Y Grŵp Cyngor Technegol: niwed moesol i weithwyr gofal iechyd yn ystod pandemig COVID-19

Moral injury can occur when someone engages in, fails to prevent, or witnesses acts that conflict with their values or beliefs and when they experience betrayal by trusted others especially when this is perceived as avoidable, or they are powerless to change it.

Healthcare workers may be or may have been at increased risk of exposure to potentially morally injurious experiences (PMIEs) because of the COVID-19 pandemic. Examples include:

• when present at a patient’s death without loved ones present
• allocating restricted resources to severely unwell patients
• feeling let down by others with regards to their safety

Moral injury is not a mental illness but can contribute to other mental health problems, such as Post-Traumatic Stress Disorder (PTSD), stress, as well as low morale and hostility. Long-term negative outcomes in healthcare workers of exposure to PMIEs and consequent impacts for patients and the organisations they work in are not inevitable.

Health care workers, their colleagues, and leaders can use strategies to improve outcomes both during and after potential morally injurious situations, to support recovery. These include:

• preparation for the likely moral injuries they will face
• processes to support shared team decision making and responsibility
• peer support mechanisms and programmes
• staff reporting psychological distress should be identified early and offered specialist support. Consider active monitoring due to issues with help-seeking
• where distress is longer term or associated with mental ill-health, such as PTSD, specialist support and evidence-based interventions should be available accordingly

This is a short briefing paper highlighting key principles and recommendations with regards to moral injury in healthcare workers including those responsible for direct patient care to laboratory-based staff. The impact of the pandemic on the mental health of health and social care workers is summarised in the Wales COVID-19 Evidence Centre Report.

Moral injury can occur when someone engages in (an act of commission), fails to prevent (an act of omission), or witnesses acts that conflict with their values or beliefs.

Experiences that may lead to moral injury in healthcare workers include:

• having to make decisions that affect the survival of others or where all options lead to a negative outcome
• having to balance one important set of values, such as caring for patients with an infectious disease, over another, such as protecting family members from infection
• allocating restricted resources to severely unwell patients
• balancing their own physical and mental health needs with their duty to patients
• betrayal or feeling let down by trusted others especially when this is perceived as avoidable or they are powerless to change it e.g. responsible others had no interest in their safety/ availability of Personal Protective Equipment (PPE)

Moral injury can also develop in health care workers when they are present at a patient’s death which is counter to their beliefs about how people should die, such as patients dying without loved ones present ^{[footnote 1]}. Such potentially morally injurious experiences (PMIEs) may lead to feelings of moral distress such as guilt, shame, and anger. Healthcare workers have been and may continue to be at increased risk of exposure to such PMIEs as a consequence of the COVID-19 pandemic.

Moral injury is the lasting mental, behavioural or social impact that may result from these experiences. Typically, many health care workers do not experience significant distress from difficult or complex situations at work because of their training, occupational cultural norms, behaviour of peers and leaders and acceptance by families and society at large. However, during natural or large-scale disasters, combat and pandemics, health care workers may be faced with unfamiliar work circumstances, often in the context of higher levels of mortality than usual, where they must make challenging decisions that may contradict their deeply held beliefs in the context of restricted resources. Some may experience ‘post-traumatic growth’- in self-esteem, outlook and resilience others a psychological injury ^{[footnote 1]}.

Any resultant moral injury is not a mental illness but can contribute to other mental health problems, such as PTSD. Evidence from a recent systematic review of occupational moral injury ^{[footnote 2]}, suggests there is a moderate-to-strong relationship between moral injury and PTSD symptoms (mean effect size based on Pearson correlation = 0.30; CI 0.20–0.39), weak-to-moderate relationships with depression, stress, suicidality and hostility, and negative associations with social adjustment, positive affect and resilience. These may result in changes in sleep, significant and persistent negative changes in behaviour or habits, mistakes, isolation, compulsive behaviour (e.g., overworking, overeating), a weakened sense of empathy or compassion, low morale and a desire to leave practice. It is worth noting this evidence mostly relies on cross-sectional studies. Moral injury has been linked to increased difficulties coping with occupational stressors, self-blame, shame and where there is a sense of betrayal, difficulties with those in authority and diminished confidence in leaders. Socially, individuals may withdraw from others, which can lead to relationship breakdown that may exacerbate any impact.

The development of longer term psychological impacts is not inevitable and will depend on several factors including levels of support available before, during and after the PMIE. A few risk and protective factors for moral injury have been proposed, based on a military context ^{[footnote 3]}. These include:

• increased risk if loss of life is a vulnerable person (e.g. woman, child, elderly)
• increased risk if perceived lack of support from leader or family and friends post event
• increased risk if unaware or unprepared for the emotional consequences of decisions
• increased risk if the PMIE occurs alongside other trauma
• decreased risk if receiving empathetic support after the event, particularly from peers who have experienced similar
• decreased risk if leaders and decision makers take responsibility

There does not appear to be clear evidence of inequalities in those most vulnerable to experiencing moral injuries, but consideration should be given to the potential of occupational roles, educational attainment, socio-economic factors and belief systems/ religion resulting in disparities. Given the nature of morally injurious experiences, some healthcare workers may be reluctant to seek help or talk about their experiences due to potential social, occupational or legal repercussions as well as to their core identities. The recognition of avoidance as a key feature of trauma means that monitoring and management of healthcare workers needs to be active rather than solely reliant of help- seeking and incorporate provision of services distinct from the NHS.

Long-term negative outcomes in healthcare workers from exposure to PMIEs and consequent impacts for patients and the organisations they work in are not inevitable. Health care workers, their colleagues, and leaders can use strategies to improve outcomes both during and after potential morally injurious situations, to support recovery and potentially even gain insights and new ways of working. 

Recommended actions for protecting HCWs ^{[footnote 1] [footnote 2] [footnote 4]}

• acknowledgement of their hard work
• a supportive workplace environment
• preparation for the likely PMIEs they will face and encouraging open honest dialogue
• processes to support shared team decision making and responsibility
• Iintroducing resilience training, including sleep enhancement
• time and space to talk about their experiences, reflect on them, make sense of the difficult decisions and learn. This should extend to after the crisis.
• a safe space to rest
• working and sharing breaks with the same team within relevant social distancing context
• peer support mechanisms and programmes across organisational staffing levels available to all health care staff
• mental health literacy across the organisation i.e. causes and signs
• an open organisational culture to those in psychological difficulties where pathways to accessing care are well sign-posted including informal sources of support such as from their hospital chaplaincy and the third sector
• consider active monitoring to staff to identify those who are unwell ^{[footnote 4]}
• staff reporting psychological distress should be identified early and offered specialist support. The configuration of this support should recognise the difficulties healthcare workers have seeking help
• implementation of true crisis teams that can respond immediately if required
• where distress related to a PMIE is longer term or associated with mental ill-health, such as PTSD, specialist support and evidence-based interventions should be available accordingly
• be mindful of language related to ‘normal’ or ‘recovery’ and actively address staff morale and capacity. Healthcare staff continue to work in challenging circumstances both in relation to any future COVID-19 waves, delivering vaccination programmes and meeting new, delayed and backlogged healthcare needs (e.g. elective surgeries, out-patient appointments)

1. Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during covid-19 pandemic BMJ 2020; 368 :m1211 doi:10.1136/bmj.m1211
2. Williamson V, Stevelink SAM, Greenberg N. Occupational moral injury and mental health: systematic review and meta-analysis. Br J Psychiatry. 2018 Jun;212(6):339-346. doi: 10.1192/bjp.2018.55. PMID: 29786495
3. Williamson V, Murphy D, Stevelink SAM, Allen S, Jones E, Greenberg N. The impact of trauma exposure and moral injury on UK military veterans: a qualitative study. Eur J Psychotraumatol. 2020;11(1):1704554. Published 2020 Jan 9. doi:10.1080/20008198.2019.1704554
4. National Institute for Health and Care Excellence. Post-traumatic stress disorder. NG116. 2018. https://www.nice.org.uk/guidance/ng116