Moral Injuries in Healthcare Workers: What Causes Them and What to Do About Them?

Abstract

Moral injury (MI) refers to the persisting distress which may occur following exposure to potentially morally injurious events (PMIEs). The COVID-19 pandemic has drawn attention to MI in healthcare workers, who have been found to experience more frequent PMIEs in their day-to-day work than those in other occupational groups such as the military. These events may occur on an individual, team, organizational or system level and have been associated with increased clinician burnout and distress, and poor psychological wellbeing. This paper focuses on healthcare workers’ experiences of MI, including potential causes and ways to reduce them. There are myriad challenges that influence the development of MI, such as chronic understaffing and the pressure to treat high numbers of patients with limited resources. There are also multiple impacts of MI: at the individual-level, MI can lead to increased staff absences and understaffing, and prolonged patient contact with limited decision-making power. COVID-19 exacerbated such impacts, with a lack of organizational support during a time of increased patient mortality, and uncertainty and heightened pressure on the clinical frontline associated with scarce resources and understaffing. Potential methods for reduction of MI in healthcare workers include pre-exposure mitigation, such as fostering work environments which treat PMIEs in the same way as other occupational hazards and post-exposure mitigation, such as facilitating healthcare workers to process their experiences of PMIEs in peer support groups or with spiritual advisors and, if MI is associated with mental ill-health, talking therapies using trauma-focused and compassion-oriented frameworks.

Keywords:

• moral injury
• healthcare workers
• causes
• effects
• mitigation
• pandemic
• prevention
• treatment

Acknowledgments

This work is independent research supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) North Thames. This work was part funded by the National Institute for Health and Care Research Health Protection Research Unit (NIHR HPRU) in Emergency Preparedness and Response, a partnership between the UK Health Security Agency, King’s College London and the University of East Anglia. The views expressed are those of the author(s) and not necessarily those of the NIHR, UKHSA or the Department of Health and Social Care.

Disclosure

S.W. is a senior NIHR Investigator and has received speaker fees from Swiss Re for two webinars on the epidemiological impact of COVID-19 pandemic on mental health. He is also a Non Executive Director on the Board of NHS-England. S.AM.S. reports grants from UKRI/ESRC/DHSC, grants from University College London, grants from Rosetrees Trust, grants from King’s Together Fund, and an NIHR Advanced Fellowship [ref: NIHR 300592]. N.G. is the managing director of March on Stress Ltd which has provided training for a number of NHS organisations, although it is not clear if the company has delivered training to any of the participating trusts or not as N.G. is not directly involved in commissioning specific pieces of work. D.L. is funded by the NIHR ARC North Thames. The other authors report no competing interests in this work.