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

Sarah Rabin,1 Natalia Kika,1 Danielle Lamb,2 Dominic Murphy,1,3 Sharon AM Stevelink,1 Victoria Williamson,1,4 Simon Wessely,1 Neil Greenberg1 1Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK; 2Department of Applied Health Research, University College London, London, UK; 3Research Department, Combat Stress, Leatherhead, UK; 4Department of Experimental Psychology, University of Oxford, Oxford, UKCorrespondence: Sarah Rabin, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, Weston Education Centre, London, SE5 9RJ, UK, Tel +44 02078485351, Email sarah.p.rabin@kcl.ac.ukAbstract: 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