A Healer’s Wounds: Predictors of Moral Injury in Healthcare Workers in Lebanon Following the 2024 War

Abstract

The war on Lebanon, which began in October 2023 and rapidly escalated between September and November 2024, with continuous and ongoing ceasefire violations to date, resulted in an estimated 3,768 people killed and 15,699 injured. During this period, the World Health Organization (WHO) reported 140 attacks on healthcare facilities, with 233 healthcare workers killed and 206 wounded while on duty.

Healthcare workers (HCWs), particularly those working in contexts of war and conflict, are at risk of Moral Injury (MI) as they are frequently exposed to high-stakes situations in which conflicting ethical and moral dilemmas arise. MI is the psychological distress that stems from actions or inactions that violate an individual’s moral or ethical code. It has been associated with poorer occupational and mental health outcomes. However, the predictors of MI in HCWs, particularly in Arab populations and conflict settings, remain underexplored.

This study, in the context of Lebanon’s 2024 war, served as a preliminary investigation of the prevalence of MI among HCWs in Lebanon, the relationship between MI and mental health, and the predictors of MI, including demographic, occupational, and psychological factors. The study utilized a cross-sectional, quantitative design. Following a pilot and interviews with 15 HCWs, data was collected from around 70 HCWs across Lebanon through online surveys. Quantitative analyses included correlations and multiple regressions. Preliminary findings indicated a significant correlation between MI and several mental health outcomes. Positive Religious Coping negatively predicted MI scores in healthcare workers, even after controlling for demographic and occupational factors. Gender and relationship status also predicted MI scores. Initial testing found the Moral Injury Symptom Scale - Health Professional (MISS-HP) to be a valid and reliable tool for use with HCWs in Lebanon.

This study is one of the first to address the significant gap in the understanding of MI and its predictors in HCWs within Arab populations and conflict settings. It also translated and tested an MI measure not used previously in research with Lebanese or Arab HCWs. Recommendations to inform targeted interventions and policies to prevent and treat MI in HCWs within the context of war and conflict were presented.