Burnout following moral injury and dehumanization: A study of distress among Italian medical staff during the first COVID-19 pandemic period

Clinical Impact Statement The COVID-19 pandemic also presents high mental health challenges for medical staff. The present study highlights how the COVID-19 pandemic has stressed Italian medical staff and how dehumanization of patients and colleagues has been associated with distress, alienation, and moral injury. The results show that the processes involved in humanizing care in medicine strengthen the patient-centered relationship but may have been affected by the impact of the pandemic. It is necessary to generate more in-depth research on the relationship between dehumanization, humanization, and medical staff well-being. Regarding humanization of care in medicine, the results suggest that training needs to be both implemented to enable medical staff to learn how to properly manage relationships and communication with patients and colleagues and conducted by mental health professionals.Background: Italy was the first country outside Asia to deal with the early phase of the COVID-19 pandemic, and health care facilities and medical staff were not fully prepared. Research worldwide has documented the enormous effect of the COVID-19 pandemic on health care providers' mental health, including experiences of dehumanization, but less work has focused on factors which may influence the development of these outcomes in response to COVID-19-related stress. Objective: This study examined the association of dehumanization, self-efficacy, and alienation to burnout, depression, and PTSD among medical staff. Potential moderators included moral injury, professional role, COVID workload, and work in a critical care unit (CCU). Method: Participants were recruited through the Internet. The sample consisted of 270 medical staff members who completed a self-report survey online. Instruments included: Human Traits Attribution Scale for dehumanization; NYP-Queens Survey - Self-Efficacy Subscale for self-efficacy; Moral Injury Events Scale for moral injury; Alienation Scale for alienation; PTSD-8 for posttraumatic stress disorder; Patient Health Questionnaire-9 for depression; and a single item for burnout. The analytic plan included ANOVAs, zero-order correlations, logistic regression analyses, multiple linear regression models, and parallel mediation. Results: Results show that dehumanization was associated with higher levels of burnout, PTSD, and depressive symptoms and effects were consistent across professional role and work context. Dehumanization was significantly associated with PTSD symptoms only among those who had increased COVID-19-related caseloads. Moral injury was positively associated with dehumanization, displayed an independent association with all 3 mental health outcomes, over and above dehumanization, and tended to exacerbate the effects of dehumanization. The effect sizes across analyses were small to medium. Conclusion: This research confirms that the COVID-19 pandemic stressed Italian medical staff in a way not documented in the prepandemic literature. There is a need to support staff in their complex relationships and communication with patients.