Mental health of health workers remains a major concern following pandemic
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Key takeaways:
- Moral injury can affect burnout and turnover rates of health care workers, as well as patient quality of care.
- PTSD prevalence was more than threefold higher among physicians than the general population.
The COVID-19 pandemic had a great impact on the health care system and the well-being of health care professionals, the effects of which are still felt today.
In one of two new studies investigating the consequences of these impacts, researchers examined how the pandemic triggered moral injury among health care workers, defined as “psychological distress following events where actions transgress moral beliefs/expectations.”
In a second study, researchers found a strikingly higher prevalence of PTSD in a physician population.
Incidence, impact of moral injury
Health care workers reported high prevalence of moral injury during the pandemic, especially if they worked in group care settings and with patients with confirmed or suspected COVID-19, according to a study published in PlosOne.
“Moral injury is a relatively new in terms of clinical research,” Arielle Scoglio, PhD, assistant professor of health studies at Bentley University in Massachusetts, told Healio. “It was first identified in military veterans and only recently has been considered in a health care context. The experience of the COVID-19 pandemic brought with it a lot of uncertainty and unfortunately made for moral dilemmas among health care workers.”
Such dilemmas include high-stakes scenarios involving dying patients who are unable to connect with family members, unethical health care practices and the need for triaging, according to the researchers.
Given increasing rates of turnover and attrition within the nursing field, Scoglio and colleagues utilized a Total Worker Health framework — which considers contextual factors, worker characteristics and homelife, organizational policies and workplace conditions — to explore what factors led to moral injury among 14,516 participants (white, 96.1%; women, 98.9%) from three prospective cohorts of registered nurses, licensed practical/vocational nurses, nursing students and other health care workers.
Participants completed an initial mixed-methods survey between May 2020 and August 2020 followed by additional questionnaires.
Of the participants, 9.9% reported moral injury.
Those who worked in a group care setting showed 41% (OR = 1.41; 95% CI 1.13-1.76) higher odds of reporting moral injury compared with inpatient workers. In contrast, those who worked in outpatient settings (OR = 0.63; 95% CI 0.56-0.71), school clinics (OR = 0.32; 95% CI 0.17-0.58) or home health (OR = 0.64; 95% CI 0.47-0.88) reported significantly lower odds of moral injury compared with those working in inpatient settings.
Odds of moral injury also appeared significantly higher when working with patients with confirmed (OR = 1.76; 95% CI 1.46-2.11) or presumed (OR = 1.94; 95% CI 1.67-2.25) COVID-19, as well as when participants had inadequate personal protective equipment (OR = 2.53; 95% CI 2.11-3.03).
Odds of moral injury decreased 16% (OR = 0.84; 95% CI, 0.8-0.88) for every decade older in age.
Although researchers noted the subset was limited by a less diverse set of participants, they found that Black-identified participants reported nearly two times higher odds of moral injury (OR = 1.91; 95% CI, 1.16-3.16).
Additional qualitive findings from a cohort of 95 participants who reported moral injury in the first surveys showed rapidly changing policies, increased exposure to COVID-19, and fear or retribution for speaking out were among factors that increased moral injury, according to the researchers. Interpersonal conflicts included bullying, unsupportive supervision, and witnessing unethical or discriminatory conduct.
“It was striking to hear the ways that health care workers were instructed to implement COVID-19 containment or mitigation policies that felt to them like bad patient care, such as separating newborn babies from COVID-positive moms, and how they also felt that they might be punished for speaking up,” Scoglio said.
Moral injury can affect the quality of patient care and retainment of health workers, according to the researchers, with some workers reporting looking for new jobs in health care or leaving the field entirely.
“In the aftermath of the COVID-19 pandemic, we continue to see burnout and high turnover among health care workers,” Scoglio added. “It is imperative to take care of health care workers’ mental health and well-being, to ensure a continued and robust health care workforce which can meet the demands of patient care.”
Extreme levels of stress
During the COVID-19 pandemic, 18.3% of physicians reported symptoms consistent with PTSD, with variation by specialty and higher risks found among trainees, women and older physicians, according to a meta-analysis published in JAMA Open Network.
“We previously studied physician mental health visits during COVID-19 and observed a 27% increase in the year immediately following the onset of the pandemic,” Manish M. Sood, MD, assistant professor of medicine at the University of Ottawa, told Healio.
Sood and colleagues conducted a systematic review and meta-analysis of 57 studies evaluating PTSD among physicians using validated questionnaires, which involved 28,965 participants across 25 countries.
Overall, the estimated pooled prevalence of PTSD was 18.3% (95% CI, 15.2-22.8).
Among the 14 studies that reported sex, female physicians were significantly more likely to develop PTSD compared with male physicians (OR = 1.93; 95% CI, 1.56-2.39).
Sixteen studies reported career stage, showing that medical trainees were also significantly more likely to develop PTSD (OR =1.33; 95% CI, 1.12- 1.57).
In addition, eight of the 10 studies that differentiated PTSD by age found that PTSD was more prevalent among older clinicians.
Multiple studies found a differentiation in specialty and PTSD frequency. The mean PTSD prevalence appeared highest for family medicine (31.2%), emergency medicine (23.4%), otolaryngology (23%) and surgery (22.4%).
“The primary results were higher than we anticipated,” Sood explained. “Finding that PTSD was nearly twice as likely in women compared to men was also surprising.”
Overall, compared with earlier data, the researchers found that PTSD prevalence in physicians from this analysis was more than three times higher than that of the general population and the physician population before the COVID-19 pandemic.
“In forthcoming studies, I would like to see randomized trials of early support/access to mental health care for physicians vs. no additional care in high-risk situations for developing PTSD,” Sood added. “Now in future pandemics, we should anticipate PTSD will occur in physicians and offer support and interventions early and often.”
References:
- Kamra M, et al. JAMA Netw Open. 2024;doi:10.1001/jamanetworkopen.2024.23316.
- Scoglio A, et al. PlosOne. 2024;doi:10.1371/journal.pone.0304620.