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Moral injury is a relatively new, but increasingly studied, construct in the field of mental health, particularly in relation to current and ex-serving military personnel. Moral injury refers to the enduring psychosocial, spiritual or ethical harms that can result from exposure to high-stakes events that strongly clash with one's moral beliefs. There is a pressing need for further research to advance understanding of the nature of moral injury; its relationship to mental disorders such as posttraumatic stress disorder and depression; triggering events and underpinning mechanisms; and prevalence, prevention and treatment. In the meantime, military leaders have an immediate need for guidance on how moral injury should be addressed and, where possible, prevented. Such guidance should be theoretically sound, evidence-informed and ethically responsible. Further, the implementation of any practice change based on the guidance should contribute to the advancement of science through robust evaluation. This paper draws together current research on moral injury, best-practice approaches in the adjacent field of psychological resilience, and principles of effective implementation and evaluation. This research is combined with the military and veteran mental health expertise of the authors to provide guidance on the design, implementation and evaluation of moral injury interventions in the military. The paper discusses relevant training in military ethical practice, as well as the key roles leaders have in creating cohesive teams and having frank discussions about the moral and ethical challenges that military personnel face., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Evidence is growing regarding the impact of potentially morally injurious events (PMIEs) on mental health; yet how moral injury may affect an individual's occupational and familial functioning remains poorly understood., Method: Thirty male veterans who reported exposure to either traumatic or morally injurious events and 15 clinicians were recruited for semi-structured qualitative interviews., Results: While many veterans experienced psychological distress postevent, those who experienced PMIEs especially reported social withdrawal and engagement in aggressive, risk-taking behaviours. This was highly distressing for family members and created a tense, volatile home and workplace environment that was difficult for others to navigate. Following PMIEs, employment could be used as a cognitive avoidance strategy or as a means to atone for transgressive acts. In cases of moral injury, clinicians considered that targeted support for spouses and accessible guidance to help children to better understand how their military parent may be feeling would be beneficial., Conclusions: This study provides some of the first evidence of the pervasive negative impact of PMIEs on veterans' familial and occupational functioning. These findings highlight the need to comprehensively screen for the impact of moral injury on daily functioning in future studies that goes beyond just an assessment of psychological symptoms., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

The COVID-19 pandemic has extracted an enormous physical health toll on many millions worldwide, and the wider societal impact from economic turmoil, unemployment, social isolation and so forth continue to be measured. A less explored aspect has been the psychological impact on treating healthcare staff, with emerging evidence of 'moral injury' and mental illness for some. This review explores the evidence base for implementing a tiered model of care to minimise this and foster 'post-traumatic growth', and describes the authors' implementation of this in the London Nightingale hospital, with lessons for the armed forces., Competing Interests: Competing interests: NG runs a psychological health consultancy that provides resilience training for a wide range of organisations, including a few NHS teams. The work was supported by the National Institute for Health Research (NIHR) Health Protection Research Unit in Emergency Preparedness and Response at King’s College London, in partnership with Public Health England and in collaboration with the University of East Anglia and Newcastle University., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Predeployment stress management/mental health training is routinely delivered in an effort to mitigate potential adverse psychological effects. Little is known about the effectiveness of such interventions., Methods: A systematic literature review explored research outcomes related to this subject, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. An electronic database search using key terms identified studies published between January 2007 and March 2019. Comprehensive inclusion/exclusion criteria were applied and study quality was appraised by two reviewers using 12 criteria adapted from the Critical Appraisal Skills Programme (CASP) checklist. Papers were excluded if they were allocated CASP scores ≤10 out of 24., Results: 2003 references were identified; 15 papers fulfilled inclusion criteria and quality threshold requirements. Included studies were randomised controlled trial design (n=8), quasi-experimental (n=5), case report (n=1) and cross-sectional (n=1). Duration of follow-up assessment varied from immediately postintervention to 24 months. The included studies were heterogeneous so clear recommendations relating to predeployment training for military personnel could not be made. Although somewhat disparate, predeployment interventions shared the aim of promoting prior to, during and after deployment health and well-being. Social benefits such as improved cohesion and improved stress management skills were identified in some studies, although substantial mental health and well-being benefits were not found., Conclusions: Evidence for the effectiveness of predeployment psychological interventions is scant. Every attempt should be made to use methods and measures to facilitate comparisons across studies, to attempt a longer follow-up timescale and to clarify key trainer characteristics., Competing Interests: Competing interests: NJ is a full-time reserve member of the British Army currently seconded to King’s College London. AS is a full-time member of the British Army similarly seconded. NG is the Royal College of Psychiatrists Lead for Military and Veterans Health and trustee with two military charities; however, he was not directed by these organisations in any way in relation to his contribution to this paper. He is affiliated to the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Emergency Preparedness and Response at King’s College London in partnership with Public Health England, in collaboration with the University of East Anglia and Newcastle University. AP, CW and LH received funding from the Ministry of Defence for the duration of the study but were not instructed in any way in the production of this manuscript., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Research suggests that moral injury (MI) in US veterans is associated with poor psychological outcomes and disruption in functioning. However, little is known about how MI may impact UK Armed Forces (AF) veterans. This study aimed to explore the impact of MI on veteran psychological well-being and functioning., Methods: Six veterans identified as having had exposure to MI and four clinicians who treated veterans with MI were recruited from a UK charitable organisation which provides psychological care for veterans. Data were analysed using thematic analysis., Results: MI was perceived to cause substantial psychological distress in this sample. Our data suggest that some veterans held extremely negative self-appraisals which appeared to contribute towards and maintain their distress. Issues relating to spirituality following MI were thought to be infrequent; however, a loss of faith was perceived by clinicians to be more common in morally injured veterans than heightened spiritual/religious views. Several difficulties relating to employment were described, including increased trouble coping with occupational stress and authority figures. Interpersonal difficulties were frequently reported, with withdrawal from others often leading to relationship breakdown with spouses and children., Conclusion: This study provides some of the first evidence of the impact of MI on UK AF veterans' psychological, spiritual, social and day-to-day functioning all of which would pose challenges to clinicians aiming to manage such difficulties. These findings highlight several gaps in existing care provision for morally injured veterans, including addressing issues related to spirituality, employment and family functioning, which could ultimately improve veteran well-being., Competing Interests: Competing interests: NG is the Royal College of Psychiatrists Lead for Military and Veterans’ Health but was free to provide his independent views on this research., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

As disasters become increasingly prevalent, and reported on, a wealth of literature on post-disaster mental health has been published. Most published evidence focuses on symptoms of mental health problems (such as post-traumatic stress disorder, depression and anxiety) and psychosocial factors increasing the risk of such symptoms. However, a recent shift in the literature has moved to exploring resilience and the absence of adverse lasting mental health effects following a disaster. This paper undertakes a qualitative review of the literature to explore factors affecting psychological resilience, as well as the potential positive impact of experiencing a disaster (post-traumatic growth) by examining the literature on employees in disaster-exposed organisations. We identify several protective factors: training, experience, and perceived (personal) competence; social support; and effective coping strategies. Post-traumatic growth frequently appeared to occur at both personal and professional levels for those rescue staff after a disaster, giving employees a greater appreciation of life and their relationships, enhancing their self-esteem and providing a sense of accomplishment and better understanding of their work. Implications, in terms of how to build a resilient workforce, are discussed., Competing Interests: Competing interests: NG runs a psychological health consultancy which provides, among other services, TRiM training., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2020. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)