My name is Niek Kok. I am a PhD student in Clinical Ethics at the Radboud University Medical Center in Nijmegen, The Netherlands. During the COVID-19 pandemic, professionals working on intensive care units may have been at risk of what is known as moral injury. To uncover whether this is indeed the case, my colleagues and I have interviewed ICU professionals since the start of the COVID-19 pandemic in The Netherlands. Our study has been accepted by Critical Care Medicine, and today we would like to highlight to you some of our results. But first I will have to say something about what I am referring to with the term moral injury. Moral injury is a lasting character wound which results from acts of transgression that violate core beliefs about right and wrong. As an example, we may take an ICU nurse who has taken care of more than two patients during one shift. And due to having to take care of the other patients, the nurse fails to be present when one of the patients dies. Her patient dies alone, as no family was allowed to visit due to the COVID-19 restrictions. And this situation violates the nurse's core beliefs about what a right sort of death is like. The nurse feels she has failed the patient and has a lasting sense of guilt about the situation. As a concept, moral injury originated in the literature on military trauma. Within healthcare, we usually speak about moral distress. During the COVID-19 pandemic, however, experts expressed worries that moral distress in medicine would be amplified, leading to moral injury. These worries were mainly expressed in editorial pieces and letters to journals, some of which you can see here. We noticed, however, that there were not many empirical studies addressing moral injury in healthcare workers. And while much is known about moral distress in healthcare and much is known about moral injury in military personnel, not much is known about how moral injury actually develops in ICU professionals. Prior to the COVID-19 pandemic, my research team and I started on a study on moral distress and burnout among ICU professionals. Moral distress differs from moral injury. Moral distress is experienced when an ICU professional is constrained from doing what he or she believes is the right thing to do. But unlike moral injury, moral distress does not necessarily have to have a lasting impact on the individual. So while moral injury is lasting, moral distress is episodic. The distress may fade over time. At the same time, there is also overlap between moral distress and moral injury. Both are characterized, for instance, by feelings of guilt. And lastly, both moral injury and moral distress have also been likened to burnout, which is a work-related syndrome defined by high emotional exhaustion, a high level of depersonalization, and a reduced sense of personal accomplishment. Based on the literature, we created this Venn-shaped diagram, which shows the way in which the symptoms of moral injury, here seen in the bottom, overlap with both moral distress, which is in the top left, and burnout, in the top right. And we can see that some of the symptoms of moral distress and moral injury overlap, such as guilt, shame, and a sense of betrayal. At the same time, there are some symptoms of burnout and moral injury which overlap, such as detachment and depersonalization. Based on the literature, we can add that if an ICU professional accumulates a lot of moral distress, this may lead to burnout or moral injury, or perhaps even both. The Venn diagram means to show that the distinction between moral distress, moral injury, and burnout is not straightforward. They are not easily recognized apart from each other. And this is problematic, because a morally injured professional may need different support compared to a morally distressed professional or a professional who suffers from a burnout. Now, as a team, we set out to study morally injurious experience among the ICU professionals in our own department. We asked whether moral injury developed among ICU professionals during the pandemic, and if it does, how does this happen, and when does this happen? To answer our question, we conducted a qualitative study. We serially interviewed 26 ICU professionals, among which were intensivists, residents, and ICU nurses. These were semi-structured interviews, which we recorded and transcribed, and subsequently, we coded the transcripts with moral injury as a theoretical focus. During the interviews, we asked the professionals how they were doing, and what sort of challenges and dilemmas they faced. Whenever professionals described specific situations, we asked what happened, how they acted, and how the situation made them feel. And during the follow-up interviews, we returned to the earlier described situations, and we assessed how ICU professionals felt about the situation when looking back. This figure shows the amount of new ICU admissions per day in the Netherlands from February 2020 to May 2022. In this period, we conducted three rounds of interviews. The first took place right at the peak of the first surge of COVID-19 patients. The second round took place when the second surge was in full swing in November 2020, and the last round of interviews took place in the summer of 2021. 26 ICU professionals participated in this study. They are shown in this figure, where you can also see the time points at which each professional participated, which are indicated by the black dots. You can see that we started the study with 16 professionals, most of whom we were able to interview three times. We sampled these professionals with an eye to maximum variation, because we wanted to include an equal number of professionals from all groups of intensivists, residents, and ICU nurses. In the second round of interviewing, we included another nine professionals, of whom all, except one, participated in the last interview as well. These nine professionals were sampled as most likely cases of being at risk for moral injury, based on the data that we had already collected in the first round of interview. Finally, in the last round, we added one more professional who was a resident, due to many residents dropping out of our sample. Having analyzed all interviews, we identified six themes, which you can see on this slide. First of all, ICU professionals indicated that they had to anticipate life and death decisions, and that this made them very anxious about the future. Secondly, ICU professionals recounted about knowledge deficits regarding treatment of COVID-19 patients. Third, ICU professionals also told us about feelings of powerlessness and failure during the care process. Then, in later interviews, mostly at six and 12 months, ICU professionals started to talk about feeling abandoned and betrayed by society, politics, or one's own healthcare organization. A fifth theme, which we identified, revolved around feelings of detachment toward patients and families, and this detachment grew slowly larger during the COVID-19 pandemic. Lastly, ICU professionals told us about feelings of disorientation about one's own feelings and attitudes, which slightly changed during the COVID-19 pandemic, and which made them feel alienated from themselves. I will discuss each of these themes in the chronological order in which they appeared during our study, and I will illustrate some of them with quotes from interviews. This figure shows the timeline of our study, starting in April 2020, and with the last interviews taking place in May 2021. I will place all of our themes in chronological order in this figure. And well, first, ICU professionals expressed anticipatory anxiety about having to make life and death decisions in the case that the number of COVID-19 patients would exceed the number of available beds. These feelings were mainly present during the first surge of the pandemic. These feelings of anticipatory anxiety are illustrated by this quote from an intensivist, who tells us that triaging patients in the event of full bed occupancy was a subject he obsessed over and he greatly feared. He worried that it would become a terrible affair. During the first surge of COVID-19 patients, ICU professionals also experienced knowledge deficits regarding the treatment of COVID-19 patients. These deficits sometimes led to feelings of powerlessness or failure. Powerlessness and failure were, moreover, incited by all sorts of situations in which ICU professionals were constrained from doing what is right. One example of this powerlessness was this case of an ICU nurse who describes a situation in which she was in a room with a patient and the family was outside of the room looking into the room. And she describes that there was nothing she could do for the patient. The family was outside looking in and it felt to her as if the family said to her do something, but she just wasn't able to help the patient. The second round of interviewing, in November 2020, ICU professionals started to express that they sometimes felt abandoned or even betrayed by society, politics and in some cases even the hospital in which they worked. By this I mean that ICU professionals worried that the Dutch public no longer thought of COVID-19 as a serious disease. With regards to politics, mainly nurses felt that their efforts were not appreciated and that they were seen as dispensable. Lastly, with regard to their own hospital, several ICU professionals indicated that they worried the hospital did not always put their safety first. In later interviews then, ICU professionals started to describe that they were increasingly becoming indifferent towards patients and families and in some instances their own colleagues. They described this as a way of coping with the situation. An example is this intensivist who described in the first interview his great worries about triage. But in that 12-month interview he told us that that terrible feeling of having to decide who can be admitted to the ICU and who cannot had weakened. It had become, in his words, just another thing you would have to do. These feelings of detachment directly countered previous feelings of powerlessness, abandonment and betrayal. And as detachment grew, these previously felt negative experiences weakened. All of this led to some feelings of disorientation among ICU professionals. The detachment created a sense of self-alienation because whenever ICU professionals stated to us in interviews that they felt they were becoming indifferent, they immediately added that this was not who they were or who they wanted to be as healthcare professionals. Here is an example of one intensivist who told us that she felt increasingly cynical towards COVID-19 patients who had not abided by the COVID-19 restrictions. This intensivist immediately added that you do not want to be cynical as a physician. And she said that this fact alone made her feel ashamed of herself. Now it is mainly in the feelings of abandonment, betrayal, detachment and disorientation that we find evidence of moral injury developing. These signs have previously been identified as signs of moral injury in the literature. And it is also these signs which may in the longer term have a profound impact on ICU professionals. To wrap up, we have repeatedly interviewed ICU professionals during the COVID-19 pandemic about potentially morally injurious experiences. We concluded that several ICU professionals show signs of moral injury in the form of feelings of betrayal, detachment and disorientation. This does not mean, however, that we can tell for sure that moral injury has developed. Moral injury is, after all, a lasting character wound which ICU professionals may come to struggle with years after the COVID-19 pandemic. A longer study timeframe, perhaps of 5 or 10 years in the future, is necessary to assess how ICU professionals look back on their experiences during the COVID-19 pandemic. For now, what is essential is that healthcare organizations should continue to monitor signs of moral injury among their personnel. Moral injury may yet develop, and if the signs remain unaddressed, ICU professionals may fall into alienation and isolation. In our view, healthcare organizations should do three things. First of all, they should emphasize to their healthcare workers that moral injury is not a disease or a disorder. It is a normal human response to extraordinary circumstances. Secondly, healthcare organizations should facilitate discussions among ICU professionals or potentially other healthcare workers about the potentially morally injurious experiences. It is important for these professionals themselves as well to be able to recognize the signs of moral injury. Third, healthcare organizations should proactively explain to healthcare workers why the organization has had to make some tough moral choices during the pandemic and potentially in future pandemics. We can think, for instance, of the choice to restrict families from visiting patients. I would like to thank you for your attention, and if you have any queries regarding the article, feel free to contact me.

moral injury

ICU professionals

COVID-19 pandemic

Netherlands

healthcare organizations