Moral injury: the overlooked stressor of the NHS

The UK Governments’ Coronavirus Action Plan to contain, delay and mitigate the spread of Coronavirus (with investigative research conducted throughout) was designed to ease the burden on the NHS by facilitating a steady influx of patients, thereby avoiding an overwhelming surge in NHS demand. Despite former NHS staff coming out of retirement, donations of equipment from other private healthcare bodies (e.g. Nuffield) and alternative sources of support (e.g. British Vets Association has offered human-compatible ventilators and monitors), the NHS continues to experience the greatest strain on their resources in over 70 years.

During this pandemic, a weekly nationwide acknowledgement of the effort and sacrifice made by the NHS staff has taken place at Thursday at 8pm, with people standing at their open doors and windows to clap and cheer as a ‘thank you’. For most NHS staff, this will be heard as they return from their 13-hour shifts. Despite this acknowledgement being undoubtedly meaningful to these keyworkers, it cannot compensate for the psychological strain each frontline healthcare worker experiences or witnesses at work; deciding who is allocated resources, witnessing upset and isolated patients, caring for patients who ultimately do not survive the disease.

A recent editorial in the BMJ by Prof. Neil Greenberg and colleagues (2020), highlights the impact this consistent exposure can have on frontline NHS staff (e.g. nurses and doctors), as well as the role junior leaders (e.g. nurse managers, consultants) must play during this extraordinary time.

Psychological strain is a particular hazard for health workers during the COVID-19 pandemic.

Methods

The authors draw upon existing research to illustrate possible outcomes following exposure to trauma and what staff can do before, during and after a crisis to reduce the traumatic effects.

Results

This article (Greenberg et al, 2020) is not a research paper and therefore empirical findings were not provided. However, the authors explain that following exposure to a challenging situation, one of the following outcomes can emerge:

• Psychological growth: a dramatic improvement in psychological resilience, esteem and outlook.
• Psychological/moral injury: Psychological distress which results from action or inaction which violates an individual’s moral or ethical code. This can lead to shame, guilt or disgust. In extreme cases, the individual can go on to develop mental illness including symptoms of depression, post-traumatic stress disorder (PTSD) or even suicide ideation or behaviour.

The authors outline how supervisors and managers can provide valuable support to the workforce before, during and after a crisis, thereby reducing or avoiding the traumatic effects of the events experienced:

Before

1. Use of frank, open and honest dialogue to prepare staff for the challenge ahead of them. This will help manage the expectations of the staff and avoid disillusionment.
2. Encourage emotional ‘off-loading’ and self-disclosure of experiences of moral challenges garnered from caring for patients.
3. Make staff aware of moral injuries and encourage the use of a support network or peer support programs.

During

1. Ensure staff are not avoiding discussions of emotionally challenging instances, as this can be a sign of trauma, e.g. avoiding or not attending meetings.
2. Support (or refer to a team leader) if staff become overly distressed as this can be a sign that other things have been building-up below the surface. In more severe cases a specialist may be more appropriate to support them.
3. Senior management should be particularly mindful of the health and wellbeing of the junior managers who are supporting the frontline staff, as they themselves may start to experience moral injury.

After

1. Positive reframing of the crisis, where it is reflected and learned from, as opposed to being a traumatic event better forgotten.
2. Active monitoring of staff enables quick identification of those experiencing moral injury. This allows efficient signposting for early interventions.
3. Treatment for moral injuries should include discussion of shame and guilt; topics which the patient may try to avoid.

The response to a crisis can result in psychological growth or psychological injury, so services need to be prepared to support staff as appropriate.

Conclusions

Moral challenges are almost inevitable for NHS staff during the Coronavirus outbreak; caring for strangers in high-risk Coronavirus environments is an enormous stressor on-top of those experienced daily by the rest of the nation.

It is important to realistically prepare the staff as to what to expect, and to encourage conversation and peer-support as an effective coping tool during this time.

In applying these strategies and practices, frontline staff can experience psychological growth as a result of the challenges faced by COVID-19, rather than experiencing psychological injury.

In addition, it is important to be mindful of the psychological wellbeing of junior leaders, as, by taking on the emotions of others, this stress may reverberate further up the command-chain and impact others.

Social and emotional supports can mitigate or even avoid moral injury.

Strengths and limitations

This paper provides an array of suggestions to help support frontline staff before, during and after a crisis. Despite drawing upon research from military situations, which reflect the limited resources and huge moral burdens experienced by the NHS at present, the paper does not provide any empirical data to illustrate prevalence or susceptibility of moral injury. Furthermore, the paper does not describe any research which has investigated the effects of the interventions it recommends. Despite this, the paper is easy to read and thereby accessible to the vast majority of the public for their own interest and awareness. The strategies the article highlights would be of benefit to any organisation in order to support all levels of the organisational hierarchy.

The most powerful contribution of this article is that it provides a label for the invisible stressors experienced by healthcare staff beyond that of contagion, time and means experienced across the NHS. By labelling this stressor, and making it known to NHS staff that the emotions they are experiencing are real, valid and recognised, we can open the door to them speaking up and receiving more effective support.

These guidelines by Greenberg et al (2020) are applicable beyond Coronavirus, and several organisations would benefit from implementing them.

Implications for practice

Although this BMJ article (Greenberg et al, 2020) is written to address NHS staff wellbeing during the Coronavirus, the advice provided here should also be applied as standard to support the general functioning of the NHS and any other organisation.

NHS workers at the front line, as well as junior and mid-level management, would benefit from applying the strategies listed here, including the opportunity for debriefing, workplace support groups and monitoring of staff from senior members. Additionally, this paper serves as a reminder that once life returns to normal for most of the nation, focus should be shifted to support those staff who have experienced and witnessed the worst of the crisis. The article here provides strategies to support this, including active monitoring and positive re-framing to ensure health workers reflect on the events positively, with an opportunity for psychological growth.

If you work in mental health services, please take this survey now to help the Mental Health Policy Research Unit better understand what’s happening now in mental health care: https://elfi.sh/covidmh-survey

Statement of interests

None.

Links

Primary paper

Greenberg, N., Docherty, M., Gnanapragasam, S., & Wessely, S. (2020). Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ, 368. https://doi.org/10.1136/bmj.m1211

Other references

Coronavirus Action Plan. Department of Health and Social Care, 3 March 2020.

Gallagher P. (2020) Coronavirus in the UK: NHS facing biggest challenge since 1948 with rise in Covid-19 patients. The Independent, 24 March 2020.

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