The Hidden Crisis: Understanding Potentially Morally Injurious Events Experienced by Healthcare Providers during COVID-19 in Canada

Abstract

Background: Healthcare providers (HCPs) may be at elevated risk for moral injury due to increased exposure to potentially morally injurious events (PMIEs) throughout the COVID-19 pandemic. Identifying PMIEs experienced during the COVID-19 pandemic is a critical first step for understanding moral injury in HCPs. Accordingly, the purpose of the present study was to gain a deeper understanding of the work-related PMIEs experienced by HCPs in Canada during the pandemic. Methods: Canadian HCPs completed an online survey between February and December 2021 about mental health and functioning, including demographics and the Moral Injury Outcome Scale (MIOS). We conducted a qualitative thematic analysis of PMIEs described extemporaneously by HCPs in the open-text field of the MIOS. Results: One-hundred and twenty-four (N = 124) HCPs were included in analysis. Eight PMIE-related themes were identified, comprising patients dying alone; provision of futile care; professional opinion being ignored; witnessing patient harm; bullying, violence and divided opinions; resources and personal protective equipment; increased workload and decreased staffing; and conflicting values. Conclusions: Understanding broad categories of PMIES experienced by Canadian HCPs during the COVID-19 pandemic provides an opportunity to enhance cultural competency surrounding their experiences which will aid the development of targeted prevention and intervention approaches.

From Crisis to Opportunity: A Qualitative Study on Rehabilitation Therapists’ Experiences and Post-Pandemic Perspectives

“…Consistent with our findings, other studies observed that healthcare workers caring for patients with COVID-19 showed significantly more moral distress, anxiety, and depressive symptoms than those not caring for COVID-19 patients [59], and in interviewed occupational therapists, moral distress was experienced as post-traumatic stress disorder [60]. Similar experiences of moral distress in rehabilitative professionals and other health professions during COVID-19 have been reported in the literature [61,62]. Witnessing patient harm in the form of reduced care, physical deconditioning, and social isolation while feeling helpless was also described in our study by RTs.…”

“…Witnessing patient harm in the form of reduced care, physical deconditioning, and social isolation while feeling helpless was also described in our study by RTs. These findings align with COVID-19 research of other healthcare providers observing neglect of patients' care needs, failure to prioritize patient care, and feeling responsible for contributing to substandard care standards [62].…”

The independent and combined impact of moral injury and moral distress on post-traumatic stress disorder symptoms among healthcare workers during the COVID-19 pandemic

“…Team- and system-related MD may involve conflicts within units, among colleagues, within the organisation, or within the healthcare system (Epstein et al, 2019 ). Indeed, many HCWs have described interpersonal and organisational issues that caused them distress during the COVID-19 pandemic, including working with colleagues who lacked experience in critical care, and feeling unsupported by their organisation when working with inadequate staffing levels, resources and personal protective equipment (Billings et al, 2021 ; Riedel et al, 2022 ; Ritchie et al, 2023 ; Xue et al, 2022 ). Here, our findings are consistent with Dean et al’s ( 2019 ) conceptualisation of MI in healthcare, which emphasised MI as arising from being constrained from acting in line with the interests of a patient due to broken systems that emphasise profit over patient care (Dean et al, 2019 ).…”

“…exposure to actual or threatened death, injury or sexual violence), including intrusion symptoms, avoidance behaviours, negative changes in cognitions and mood and alterations in reactivity (American Psychiatric Association, 2013 ; CIPSRT Glossary of Terms, 2019 ). In addition to PPTEs, HCWs have also faced ethical and moral dilemmas during the pandemic period, including potentially morally injurious events (PMIEs) (Litz, Stein et al, 2009 ), thus heightening risk of developing moral injury (MI) (Billings et al, 2021 ; Litz, Stein et al, 2009 ; Riedel et al, 2022 ; Ritchie et al, 2023 ; Xue et al, 2022 ). PMIEs are described as situations in which an individual: (i) personally violates their moral values by either acting (commission) or failing to act (omission); or (ii) experiences a violation of their morals by the actions or inactions of others, including betrayal by a trusted authority (Litz, Stein et al, 2009 ; Shay, 2014 ).…”

“…PMIEs are described as situations in which an individual: (i) personally violates their moral values by either acting (commission) or failing to act (omission); or (ii) experiences a violation of their morals by the actions or inactions of others, including betrayal by a trusted authority (Litz, Stein et al, 2009 ; Shay, 2014 ). For example, throughout the pandemic period, HCWs reported having to enforce no visitor policies, witnessing patients dying alone, working with inadequate personal protective equipment (PPE), strained working relationships with healthcare leaders and a lack of perceived support from the government as PMIEs (Brophy et al, 2021 ; Hegarty et al, 2022 ; Riedel et al, 2022 ; Ritchie et al, 2023 Xue et al, 2022 ). Indeed, almost 50% of Romanian physicians ( N = 114) reported exposure to a PMIE during the initial months of the COVID-19 pandemic (Maftei & Holman, 2021 ).…”