Prevalence of Moral Injury, Burnout, Depression, and Anxiety among Healthcare Workers during COVID-19

Context: A Moral Injury (MI) inventory (MISS-HP) has been validated for physicians and been used to demonstrate a stable burnout prevalence with increasing moral injury during the COVID-19 pandemic. However, that instrument relies on the Duke Religiosity Index, which may undercount healthcare workers, who have lower religiosity than their peers.

Objective: We sought to identify burnout and moral injury across healthcare workers of all types in a large healthcare system using a more inclusive MI survey.

Methods: Study Design: Cross-sectional online survey. Setting: Healthcare workers affiliated with a large academic medical center in a mid-Atlantic state. Population: All employees. Instrument: The survey screened for depression (PHQ-9), anxiety (GAD-7), burnout (CBI), and moral injury using the MISS-HP, and a novel, more inclusive inventory, the Inclusive Moral Injury Inventory (IMII). Outcomes: Prevalence of conditions based on their respective screening tools.

Results: Response rate was 11.4% (n=1,945 completed surveys). Respondents primarily self-identified as white (92.3%), non-Hispanic (97.8%), and female (76.9%). They worked in rural (22.8%), suburban (71.5%), and urban (5.7%) settings, in academic (56.0%) and non-academic (44.1%) roles. Respondents included physicians (21.5%), licensed independent practitioners (8.0%), nurses (25.4%), administrators (11.1%), and support staff with (14.1%) and without (11.0%) direct patient contact. Overall, 25.4% screened positive for major depressive disorder (PHQ-9≥10); 24.8% screened positive for generalized anxiety disorder (GAD-7≥10); and 8.1% had been bothered by thoughts they would be better off dead or of hurting themselves “several days” or more frequently. CBI scores (mean±SD) were 53.2±22.7 for personal burnout, 51.4±24.6 for work-related burnout, and 36.1±26.0 for patient-related burnout. (CBI score 50-74 is moderate burnout; 75-99 is high burnout). Significant impairment from moral injury was reported by 40.6% (MISS-HP≥36).

Conclusions: Our results paint a grim picture of healthcare workers’ well-being, with the average worker in this sample experiencing moderate burnout in personal and work life, about 25% having anxiety and/or depression, and many experiencing moral injury to a level of moderate or greater functional impairment. Most disturbing, nearly 1 in 12 respondents regularly had thoughts that they would be better off dead or of hurting themselves.