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.

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…