Psychoanalytic Perspectives on Moral Injury in Nurses on the Frontlines of the COVID-19 Pandemic

Abstract

Objective To raise awareness of the potential for moral injury in nurses working on the frontlines of COVID-19 patient care and to present aspects of mental functioning that may increase the likelihood of psychological distress. Approaches that draw on psychoanalytic thinking to support frontline nurses’ mental health are explained. Method This article draws on recent work that is available from multiple sources, including published journal articles on moral injury, recent reports from news services highlighting the crisis state of the pandemic and effects on nurses, established literature on the structural model of the mind, and recent webinars and online lectures addressing mental health crisis interventions. The author draws on expertise from years of training in the Adult Psychoanalytic Training Program at the Michigan Psychoanalytic Institute and graduation as an academic analyst. Results How nurses navigate moral hazards inherent in the current state of frontline health care may depend on their existing ego strengths and levels of self-blame and guilt from a harsh superego. Conclusions Mental health professionals need to be aware of the mental minefields that frontline nurses must navigate when providing care that, due to circumstances beyond their control, may be morally ambiguous. Educating nurses about the meaning of their own emotional and psychic responses amid the realities in the field may help to decrease the damaging effects of moral injury.

COVID-19 Pandemic and Mental Health of Nurses: Impact on International Health Security

“…Nurses who work at maximum capacity also experience various problems such as deciding which critically ill patients may be allocated to the intensive care unit and which patients can be provided with a respiratory device; they accompany the end-of-life journey of both the patient and the family in the face of deterioration faster than they are accustomed to [33][34][35]. At the same time, because of isolation precautions and rules, patient relatives are not able to be with the patients, which results in nurses' providing the necessary support and establishing remote communication between the patient and relatives, giving nurses additional responsibilities [36].…”

Understanding and mitigating moral injury in nurses

“…Feelings that may arise in a person when they sustain moral injury include shame, guilt, self-blame and disgust (Greenberg et al 2020, Hossain and Clatty 2020, Lesley 2020, Stovall et al 2020. While moral injury is not in itself a mental health issue (Greenberg et al 2020), it has been suggested that it places the person at risk of developing burnout, post-traumatic stress disorder (PTSD), anxiety and depression (Stovall et al 2020).…”

“…This feeling of powerlessness can result in an inability to fulfil their professional duties, leading to compromised patient care and suboptimal patient outcomes (Welborn 2019). People who have sustained moral injury may also experience an altered sense of self and a loss of trust (Lesley 2020, Stovall et al 2020.…”

Moral Distress and Perceived Community Views Are Associated With Mental Health Symptoms in Frontline Health Workers During the COVID-19 Pandemic

“…The COVID-19 pandemic has led to growing international awareness regarding the prevalence of moral distress and psychological symptoms amongst frontline healthcare workers (HCWs) [1,2]. Moral distress, also referred to as 'moral injury', is defined as 'perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply help moral beliefs and expectations' [3; page 695].…”