Moral Injury

Could you be at risk of Moral Injury as a result of the COVID-19 pandemic crisis?

Are you a frontline keyworker who has been involved in or had to make difficult decisions during the COVID-19 pandemic crisis about who gets lifesaving treatment and who may not due to pressures in the frontline that you had no control over and now

  • Cannot sleep?
  • Find you are spontaneously crying for no reason?
  • Feel immensely guilty?
  • Feel angry, shameful or full of disgust?
  • Worried that you may be causing undue harm to others even though you are there to help and protect?
  • Feel helpless because you have been in quarantine when colleagues of yours are in the frontline putting themselves at potential risk?

You are not alone and may be suffering with a degree of moral distress or 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. It is not a mental illness but it has been associated with Post Traumatic Stress Disorder (PTSD), depression and suicidal thoughts.

In the COVID-19 pandemic lives will inevitably be lost that could, in other circumstances, have been saved. This has the potential to cause moral injuries in key workers.

Hospitals have been under significant pressure as the number of COVID-19 cases rise, essential resources such as critical care beds and ventilators could leave staff feeling unable to provide adequate care.

Many frontline key workers such as health care workers, social workers and prison staff will experience a degree of moral distress and some will experience moral injuries as a result of the lack of resources, clear guidance or training leading to a perception that your own health is not being properly considered by your employers and feel at increased risk of disease exposure. Similar challenges may also be experienced by other essential workers such as supermarket workers or delivery drivers, who routinely would not consider yourselves as providing critical services to the public.

Moral injury occurs following a morally injurious event, this can lead to negative thoughts about oneself or others developing, alongside feelings of shame, guilt or disgust.

It is important to note, just as not all individuals who experience trauma necessarily develop PTSD, exposure to potentially morally injurious events does not automatically result in moral injury.

During the COVID-19 outbreak in the Hubei province China, surveys of healthcare staff found prevalence rate for depression was 50.7%, anxiety disorders 44.7%, insomnia 33.6% and Post Traumatic Stress Disorder was 73.4 %. Moral injury is also a psychological sequela experienced by clinicians during a pandemic and can increase the risk of PTSD.

Even before this pandemic psychiatric morbidity and burnout amongst healthcare professionals has been high.

Suicide rates in health care professionals before the crisis were known to be high and in some groups, higher than age matched populations. With increasing risk of mental health problems due to this unprecedented challenge, this will be a serious cause for concern both now and the future.

The current emotional strain has been reported by a number of health and care staff across the NHS. This is captured in the quotes from different professional groups.

“I felt like I was the only one who felt this way. I couldn’t make simple decisions at home” ITU Consultant

“I worry about my family a lot and am finding coming into work very stressful” Staff Nurse.

“The hardest thing is not being able to help families meet their loved ones in the final moments”. Staff Nurse.

“I felt like I didn’t know things anymore because what you know works didn’t” Acute Medicine Consultant

“The world is like a horror film at the moment and I still have to go to work and be professional” Emergency Department Nurse

“There is so much change every day in work- I feel overwhelmed” Emergency Department Consultant.

“I just said goodbye to a colleague at their retirement a couple of weeks ago, and we laughed about their cough being possible COVID-19, now they’re ventilated with a poor prognosis, I’m horrified!” Paramedic

“I’m horrified that I am shielding because I’m in the highest risk group and not stood side-by-side with my colleagues who are fighting this disease at the frontline – I can barely bring myself to listen to the clapping on a Thursday” Paramedic

“I feel under so much pressure to keep patients out of ED and hospital, I worry that I’ve made the right decisions every single night” GP

Could you be at risk of Moral Injury ?

Are you:

1. In a position of being well.

2. Already managing a significant Life Trauma.

3. Have a history of a significant Mental Health illness.

4. Recovering from/managing a present Mental Health Illness.

The stresses that you are facing in these challenging times are considered in four areas.

1. Overworking/ pushing beyond normal working experience.

2. Sleep deprivation.

3. Exposure to trauma and/or death of patients or colleagues.

4. Exposed to a perceived risk of dying yourself or putting family members at risk of dying.

Key workers are at increased risk of moral injury if:

  • The life of a vulnerable person is lost, such as a child.
  • When workers don’t feel supported or that leaders haven’t taken responsibility.
  • When staff are not prepared for the emotional consequences of the decisions they are making.
  • If other traumatic events occur at the same time such as a personal bereavement.
  • If they have a lack of social support.

The following recommendations may be beneficial:

  • You should be aware of the possibility of potentially morally injurious events, and develop psychological preparedness.
  • Please seek informal support from managers, colleagues, chaplains and other welfare providers.
  • Seek professional help at an early point, especially if you are having trouble functioning.
  • Managers should check in with your team at regular points to provide support and to signpost you to services if needed.
  • Employers should actively monitor staff like yourself and provide sources of support.

What can we do to help you?

  • Your GP is the first port of call alongside occupational health to support your health and wellbeing. It is essential you seek help early and not pretend all is OK
  • The NHS has worked quickly with the colleges, mental health charities, 3rd sector organisations and Arm’s Length Bodies to offer a range of apps, online tools and podcasts to help bolster resilience. Access to this is through the telephone number 0300 131 7000, or text FRONTLINE to 85258 or online Health and wellbeing support.

You can also get the following help but it is important that you do this in conjunction with the above

With thanks to Dr Andrew Coley, Dr Rajkumar and the Clinical Leaders Network Board and information taken from COVID-19 and experiences of moral injury in front-line key workers