In the COVID-19 environment, healthcare workers around the world are facing situations that have the potential to be morally challenging, stressful and possibly injurious. Phoenix Australia, together with the Canadian Centre of Excellence on Posttraumatic Stress Disorder, has developed a practical resource for healthcare workers and organisations – the Brief Guide to COVID-19, Moral Distress and Moral Injury. The guide provides an understanding of moral injury and an organisational framework to support workforces and prevent lasting moral injury or harm.
What is moral injury?
Moral injury refers to the psychological, social and spiritual impact of events involving betrayal or transgression of one’s own deeply held moral beliefs and values occurring in high stakes situations. The concept was developed in response to soldiers returning from deployment having been involved in events that transgressed deeply held moral convictions, and suffering enduring harms to psychological, social and spiritual health as a result. There are two broad types of moral transgression events: moral transgressions that involve people doing or failing to do things themselves (deliberately or unwittingly); and being exposed directly or indirectly to transgressions on the part of someone else (betrayal, or bearing witness to grave inhumanity).
The effects of moral injury can include feelings of guilt, shame, anger, sadness, anxiety and disgust; beliefs about being bad, damaged or unworthy; loss of faith in people and avoidance of intimacy; and loss of religious faith, or loss of faith in a just world.
Moral injury and COVID-19
In the context of COVID-19, healthcare workers may face situations that do not allow them to deliver care in the way they have been trained (that is, to help people and do no harm), such as when there are insufficient hospital beds, and insufficient equipment or access to equipment. They may be forced to decide who receives life-saving treatment and who does not. They may need to prevent family members from being at the side of a dying relative, and have to follow clinical directions that they may feel are unethical.
These types of experiences may lead to enduring psychological, social and spiritual harm, with adverse impacts on mental health, relationships, and quality of life. When this occurs, a moral injury has been sustained.
It is important to recognise that while some people exposed to moral stressors may experience significant distress and injury, others may experience posttraumatic growth, including improved psychological resilience, increased esteem, compassion and engagement.
For healthcare organisations, given that the COVID-19 environment poses the potential for mental health impacts and moral injury, it is imperative to implement a preventative and early intervention approach to reduce risks and maximise protective factors for workers.
A framework for managing potentially morally injurious events in the workplace
A whole-of-organisation approach that considers the role of managers and leaders, wellbeing support services, and individuals, is recommended as the best practice approach to mitigating the risk of moral injury. There are several recommendations for practical measures emerging from the research literature.
At the organisational level, policies are needed to guide difficult ethical decisions; levels of exposure to trauma and staff wellbeing should be monitored; and peer support programs should be established to address moral injury and provide timely and accessible psychological support for frontline workers.
At the peer, or team level, promoting a strong sense of shared purpose and strong leadership has been shown to reduce rates of mental health problems in staff. Open, empathic leader-led team discussions, modelling positive coping skills, and encouraging peer and social support are all important strategies.
And at the individual level, staff wellbeing should be promoted by supporting workers to learn about moral stressors and moral injuries, engage in positive self-care both within and outside of work, and to seek professional support if needed.
The COVID-19 pandemic is placing enormous pressure on the healthcare system in many parts of the world, raising awareness internationally of the potential for moral injury amongst healthcare workers. Providing support to those workers is critical if we are to avoid the most severe harms. The Brief Guide to COVID-19, Moral Distress and Moral Injury provides organisations and individuals with an understanding of moral injury, and outlines the need for a whole-of-organisation approach to managing potentially morally injurious events and mitigating the risk of moral injury amongst healthcare workers who are at the frontline of supporting communities to overcome the global pandemic.
The Brief Guide to COVID-19, Moral Distress and Moral Injury will be available in June 2020 from the Phoenix Australia website.