‘Against everything that got you into the job’: experiences of potentially morally injurious events among Canadian public safety personnel

ABSTRACT

Background: Moral injury (MI) has become a research and organizational priority as frontline personnel have, both during and in the years preceding the COVID-19 pandemic, raised concerns about repeated expectations to make choices that transgress their deeply held morals, values, and beliefs. As awareness of MI grows, so, too, does attention on its presence and impacts in related occupations such as those in public safety, given that codes of conduct, morally and ethically complex decisions, and high-stakes situations are inherent features of such occupations.

Objective: This paper shares the results of a study of the presence of potentially morally injurious events (PMIEs) in the lived experiences of 38 public safety personnel (PSP) in Ontario, Canada.

Method: Through qualitative interviews, this study explored the types of events PSP identify as PMIEs, how PSP make sense of these events, and the psychological, professional, and interpersonal impacts of these events. Thematic analysis supported the interpretation of PSP descriptions of events and experiences.

Results: PMIEs do arise in the context of PSP work, namely during the performance of role-specific responsibilities, within the organizational climate, and because of inadequacies in the broader healthcare system. PMIEs are as such because they violate core beliefs commonly held by PSP and compromise their ability to act in accordance with the principles that motivate them in their work. PSP associate PMIEs, in combination with traumatic experiences and routine stress, with adverse psychological, professional and personal outcomes.

Conclusion: The findings provide additional empirical evidence to the growing literature on MI in PSP, offering insight into the contextual dimensions that contribute to the sources and effects of PMIEs in diverse frontline populations as well as support for the continued application and exploration of MI in the PSP context.

HIGHLIGHTS

• The objective of this study was to understand the types of events that Canadian public safety personnel (PSP) experience as potentially morally injurious events (PMIEs) as well as the impacts that they associate with these events.

• The findings illuminate that contextual dimensions are significant in the origin of PMIEs, which PSP experience in the completion of routine duties, because of the organizational culture, or as a result of issues in the broader healthcare system, which led to many negative consequences in their personal and professional lives.

• PMIEs reduced the trust PSP had in their leadership and the healthcare system to protect the public and themselves, were associated with feelings of anger, frustration, resignation, and helplessness, and connected to internal struggles marked by inner conflict and the erosion of self-concept.

Antecedentes: El Daño Moral (DM) se ha convertido en una prioridad organizacional y de investigación ya que el personal de primera línea ha desarrollado preocupaciones, tanto durante como en los años que precedieron a la pandemia por COVID-19, acerca de las expectativas repetidas de tomar decisiones que transgreden su moral, creencias y valores profundamente arraigados. En la medida que aumenta la consciencia del DM, lo hace también la atención a su presencia e impactos en trabajos relacionados, tales como aquellos en seguridad pública, dado que los códigos de conducta, las decisiones moral y éticamente complejas y las situaciones de alto riesgo son características inherentes a esas ocupaciones.

Objetivo: Este trabajo comparte los resultados de un estudio sobre la presencia de eventos de potencial daño moral (PMIEs por su sigla en inglés), en las experiencias vividas de 38 funcionarios de seguridad pública (PSP, por su sigla en inglés), en Ontario, Canadá.

Método: Mediante entrevistas cualitativas, este estudio exploró los tipos de eventos que los PSP identifican como PMIEs, cómo los PSP asimilan tales eventos y los impactos psicológicos, profesionales e interpersonales de los mismos. El análisis temático apoyó la interpretación de las descripciones de los eventos y experiencias de los PSP.

Resultados: Los PMIEs aparecen en el contexto del trabajo de PSP, concretamente durante el desempeño de responsabilidad específicas del rol, dentro del clima organizacional y por deficiencias en el sistema de salud más amplio. Las PMIEs son tales dado que violan creencias centrales comúnmente mantenidas por los PSP y comprometen su capacidad para actuar en concordancia con los principios que los motivan en su trabajo. Los PSP asocian las PMIEs, en combinación con experiencias traumáticas, y el estrés de la rutina, con resultados negativos psicológicos, profesionales y personales.

Conclusión: Los hallazgos proveen evidencia empírica adicional a la creciente literatura sobre DM en los PSP, ofreciendo una comprensión de las dimensiones contextuales que contribuyen a las fuentes y efectos de las PMIEs en diversas poblaciones de primera línea, así como también soporte para la aplicación continua y exploración de DM en el contexto del PSP.

背景：道德伤害 (MI) 已成为研究和组织的优先事项，因为在 COVID-19 疫情前几年和期间，引起了人们对一线人员反复期望做出违背其根深蒂固道德观、价值观和信念的选择的担忧。 随着对 MI 认识的提高，人们也越来越关注它在公共安全等相关职业中的存在和影响，鉴于行为准则、道德和伦理上的复杂决策以及高风险情况是此类职业的固有特征 。

目的：本文分享了一项关于加拿大安大略省 38 名公共安全人员 (PSP) 的生活经历中是否存在潜在道德伤害事件 (PMIE) 的研究结果。

方法：通过定性访谈，本研究探讨了 PSP 识别为 PMIE 的事件类型、PSP 如何理解这些事件，以及这些事件对心理、职业和人际关系的影响。 主题分析支持 PSP 对事件和经历描述的解读。

结果：PMIE 确实出现在 PSP 的工作环境中，即在执行特定角色的职责期间、在组织氛围内，以及由于更大范围的医保系统的不足。PMIE 之所以如此，是因为它们违反了 PSP 普遍持有的核心信念，并损害了他们按照激励他们工作的原则行事的能力。PSP 将 PMIE 与创伤经历和日常压力联系起来，带来不良的心理、职业和个人结果。

结论：研究结果为 PSP 中不断增长的 MI 文献提供了额外的实证证据，在 PSP背景中提供了对不同前线人群中 PMIE 来源和影响的背景维度的洞察，并支持 了对MI的不断应用和探索。

KEYWORDS:

• Moral injury
• potentially morally injurious event
• moral distress
• organizational betrayal
• public safety personnel
• first responder
• paramedics
• 911 call-takers
• mental health
• trauma

PALABRAS CLAVE:

• Daño moral
• evento de potencial daño moral
• estrés moral
• deslealtad institucional
• personal de seguridad pública
• personal de primera línea
• paramédicos
• tomadores de llamada del 911
• salud mental
• trauma

关键词:

• 道德伤害
• 潜在道德伤害事件
• 道德困境
• 组织背叛
• 公共安全人员
• 急救人员
• 护理人员
• 911 接线员
• 紧急医疗服务
• 心理健康
• 创伤

1. Introduction

During the COVID-19 pandemic, reports quickly mounted about the extraordinary working conditions that those deemed essential workers faced to maintain the safety, functioning, and health of their communities and themselves. Healthcare professionals (HCP) in particular struggled to balance their duty to care with protecting themselves and their loved ones from infection, with limited pandemic preparedness in their organizations and healthcare systems, and with rapid changes communicated with limited explanation (Koontalay et al., 2021). As awareness of these conflicts increased, conversations in the media, professional associations, and research communities coalesced around moral injury (MI) (Bains, 2020; British Medical Association, 2021; Canadian Medical Association, 2021), a construct first identified in the military and veteran context to describe the impacts of a betrayal of ‘what’s right’ in a high-stakes situation, either by a person in a position of authority or by oneself (Shay, 1991; Shay, 2014).

Epidemiological and qualitative research on MI in healthcare has increased dramatically since the start of the pandemic. As this literature grows, so, too, does interest in the presence and impacts of MI in related frontline occupations, such as law enforcement and firefighting. Given that codes of conduct, morally and ethically complex decisions, high-stakes situations, and high rates of trauma exposure are inherent and well-known features of such occupations (Blumberg et al., 2018; Papazoglou et al., 2020), MI has emerged as a construct that may be relevant for the first responder and public safety context. The present paper contributes to this emergent literature, drawing on a thematic analysis of the lived experiences of potentially morally injurious events (PMIEs) in 38 public safety personnel (PSP) working for a paramedic service in Canada. The findings illuminate contextual dimensions as a significant factor in the origin of PMIEs, which arise in the completion of routine duties, from the organizational culture, or because of issues in the broader healthcare system. PMIEs lead to many negative consequences, including reducing the trust PSP have in leadership and the healthcare system, feelings of anger, frustration, resignation, and helplessness, and internal struggles marked by inner conflict and the erosion of self-concept.

2. From military moral injury to workplace moral injury

2.1. Moral injury: an evolving construct

Moral injury was identified when clinicians working with veterans determined that the diagnosis of PTSD did not sufficiently capture the full and lasting extent of veterans’ experiences or outcomes, particularly during and as a result of deployment (Shay, 2014). The notion that ‘a betrayal of what’s right’ was a commonly reported combat-related experience was first articulated by Jonathan Shay, who recognized that as models of PTSD evolved, particularly with subsequent editions of the DSM, the attention paid to moral and ethical conflicts, and associated moral emotions such as guilt and shame, diminished (Shay, 1991; Shay, 2014). Yet, clinicians working with veterans continued to observe expressions of betrayals in veterans’ accounts, and MI, as a construct, began to crystallize. Since then, the research literature has developed to propose models of MI (Litz et al., 2009), distinguish MI from PTSD (Barnes et al., 2019), develop scales and instruments to assess MI (Litz et al., 2022), and develop and evaluate interventions to treat MI in veterans (Borges, 2019; Farnsworth et al., 2017).

More recently, specific attention has been paid to the psychological, social, spiritual, and biological sequelae of MI (Carey & Hodgson, 2018; Jinkerson, 2016). Recent theorizations suggest that contextual factors, such as military culture and the prevailing political and social climate, are inextricably linked with and ‘relevant to soldiers’ suffering, and that the concept of moral injury has the potential of illuminating this relevance’ (Molendijk et al., 2022, p. 746). In the military organizational context and culture, personal moral beliefs are often in irreconcilable conflict with professional commitments (Molendijk et al., 2022) and systemic factors such as betrayals by leadership engender the conditions for MI (Shay, 2014). Recent qualitative studies about MI in veterans have provided empirical evidence for how contextual factors, such as chaos, compromise the capacity for sound moral appraisals and decisions, which can contribute to MI (Held et al., 2019).

Although there are now more than two dozen definitions of MI, and consensus on a definition has yet to be reached (Jamieson et al., 2020), the construct has been proposed as a productive one for other occupational contexts such as healthcare. Proponents of the ‘moral injury of healthcare’ suggest that, in healthcare, the nexus of moral injury lies in being unable to uphold professional standards of medicine in a corporatized healthcare system (Dean et al., 2019). They maintain that MI captures the cumulative and lasting effect of routine moral stressors in a way that related constructs, namely burnout and moral distress (MD), cannot (Dean et al., 2019). Others have noted that daily or recurring moral stressors can produce a residue that builds over time – a ‘crescendo effect’ – and can lead to MI (Epstein & Hamric, 2009). Further, MI encompasses the existential and spiritual perceptions associated with moral transgressions, which are typically not captured by definitions of MD. MD, which arises when institutional constraints make it nearly impossible for an individual to pursue what they know to be the right course of action (Jameton, cited in Epstein & Hamric, 2009), puts emphasis on situational aspects (British Medical Association, 2021). MD is also less concerned with the manifestation of moral emotions such as guilt and shame, which are a foundation of MI (Drescher et al., 2011; Litz & Maguen, 2012; Molendijk, 2018a), and with the erosion of self-concept and worldview (Jamieson et al., 2020). Existential or spiritual perceptions are also not captured by PTSD, which focuses on psychological and physiological effects associated with traumatic events that may or may not have a moral register. In turn, recent studies of MI in HCP have examined whether exposure to ethical and moral violations may lead to MI (e.g. Hagerty et al., 2022a; Lai et al., 2020; Nelson et al., 2022; Petrie et al., 2022); the prevalence of MI symptoms in HCP who worked during the pandemic (Rushton et al., 2022); associations between exposure to PMIEs and symptoms of PTSD in HCP (Jovarauskaite et al., 2022); and the workplace and systemic factors that may contribute to MI in HCP (Xue et al., 2022; Zahiriharsini et al., 2022). Alongside this, studies of first responder or public safety personnel are drawing on MI to examine the psychological distress associated with the moral and ethical conflicts that arise in these occupations (Jafari et al., 2019; Papazoglou et al., 2020; Smith-MacDonald et al., 2021; Tapson et al., 2022).

2.2. Public safety personnel and risks of MI

Public safety personnel (PSP) play a vital role in protecting people and communities. In Canada, PSP is a recommended term to capture the various occupations that ensure the safety and security of people and communities by responding to emergencies, crimes, and disasters. It includes, but is not limited to, first responders (e.g. paramedics, firefighters, police officers) as well other frontline personnel such as border officials, correctional services officers, and search and rescue personnel (CIPSRT, 2019). PSP save lives, maintain order, protect property and the environment, and frequently put themselves at risk to carry out their duties. Like military personnel and HCP, the nature of their work means that PSP are uniquely and repeatedly exposed to situations that may be traumatic and that may have serious, long-term mental health impacts. They may also face situations that violate or challenge their core beliefs, morals, values, and ethics (Blumberg et al., 2018; Lentz et al., 2021; Özcan et al., 2014), or that involve betrayal by a leader or trusted authority. For example, betrayal by leadership may involve PSP exposure to corruption (Brazil et al., 2010), capriciousness, or ineffectiveness in protecting the welfare of PSP (Schafer, 2010). Such (in)action can prompt a moral or ethical conflict (Brazil et al., 2010), undermine trust and integrity and/or break the psychological contract between the individual and the organization (De Clercq et al., 2020; Smith & Freyd, 2014). Recent reviews and empirical studies suggest that contextual dimensions and factors are also significant for theorizing and understanding MI in PSP. Paramedics, for example, may be morally frustrated by not having the tools or authority to act (e.g. provide medication) (Lentz et al., 2021); this may include situations where their expertise may be devalued or not appreciated by emergency room personnel (Qashu Lim, as cited in Lentz et al., 2021). Although many PSP may recognize and accept morally and ethically complex situations as inherent to their roles, such events may still be difficult to understand, reconcile, and cope with. These experiences have, as recent reviews demonstrate, been associated with outcomes related to MI and worsening mental health outcomes in PSP (Lentz et al., 2021).

Given the relationship between PSP roles and moral and ethical challenges, MI may offer a novel and applicable lens for research and treatment in this context. Recent studies of MI in PSP have, similar to those on MI in veterans and HCP, endeavoured to examine the types of events that PSP experience as PMIEs and the impact of those events on well-being. To date, there has been some exploration of MI in law enforcement (Papazoglou et al., 2020; Papazoglou & Chopko, 2017), but extension to other PSP occupations, such as paramedics and 911 call-takers and dispatchers, remains nascent (Smith-MacDonald et al., 2021). Considering the limited research on PMIEs in PSP, as well as the stated importance of recognizing that PSP roles and contexts present challenges distinct from healthcare, our study focused on the lived experiences of PMIEs and their impacts in PSP working for a paramedic service in Canada.

3. Design and methods

Aiming to understand the perceptions and interpretations of PSP in relation to events that transgress their morals, values or ethics, this study was informed by phenomenology, which takes lived experience as a starting point (Merleau-Ponty, 2013; Oksala, 2004; Van Manen, 1990). In phenomenological inquiry, lived experience designates not just an account of an experience as one has lived through it (Van Manen, 1990), but also ‘the way an individual makes sense of her situation and actions’ which are ‘sedimented over time through [her] interactions with the world’ (Moi, 2001, p. 63). A phenomenological approach has informed similar studies about the lived experiences of PSP (e.g. Adams et al., 2015; Alexander & Klein, 2001; Tapson et al., 2022), including on work-life balance, experiences of PTSD, and, more recently, coping during the COVID-19 pandemic (Carbajal et al., 2022; Casas & Benuto, 2022; Jaeger et al., 2021).

As the study’s aims were to understand the types of events and experiences that PSP themselves identify and interpret as potentially morally injurious, we in turn asked participants to describe what signified, to them, a transgression or violation of their morals, ethics, or values. Given the exploratory nature of this study, we did not endeavour to align PSP’s descriptions of events or their outcomes with any particular definition of MI, nor did we endeavour to validate any particular definition of MI. As the conceptualization of MI in PSP is nascent, and little is currently known about whether or how PMIEs or MI manifest in PSP, such an approach ensured that descriptions of events and impacts could be explored and analysed without assessment in relation to definitions not developed in or for the public safety context. Interview transcripts were coded diversely for descriptions related to transgressions of self-reported morals, values, or ethical principles and for descriptions of interpretations and impacts of those transgressions. Further, coding was conducted without attention to what themes might have been generated in prior research on moral injury in PSP, as the intention was to produce themes that reflect the data, which may parallel or add to those identified by recent studies. In what follows, the term PMIE is used to describe any event that a participant shared as one that transgressed their morals, ethics, or values.

We conducted semi-structured, one-on-one interviews with 38 PSP from a public safety organization in Ontario, Canada, who opted into the study via an online expression of interest. PSP were eligible to participate in the study if they were currently or formerly employed by the partner organization (current employees included those on active duty as well as those on leave; former employees included those who had left or retired from the organization but remained contactable through an internal listserv), at least 18 years old, and comfortable speaking English or French. Participants were paramedics, communications officials, logistics technicians, and members of management who had once served in frontline roles (see Table 1) and were diverse in terms of age, gender, and level of education (see Table 2).¹ Interviews with eligible participants took place between March and July 2021. Prior to scheduling interviews, eligible participants provided their informed consent.² During the interview, participants were asked about the morals, values and ethics that guide them in their work, descriptions of an event(s) that transgressed their morals, values and/or ethics (including during the pandemic), why the event(s) was morally or ethically problematic, and how the event(s) have impacted them, personally or professionally.³ The study was approved by the Research Ethics Board at the University of Ottawa Institute for Mental Health (IMHR-REB #2020025) and relevant approvals were secured from the partnering organization prior to recruitment and data collection. In recognition of their time and contribution, participants received a gift card. All names are pseudonyms.

Table 1. PSP participants.

Table 2. Participant demographics.

Thematic analysis, a method for identifying, analysing and reporting patterns in qualitative data, was used to examine the dataset (Braun & Clarke, 2006; Braun & Clarke, 2012). In thematic analysis, a theme captures something important about the data vis-à-vis the research question and ‘represents some level of patterned response or meaning within the data set’ (Braun & Clarke, 2006, emphasis in original). Using NVivo, the six phases of TA were followed: becoming familiar with the data; generating codes; searching for themes; reviewing themes; naming themes; reporting. First, each transcript was read and re-read in NVivo by two of the three coders (SR, JMM, or MN); the coders took notes to mark initial observations and generate open codes, which were generated inductively from transcripts rather than from existing theoretical frameworks or hypotheses (Kirby et al., 2006; Strauss & Corbin, 1990). The data were also considered from a constructivist perspective, as it enables consideration structural conditions and sociocultural contexts that enable participants to produce the individual accounts that they do. Examples of open codes include ‘unable to help,’ ‘carelessness,’ ‘harmful treatment,’ ‘resource constraints’, ‘PSP neglected’, and ‘policy issues’. Coders then engaged in a second, closer reading of each transcript that they initially coded, independently organizing and clustering codes. From there, to support inter-rater reliability, each coder acted as third coder on transcripts they had not previously coded, and discrepancies were subsequently resolved through discussion and consensus-building. Then, coders jointly harmonized, condensed and clustered remaining codes into a set of themes that accurately described the data. At that point, themes were reorganized, refined, condensed, or discarded, which produced a list of master themes. Following analysis, quotes were extracted from the transcripts and organized such that each theme had diverse, narrative evidence to support it. Validity checks were conducted via member and peer debriefing. Prior to reporting, the first two authors shared findings with the study’s advisory committee, which was composed of researchers with expertise in PSP mental health and in moral injury as well as frontline PSP. This process validated the interpretations of the data and the relevance of the findings.

4. Findings

In order to understand what types of events might violate PSP morals, values, and ethics, and why, it was important to first identify the principles that comprise their values or moral code. Although participants were differently inspired to work as PSP, many participants shared similar values, which motivated them in life and work. When asked about their core beliefs and what they value, professionally and personally, wanting to make a difference, wanting to help others, fairness, kindness, honesty, trust, integrity, the ‘golden rule’ (to treat others as they themselves would want to be treated) and the ‘do no harm’ principle were commonly cited values. Grant, a paramedic, spoke about helping people:

I think what I value most is being able to be present in someone’s, like, most dark or, like, painful moment and be able to make it even just a fraction better, either by kind of talking to them and making them feel a little bit more comfortable.

Garrett, a logistics technician, addressed the ‘golden rule’:

… my core value at this point in my life is that you should always treat people the way that you want to be treated and that you never know what struggle or what baggage, for a lack of a better term, a person is carrying with them. So, no matter how they’re approaching you, you should always approach them with kindness and respect.

Yet, as we explore in this section, PSP often face situations in which they see or do things that transgress these deeply held beliefs.

4.1. Types of PMIEs

4.1.1. PMIEs arise in the performance of routine duties

One group of PMIEs related to transgressions that arise while PSP perform routine duties. At this micro-level, PMIEs were associated with the (in)action of the participant themselves, or the (in)action of a colleague or trusted authority. First, having to treat someone who has caused harm to others, or whose actions they find reprehensible, was described as a PMIE. An experience of this nature was shared by Pam, who was called to a correctional facility to treat a convicted sex offender:

At the time, my daughter was probably three or four years old. And I’m having to deal with this guy that – like, every fibre of my being was just, like, ‘I want you to rot in hell’. […] You’re just at odds with what you feel and what you have to do. That’s difficult.

PSP also experienced PMIEs when established policies or standard operating guidelines compelled them to provide treatment they deemed harmful or futile. Brenda, a paramedic, described having to backboard a patient for transport to hospital, which caused unnecessary suffering:

By the time we got [to the hospital], he was starting to get really agitated; he was very uncomfortable, he wanted out. […] He was screaming in pain. […] Now, he had back pain. He didn’t before; now he does. And that’s really difficult to deal with when you’re called to, you know, help make a patient feel better and I made his whole situation worse. […] That’s one example where I found was morally wrong.

Henry, also a paramedic, described a call to help a fragile, elderly patient. During that call, Henry and his partner felt that, because of his fragility, the patient should walk and not be carried to the stretcher, but procedure and the presence of a supervisor at the scene prevented them from following through:

Book says to carry him, so we carried him to the stretcher. But in doing so, his skin was so fragile that we ripped the skin off his arm. We followed the book, and ended up hurting our patient.

Another source of role-related PMIEs for PSP were situations in which PSP were unable to provide treatment or unable to do more to help a patient. In some situations, PSP were prevented from continuing treatment on patients, even though it went against their clinical judgment. As Jack put it:

I was given directions from a physician to stop resuscitation on someone. I didn’t feel we should stop. I felt that there was still a chance. So, [that was a] morally difficult situation where I’m being told to do one thing and I don’t feel it’s the appropriate decision.

PMIEs also occurred when PSP witnessed others’ actions or inaction. Several spoke about experiences when deference to one’s partner hindered their ability to try to influence the situation and do things differently. Henry described a situation in which he felt that his more senior partner’s treatment decision was not the right one, but that he ‘was not strong enough’ to challenge the decision:

I knew there was a risk […] but […] my partner decided […]. And he was a higher medical authority and I followed his lead, and it was an adverse outcome [for that patient]. So that was very, very hard on me.

For PSP, treating people who have caused harm prompts a conflict between one’s moral code and one’s duty to provide care. When providing treatment deemed harmful or futile, PSP see that patients are put at risk, not helped, or actively harmed, but are often unable to exercise judgement and do what is right. Similarly, PMIEs attributed to negligence and neglect are distressing because of the potential or actual consequences these actions have on patients.

4.1.2. Organizational culture is a source of PMIEs

PMIEs were also associated with or arose because of the organizational culture or climate. Regarding unmet needs, several PSP identified shifts without lunch and/or bathroom breaks, both as a typical occurrence but especially during COVID-19 lockdowns when stops at cafés or restaurants were not possible but requests to return to headquarters to use facilities were denied because it would disrupt operations. Oliver, a paramedic now in management, described a phenomenon where the ‘operational needs supersede the person’s personal needs’, leaving PSP unable to take time between calls to reset:

So basically, if [communications] calls you, it’s, like, ‘Okay, […] we need coverage here. We need you to go here’. It’s, like, ‘Well, hang on a second. Like, we need a few minutes to, you know, get our headspace back’. And then they jump right [to] ‘Well, are you refusing to do the call?’ Like, it becomes an adversary instantly. So, you have no other option but to go to that call. Now you’re dragging the last trauma into this one.

PSP also described experiences in which they were pressured to withdraw complaints or recommendations or when they were sanctioned, formally or informally, for doing what they thought was right. Audrey, in management, described being pressured into rescinding a recommendation she made due to political concerns raised by her superior:

It was just constant day-to-day interactions with my boss trying to force me [to back down], saying, […] ‘You’re not listening to me. And you’re so difficult to work with’. It was just constant badgering and bullying from my boss in an attempt to force me to do something that I didn’t agree with.

In these examples, PMIEs arise because, as PSP strive to do the right thing, the organizational culture or climate often contradicts or makes it challenging for PSP to act in accordance with those values.

4.1.3. PMIEs occur in the broader healthcare system

The third source of PMIEs occurred at the macro level, in the broader healthcare system, and related to issues and failures in aspects such as governance, regulations, service delivery and provision, and workforce distribution and health. Pervasive stress on the healthcare system often trickles down and impedes and devalues PSP work. For example, PMIEs that manifest from underfunding of emergency services include the problem of ‘offload delay’, which occurs when patients arriving at hospital cannot be transferred due to a shortage of emergency beds. While the patient awaits transfer, which can take hours, they remain on the ambulance stretcher and under the supervision, but not treatment, of paramedics:

… the service has this stance where they don’t want you to treat your patient while you’re waiting. Because that’s just gonna make the offload delay longer [and] give the nurses a reason to keep you waiting […]. You’re not supposed to do anything and sometimes it can be hours and hours and people can be very uncomfortable, especially the elderly, and it’s a hard situation […] I’ll still give them medication if they need it or whatever. I haven’t yet had my hand slapped but I just know that it’s something that I could get my hand slapped for. That’s what really bugs me. (Shirley, paramedic)

Further, PSP spoke frequently about PMIEs associated with the ongoing ‘no crew available’ (NCA) problem,⁴ in which there is no available ambulance to respond to emergency calls:

… it’s hard because we’re at [NCA] all the time. So that’s the [reason for being told], ‘Get back out there. Get back out there. Get back out there’. […] It hasn’t been fixed no matter how many staff we throw at it, so clearly there’s another issue there. (Brenda, paramedic)

PSP noted that stress on the healthcare system is exacerbated by longstanding underfunding and under-resourcing of emergency and social services in their province. As a consequence, PSP are often a stop-gap measure in the mental health system, which increases their workload and makes them responsible for duties for which they are untrained. Sam, in communications, noted that many 911 callers are seeking a human connection to reduce social isolation:

… you can see the history of when’s the last time they called, and you can see, like, there’s calls day after day after day. And it’s, like, you know that it’s a frequent caller. There’s also people that – obviously, I don’t know if they live alone or they’re rejected from society and it’s, like, almost a way for them to reach out. And they call us because, obviously, paramedics give their attention. […] It’s an abuse [of the system].

Systems-level PMIEs leave PSP caught between their organization’s priorities, the hospital’s rules, and their commitment to help people. In addition, an overwhelmed healthcare system also exhausts individual PSP bandwidth and compassion. Although these persistent issues are potentially morally injurious, many PSP feel, as we demonstrate in the next section, that there is little they can do to effect change.

4.2. Making sense of PMIEs

4.2.1. PMIEs generate moral dilemmas

One interpretation that PSP had for why these events were problematic was that, even though they knew that an action or treatment was not appropriate or beneficial, they felt they had no choice but to do things ‘by the book’, and comply. Reflecting on a call in which he had to perform resuscitation on a patient who was unlikely to recover, Grant said that while the right thing to do would have been to terminate, established protocol did not allow for it:

I felt not comfortable whatsoever because there was, like, there’s no benefit. It was just best to kind of leave him be and let family have their wish and let him have his final wish, but unfortunately we were just stuck between a rock and a hard place and we just had to proceed.

Further, PMIEs generate moral conflict as they put PSP in a ‘no-win’ position: choose to adhere to a policy but put patient care or safety at risk, or adhere to their values (and do what is in the best interest of the patient) but risk professional consequences. For many, like Skylar, being repeatedly asked to suspend one’s moral position during the completion of job-related duties was a source of moral conflict and contravened what drove her, and many PSP, to the profession in the first place:

It’s in our nature. […] We had a passion for helping people and to providing medicine. So then to sit there and just not do anything when somebody’s having a medical emergency just feels so wrong and against everything that got you into the job.

4.2.2. PMIEs break trust in leadership

Another explanation for what was morally or ethically concerning about the types of events shared is that they broke the trust PSP place in leadership. For example, Thea lost trust in leadership after her request for workplace accommodation was questioned and ultimately denied. She wanted to appeal, but relented in the face of intimidation and bullying by leadership. The experience prompted a critical re-evaluation of her view of the organization:

You think that they’re going to be a good parent and do the right thing, but they’re not. […] Eventually, I had to drop it. At that point, I flipped from, ‘Oh, your supervisors know what’s best, what’s the right thing’, to, ‘**** you guys’. [That experience] represented a big turning point of my morals and my view of how an organization that says, ‘We’re going to take care of you. We care about your mental health’. […] Blah, blah, blah, blah. It’s not true. […] Even though they’ve done training and things are supposed to be changing, it’s still quite a culture of bullying and harassment and fear.

Brenda reflected on the insufficient processing and/or break time between calls. For her, this indicated that the organization has turned its back on PSP and it has produced a dehumanizing effect:

We don’t matter. We’re not human. That’s how this profession has made me feel; disrespected, and that I don’t matter. […] They don’t care about us because, if they did, they would change. They would change our system. But they don’t, because what matters is their bottom line.

4.3. Impacts of PMIEs

In exploring the mental and physical health impacts that PSP associate with or experience as a result of PMIEs, we found that the nature of the work in general, either alone or alongside a ‘breaking point’ event, was the primary source of negative impacts on physical and mental health, more so than a single PMIE or traumatic experience. PSP associated their experiences at work with a range of self-identified impacts, including adverse intrapersonal and interpersonal outcomes.⁵

4.3.1. Adverse emotional responses

Anger and frustration were the most predominantly cited emotional reactions, and were often experienced concurrently. For Audrey, for example, the experience of being pressured to rescind her recommendation sparked anger and frustration, which was new and has persisted:

I have never been as angry as I am in the last probably year and a half. It’s not my personality at all. […] This anger and frustration is something that is completely new to me, and I don’t like it. It’s not who I am at the core. […] I don’t want to be angry. I don’t want to be frustrated. I don’t want to be negative. And that’s what I’m dealing with […].

Several PSP also felt helpless or resigned in the face of these events. Eroding the will they have for advocating for what’s right, some, like Anthony, explicitly tied these events to moral injury:

… when you’re talking about moral injury, I feel like, if anything, it’s one of those, like, long-term erosions of, like, your willingness to stand up for things, absolutely. Especially in this kind of workplace […] you have to weigh the risks and the benefits for some of the decisions that you make, not only on yourself but on your colleagues and on the patients. And after a while, I will admit, you just stop caring.

4.3.2. PMIEs spillover into personal life and self-concept

Specific PMIEs, as well as the occupation in general, impacts the lives of PSP outside of work. PSP reported bringing work complaints into their home lives, impaired relationships with loved ones, withdrawing from their social lives and/or community involvement, and feeling like their parenting has suffered. Thea, a paramedic, described how her interest in social and community life waned:

I dropped a bunch of extra things that I had done, volunteer things that I had been active in. […] I will bail on plans with friends. And that has cost me friendships, because I’ve flaked too many times because I just – I couldn’t deal.

Some expressed that these events had an impact on their perception of themselves, or who they understand themselves to be as individuals. These PSP experienced an accumulation of events that, for some, reached a ‘final straw’ that resulted in outcomes associated with MI. For example, Brenda described how she has been impacted by her work as a paramedic:

I didn’t like who I was becoming and what the system was turning me into. In order for me to live and function in that system, I had to break my morals, and I had to not care in order to survive. And I was terrified about who I was becoming. […] And my soul was just saying, ‘No more, I just can’t do this job anymore’, from the difficult stuff that I see and that I deal with. But I think I was just also broken by the system, and I was just done.

Pam, a paramedic, was similarly impacted by her work, sharing that:

My biggest complaint about [my] profession, is the impact it has on me as a person. […] I definitely feel shut off and I feel like I assume the worst in people, and I’m always looking for what’s wrong in people. […] For me, it’s a moral problem [because] it’s degraded aspects of me that are human, that connect with other people.

While several PSP indicated that PMIEs or stressful experiences impact how they feel about themselves in the moment(s) following the event, these experiences did not change them in any pervasive or long-term sense. For Brenda and Pam, however, their reflections indicate that repeated exposure to a combination of PMIEs and traumatic events has eroded their self-concept. In this way, they recognize the existential impact of the job, as they notice and experience changes to themselves as individuals, as well as erosion of their sense of self.

5. Discussion

Our findings reveal that PMIEs are in fact a feature of the PSP experience and that PMIEs make it difficult for PSP to act in accordance with their core beliefs. Routine exposure to stressful and potentially traumatic situations in combination with a single, intense PMIE was not uncommon, and had varying impacts on the PSP who shared and reflected on their experiences. Although this study did not endeavour to associate participants’ experiences or outcomes with any particular definition of MI, there are discernable points of convergence and divergence between our findings and existing literature on PMIEs and definitions and outcomes of MI. PSP in this study described experiences in which they did not have the authority to act and in which their experience was undermined (Lentz et al., 2021). The emotional responses most commonly expressed by participants were anger, frustration, helplessness, and resignation, which are consistent with extant research (Hagerty et al., 2022a). These emotions were frequently linked to particular PMIEs. Additionally, PSP reported repercussions that resonate with contemporary qualitative investigations of MD in HCP, such as detrimental effects on job performance and morale (Mitton et al., 2010). A considerable number of PSP in our study indicated that PMIEs engendered disillusionment, erosion of trust in the institution, and introspection regarding their personal and professional meaning and purpose. Perceived betrayals, along with other situations, led some PSP to feel as though PSP ‘don’t matter’ and are ‘not human’. Analogous outcomes pertaining to how moral injury (MI) contributes to the loss of significance and the attrition of fundamental human principles have been documented in recent qualitative inquiries of MI among veterans (Held et al., 2019). The dehumanizing effect of PMIEs has been identified in recent studies about the experiences of healthcare workers during the COVID-19 pandemic (Hagerty & Williams, 2022b).

There were also notable points of divergence between this study’s findings and the broader MI literature. Although a single, intense event may lead to outcomes associated with MI, this study found that PSP more frequently described an accumulation of PMIEs, in combination with stressful and traumatic experiences, until a ‘final straw’ event led to consequences such as impaired social functioning, self-loathing, and feeling damaged. Notably, all of these outcomes have been associated with or are symptomatic of MI (Currier et al., 2015; Nash & Litz, 2013). This accumulation to a final event was, as described in a recent editorial on MI in paramedicine, one in which ‘difficult experiences (both from work and life) build up, and the ‘bucket’ containing our emotional life starts to overflow’ (Murray, 2019, p. 425). For PSP in our study, PMIEs did not provoke guilt and shame, moral emotions that are among the primary features of MI. The current literature maintains that PMIEs frequently contribute to unresolved feelings of guilt and shame (Litz et al., 2009), which can lead to intrusive thoughts or rumination (Williamson et al., 2019). Although guilt and shame were not explicitly expressed by PSP in our study, negative self-evaluations around one’s humanity may suggest shame. These may also be a response to how PSP are treated by the organization and healthcare system rather than, as per the MI literature, based on their actions or decisions following an event (Held et al., 2017). It was, as noted, important to approach the data without preconceived notions of what did or did not constitute PMIEs or MI in PSP – given how little is known about MI in PSP and the contextual differences between PSP and military and veteran settings – it is nonetheless pertinent for researchers to further examine these points of overlap and difference in support of efforts to advance expansions of MI into occupational settings.

Contextual dimensions, namely organizational and systemic factors contributed significantly to the occurrence and outcomes associated with PMIEs for PSP. As PSP identify and describe their experiences, PMIEs originate from multiple contexts and multiple levels specifically because as PSP strive to exercise sound judgment and help people, their expectations are frustrated by the expectation of the organization for which they work and the rules and regulations of the broader healthcare system. At the micro level, the PMIEs that PSP experienced were due to the very nature of their work and occurred during the performance of the routine duties that are part of their occupation. The micro-level PMIEs experienced by PSP in our study resemble those identified in the extant literature, which include not acting in a patient’s best interest, having to deny family members the opportunity to see their loved ones, and, as noted above, not having the authority to provide certain treatment (Lentz et al., 2021; Smith-MacDonald et al., 2021). PMIEs that originate from meso- and macro-level forces include events caused by or attributed to the organizational culture or climate, and from failures at a systems level, respectively. PSP are exposed to and experience PMIEs specifically originating from their organization when inefficient, non-existent, or callous response by the organization in response to problematic situations breaks the psychological contract between the individual and the organization (De Clercq et al., 2019; De Clercq et al., 2020). PSP, like workers in other sectors, depend on the organization and its leadership for stability and consistency and they trust that leadership will protect them and uphold espoused values (De Clercq et al., 2020). However, when PSP experience or are exposed to situations that contravene those expectations, or put them in harm’s way, the trust they place in authority figures and/or the organization is broken (Smith & Freyd, 2014). At the macro-level, PSP experienced limited control or autonomy over their work, struggled with competing policies and priorities, and experienced the consequences of systems operating at or beyond capacity, a finding also consistent with recent studies (Smith-MacDonald et al., 2021).

It is important for studies of MI in non-military settings, such as healthcare and public safety, to also consider similarities and differences between these contexts and the military/veteran context. Upon closer examination, there are many differences, but the contextual distinctions between the military and PSP settings may not be as pronounced as they initially appear. Public safety organizations (i.e. policing) are command structures, but with rules of engagement that differ from each other and the military. Police in particular are one of the few non-military occupations in which use of force is sometimes a necessary and accepted tool that increases moral complexity (Lentz et al., 2021). Like military members, PSP operate within high-stakes environments, shouldering immense responsibilities as they routinely confront human suffering (Papazoglou & Chopko, 2017). Further, they often navigate inherent tensions between their assigned tasks and external pressures stemming from administrative procedures, economic constraints, and bureaucratic demands. In turn, the broader societal context exerts a significant influence, further underscoring the parallels between these ostensibly disparate occupational groups.

5.1. Limitations and future directions

Participants in this study represent three of the many PSP occupations in Canada, and were drawn from one organization in an urban centre. As a result, the findings may not be transferable to other occupations or contexts, including those with different populations, service needs, and operational realities. In addition, although demographic data was collected from participants, the study did not have sufficient participation from people with disabilities, sexual minority, or racialized participants to identify themes in relation to identity. From here, there are further investigative and theoretical inquiries to pursue, as what has been demonstrated in this study as well as other recent studies of MI in PSP have only begun to contemplate the origins, expressions, and effects of PMIEs in this population. Further explorations in this emergent area may consider, for example, how the types of events identified as PMIEs and the impacts of these events on PSP well-being might differ if other contexts and settings are taken into account. Intersectional studies of MI in PSP will be critical to understand the unique experiences of diverse PSP, as well as how PMIEs may co-occur with discrimination and/or harassment. Future studies may also consider the role of tenure to enhance understanding of what interaction may exist between length of time in service and interpretations of and reactions to PMIEs.

6. Conclusion

Although the MI literature continues to grow, evidence on its origins, manifestations, and symptomology in non-military settings remains nascent. A suite of scholarship is emerging to understand what PMIEs and MI look like in healthcare and public safety occupations and settings. The findings of this study align in many ways with those of the foundational MI literature as well as recent research on MI in HCP and PSP, particularly in relation to leadership and institutional betrayals. At the same time, noticeable points of divergence emerged, such as the lack of expression of guilt and shame, key moral emotions associated with MI. Ultimately, the findings provide further evidentiary support for the extension of the application of MI into non-military workplace settings, such as healthcare and public safety. In addition, this study’s attention to the institutional realities that contribute to the occurrence and mental health outcomes associated with PMIEs reveal that the broader social, economic and political context can create the conditions for MI. The findings strengthen prior calls to consider how MI may be attributable to systemic failures and that MI is neither solely located within nor solved by attention to individual’s intra-psychic processes (Molendijk et al., 2018b). Future research should continue to consider and examine the role of contextual dimensions in MI, as attention to these dimensions illuminates that MI is neither isolated from nor independent of the context in which it occurs, and are critical in both understanding and determining appropriate responses to MI. For MI to be a productive construct for PSP, it is important to critically examine the conceptual boundaries of MI, such that events, origins, and outcomes that are undoubtedly germane to MI may not be captured in assessment measures, models, and empirical studies.

Acknowledgements

The authors are grateful to the members of the study’s advisory committee for their advice and guidance on study design and execution.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available.

Additional information

Funding

The Atlas Institute for Veterans and Families is funded by Veterans Affairs Canada. Views and opinions expressed are solely those of the Atlas Institute and may not reflect the views and opinions of the Government of Canada.

Notes

1 Paramedics refers to advanced and primary care paramedics, and communication officials refers to 911 call-takers and dispatchers (CIPSRT, 2019). Logistics technicians, a neologism created to protect the identity of the participating organization, are part of some, but not all, public safety organizations in Canada. Their role is to inspect, decontaminate, and supply all front-line vehicles. Although not named in the cited definition of PSP, the study site indicated that logistics technicians impact (and are impacted by) the work of paramedics and communications officials, and often go into the field; as such, they were included in the study.

2 MN enrolled participants into the study. SR, MN, and JMM conducted interviews.

3 Participants were also asked about the role of peers in managing the impact of PMIEs and about how life experiences (e.g., parenting) or identity (e.g., gender, sexual orientation) informed their response to PMIEs, but findings related to these areas of inquiry are beyond the scope of this paper.

4 ‘No crew available’ is a neologism created to protect the identity of the participating organization.

5 In addition, a majority of participants self-reported diagnoses of PTSD, anxiety, and/or depression, which were attributed to the profession overall and not to a specific PMIE. Participants were not directly asked to disclose if they did or did not have a mental health diagnosis; these disclosures arose organically during interviews.