Moral injury and peri- and post-military suicide attempts among post-9/11 veterans

Background Our goal was to examine the association between moral injury, mental health, and suicide attempts during military service and after separation by gender in post-9/11 veterans. Methods A nationally representative sample of 14057 veterans completed a cross-sectional survey. To examine associations of exposure to potentially morally injurious events (PMIEs; witnessing, perpetrating, and betrayal) and suicidal self-directed violence, we estimated two series of multivariable logistic regressions stratified by gender, with peri- and post-military suicide attempt as the dependent variables. Results PMIE exposure accounted for additional risk of suicide attempt during and after military service after controlling for demographic and military characteristics, current mental health status, and pre-military history of suicidal ideation and attempt. Men who endorsed PMIE exposure by perpetration were 50% more likely to attempt suicide during service and twice as likely to attempt suicide after separating from service. Men who endorsed betrayal were nearly twice as likely to attempt suicide during service; however, this association attenuated to non-significance after separation in the fully adjusted models. In contrast, women who endorsed betrayal were over 50% more likely to attempt suicide during service and after separation; PMIE exposure by perpetration did not significantly predict suicide attempts before or after service among women in the fully adjusted models. Conclusions Our findings indicate that suicide assessment and prevention programs should consider the impact of moral injury and attend to gender differences in this risk factor in order to provide the most comprehensive care.

Moral injury and well-being in essential workers during the COVID-19 pandemic: local survey findings

BackgroundEssential workers have faced many difficult situations working during the pandemic. Staff may feel that they, or other people, have acted wrongly and be distressed by this. This represents moral injury, which has been linked with significant mental ill health.MethodsThis survey asked essential workers in County Durham and Darlington about their experiences during the first wave of the pandemic and anything they felt would help. Well-being and moral injury were rated using sliders.ResultsThere were 566 responses. A majority of respondents reported feeling troubled by other people’s actions they felt were wrong (60% scored over 40, where 0 is ‘not at all troubled’ and 100 ‘very troubled’, median score=52.5). Respondents were generally less troubled by their own actions (median score=3). Well-being and moral injury scores varied by employment sector (eg, National Health Service (NHS) staff were more troubled by the actions of others than non-NHS staff).Staff suggestions included regular supervisor check-ins, ensuring kindness from everyone, fair rules and enforcement and improving communication and processes. Respondents offered simple, practical actions that could be taken by leaders at team, organisation, societal and governmental levels to tackle moral injury and the underlying causes of moral injurious environments.ConclusionUsing these findings to develop a strategy to address moral injury is important, not only for staff well-being, but staff retention and continued delivery of vital services in these challenging times. Working together, we can seek to reduce and mitigate ‘moral injury’ the same way we do for other physical workplace ‘injuries’.

Moral Injury, Traumatic Stress, and Threats to Core Human Needs in Health-Care Workers: The COVID-19 Pandemic as a Dehumanizing Experience

The pandemic has threatened core human needs. The pandemic provides a context to study psychological injury as it relates to unmet basic human needs and traumatic stressors, including moral incongruence. We surveyed 1,122 health-care workers from across the United States between May 2020 and August 2020. Using a mixed-methods design, we examined moral injury and unmet basic human needs in relation to traumatic stress and suicidality. Nearly one third of respondents reported elevated symptoms of psychological trauma, and the prevalence of suicidal ideation among health-care workers in our sample was roughly 3 times higher than in the general population. Moral injury and loneliness predict greater symptoms of traumatic stress and suicidality. We conclude that dehumanization is a driving force behind the psychological injury resulting from moral incongruence in the context of the pandemic. The pandemic most frequently threatened basic human motivations at the foundational level of safety and security relative to other higher order needs.

Moral Injury during the COVID-19 pandemic: A delphi model survey of family medicine residents

Objectives The objective is to investigate the primary factors that created experiences leading to moral injury in family medicine residents during the COVID-19 pandemic and also to identify any barriers keeping these residents from seeking or receiving help when they experienced moral injury. Method A DELPHI model study utilizing three rounds of surveys was conducted at four family medicine residency programs in the United States. Resident responses to Survey 1 generated factors perceived to be causing them moral injury or constituting barriers to their seeking help. Thematic analysis identified common themes which were presented to residents in Survey 2 for rating and justification. Results and feedback from Survey 2 were shared with residents in Survey 3, where residents were prompted to reevaluate their ratings for factors and barriers for the purpose of generating consensus among themselves. A ranked list of factors and barriers was thereby created for the participating sites. Results Residents shared several stories about the factors that most pressured them to violate their moral values. The most severe and frequent factors contributing to moral injury involved disruptions to doctor–patient relationships, patient–family relationships, and relationships with other healthcare professionals. Time was the major barrier to residents seeking help. Conclusion During times of crisis, moral injury among residents may be minimized by protecting and promoting important clinical and professional relationships with patients, colleagues, and other medical professionals. While residents report that lack of time was the most significant barrier to seeking help, it is unclear how this complicated and ubiquitous problem would be resolved or mitigated.