Edited by: Anders Hakansson, Lund University, Sweden
Reviewed by: Sigrid Stjernswärd, Lund University, Sweden; Lars de Vroege, GGz Breburg, Netherlands
This article was submitted to Psychopathology, a section of the journal Frontiers in Psychiatry
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
In the context of the global pandemic of the SARS-CoV-2 coronavirus (COVID-19), healthcare providers (HCPs) have experienced difficult moral and ethical dilemmas. Research is highlighting the importance of moral injury (MI)–a trauma syndrome related to transgressing personal morals and values–in understanding the psychological harm and occupational impairment experienced by HCPs. To date, MI treatments have largely been developed for military personnel and veterans and rely on in-person one-on-one psychotherapy.
This project aims to explore the feasibility and acceptability of an evidence-informed online Acceptance and Commitment Therapy-based group therapy for MI in HCPs called “Accepting Moral Pain and Suffering for Healthcare Providers” (AMPS-HCP).
This feasibility and acceptability study included three separate phases with the first two phases focused on the development of the psychotherapeutic intervention and the third phase focused on the evaluation of the psychotherapeutic intervention. Eight participants (including registered nurses, practical nurses and respiratory therapists) completed seven 90-min sessions in an online group format. The focus of these sessions included ACT and MI psychoeducation and experientials. Qualitative semi-structured interview data was thematically analyzed while demographic and quantitative self-reported outcome data underwent descriptive analysis and non-parametric testing.
Results show that the intervention was highly feasible and acceptable to healthcare providers who worked on the frontline during COVID-19. Feasibility (referrals, eligibility, retention, participation engagement) was strong (8 out of 10 participants; 80% vs. desired >70% eligibility) and overall, 80% of participants completed 71% of the intervention. Data further supported the applicability and acceptability of the intervention. Preliminary data suggests that AMPS-HCP may supports HCPs to address MI.
This study is the first to report on the development and evaluation of an online MI group intervention for registered nurses, registered practical nurses, and respiratory therapists working during COVID-19. Results showed the use of both the online and group components of the intervention were acceptable and feasible during the third wave of COVID-19.
The global pandemic of the SARS-CoV-2 coronavirus (COVID-19) has placed untold strain and threat to global healthcare systems and healthcare providers (HCPs) (
It is widely acknowledged that a large mental health crisis will be forthcoming for HCPs once the pandemic is over (
Moral Injury (MI)–a specific trauma syndrome associated with the distress of witnessing or participating in acts that transgress personal morals, values, and beliefs (
While the long-term impacts of the coronavirus cannot be known at this time, MI is associated with significant mental health challenges, psychosocial issues, and occupational impairments. In a recent review, MI is associated with mental illnesses (e.g., PTSD, generalized anxiety disorder, major depressive disorder), physical health challenges (e.g., pain, sleep disturbances), behavioral issues (e.g., substance misuse, suicidal ideation) and occupational impairment (e.g., burnout, compassion fatigue, and work absenteeism) (
Central to the problem of MI is the lack of evidence-based treatment. To date, MI treatments have largely been developed for military personnel and veterans and rely on in-person one-on-one psychotherapy. Evidence-based, trauma-focused treatment approaches, such as Eye Movement Desensitization and Reprocessing, Prolonged Exposure, and Cognitive Processing Therapy, fail to directly address MI. Moreover, current scientific knowledge of MI highlights that this injury, while trauma-based, requires a different therapeutic approach (
Acceptance and Commitment Therapy (ACT) is a functional contextual cognitive behavioral psychotherapy approach that emphasizes mindfulness, acceptance, perspective-taking and values-based behavior change (
Importantly, ACT has been theoretically suggested as a potentially ideal therapeutic modality for MI because of its therapeutic focus on cognitive flexibility, mindfulness, and value-driven behavior (
This project aims to explore the feasibility and acceptability of an evidence-informed online ACT-based group therapy for MI in HCPs, called “
This pilot study included three separate phases with the first two phases focused on the development of the psychotherapeutic intervention and the third phase focused on the evaluation of the psychotherapeutic intervention. Mixed data collection was selected for the third phase as both quantitative and qualitative data are necessary to assess feasibility and acceptability.
A systematic and critical review was conducted of the MI academic literature focused on MI interventions. Additionally, we consulted with 12 international MI Subject Matter Experts. The aim of this phase was to identify MI treatment approaches and components, along with potential benefits, barriers, and recommendations to the delivery of MI treatment via digital health platforms.
Upon determining that no current intervention would be appropriate, the research team selected ACT as the evidence-based modality given its focus on value-driven behavior and grafted key MI constructs onto the six processes of ACT. This resulted in the development of a 100-page standardized clinician manual for AMPS-HCP. Training of registered mental health clinicians (i.e., psychologists, occupational therapists, psychotherapists) (
The AMPS-HCP intervention was delivered and researched for its feasibility and accessibility.
Potential participants were recruited via convenience and snowball sampling. An initial contact email with an electronic poster was sent to leaders within participating healthcare organizations asking them to forward the recruitment material. Additionally, given the need to recruit remotely, recruitment posts were placed on appropriate social media sites (with expressed consent). Potential participants were asked to directly contact the researchers and were subsequently screened for eligibility. If deemed eligible, participants were sent an electronic consent form to sign digitally via RedCap (an online data capturing platform) indicating their consent to participate in the intervention. Research Ethics Board and operational approvals were sought prior to commencing with the study. Participants were included if they were 18 years or older, spoke and understood English, were a registered nurse, registered practical nurse, or respiratory therapist (RT) who had been working during the COVID-19 pandemic, and felt they had been exposed to a potentially morally injurious experience. Ten potential participants initially expressed interest, meet inclusion criteria and we included in the study, but two dropped out before the intervention started due to personal reasons. No other participants were recruited as the recruitment material had been taken down (given fully the sample size in <48 hours) and the research team had informed the participating organizations that the study was closed. The final sample size was eight (
A demographics form was administered at baseline to assess age, gender, ethnicity, education, marital status, health profession, number of years in the profession, job title, and employment status.
To assess for acceptability the Client Satisfaction Questionnaire (CSQ-8) (
Feasibility of AMPS-HCP was operationally defined as: sufficient patient referrals (ability to meet the minimum sample size of 8), eligibility (> 70% of potential participants meet the eligibility criteria), and enrollment (>50% of potential participants meet the eligibility criteria). The justification for the small sample size (
Fidelity was established in terms of >80% adherence to clinician manual and ACT principles. Additionally, all four clinicians met for 30-min upon completion of each session to debrief, reflect, iteratively discuss changes to the previous and upcoming session, and to review the fidelity checklist.
Several measures of psychological health (PCL-5 and DASS-21), MI (MIOS), social function (MSPSS), occupational impairment (ProQoL), emotional regulation (DERS-18), coping (B-COPE), cognitive flexibility (AAQ), post-traumatic growth (PTGT), and resilience (CDRS-10) were administered pre-post intervention to help guide a future randomized controlled trial designed to assess the effect of AMPS-HCP (
The purpose of this transdiagnostic MI intervention was to support participants in cultivating acceptance of moral pain in the service of one's values rather than challenging the content of moral pain. The AMPS-HCP intervention consists of seven (one introductory and six therapeutic) 90-min online sessions administered over the course of consecutive weeks. Each session had the following structure: an opening poem/meditation, a review of the week using the Matrix (a tool help discriminate between internal and external experiences and identify actions that aligned with personal values), psychoeducation of an ACT principle, an integrative exercise, followed by psychoeducation of a MI principle, another integrative exercise to solidify learning and skill competence, and a closing poem/meditation. Time was allotted for individual and group reflections within each session to support learning and group cohesion. The therapeutic components of this intervention consisted of teaching six core processes within the sessions: (1) acceptance and self-compassion related to moral pain; (2) defusion related to self-criticism and resentment; (3) contact with the present moment, including contacting grief; (4) self-as-context and the role of meaning-making, narratives, and story-telling in perpetrating moral suffering; (5) contacting values related to moral injury, especially values behind our laments; (6) committing to value-driven actions of self-compassion and other reparative practices aimed to heal relationships with self-and/or others (see
Summary of AMPS-HCP sessions.
Introductory | Identify MI, potentially morally injurious experiences (PMIEs), and symptoms of MI. Explore how MI is related to violated values. Introduction of ACT and the Matrix as the framework for the sessions | - Introduction to ACT |
One | Help participants identify the need for acceptance as the primary step toward healing of MI. Identification of the ways in which participants have been harmed during COVID-19, and the PMIE(s) which are most difficult to accept. Explore the role of compassion in helping to manage and accept moral pain | - Introduction to the concept of acceptance |
Two | Help participants learn skills related to defusion and getting unstuck from negative or unwanted thoughts, emotions, and sensations. Emphasize the importance of viewing these as only thoughts, emotions, or sensations that will pass. Explore how PMIEs may impact and direct thoughts that further perpetuate suffering | - Introduction to the concept of fusion and defusion |
Three | Help participants to explore how they can stay in the present moment, and be more present and open to their thoughts, emotions, and sensations. Explore the intersectionality between grief and MI to show that MI includes loss because of the moral violation that occurred. Encourage participants to be open to grief and mourning the losses they have experienced while working during COVID-19 | - Introduction of the concept of present moment awareness |
Four | Help participants to see themselves as being within the current context of COVID-19, while also encouraging recognition for the larger more transcendent self. Exploration of the ways in which COVID-19 may have permanently or temporarily caused harm to the “self.” Utilize narrative and storytelling as a way to have participants begin to explore their individual MIEs and also frame those within the larger story of the pandemic | - Introduction to the concept of self-as-context |
Five | Help participants to continue exploring how MI or PMIE(s) may be impacting their behaviors and causing them to no longer be behaving in a value congruent manner. Help participants to continue exploring the ideas introduced by the “hero's journey” with specific attention given to the struggles of “ordeal in the abyss” and unresolved points of moral pain | - Introduction of the concept of values |
Six | Help participants to begin to explore how they could move to the “toward” side of the Matrix through value-driven behavior. Participants are encouraged to write down the values they have identified throughout the group as being harmed and to now match them to morally reparative behavior and action. Participants are reminded not to see these behaviors and actions as undoing their moral pain but allowing them to begin to re-experience vitality and meaning. Group wrap out and closing also occurs | - Review of the Matrix |
As the primary outcome of this study was to explore feasibility and acceptability of AMPS-HCP, semi-structured 45-min interviews via Zoom occurred ~1 week after completion of AMPS-HCP with participants. Interviews used the NEII questions to assess for acceptability of the study. They were then audio-recorded with permission and transcribed. Additionally, semi-structured 45-min interviews with the four clinicians providing AMPS-HCP were also conducted to assess for fidelity to the intervention and differences in opinions regarding feasibility and acceptability. The clinician weekly debrief notes and fidelity check-lists were also included as part of the data collection. To explore potential quantitative outcomes, REDCap was used to gather informed consent and the pre-post-questionnaire data.
Quantitative analysis included descriptive statistics (e.g., mean values, frequencies, and proportions) to summarize demographic data. Non-parametric analysis using Wilcoxon rank-sum was also conducted comparing pre-post differences within the participants. Qualitative data were thematically analyzed. Braun and Clarke (
The descriptive statistics of the participants are contained in
Participant demographics.
Age (Average) | ~37 years | |
Gender | Female | 8 (100%) |
Male | 0 (0%) | |
Ethnicity | Caucasian | 7 (88%) |
African-Canadian | 0 (0%) | |
Latino | 1 (12%) | |
Asian | 0 (0%) | |
South Asian | 0 (0%) | |
First nation or metis | 0 (0%) | |
Healthcare profession | Registered nurse | 4 (50%) |
Licensed practical nurse | 1 (12%) | |
Respiratory therapist | 3 (38%) | |
Highest level of education | High school | 0 (0%) |
Diploma/college | 3 (38%) | |
Undergraduate degree | 4 (50%) | |
Graduate degree | 1 (12%) | |
Years in the profession | First year in profession | 0 (0%) |
1–5 years | 4 (50%) | |
5–10 years | 0 (0%) | |
10–15 years | 3 (38%) | |
15–20 years | 1 (12%) | |
Employment status | Fulltime | 5 (63%) |
Parttime | 2 (25%) | |
Causal | 1 (12%) |
Within 1 week of recruiting the study was full (
All eight participants completed the NEII and seven of the eight participants completed the CSQ-8. The mean score of the CSQ-8 was 30 (the highest possible score being 34) and all participants rated the intervention as either “excellent” or “very good.” Qualitative thematic analysis further supported the acceptability and acceptability of the intervention. Specific sub-themes and supportive quotes are listed in the boxes below.
Participants noted that the AMPS-HCP intervention was highly applicable to their experience of COVID-19. Many participants noted they were often expected as HCPs to “shove it down” or “deal with it” when mental health concerns arose. In particular, participants noted feeling failed by management as there was an expectation that frontline nurses and RTs would be able to manage on their own. Through engaging in the AMPS-HCP intervention, participants found they were allowed the space and validation to be “human beings” again and begin receiving the mental help they might not have found otherwise.
Participants expressed an openness and acceptability to engaging in the online group format of the intervention. They found the option of attending from home convenient as it allowed more flexibility within their work and home schedules and meant there was no time needing to be allocated toward travel. Participants also noted the online format increased their sense of comfort as they had more control over their environment and could turn off their microphones or cameras for increased privacy. When discussing the group format, many of the participants commented on the validation they were able to receive through knowing “
Overall, feasibility did not arise as a significant issue for participants as most were able to attend most or all of the offered group sessions and found the online delivery accessible and convenient. The primary barrier participants referenced in attending the group was scheduling time around shift work (i.e., irregularity and inflexibility) which meant that some participants had to miss a session or two. In addition, some participants found the time the intervention was offered (5 pm) interfered with aspects of their personal or family lives, requiring them to make alternate arrangements for childcare or meal routines. Participants also noted that receiving information about the intervention (i.e., handouts or updates) via email was challenging given the number of emails they received every day during the pandemic.
Participants also expressed that there were specific components of the AMPS-HCP intervention that were most helpful including: (1) permission to begin expressing the emotions they felt as a result of the pandemic; (2) a safe space to engage and unpack; (3) encouragement to begin to explore painful and distressing memories and emotions which they had otherwise tried to suppress; (4) a focus on application of the learned skills vs. straight psychoeducational content; and (5) the diversity of the facilitators which facilitate different styles and insights around session topics.
Participants generally found that participation in the group was beneficial to their mental health and in providing insight into further areas they want to work on. The participants commented on how the group helped them to gain awareness of the difficulties they were experiencing and to also gain the tools and resources to cope with these difficulties. In particular, participants found that realigning themselves with their values was highly beneficial. Several participants commented how they are more likely to seek out therapy in the future after participating in this group, as there are still things that they believe would be helpful for them to work through.
A review of the fidelity checklist and debrief notes showed the facilitators were able to largely follow the standardized manual sessions per week (6 out of 7 weeks; 85% fidelity). However, the facilitators noted greater ability to maintain fidelity to the ACT content and exercises than the MI content and exercises. The facilitators noted that engaging in MI exercises required iterative adaptations both within and between sessions to effectively reflect the group process and honor the lived experiences of participants in the group. For example, 1 week's content shifted from reconciliation/forgiveness work to honoring values, coping amid current struggles and unknowns, taking inventory of losses and betrayals, and finding ways to accept difficult feelings. Other minor changes to the standardized manual included moving some of the psychoeducational content into the handouts rather than in the session content to allow for more time for the exercises and group discussions, the addition of more images, and the streamlining of metaphors throughout the manual so that these could be built upon each week. A full analysis of the facilitators' perspective will be forthcoming.
This study was not designed to test or ascertain the efficacy of the interventions, and non-parametric testing was limited because of the extremely small sample size. Self-reported questionnaires used were statistically insignificant with the exception of the DASS-21 (stress) subscale (
Participants self-reported outcomes.
MIOS | 68.63 | 58.75 | 9.88 | 18.08 | 32.59 | 0.401 |
PCL5 | 31.38 | 25 | 6.38 | 11.15 | 20.58 | 0.263 |
DASS21- |
25.13 | 17.25 | 7.88 | 5.36 | 15.22 | 0.159 |
DASS21-stress | 11.75 | 5.43 | 6.32 | 2.76 | 5.13 | 0.018** |
DASS21-anxiety | 6.38 | 6 | 0.38 | 4.72 | 4.93 | 0.395 |
DASS21-depression | 7 | 5.43 | 1.57 | 2.83 | 5.13 | 0.235 |
PROQoL | 93.37 | 91.25 | −2.12 | 9.71 | 6.18 | 0.612 |
DERS-18 | 42.63 | 32.50 | 10.13 | 11.95 | 21.2 | 0.161 |
BCOPE | 69.63 | 56.38 | 13.25 | 9.86 | 36.02 | 0.674 |
AAQ | 32.38 | 30 | 2.38 | 5.63 | 3.51 | 0.236 |
MSPSS | 58.75 | 45.75 | −13 | 32.59 | 29.36 | 0.499 |
CDR10 | 26.14 | 20.13 | −6.01 | 3.723 | 12.85 | 0.397 |
PGTI | 40.75 | 37 | −3.75 | 10.33 | 29.49 | 0.674 |
The AMPS-HCP intervention is one of the first of its kind to explore the feasibility and acceptability of addressing MI using either a group or online format. These results are noteworthy given the overall lack of MI treatments, and that those currently being proposed predominately require one-to-one psychotherapy. Moreover, this is the first MI intervention to be developed exclusively for HCPs (nurses and RTs). While our results are preliminary, they showed that the AMPS-HCP was highly tolerated and meaningful, and participants perceived personal benefit to their mental health. Participants found the use of both the group and online format to be acceptable to them, and in some cases, perceived it as being more beneficial than if they had done it through in person one-on-one therapy. The need for novel evidence-based treatments cannot be overstated (
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While COVID-19 has caused a dramatic increase in the use of digital technology to provide mental health treatment, questions remain about the efficacy particularly for serious mental health conditions or vulnerable populations. As there is no literature to date on the use of digital health for MI, ensuring that an online delivery would not be problematic to participants was central to our study. Our results indicate that participants did not find it to be problematic or an impediment to MI treatment, thus supporting a growing body of literature which shows that online means may be useful for a number of serious mental health conditions including psychosis (
Group therapy has been shown to be equally effective compared to individual treatment (
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While group therapy has theoretically been suggested for MI because of these specific therapeutic components, little research has been done to validate its use. Our results suggest that group therapy may be a highly effective modality to use for MI. The use of an online format did not impact the ability to offer a group intervention. During COVID-19, particular focus has been given to the potential impact of video conferencing on the therapeutic process; indeed, video conferences in times of COVID-19 seem to be accepted and perceived as helpful by patients and providers (
This study also provides useful information regarding MI and HCPs. Initially the researchers wondered if participants would relate to the concept of MI given the previous focus on moral distress especially within nursing literature (
Key learnings were also gleaned regarding topics for the treatment of MI in HCPs. Ambiguous loss and disenfranchised grief were important concepts. Studies are currently lacking regarding the potential interplay or overlap of grief and MI; though some MI researchers have highlighted the potential grief elements of MI (
Further works is therefore warranted for AMPS-HCP. This should include a mixed-methods multisite randomized waitlist-controlled pilot study focused on exploring the efficacy of AMPS-HCP. In particular, it may be helpful to randomize severely affected COVID-19 healthcare sites as this would allow for greater comparability and assist in recruiting a statistically powered sample size of RNs, licensed practical nurses and RTs to further investigate the merit of AMPS-HCP as an evidence-based intervention. Given the larger sample size specific attention would be given to GBA + considerations (e.g., gender, ethnicity, minority status). Additionally, if the results from a AMPS-HCP pilot study were positive, care will be taken to explore implementation science processes to support scale and spread of the intervention.
There were several limitations of the current study that should be taken into consideration when interpreting the findings. First, the sample size is extremely small, and therefore generalizability is low. Second, participants were also recruited via convenience and snowball sampling and were therefore self-selected. This self-selection could mean that participants who were part of the sample were those who most identify with being morally injured because of COVID-19 or who were open to receiving treatment and support. The sample was also largely homogeneous with participants representing registered nurses, registered practical nurses, and RTs respiratory therapists. Additionally, all participants identified as female challenging the research team's ability to explore inclusion, diversity and equity principles; this should be addressed in future randomized control trials. Fourth, the sample size was not powered nor large enough to determine intervention effect, nor were the found effects explored longitudinally to determine sustainability. Fifth, as some participants were not able to attend all intervention sessions and did not complete all of the standardized outcomes measures this may have influenced the quantitative results. Sixth, it has been widely acknowledged in the literature that standardized questionnaires for MI are poor, and may be lacking in reliability, validity, and sensitivity (
This study is the first to report on the development and evaluation of an online MI group intervention for registered nurses, registered practical nurses, and RTs working during COVID-19. Results from this study showed the use of both the online and group components of the intervention were acceptable and feasible during the third wave of COVID-19. Moreover, participants identified strongly with the concept of MI and expressed the benefit and need for ongoing support to process the morally injurious experiences they had been exposed to in their work. As COVID-19 continues, there is an urgency to provide evidence-informed MI interventions which are tailored to address the unique needs of healthcare providers (HCPs) and the realities of COVID-19. Building on this feasibility and acceptability study, future research to explore and test AMPS-HCP seems warranted. Without this, healthcare systems risk that their most precious resource–their highly trained staff–will succumb to occupational injuries, mental illnesses, MI, or burnout. Fundamentally, when essential HCPs are doing well and are able to maintain health, safety, and security, all Canadians stand to benefit.
The data are not publicly available due to their containing information that could compromise the privacy of research participants. Requests to access the datasets should be directed to
The studies involving human participants were reviewed and approved by University of Alberta, Research Ethics Board, Pro00106350. The participants provided their written informed consent to participate in this study.
LS-M, JL, DL-B, and SB-P all equally participated in the conceptualization, development, delivery of the AMPS-HCP intervention, and also engaged in the original and final manuscript write-up. KB, AL, MV, SS, EC, AP, and CJ were involved in the data collection and analysis components of the research project and contributed to the writing and editing of the final manuscript. All authors agreed upon the authors order and attest to their involvement in the research project.
This work was supported by the Government of Canada Innovation for Defense Excellence and Security (IDEaS) Grant #CPCA-0626-GUAlberta.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.