Moral injury and mental health outcomes among Israeli health and social care workers during the COVID-19 pandemic: a latent class analysis approach

Background: The COVID-19 pandemic poses unique challenges to health and social care workers (HSCWs) who face morally challenging and life-threatening decisions. Following exposure to events that transgress moral beliefs and expectations, HSCWs might experience psychological, social, and spiritual problems referred to as Moral Injury (MI). Objective: The objectives of this study were to examine patterns of exposure to potentially morally injurious events (PMIEs) among HSCWs and their associations with MI, mental health outcomes and psychological correlates. Method: A sample of 296 Israeli HSCWs volunteered to complete a cross-sectional electronic survey with validated self-report questionnaires in February and March 2021. Latent Class Analysis (LCA) was used to identify classes characterized by unique patterns of exposure to PMIEs. Socio-demographic, work and COVID-related variables were used to predict patterns of exposure to PMIEs, and differences in mental-health outcomes and psychological correlates between classes were assessed. Results: Three subgroups were identified: ‘high exposure’ (19.5%), ‘betrayal-only’ (31.3%), and ‘minimal exposure’ (49.4%). Perceived stress increases the odds for inclusion in the ‘high exposure’ and ‘betrayal-only’ classes. Participants in both the High Exposure class and the betrayal-only classes reported higher levels of depressive, anxiety, posttraumatic and more moral injury symptoms as compared to the ‘minimal exposure’ class. Importantly, both ‘high exposure’ and ‘betrayal-only’ classes reported lower levels of self-compassion and higher levels of self-criticism, relative to those in the ‘minimal exposure’ class. Conclusions: The study’s findings offer an overview of the complex associations between patterns of exposure to PMIEs and associated predictors and outcomes. Clinicians treating HSCWs coping with COVID-19 related stress should be aware of the contribution of exposure to PMIEs to HSCWs’ distress and to the unique constellation of high self-criticism and low self-compassion among HSCWs with exposure to PMIEs.