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

ABSTRACT

Background: Healthcare workers (HCWs) across the globe have reported symptoms of Post-Traumatic Stress Disorder (PTSD) during the COVID-19 pandemic. Moral Injury (MI) has been associated with PTSD in military populations, but is not well studied in healthcare contexts. Moral Distress (MD), a related concept, may enhance understandings of MI and its relation to PTSD among HCWs. This study examined the independent and combined impact of MI and MD on PTSD symptoms in Canadian HCWs during the pandemic.

Methods: HCWs participated in an online survey between February and December 2021, with questions regarding sociodemographics, mental health and trauma history (e.g. MI, MD, PTSD, dissociation, depression, anxiety, stress, childhood adversity). Structural equation modelling was used to analyze the independent and combined impact of MI and MD on PTSD symptoms (including dissociation) among the sample when controlling for sex, age, depression, anxiety, stress, and childhood adversity.

Results: A structural equation model independently regressing both MI and MD onto PTSD accounted for 74.4% of the variance in PTSD symptoms. Here, MI was strongly and significantly associated with PTSD symptoms (β = .412, p < .0001) to a higher degree than MD (β = .187, p < .0001), after controlling for age, sex, depression, anxiety, stress and childhood adversity. A model regressing a combined MD and MI construct onto PTSD predicted approximately 87% of the variance in PTSD symptoms (r² = .87, p < .0001), with MD/MI strongly and significantly associated with PTSD (β = .813, p < .0001), after controlling for age, sex, depression, anxiety, stress, and childhood adversity.

Conclusion: Our results support a relation between MI and PTSD among HCWs and suggest that a combined MD and MI construct is most strongly associated with PTSD symptoms. Further research is needed better understand the mechanisms through which MD/MI are associated with PTSD.

HIGHLIGHTS

• MI and MD were each independently associated with PTSD symptoms (including dissociation), when controlling for sex, age, childhood adversity, depression, anxiety and stress.

• Combining both MI and MD constructs into a single latent variable accounted for the greatest proportion of variance explained in PTSD symptoms among HCWs during the COVID-19 pandemic.

• Results suggest that expanding the construct of MI to include team and systemic organisational MD may be appropriate in the healthcare context.

Antecedentes: Trabajadores sanitarios (HCWs, en sus siglas en inglés) de todo el mundo han manifestado síntomas de trastorno de estrés postraumático (TEPT) durante la pandemia de COVID-19. El daño moral (MI, en sus siglas en inglés) se ha asociado a poblaciones militares, pero no se ha estudiado bien en contextos sanitarios. La angustia moral (MD, en sus siglas en inglés), un concepto relacionado, puede mejorar la comprensión del MI y su relación con el TEPT entre los HCWs. Este estudio examinó el impacto independiente y combinado de la IM y la DM sobre los síntomas de TEPT en los HCWs canadienses durante la pandemia.

Métodos: Los HCWs participaron en una encuesta en línea entre febrero y diciembre de 2021, con preguntas sociodemografícas, salud mental y antecedentes de trauma (por ejemplo, MI, MD, TEPT, disociación, depresión, ansiedad, estrés, adversidad infantil). Se utilizó un modelo de ecuaciones estructurales para analizar el impacto independiente y combinado del MI y la MD sobre los síntomas de TEPT (incluida la disociación) entre la muestra cuando se controló el sexo, la edad, la depresión, la ansiedad, el estrés y la adversidad infantil.

Resultados: Un modelo de ecuación estructural que regresionaba de forma independiente tanto el MI como la MD sobre el TEPT explicaba el 74,4% de la varianza en los síntomas del TEPT. Aquí, el MI se asoció fuerte y significativamente con los síntomas de TEPT (β = 0,412, p < 0,0001) en mayor grado que la MD (β = 0,187, p < 0,0001), después de controlar la edad, el sexo, la depresión, la ansiedad, el estrés y la adversidad infantil. Un modelo de regresión de un constructo combinado de MD e MI sobre el TEPT predijo aproximadamente el 87% de la varianza en los síntomas de TEPT (r² = 0,87, p < 0,0001), con MD/MI fuerte y significativamente asociado con el TEPT (β = 0,813, p < 0,0001), después de controlar la edad, el sexo, la depresión, la ansiedad, el estrés y la adversidad infantil.

Conclusión: Nuestros resultados respaldan la relación entre el MI y el TEPT entre los HCWs y sugieren que un constructo combinado de MD y MI se asocia más estrechamente con los síntomas de TEPT. Se necesitan más investigaciones para comprender mejor los mecanismos a través de los cuales MD/MI se asocian con el TEPT.

KEYWORDS:

• Post-traumatic stress disorder
• moral injury
• moral distress
• healthcare workers
• COVID-19

PALABRAS CLAVE:

• Trastorno de estrés postraumático
• daño moral
• angustia moral
• personal sanitario
• COVID-19

Acknowledgements

We thank all Canadian HCWs who served at the forefront of the COVID-19 pandemic, and we are grateful to those who participated in this study. The authors recognise and acknowledge that this work was conducted on the traditional territories of the Mississauga and Haudenosaunee nations, and within the lands protected by the Dish with One Spoon wampum belt agreement.

Data Availability Statement

The data used in this study come from the McKinnon Trauma and Recovery Research Unit at McMaster University. All interested researchers may apply for access to these data through online application subject to review by the Data Access Committee, ethics approval, and signing of a data sharing agreement. Data are provided only once a data sharing agreement is in place between McMaster University (the custodian of the data) and the researchers’ institution. For more information about data access please contact https://www.thetraumaandrecoverylab.com/contact.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This research was supported by a contract to McMaster University from the federally funded Atlas Institute for Veterans and Families, a generous donation from Homewood Health Inc. to Homewood Research Institute, a grant from the Canadian Institutes of Health Research (grant number MVP-171647) to MCM and RL, and a grant to MCM from the Public Health Agency of Canada. MCM is supported as the Homewood Chair in Mental Health and Trauma at McMaster University. RL is supported as the Harris-Woodman Chair in Psyche and Soma at Western University of Canada. A.M.D’A-L is supported by the CIHR Canada Doctoral Graduate Scholarship (#493412), the Horne Family Memorial Fellowship in Post-Traumatic Stress Injury and Recovery Fellowship, and the Research Institute of St. Joe's Hamilton Studentship Award.