Moral injury

Derek K Tracy, Mark Tarn, and Neil Greenberg wrote in thebmjopinion of 30 April this year:

“A recent article in The BMJ highlighted the mental health challenges faced by healthcare workers in the covid-19 pandemic. The authors discussed the risks of “Moral injury” which may become the signature injury for healthcare staff dealing with the covid-19 pandemic. Derived from the military, it describes the ethical and moral suffering arising from experiences which strongly clash with one’s moral code. It is likely to be particularly prevalent in psychologically and practically ill-prepared, inexperienced, poorly supported personnel. These situations are now manifesting across healthcare as healthcare workers manage the covid-19 pandemic. Staff have insufficient personal protective equipment (PPE) to protect themselves or to do their job effectively. They are unable to easily communicate with patients or colleagues when wearing full PPE. Many are working in an unfamiliar clinical environment, caring for large numbers of very unwell patients (many of whom die), and may find themselves questioning their competency and training for the role. All of this is likely to exacerbate the risk of moral injury.

Providing care in such situations can understandably create complex feelings of guilt, remorse, and shame; it can also lead to mental illness in some. Yet most individuals facing trauma do not develop mental illness, and many will show post-traumatic growth. How then, should the NHS help staff avoid illness and experience growth instead? At the London Nightingale hospital the welcome letter sent to prospective staff congratulates them on undertaking a rewarding role, assuring them of appropriate support, but also directly notes that the work will be challenging, people may die despite staff’s best efforts and the environmental situation can be uncomfortable. 

Well, despite the unprecedented nature of the pandemic, we actually do have precedent in managing traumatic events—indeed a strong evidence base from military experiences, terrorist attacks and natural disasters. The key points, from a psychological perspective, are properly preparing people for the tasks ahead, ensuring that everyone, but most importantly supervisors, are able to have supportive conversations, and having tiered levels of appropriate support…”

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