Introduction
What Is Moral Injury and Potential Consequences?
What Does Moral Injury Consist of in Healthcare?
How Can Moral Injury Be Prevented?
Is There a Treatment for Moral Injury?
References

Moral injury is the cognitive and emotional response that occurs after events that violate a person's moral or ethical code. Events that constitute moral injury include a person's own or other people's acts of omission or betrayal by a trusted person in a high-stakes situation.

A salient example of this is healthcare staff working during the COVID-19 pandemic. Staff experienced moral injury due to the perceived notion that they did not receive adequate personal protective equipment or that their workload exceeded their capacity. The standards of care fell below what they would consider to be acceptable.

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What Is Moral Injury and Potential Consequences?

Moral injury is distinct from post-traumatic stress disorder, which is experienced following a threat-based trauma. Events that have the potential to induce moral injury do not necessarily involve a threat to life; instead, they codify feelings of shame and guilt, needing alterations in self-belief and cognition. For example, those who experience moral injury may believe that they are a failure and that colleagues and family do not care about their welfare.

Moreover, moral injury may cause maladaptive coping responses. These include social withdrawal, self-destructive acts, and substance misuse. These altered beliefs and appraisals can subsequently lead to mental health problems. A meta-analysis conducted in 2018 found that exposure to potentially morally injurious events strongly correlated with post-traumatic stress disorder, depression, and suicidal ideations.

Moral injury is not limited by occupation and can arise in various fields, including journalism, policing, veterinary medicine, and more intuitive jobs such as the military. In the context of healthcare, moral injury has become increasingly prevalent. It is now considered the greatest challenge reported by the UK National Health Service in response to the COVID-19 pandemic. Due to the undue pressure faced by frontline healthcare workers, moral injury is significantly associated with post-traumatic stress disorder and depression.

What Does Moral Injury Consist of in Healthcare?

Healthcare workers experience moral injury when circumstances and events clash with their sense of moral or ethical obligation. The situations that may lead to moral injury are unique but may be categorized in the following way:

• Acts of commission: a health care worker may temporarily silence the alarm on a ventilator to avoid present disruption but may be called away, resulting in subsequent harm to the patient in the case that an adverse health-compromising event occurs; i.e., rapid decline in lung function and ventilation
• Omission: a healthcare worker may notice a distressed junior staff member or patient but ignore this in favor of finishing their shift and returning home
• Feelings of betrayal, most often by a higher authority: a healthcare worker may not feel as though they have been provided with adequate equipment, resulting in the feeling that they must choose between delivering poor quality healthcare or risking their safety (a scenario which has become pronounced during the COVID-19 pandemic)

How Can Moral Injury Be Prevented?

Preventative healthcare approaches are considered a more useful structure for understanding how to support those suffering from a health condition. This also applies in the case of moral injury and is arguably poignant as moral injury in itself is innocuous; the health effects occur as a consequence of experiencing moral injury, i.e., depression and suicidal ideation.

The preventative onset of ill-health is called primary prevention; identifying early indicators of prospective ill-health is secondary prevention; providing early treatment in response to the occurrence of ill health is referred to as tertiary prevention. The armed forces employ these tiers of preventative measures to support their staff. They are considered an appropriate framework as the principles of supporting armed staff are similar in the health care setting.

Primary prevention can be realized by preparing staff with role-specific training, providing them with sufficient equipment for supervision, and engendering a feeling of support between team members, particularly in hierarchy cases. In this sense, supervisors should take an active interest in the mental well-being of their colleagues and foster this among their team. An example of this is 'buddy up' systems and when supervisors conduct end-of-shift check-ins with staff.

Secondary prevention can be realized by fostering a sense of confidence between team members. For example, a healthcare worker feels confident enough to have an informed conversation with a potentially distressed staff member. These conversations need not be related to psychological topics and may be actualized through problem-solving; for example, a healthcare worker who fears making a mistake when delivering a form of treatment may have this fear alleviated through the provision of training and mentoring as opposed to psychological intervention such as psychotherapy or time off work.

In the military setting, the concept of what is known as Forward Psychiatry was established following the First World War. This Forward Psychiatry concept comprises several facets of treatment that are presently deployed; proximity, immediacy, expectancy, and simplicity (PIES).

Proximity refers to ensuring that healthcare workers are kept in a lower stress role with good support. Immediacy indicates a time-sensitive approach, fostering active, meaningful, and psychologically aware conversations with colleagues. Expectancy refers to reassuring healthcare workers that their reactions are normal and not indicative of a clinical issue at first while reassuring them that professional support can be sought if they are not resolved.

Simplicity reinforces the benefits of practical and everyday self-care activities such as good sleep, a balanced diet, and engaging in regular and enjoyable physical activity. PIES attempts to move away from categorizing feelings in a clinical sense and instead 'normalizes' the expected/common responses while reinforcing supervisor-implemented practical measures. In this situation, healthcare workers can proactively manage these symptoms early on. However, the National Institute for Health and Care Excellence (NICE) recommends active monitoring of trauma-exposed staff, and a minority will require formal, clinical intervention rather than PIES.

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Is There a Treatment for Moral Injury?

At present, no validated treatment for moral injury exists. Those who experience mental health problems caused by moral injury can be challenging for healthcare workers. Firstly, exposure-based approaches can be harmful when inadequate attention is paid to the emotional processing of feelings of shame and guilt.

Moreover, evidence-based treatments for related disorders such as trauma-related mental health problems often involve a cognitive restructuring of a patient's self-beliefs and appraisals and replacement within and adaptive self-belief appraisals when faced with a similar event. These may not be effective or appropriate when transgressive acts of perpetration bring about feelings of shame and guilt instead of erroneous ideas of self.

For example, a healthcare worker who has caused harm to a mental health patient by restraining them with undue force. In this situation, it may increase the likelihood of future perpetration if a person was subject to evidence-based approaches that challenged the person's accurate appraisal of wrongdoing.

The literature indicates that moral injury may be an important public health concern in the absence of treatment. Treatment approaches that focus on self-forgiveness, self-compassion, acceptance, and, in distinct situations, the opportunity to make amends may be more effective. In many cases, the effects of moral injury extend beyond psychological and involve spirituality; as such, spiritual care providers have an essential role alongside mental health clinicians in alleviating its effects. Thus, prevention is the mainstay approach to moral injury.

References:

• Williamson V, Murphy D, Phelps A, et al. (2021) Moral injury: the effect on mental health and implications for treatment. Lancet Psychiatrydoi: 10.1016/S2215-0366(21)00113-9.
• Greenberg N, Tracy D. (2020) What healthcare leaders need to do to protect the psychological well-being of frontline staff in the COVID-19 pandemic. BMJ Leader. 2020; doi:10.1136/leader-2020-000273
• National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence. Post-traumatic stress disorder. NG116, 2018. Available: https://www.nice.org.uk/guidance/ng116.
• Tam CWC, Pang EPF, Lam LCW, et al. (2004) Severe acute respiratory syndrome (SARS) in Hong Kong in 2003: stress and psychological impact among frontline healthcare workers. Psychol Med. doi: 10.1017/s0033291704002247.
• Kearns MC, Ressler KJ, Zatzick D, et al. (2012) Early interventions for PTSD: a review. Depress Anxiety. doi: 10.1002/da.21997.

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Written by

Hidaya Aliouche

Hidaya is a science communications enthusiast who has recently graduated and is embarking on a career in the science and medical copywriting. She has a B.Sc. in Biochemistry from The University of Manchester. She is passionate about writing and is particularly interested in microbiology, immunology, and biochemistry.