Essential workers during COVID-19 susceptible to 'moral injury' and PTSD, hospital says

Health-care workers on the front lines of the COVID-19 pandemic are at risk of severe stress that could cause long-term psychological damage, the Centre of Excellence on Post-Traumatic Stress Disorder says.

The centre at the Royal Ottawa Hospital has teamed up with the Phoenix Australia Centre for Posttraumatic Mental Health to develop a guide for facilities including hospitals and peer-support organizations in an effort to reduce the impact on those susceptible to so-called moral injury, a type of PTSD.

It can result from dilemma on the job from witnessing or performing an action that goes against someone's beliefs, similar to what has been documented in war veterans, the centre says.

Dr. Patrick Smith, CEO of the Canadian centre, said the guide applies to anyone doing essential work, including in long-term care homes and grocery stores.

"We will be working with hospitals, clinics, provinces, municipalities," he said Tuesday. "Everyone who's already finding themselves trying to support their health-care workers, their essential workers, will be supported to use this guide."

Many medical associations across the country have for decades implemented wellness programs focusing on doctors practising self-care to prevent burnout from working long hours, for example.

However, Smith said the guide calls on organizations to put widespread preventative measures in place to support staff grappling to make the right decisions during an unprecedented work experience while fearing their jobs may put themselves and their families at risk of becoming infected with COVID-19.

"They need to have the licence to put up their hands and say they are struggling," he said.

"The obligation to protect essential workers falls on those in charge the supervisors and administrators who may also be suffering moral stresses and dilemmas of their own as a result of sending workers into dangerous situations."

Practise self-care

The guide, which is available online, calls on employers to take measure such as rotating staff between high- and low-stress roles, establishing policies to guide them through ethically tough decisions and promoting a supportive culture.

It also urges workers, including doctors, nurses, lab technicians and social workers, to practise self-care through proper nutrition, exercise and social connection and to seek professional help when needed.

Fardous Hosseiny, the Canadian centre's vice-president of research and policy, said first responders could develop a "moral injury" leading them to question whether their actions were justified, for instance if they led to poor outcomes from having to cancel someone's surgery.

"One doctor we talked to said he and his team turned a COVID-19 patient on his back who then quickly started breathing. But when they tried the same technique the next day on another patient, that person flatlined," he said, suggesting physicians may have felt guilty about their abilities with a decision that contributed to someone's death.

'Space suits' create barrier to human contact

Hosseiny noted that while doctors and nurses in Canada have not had to decide which patients get access to ventilators, for example, they have faced risks from a lack of personal protective equipment in some parts of the country early in the pandemic.

Moral injury is not yet clinically diagnosable but is generally considered to include an experience that caused people moral conflict, guilt, shame and loss of trust in themselves as well as depression, anger or moral conflict, he said.

Health-care workers of colour have faced additional issues amid systemic inequities in health care and growing national attention to racism, Hosseiny said, adding Ontario residents living in ethnically diverse areas have twice the risk of dying from COVID-19.

"Health-care workers of colour have reported stress because of identification with patients and the need to keep their frustration with health inequities to themselves."

Sarah Beanlands, a nurse at a supervised consumption site in Ottawa, said many of the usual clients are no longer accessing the service because they don't recognize staff behind head-to-toe personal protective gear and staff is concerned about the well-being of those at risk of overdose.

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"Space suits" of face shields, gowns, masks and gloves create barriers between workers and clients, who are required to wear a mask, as part of a service that relies on human contact and trust, Beanlands said.

Staff can't offer some services that are no longer available in the community and many clients have refused to stay in shelters, she said, adding multiple changes during the pandemic have led to connections with vulnerable people being fractured.

"All of this causes moral anguish for my co-workers and me. It weighs on us heavily as we try to provide the best service under these new circumstances."