Longitudinal associations between moral injury perceptions and mental health among healthcare workers during the pandemic.

Abstract

Objective: The COVID-19 pandemic strained the healthcare system and resulted in higher rates of potentially morally injurious events. These events are perceived as violating one's own moral code, so a more precise construct label could be moral injury perceptions (MIPs). MIPs may exacerbate stress-related symptoms. However, consistent with the broader literature on mood-congruent cognitive bias, stress symptoms may also exacerbate MIPs. To test this bidirectional hypothesis, we examined the relationship between MIPs and stress symptoms among healthcare workers during the first year of the pandemic. Method: Online questionnaires for MIPs and stress-related symptoms (i.e., pandemic-related posttraumatic stress [PTSS], perceived stress, depression, and anxiety) were completed in April/May 2020 (time point one [T1]; N = 184), 1 month later (time point 2 [T2]; N = 135), and 6 months later (time point three [T3]; N = 112).Results: Findings from cross-lagged panel modeling favored unidirectional models, but the direction of the relationship varied by symptom type. Perceived stress, PTSS, and depression, all predicted increased MIPs at a later time point. However, in a reversal of direction, MIPs predicted increased anxiety. Conclusions: Results suggest that MIPs may function as both a predictor and an outcome of stress-related symptoms. Mood-congruent cognitive biases could account for why depression, PTSS, and perceived stress predicted subsequent MIPs, whereas MIPs may have exacerbated more generalized anxiety about the future. Broadly, these findings highlight the importance of early access to mental health services for healthcare workers during public health crises to disrupt the relationship between MIPs and stress-related symptoms. Clinical Impact StatementWe found that depression and stress-related symptoms predicted increases in moral injury perceptions (MIPs), and MIPs predicted increased anxiety. Altogether, these findings highlight the importance of early access to prevention and treatment services for healthcare workers during public health crises, such as the COVID-19 pandemic, to attenuate the mutually exacerbating relationship between MIPs and stress-related psychological symptoms.