Patterns of Potential Moral Injury in Post-9/11 Combat Veterans and COVID-19 Healthcare Workers

Jason A Nieuwsma; Emily C O'Brien; Haolin Xu; Melissa A Smigelsky; VISN 6 MIRECC Workgroup; HERO Research Program; Keith G Meador

doi:10.1007/s11606-022-07487-4

Patterns of Potential Moral Injury in Post-9/11 Combat Veterans and COVID-19 Healthcare Workers

J Gen Intern Med. 2022 Jun;37(8):2033-2040. doi: 10.1007/s11606-022-07487-4. Epub 2022 Apr 5.

Authors

Jason A Nieuwsma^{1

2

3}, Emily C O'Brien⁴, Haolin Xu⁴, Melissa A Smigelsky^{5

6}; VISN 6 MIRECC Workgroup; HERO Research Program; Keith G Meador^{5

6

7}

Affiliations

¹ Integrative Mental Health, Department of Veterans Affairs, Durham, NC, USA. jason.nieuwsma@duke.edu.
² Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA. jason.nieuwsma@duke.edu.
³ VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA. jason.nieuwsma@duke.edu.
⁴ Duke Clinical Research Institute, Durham, NC, USA.
⁵ Integrative Mental Health, Department of Veterans Affairs, Durham, NC, USA.
⁶ VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA.
⁷ Department of Psychiatry and Preventative Medicine, Center for Biomedical Ethics and Society, & Graduate Department of Religion, Vanderbilt University, Nashville, TN, USA.

Abstract

Background: Moral injury has primarily been studied in combat veterans but might also affect healthcare workers (HCWs) due to the COVID-19 pandemic.

Objective: To compare patterns of potential moral injury (PMI) between post-9/11 military combat veterans and healthcare workers (HCWs) surveyed during the COVID-19 pandemic.

Design: Cross-sectional surveys of veterans (2015-2019) and HCWs (2020-2021) in the USA.

Participants: 618 military veterans who were deployed to a combat zone after September 11, 2001, and 2099 HCWs working in healthcare during the COVID-19 pandemic.

Main measures: Other-induced PMI (disturbed by others' immoral acts) and self-induced PMI (disturbed by having violated own morals) were the primary outcomes. Sociodemographic variables, combat/COVID-19 experience, depression, quality of life, and burnout were measured as correlates.

Key results: 46.1% of post-9/11 veterans and 50.7% of HCWs endorsed other-induced PMI, whereas 24.1% of post-9/11 veterans and 18.2% of HCWs endorsed self-induced PMI. Different types of PMI were significantly associated with gender, race, enlisted vs. officer status, and post-battle traumatic experiences among veterans and with age, race, working in a high COVID-19-risk setting, and reported COVID-19 exposure among HCWs. Endorsing either type of PMI was associated with significantly higher depressive symptoms and worse quality of life in both samples and higher burnout among HCWs.

Conclusions: The potential for moral injury is relatively high among combat veterans and COVID-19 HCWs, with deleterious consequences for mental health and burnout. Demographic characteristics suggestive of less social empowerment may increase risk for moral injury. Longitudinal research among COVID-19 HCWs is needed. Moral injury prevention and intervention efforts for HCWs may benefit from consulting models used with veterans.

Keywords: COVID-19; burnout; healthcare workers; moral injury; veterans.

MeSH terms

Burnout, Professional* / epidemiology
COVID-19* / epidemiology
Cross-Sectional Studies
Health Personnel / psychology
Humans
Pandemics
Quality of Life
Stress Disorders, Post-Traumatic* / epidemiology
Stress Disorders, Post-Traumatic* / etiology
Stress Disorders, Post-Traumatic* / psychology
Veterans* / psychology

Grants and funding

COVID-19-2020-001/PCORI/Patient-Centered Outcomes Research Institute/United States