2023 HSR&D/QUERI National Conference

4053 — Prevalence and Correlates of Moral Injury among a National Sample of VA Healthcare Workers: Implications for Prevention and Mitigation Strategies

Lead/Presenter: Hajra Usman,  San Francisco VA Health Care System
All Authors: Purcell NP (San Francisco VA Healthcare System, Integrative Health and University of California, San Francisco, Department of Social and Behavioral Sciences), Bertenthal D (San Francisco VA Healthcare System, Integrative Health Service) Maguen S (San Francisco VA Healthcare System and University of California, San Francisco) Spetz JE (University of California, Department of Medicine) Hysong S (Baylor College of Medicine, Health Services Research) Usman H (San Francisco VA Healthcare System) Mehlman H (San Francisco VA Healthcare System) Seal KH (San Francisco VA Healthcare System, Integrative Health and University of California, San Francisco, Departments of Medicine and Psychiatry)

Moral injury can result from transgressing one’s values and create lasting guilt and shame that can disrupt one’s self-esteem and daily functioning. Nevertheless, little is known about moral injury in healthcare workers whose jobs can pose high risk. The main aim of this study was to describe the prevalence and correlates of moral injury among a national sample of VA healthcare workers exposed to COVID impacts.

Frontline VA healthcare workers deployed in emergency departments, acute inpatient settings [i.e., intensive care units (ICUs), medical-surgical units, and Community Living Centers (nursing homes)] at VA facilities in the upper quartile of COVID-19 deaths per bed were selected to be included in the study. From 12/10/2021 to 6/1/2022, VA healthcare providers and staff from 21 VA facilities across the U.S. completed a survey about COVID-19 impacts on themselves, their families, and workplaces. They also completed a 9-item validated screen for moral injury, considered positive if two or more of the nine items were endorsed. Chi-square tests described the association between moral injury and self-reported COVID-impacts categorized into (1) individual exposures, (2) occupational/job-related characteristics, and (3) unit/departmental climate; a p-value of 0.05 or less indicated statistical significance.

Of 10,563 VA staff invited, 2,810 completed the survey. Of these, 750 who denied working in a targeted department during the pandemic and 311 lacking complete data were excluded. Of the 1,749 remaining respondents, 1,183 (72.4%) were women; 1,001 (57.2%) were under age 50; and 763 (43.6%) were members of non-White racial/ethnic minority groups. Overall, moral injury was reported in 764 (43.7%). Moral injury was significantly associated with being younger and identifying as being White; yet was not associated with gender. Individual COVID impacts associated with moral injury included having colleagues die from COVID, having higher numbers of patients die from COVID, and frequently needing to deny family visits to critically ill patients. Occupational characteristics associated with moral injury included working as a registered nurse (compared to other occupations, i.e., physician); lacking decision-making authority; endorsing negative impacts of work on family life; and rating one’s work as demanding. Finally, unit and departmental characteristics that were significantly associated with moral injury included working in an intensive care setting; reporting sustained shortages of supplies and personnel; lack of supervisor and/or coworker support; and facility leadership not prioritizing workplace health and safety.

Moral injury was prevalent in this diverse sample of frontline healthcare workers at VA facilities highly impacted by COVID. Moral injury was significantly associated with personal losses such as deaths of colleagues and patients and needing to make decisions conflicting with one’s values. Working in high-exposure occupations with lower autonomy yet high demands on self and family and working in lower-resourced settings with little support from management, supervisors, and colleagues were associated with moral injury.

Moral injury is prevalent in frontline VA healthcare workers during the COVID pandemic. Partnership with national and local VA leadership is needed to raise awareness and develop and implement strategies to mitigate individual and occupational factors associated with the development of moral injury.