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Moral injury and the COVID-19 pandemic

4 Apr 2022

Have the pressures of the COVID-19 pandemic forced you to do things at work that go against your moral principles? You may be experiencing moral injury and its symptoms of guilt, anger, and detachment, writes Kristy Hill from CRANAplus' Mental Health & Wellbeing Team.

Kristy Hill Education and Resource Manager

As health care work­ers across Aus­tralia move into their third year of man­ag­ing the COVID-19 pan­dem­ic, we have nev­er been more grate­ful for their courage, resilience, sac­ri­fices and persistence. 

You are noticed and appreciated. 

Despite their incred­i­ble strength and resilience, they are under­stand­ably exhaust­ed from the relent­less uncer­tain­ty, stress, trau­ma and grief. Many health work­ers have expe­ri­enced numer­ous and con­tin­u­ous trau­mat­ic events which will, in many instances, neg­a­tive­ly affect their psy­cho­log­i­cal wellbeing.

In this ever-chang­ing envi­ron­ment, many health care work­ers are fac­ing sit­u­a­tions that have the poten­tial to be moral­ly chal­leng­ing, stress­ful and result in ongo­ing moral injury. 

Moral injury has emerged in the health care dis­cus­sion quite recent­ly because of the dif­fi­cul­ties and chal­lenges health care work­ers and health care sys­tems face in the con­text of the COVID-19 pandemic. 

What is moral injury?

Moral injury is described as 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’¹.

It was first described in the ear­ly 1990s, by US psy­chi­a­trist Dr Jonathan Shay when he began using the term moral injury” to describe a par­tic­u­lar kind of trau­ma he observed in the Viet­nam vet­er­ans he was treat­ing². Moral injury occurred, he believed, when sol­diers had been involved in events that con­tra­vened their deeply held moral convictions.

The lit­er­a­ture describes two broad types of moral trans­gres­sion events:

  • Moral wrong­do­ings that involve peo­ple doing or fail­ing to do things themselves
  • Being exposed direct­ly or indi­rect­ly to wrong­do­ings on the part of some­one else (betray­al, or bear­ing wit­ness to wrongdoings)³.
Photo dmytro khlystun stock adobe com

Pho­to Cred­it: dmytro_​khlystun — stock​.adobe​.com

Moral injury and COVID-19

Moral injury has been observed in health care work­ers who have faced 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.

It has also been observed in health work­ers who have been forced to decide who receives life-sav­ing treat­ment and who does not.

They may have had to pre­vent fam­i­ly mem­bers from being at the side of a dying rel­a­tive or to fol­low clin­i­cal direc­tions they felt were uneth­i­cal. When health work­ers expe­ri­ence these sit­u­a­tions, it can lead to moral injury.

What are the symptoms?

Phoenix Aus­tralia describes the symp­toms of moral injury to include feeling:

  • Guilt or shame that you can’t do what you think is right
  • Anger towards an organ­i­sa­tion, which is then pro­ject­ed onto peo­ple close to you
  • Low­ered self-esteem and the feel­ing that you’re not doing a good enough job
  • Detach­ment from per­son­al rela­tion­ships or rela­tion­ships with colleagues
  • Ques­tion­ing your career choice
  • Not want­i­ng to go to work¹.

On a pos­i­tive note, it is impor­tant to recog­nise that while some peo­ple exposed to moral stres­sors may expe­ri­ence sig­nif­i­cant dis­tress and injury, oth­ers may expe­ri­ence post-trau­mat­ic growth. With this growth, peo­ple can take new mean­ing from their expe­ri­ences and live their lives in a dif­fer­ent way. This may include an improved appre­ci­a­tion of life, improved rela­tion­ships with oth­ers, and increased per­son­al strength⁴.

Strate­gies to pre­vent or reduce the impact of moral injury

Experts are advo­cat­ing the need to pri­ori­tise a range of pre­ven­ta­tive and ear­ly inter­ven­tion strate­gies to reduce risks and max­imise pro­tec­tive fac­tors for work­ers. As a result, Phoenix Aus­tralia has col­lab­o­rat­ed with the Cana­di­an Cen­tre for Excel­lence – PTSD to devel­op a The Moral Stress Amongst Health­care Work­ers Dur­ing COVID-19: A Guide to Moral Injury¹.

This Guide pro­vides organ­i­sa­tions and indi­vid­u­als with an under­stand­ing of moral injury and out­lines an approach to man­age and mit­i­gate the risk of moral injury amongst health care work­ers. It makes a range of prac­ti­cal rec­om­men­da­tions including:

  • At the organ­i­sa­tion­al lev­el, it rec­om­mends poli­cies to guide dif­fi­cult eth­i­cal deci­sions; mon­i­tor­ing lev­els of expo­sure to trau­ma and staff well­be­ing; and estab­lish­ing peer sup­port pro­grams to address moral injury and pro­vide acces­si­ble men­tal health and well­be­ing sup­port for front­line workers.
  • At the team lev­el, it rec­om­mends pro­mot­ing a strong sense of shared pur­pose and strong lead­er­ship; encour­ag­ing open, empath­ic leader-led team dis­cus­sions, demon­strat­ing pos­i­tive cop­ing skills, and encour­ag­ing peer and social support.
  • And at the indi­vid­ual lev­el, it sug­gests sup­port­ing work­ers to learn about moral stres­sors and moral injuries; pro­mot­ing self-care both with­in and out­side of work, and seek­ing pro­fes­sion­al sup­port if needed¹.

If you need to talk things through with some­one, you can con­tact the Bush Sup­port Line on 1800 805 391 any­time to have a con­fi­den­tial chat with one of our psy­chol­o­gists.

Thank you for all that you do.

Kristy Hill
Man­ag­er Edu­ca­tion and Resources
Men­tal Health & Well­be­ing Ser­vices CRANAplus

  1. Phoenix Aus­tralia – Cen­tre for Post­trau­mat­ic Men­tal Health and the Cana­di­an Cen­tre for Excel­lence – PTSD (2020). Moral Stress Amongst Health­care Work­ers Dur­ing COVID-19: A Guide To Moral Injury.
  2. https://​insight​plus​.mja​.com​.au…
  3. Litz, B.T. and P.K. Kerig, Intro­duc­tion to the Spe­cial Issue on Moral Injury: Con­cep­tu­al Chal­lenges, Method­olog­i­cal Issues, and Clin­i­cal Appli­ca­tions. Jour­nal of Trau­mat­ic Stress, 2019. 32(3): p. 341 – 349
  4. https://​www​.apa​.org/​m​o​n​i​t​or/20

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