Moral Injury: A Challenge for Healthcare Workers During the Pandemic and Beyond

Background: Suppression of negative, uncomfortable emotions can lead to moral injury, resulting in emotional, behavioral, and social issues, as well as mental health conditions such as depression and post-traumatic stress disorder. During the COVID-19 pandemic, the concept of moral injury-typically associated with conflict situations—has gained increased attention. Objectives: This study aimed to assess the prevalence of moral injury during the pandemic and its correlation with psychological distress. Methods: Between December 2020 and January 2021, we evaluated the frequency of depression, anxiety, and stress, and their correlation with moral injury in 333 medical interns, residents, and nurses. We used validated versions of the Moral Injury Symptom Scale-Healthcare Professionals (MISS-HP) and the Depression Anxiety Stress Scale (DASS-21). Results: The study included 333 medical professionals, most of whom were aged 26 - 30. Clinically significant moral injuries were observed in nearly half of the participants. Women had higher average scores for stress and anxiety compared to men. A lack of personal protective equipment (PPE) at the workplace was associated with increased depression, anxiety, and stress. Nurses reported higher levels of depression, anxiety, and stress than other healthcare professionals. Additionally, there was a significant positive correlation between moral injury and symptoms of depression, anxiety, and stress. Female participants experienced higher rates of moral injury than male participants, and single individuals reported more suffering than married ones. Moral injury was notably higher among nurses compared to other healthcare professionals. Conclusions: The study found that healthcare professionals experienced anxiety, stress, depression, and moral injury during the COVID-19 pandemic. Moral injury was strongly associated with increased stress, worry, and depression. Female healthcare professionals exhibited higher levels of anxiety and stress, while being married appeared to offer some protection against depression. Nurses were particularly vulnerable, with end-stage patients and insufficient resources contributing to elevated levels of anxiety, stress, and moral injury.