Sarah Appleton – The rise of “Moral Injury” in NHS workers

We find ourselves in a time of great uncertainty where, amidst significant change to most areas of our lives, we continue to experience considerable change to our job roles and responsibilities.

Throughout my conversations with staff members, and mirroring my own personal experience, I have been struck by the range and intensity of emotions evoked by this change of role. Staff members have shown great strength in speaking about their experience of difficult feelings such as stress and anxiety, particularly in relation to a high clinical demand in the context of limited resources, or to a change of role prompting feelings of uncertainty or inadequacy. Staff members have also shown great strength in speaking about difficult feelings such as guilt that may arise due to their clinical load being reduced, or to feeling as if they “should be doing more”.

Across each of these challenging situations there lies a common theme; staff members are experiencing a jarring between their values (i.e. the care that they feel they should, or they want, to provide) and the care that they are practically able to deliver.

I therefore wanted to write a blog with this in mind. To raise awareness of the concept of “moral injury”, and to support staff to effectively prepare for, identify and manage potentially morally injurious events (PMIEs).

The following content is a summary of a recent paper titled “COVID-19 and experiences of moral injury in front-line key workers” authored by Williamson, Murphy and Greenberg (2020). I’ve attached the paper to this podcast and would definitely recommend giving it a read. Whilst I’ve focused predominately on understanding what moral injury is, and how to best manage this in NHS settings, they also provide really helpful recommendations for clinicians working with moral injury presentation.

What is a Moral Injury?

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.

Morally injurious events can include acts of perpetration (i.e. situations where we feel we have actively done something that goes against our moral code), omission (i.e. situations where we feel we have not helped in the way our moral code dictates) or experiences of betrayal typically from leaders or trusted others (i.e. situations where we feel that others have not treated us in the way that we would treat them).

When we experience a moral injury we might feel overwhelmed by difficult thoughts such as “I’m an awful person” or “my colleagues don’t care about me” and difficult feelings such as guilt, shame or disgust. Whilst moral injury is, in itself, not classed as a mental illness, we see how these experiences may contribute to the development of other mental health problems such as depression, anxiety or post-traumatic stress disorder.

NHS staff members will encounter PMIEs on a daily basis; redeployment may mean that clients we used to treat are without their usual care, a higher clinical load may mean that we have less time to spend with a seriously ill patient, or a lack of resources or training may mean that we do not feel that our own health and wellbeing is being properly considered by those who are supposed to protect us.

Research shows that a number of factors may also exacerbate these existing challenges, possibly increasing the likelihood of developing a moral injury. Potential risk factors for moral injury may include situations where; a vulnerable person has died, staff members do not feel adequately supported, staff members do not feel prepared for the emotional/psychological consequences of decisions, staff members experience a PMIE in addition to other traumatic events (e.g. loss of a loved one), or there is a lack of social support.

It is important to note that not everyone who encounters a PMIE will experience a moral injury. However, raising awareness of PMIEs allows us to better understand and effectively attend to an often misunderstood or neglected distress response (both in ourselves and others).

Supporting NHS Workers Exposed to PMIEs

Williamson, Murphy and Greenberg (2020) outline five practical recommendations to support staff experiencing potentially morally injurious events. These include:

  1. Raise Awareness: Staff should be made aware of the possibility of PMIE exposure in their role, and the emotions, thoughts and behaviours that might be experienced as a result. Frank discussion of this topic in advance, most probably facilitated by supervisory level leaders, may help develop psychological preparedness and allow staff to understand some inevitable symptoms of distress.
  2. Establish Support: Staff should be encouraged to seek informal support, from trained peer supporters, managers, colleagues, chaplains or other welfare provision, early on and take a ‘nip it in the bud’ approach—rather than dwelling on the PMIEs they have been exposed to. There is good evidence that social support is generally protective for mental health.
  3. Seek Professional Support Where Appropriate: If informal support does not help, professional help should be sought early on. Professional support is likely to be needed when difficulties relating to the PMIE become persistent and impair an individual’s daily functioning.
  4. Proactively “Check-In” with Staff Wellbeing: Those in leadership roles should be encouraged to proactively ‘check-in’ with their teams, offer empathetic support and encourage help-seeking where necessary.
  5. Ongoing Monitoring:  Organisations should actively monitor staff exposed to PMIEs, facilitate effective team cohesion and make informal, as well as professional, sources of support readily available. Please note the psychological debriefing techniques or screening approaches are often ineffective.

So that is just a brief overview of moral injury and some of the ways we can manage that within an NHS setting. I would definitely recommend giving the paper a read just to get a bit more in depth explanation on that as well if you are interested. Thank you.

Dr Sarah Appleton is a Clinical Psychologist working in Employee Health for Central London Community Healthcare NHS Foundation Trust. Sarah raises our awareness of the concept of “moral injury”, and how to support staff to effectively prepare for, identify, and manage potentially morally injurious events.

Sarah references the recent paper titled “COVID-19 and experiences of moral injury in front-line key workers” authored by Williamson, Murphy and Greenberg (2020).

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