key: cord-0853743-ecnefr42
authors: Hines, Stella E.; Chin, Katherine H.; Levine, Andrea R.; Wickwire, Emerson M.
title: Initiation of a survey of healthcare worker distress and moral injury at the onset of the COVID‐19 surge
date: 2020-07-16
journal: Am J Ind Med
DOI: 10.1002/ajim.23157
sha: d74c638ad8ef01c5186c97fb7cfa52fff66b2b13
doc_id: 853743
cord_uid: ecnefr42

nan

Initiation of a survey of healthcare worker distress and moral injury at the onset of the COVID-19 surge

To the Editor, Medical response to episodes of disaster have been linked to increased healthcare worker (HCW) psychiatric morbidity. A recent study of clinicians caring for patients with coronavirus disease 2019 in China reported high rates of symptoms of depression, anxiety, insomnia, and distress. 1 HCWs working during COVID-19 may face exposure to morally injurious events, such as provision of unsupported medical care or working with insufficient resources or staffing. 2 Moral injury has been defined as the psychological distress that results from actions, or the lack of them, which violate someone's moral or ethical code. 3, 4 Traditionally evaluated in military service members at risk for posttraumatic stress disorder, moral injury might also be experienced by HCWs, particularly in provision of care during periods of heightened workplace stress. Although HCW moral injury has been explored in narrative analysis and scholarly commentary, no study, to our knowledge, has quantitatively measured moral injury outcomes among HCWs. 2, [4] [5] [6] We report initial measurements of self-reported distress and moral injury among HCWs at the onset of the COVID-19 surge in a large academic medical center in Baltimore, Maryland and evaluate their relationships with demographic, occupational and resiliencerelated risk factors.

Participants were recruited via departmental (Medicine, Critical Care, Emergency Medicine) email distribution lists (n = 838). A brief email included a link to an online survey, and a reminder email invitation was delivered 2 days later. The survey period spanned 20 March to 7 April 2020. Participants were asked to confirm that they had read information describing the study and the voluntary nature of participation and electronically selected "I agree" to enter the survey. This study was approved by the Institutional Review Board of the University of Maryland, Baltimore (IRB HP-00090729).

The survey assessed demographics and occupational characteristics (Table 1) After assumptions for a linear regression were evaluated and found to be tenable, two separate hierarchical multiple regression analyses were performed to understand the impact of demographic, occupational, and resilience factors on distress and moral injury. For predictive analyses, sex was restricted to male/female, and proportion of inpatient time and proportion of clinical time were categorized as >50% and <50%. Having been evaluated for normality, resilience items were entered as continuous variables. To avoid confounding, sleep items were removed from the IES-R before predictive analyses. Participants with missing data were excluded from regression analysis. All analyses were performed using IBM SPSS v26.

Two-hundred nineteen respondents completed the survey (26% response rate). Table 1 presents demographic and occupational characteristics of our sample, means of resilience items, and IES-R and MIES total and subscale scores. All IES-R and MIES total scores and subscale scores demonstrated good to excellent internal reliability (IES-R α = 0.80 to 0.91; MIES α = 0.76 to 0.83).

As presented in Table 2 HCW moral injury has been explored in narrative and qualitative data analysis among medical students and deployed military clinicians. 5, 6 To our knowledge, our data are the first to explicitly quantify moral injury among HCW. Moral injury severity was less than that reported in Army National Guardsmen, but similar to scores in military service members exposed to 7-month war zone deployments, particularly in the reporting of betrayals by others. 10, 12 Further, moral injury scores were significantly associated with sleep disturbance and proportion of inpatient clinical time, but not with other occupational or demographic factors.

The primary limitation to our study is that our use of a convenience sample limits external validity, as we cannot exclude nonresponse bias. Our sample was obtained using readily accessible listservs targeting internal medicine, emergency medicine, and critical care providers. This may either over-or under-estimate distress levels and the extent of moral injury and limit application of our findings to a broader population working during the COVID-19 pandemic. Future studies should seek to replicate these findings among a more diverse sample of HCWs and to examine moral injury and distress over time. Finally, because sleep is a modifiable target for prevention and intervention, future research should examine the potential benefit of resilience training, including sleep enhancement, to improve outcomes among HCW.

We have surveyed the same population at 4 and 12-week intervals to determine how responses change during evolution of the pandemic. Trajectories of distress and moral injury will provide important insight into opportunities to restore physician wellness. Score range 9 to 54 (higher = more moral injury).

i Each MIES subscale max score range 1 to 6, where 1 = no moral injury, 6 = more moral injury.

T A B L E 2 Summary of hierarchical regression for variables predicting impact of events scale-revised (IES-R) (n = 164) and total moral injury event score (MIES) 9-item (n = 161)

Variable IES-R model MIES (9-item) model

Step Note: IES-R: R2 = 0.044 for step 1(P < .05); ΔR2 = 0.075 for step 2 (P < 0.05); ΔR2 = 0.191 for step 3 (P < .01) MIES (9-item): R2 = 0.052 for step 1(P < .05); ΔR2 = 0.049 for step 2 (P > .05); ΔR2 = 0.111 for step 3 (P < .01) Abbreviation: ICU, intensive care unit. * P < .05 ; ** P < .01.

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