Moral injuries threaten our front-line staff

Coping with coronavirus can cause emotional trauma, writes Dr. Patrick Smith.

When COVID-19 hit in earnest in mid-March, governments and health care institutions across Canada scrambled to provide doctors, nurses and other front-line workers with gear to protect them from infection.

But there was little opportunity, in those anxious and chaotic first weeks of the pandemic, to give thought to the other types of injuries being sustained by front-line workers who were required to attend to an onslaught of very sick patients.

First responders have had to make difficult decisions related to life and death triage and resource allocation, some may feel guilty about surviving when others are dying, and many live with fear of becoming infected and infecting their families.

These traumatic events and the resulting feelings, if left unattended, can develop into moral injury, a potentially debilitating condition that challenges a person’s sense of right and wrong and causes individuals to question their actions and the actions of others.

This can leave our front-line workers re-experiencing traumatic situations, feeling guilt, and blaming themselves for COVID-19 consequences. Moral injury is also associated with greater substance use, depression and even suicidal ideation.

Now is the time to address this looming crisis in health care.

Now is the time to reach out to those on the front lines of the disease to let them know the mental anguish is normal and natural, and that help is available. It’s also time to help them realize they are not alone and that leaders and colleagues in their workplaces are there to support them.

In the hope of flattening the curve of moral injury, we at the Centre of Excellence on Post-Traumatic Stress Disorder (PTSD) and Related Mental Health Conditions have teamed up with the Phoenix Australia Centre for Post-traumatic Mental Health to co-develop an online guide called Moral Stress Amongst Healthcare Workers During COVID-19: A Guide to Moral Injury.

It is available now at moralinjuryguide.ca

It is meant for those who are doing jobs in essential service industries — front-line health care workers, of course, but also anyone whose employment may make them susceptible to the mental challenges of the pandemic: the grocery store clerk who must return home to an elderly parent, the receptionist who must tell patients their cancer operations have been postponed, the floor cleaners in the long-term care facilities. All are vulnerable to moral injury.

We call them our “heroes.” But many say they do not feel heroic as they enter their workplaces for another difficult day of potential exposure and, in the case of health care workers, of making decisions about treating a disease no one fully understands with therapies that are not yet proven.

They must be assured that their fears and anxieties are normal responses to an abnormal situation. They need to have the licence to put up their hands and say they are struggling. They need the space to meaningfully and intentionally process what they are going through.

And I use the present tense in discussing the experiences of front-line health care workers because, even though there is a lull in the number of new cases in Canada, hospitals are still treating people with the disease and doctors and nurses are still very much in the eye of the storm.

The obligation to protect them falls on those in charge — the supervisors and administrators who may also be suffering moral stresses and dilemmas of their own as a result of sending workers into dangerous situations. That’s why our guide is also for them. It calls for a whole-of-organization approach and open communication.

We know that workers who believe their bosses and co-workers understand their challenges have significantly better outcomes.

The damage is not inevitable. It is not a fait accompli. It can be mitigated. And now is the time for action. Now is the time that hospitals, clinics, and all health care workplaces and employers can step up to the plate to put the organizational initiatives in place to support our workers and prevent the development of moral injury and/or PTSD as a result of their experiences in these unprecedented times.