Moral injury is defined as the profound psychological distress which results from actions, or the lack of them, which violate one’s moral or ethical code.

All in the medical profession sign up to a moral code that promises beneficence and non-maleficence. To not only do good for those in their care but to do no harm. The covid-19 pandemic as called on many frontline workers to push themselves to the brink. Previously called burnout, it is now recognised that when clinicians are asked, repeatedly, to act in a way, in a top-down administration, that is in opposition to their moral compass, it can cause untold damage.

Lack of resources such as beds, ventilators or medicines can mean frontline workers are unable to give the care they know can save lives, having to self-isolate while colleagues are stretched beyond capacity, knowing you’re not able to provide care for those with life limiting conditions because you’ve been re-deployed to give life-saving treatment or being involved in any keyworker roles under extreme pressure may lead to unnecessary risks being taken.

Ambulance technicians sitting in a queue instead of taking the next call, palliative care nurses preventing relatives from sitting with their loved ones as they die, admin staff sending out letters to push back patients’ outpatient appointments/surgery or any staff trying to follow policies set out by management that don’t appear to be patient centred are all events that could be considered potentially morally injurious. While in themselves, the worker may manage each individual event, it might be the build up or it might be the lack of support that can cause the most damage.

Experience of potentially morally injurious events can lead to negative thoughts about oneself such as “I’m a terrible person” or “I’m not good enough” which can lead to shame and guilt. Although moral injury itself is not a mental illness, it can lead to symptoms of post-traumatic stress disorder when the sufferer can have flash back, lack of sleep and anxiety.

There is an increased risk of moral injury if the following occurs:

1. Loss of life to a vulnerable person (e.g. child, elderly);
2. Leaders are perceived to not take responsibility for the event(s) and are unsupportive;
3. Staff feel unaware or unprepared for emotional/psychological consequences of decisions;
4. The potentially morally injurious event occurs concurrently with exposure to other traumatic events (e.g. death of loved one);
5. A lack of social support following the potentially morally injurious event.

Moral injury may not be restricted to frontline healthcare workers but can also be experienced by shop workers, teachers, social workers or prison staff for example. A lack of clear guidelines, training and resources mean they feel their own health is at risk and their unable to adequately care for those entrusted to them.

Guilt or shame surrounding this issue can mean staff are reluctant to talk about it. Lack of support and a belief that it’s “all in a day’s work” means staff can turn to unhealthy coping mechanisms to manage the impact of moral injury.

It has been found that psychological screening or de-briefing is ineffective but the following may be beneficial for anyone exposed to potentially morally injurious events:

1. Education and being made aware of the thoughts and feelings that could arise from the events and discussing the topic in advance to ensure staff are psychologically prepared;
2. Seek informal support from colleagues, peer supporters, chaplains, managers etc as early as possible;
3. If informal support doesn’t help and the events appears to be impacting the individuals daily life, professional help should be sought early. Sources of confidential support should be advertised within organisations so that it’s easily accessible.
4. Those in leadership should have psychologically informed conversations upon checking in with their staff regularly. If they don’t poses the skills, trained peer-supporters could take on this role. These “check-ins” should involve encouraging staff to seek help whenever necessary.
5. Frank discussion of events and team cohesion can help. It’s important to understand the impact on mental health as well as being aware psychological growth can be expected if staff do their best.
6. Limiting exposure to media and unreliable news outlets and instead seeking information from trusted sources such as public health England and finding evidence-based coping resources (i.e. https://www.nhs.uk/oneyou/every-mind-matters/).

Experiencing moral injury and/or needing informal or professional support doesn’t make one person stronger or weaker than another.