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Moral injury and the COVID-19 pandemic
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.
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.
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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.
Manager Education and Resources
Mental Health & Wellbeing Services CRANAplus
- 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.
- 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
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