Abstract
Health care providers who experienced giving care or abbreviating those services, during the COVID-19 pandemic, risked experiencing a sense of moral injury. Moral injury is a term to describe incidents where a health care provider knows the right thing to do, but constraints make it exceedingly difficult or impossible to execute the right course of action. These incidents likely also were present for sonographers and vascular technologists, and it is vital that these compromises for patients are recognized, and healing strategies offered to those suffering from moral injury. Some suggestions for treatment of moral injury are to recognize these experiences, seek solutions, provide empathy for patients and resources for health care providers. It may also be beneficial to allow employees and employers to forgive the mistakes made during the pandemic and focus on solutions to prevent future incidents of moral injury.
To say that sonographers, vascular technologists, and physician’s using sonography had a great fall is an understatement. The COVID pandemic pushed our sonography workforce into providing care for those afflicted with the virus, as well as continuing to care for those with non-COVID health care needs. The unprecedented need to provide all levels of health care fell on our sonography workforce without warning and has had long-term consequences, for many of our colleagues. The push to ask our colleagues to provide heroic measures for patients and ration the kind of care provided was unsustainable. 1 In our recently published qualitative research article, we focused on the lived experience of some of our colleagues providing care during the pandemic; it was noted that expressions of lingering trauma were evident. 2 At the time of data analysis, these expressions were coded as posttraumatic stress disorder (PTSD); as more health care workers have been studied regarding their COVID pandemic health care experience, it appears that PTSD may not be the proper label for what has occurred. In addition, the code used to highlight difficulties providing the intended care to patients was coded as “Care Limits.” In an article by Svoboda, she poses that what we coded as PTSD and Care Limits should be considered moral injury. 3 The term moral injury has been used to describe incidents where a provider knows the right thing to do, but constraints make it exceedingly difficult or impossible to execute the right course of action. 4 In the health care workplace, many providers were asked to make spontaneous decisions on the manner in which to dispense care to patients. 1 The confounding factors that contributed to these decisions of how and to whom to provide health care have been attributed to the supply chain, federal, state, local, and hospital enterprise mandates and reversal of standard operating procedures. This placed a variety of health care providers in the position of providing care that was in conflict with accepted practice norms. The downstream effect of these conflicted health care practices resulted in providers feeling that they had been subjected to moral injury. Moral injury has been associated with low job satisfaction, intention to leave one’s profession, burnout, PTSD, and suicidal ideation. 5 Recent research shows that health care workers who were exposed to adverse psychosocial work factors, including low job control and low support from supervisors, were significantly more likely to experience moral injury during the COVID-19 pandemic. 6 Burnout has also been shown to be associated with musculoskeletal symptoms in health care workers, as has low job satisfaction, low job control, and low support from supervisors.7,8 Moral injury is a relatively new outcome of concern in health care workers. In many ways, the experience of an individual suffering from moral injury differs from that of an individual suffering from PTSD, and therefore, a different clinical and therapeutic approach should be taken in their treatment. 9
All the King’s Horses and All the King’s Men
It has been extensively documented that work-related musculoskeletal injuries have plagued sonographers, vascular technologists, and physicians using sonography for decades. 10 As deleterious as these physical injuries are to our workforce, the toll of work-related cognitive stress is equally important to highlight. The pandemic certainly had an effect on the physical aspect of sonography, but it also now is apparent that the cognitive load may have led to some forms of moral injury. Currently, employers are focused on providing some types of physical relief such as chair massages, flexible work schedules, and so on, to attend to the physicality of the work, but the question remains of what kinds of efforts need to be extended to assist those suffering from moral injury. For a start, the population affected with this moral injury needs to be identified. This identification is vital and several survey scales have been used for this purpose. 11 In a recent study of health care workers suffering from moral injury as a result of decisions they made during the pandemic, 19% responded that they had acted in ways that violated their personal moral code or values and 45% indicated that they felt betrayed by their trusted leaders. 12 In our sonography workforce this damage has likely also occurred, and it important that we rebuild trust and support for these health care workers.
Given the coding of the survey data by using qualitative codes PTSD and Care Limits, it was important to go back and review these specific comments. The purpose was to tease out the actual comments and look for evidence of moral injury, specific to this sonography user cohort. Upon re-analysis of the comments provided, the following examples underscore that moral injury has likely occurred. Here are some examples:
“As far as doing cardiac imaging during COVID, as you probably know we are looking very closely at the coronary arteries, which are small. So, masking up and donning all the PPE required to enter the room results in two layers (which) fogged up my glasses because I overheat so badly! Frankly, when your entire job depends on what you see, you feel defeated before you even get started.”
“Since COVID, this job has really challenged my mental health to the point I needed to see a therapist, to help with my stress management. I know the survey is focused on mostly physical health, but I think the question of how healthy are you should be a two-part: How physical and mentally healthy are you?”
“I think in general; the past 20 months has been the most stressful, exhausting, and depressing time in my 30-year medical career. I am managing but I don’t know how much longer. Just hiding behind a mask every day is taking an emotional and physical toll on me.”
“In my institution, I no longer perform an extensive 120 clip fetal echo on a patient who is morbidly obese and difficult to image. I abbreviate my study to identify the basic anatomy requirements per accreditation. If I cannot get those images within a reasonable amount of scan time, I document “not well visualized” in the report.”
It will take all our efforts to attend to both the physical and mental injuries that have occurred, as a result of the work that was required during the pandemic. Occupational safety professionals, as well as health care personnel managers and administrators, need to understand this area of concern, which is associated with other more familiar adverse outcomes in health care workers. Addressing psychosocial risk factors that are associated with burnout and musculoskeletal symptoms in health care workers takes on more urgency given the linkage between psychosocial risk factors and moral injury. Employers need to recognize that it may take institutional changes within hospital systems to avert situations that result in asking health care workers to make unprecedented moral decisions. It has been suggested that internal audits review ways to improve the delivery of care are needed and not to just perpetuate the current delivery method. 3 Although the rate of patient admissions due to COVID has decreased slightly in areas, this has not solved the crisis as many health care providers who are suffering physical and mental injuries are leaving or have left the workforce, escalating the load for those left behind. 13 We have to repair the health care system, institutions, and policies to make sure workers can manage the demand for services while mitigating injury of all types. We cannot expect health care workers to carry a physical and mental load that elicits moral distress.
We Can Put Ourselves Back Together Again!
Therapies to address this form of mental stress emphasizes the importance of moral reckoning and encourage health care workers to accept that bad things have happened. The kinds of treatments that Litz et al suggested is that clients need to accept the depth of inhumanity in the world rather than attempt to blot out awareness of that inhumanity. 14 The development of scales to measure the level of moral injury have been used from Litz’s work to address the documentation and need to treat front line health care workers. Out of this push to assist health care workers cope with the traumatic experiences that they experienced, some practical tips have been put forward. Williams et al advocated that those workers who feel traumatized from providing care during COVID-19 should practice the following: 15
Recognize stress, feelings of pressure to perform, and the need for self-sacrifice. It is important for department managers and co-workers to share their experiences and help workers to feel that this is not a unique set of feelings.
Determine when 2 ethical principles are coming into conflict and seek assistance to solve these dilemmas.
Foster empathy with patients despite the constraints of PPE and other physical barriers. Inventing new ways to connect with patients and provide care can by empowering.
Seek out resources that will allow each sonographer, vascular technologist, and physician to obtain some personal repair to their confidence and regain a sense of resilience.
Based on this listing, it is important that employers understand what has occurred during the COVID-19 pandemic and seek to provide employees with this vital resource and support. The lack of senior sonographers, vascular technologists, and experienced physicians will have devastating consequences on our health care system. It is important to take care of our workforce to be able to continue providing exceptional care! It will rely on deep cooperation between administrations and health care workers to truly overcome all of the issues and injuries that the pandemic brought to our health care system. It is up to every sonographer to advocate for fair and just working conditions for themselves and their peers, and it is up to hospital administrations to be accommodating.
Conclusions
It is also important to highlight the benefits of forgiveness, by current health care workers, as they interact with their administrations, as part of the healing from moral injury. One of the most effective tools to recover from moral injury is forgiveness according to Brémault-Phillips et al. 16 An important part of moral injury is that you feel you are the guilty person but circumstances forced you to do to things that you regret, as well as those things that happened to you. It is important to start by forgiving yourself and understand that you did the best that you could, given the circumstances. When the health care worker is able to put themselves in the role of the administrator and realize that they were underprepared to make tough decisions during the pandemic, it may make this forgiveness process easier. It is also important for administrations to put themselves in the role of their employees and realize the moral hardships they went through, during the pandemic to provide care. Allowing both groups to experience forgiveness and healing, due to experiencing moral injury, is how the workplace and patient care can be made stronger. The process of healing from moral injury is not an overnight endeavor but is an important one to emphasize and make continual efforts. In the not-so-distant future, we can have better workplace conditions than even before the pandemic if we navigate this healing and rebuilding process correctly.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
