids could also be engaged by taking them to play in a nearby park—this even works while maintaining distance rules. Both measures, grocery shopping and childcare, might disburden the HCPs and create time for them to recover from the extremely stressful situation.

Coronavirus Disease 2019 Essential Reads

Update on COVID-19 and How It Changes the Brain

How Political Partisanship Can Be Deadly

JA: What are you currently working on that you might like to share about?

CK: Those work-related conditions—shattered social identity and moral injuries—may contribute to the development of a mental disorder (e.g., major depressive disorder, posttraumatic stress disorder). To prevent mental disorders and to maintain the ability to work, a video-based program might be offered to HCPs during the pandemic. Appropriate themes could include teaching stress-management skills and cognitive techniques targeting rumination and associated emotions about past situations. In the future, we would like to implement such a program as a cost-effective work-related intervention for HCPs