Coming to grips with Moral Injury

Nearly 80% of doctors say ‘Moral Distress’ resonates with their pandemic work experiences.

Covid wiped us all out. Not just physically. Front-line workers suffered most.

Tough times can be a source of great psychological growth, or they can weaken us. The choice is not always ours. But if communities get together and tackle Moral Injury head-on, we can, as Eric Greenberg suggests, effectuate a positive re-framing of traumatic experiences for growth and learning.

Moral Injury rife amongst healthcare workers in the wake of the pandemic has prompted many leaders to put in place measures to ensure proper psychological support to staff. This is a fantastic response and the rest of us should support it and encourage it in every way we can.



Understanding Moral Injury

When we are overwhelmed with our workload, we make mistakes, we forget things and we get cross with the people who put us in that position.

Associated commonly with veterans, traditionally rife in the care sector, and now a by-word by the pandemic with all key workers, Moral Injury is nothing new.

When one is compelled to do something (because it’s our job or for whatever reason) against our own beliefs or values, the resulting feelings of guilt, stress, hopelessness, frustration, and betrayal are dubbed moral injury. Technically, it’s the psychological distress caused when our actions or lack of actions violate our moral or ethical code.

The Effects

Moral Injury is associated with psychological distress and moral responses including guilt, anger and disgust – emotions which act as a barrier to recovery. Those suffering often feel reluctant to talk about their difficulties, even including clinicians.

In itself, moral injury is not a medical condition, but it could lead to or exacerbate other mental health issues and extreme cases, the individual can go on to develop symptoms of depression, post-traumatic stress disorder (PTSD), or even suicide ideation or behaviour.

A Breeding ground…

The pandemic has been a breeding ground for moral injury. The causes of Moral Injury are threefold – Acts of Commission, Acts of Omission and feelings of Betrayal from a higher authority.

A 2020 article by Victoria Williamson in a public health medical journal lists the risk factors for Moral Injury. There is increased risk someone suffering moral injury where there has been – loss of life – especially of the vulnerable like women and children; exposure to

traumatic events (like those on the front line); when people are unaware or unprepared for the emotional/psychological consequences of their decisions; if there is a lack of social support and when leaders are perceived to not take responsibility or to be unsupportive.

Occupational Moral Injury

Occupational moral injury is most common amongst those who experience traumatic and morally challenging situations at work– like the gruesome realities witnessed by the emergency services and the police force and the repeated witnessing of bereavement and grief by care workers.

The distress of being parted from their own families added to this when infection control prompted isolation of care staff.

All front-line staff found it hard to put their own health at risk – and risk their families, especially since nobody knew how they would be affected by the virus.

It extends to emotionally and physically vulnerable people and those not prepared for the distress their work will cause – like front line workers in all professions during the pandemic.

Occupational moral injury also affects those in the media, social workers, aid workers and prison staff. Supermarket workers or delivery drivers, who routinely would not have considered themselves as providing critical services to the public were also affected recently.

The causes of occupational moral injury are many – we cannot have predicted the pandemic, there are inevitably a lack of resources which affect one’s ability to care for those they are responsible for. People were unprepared for the consequences. Support systems were not put in place in time.

Nobody is exempt

During the pandemic – everyone sacrificed community traditions surrounding birth, love and death. We did this for everyone’s safety. We did it at a cost.

Those with a lack of social support are also at risk – trapped emotions with no opportunity for expression cause deeper mental health issues.

Isolation in many cases caused more issue than the virus itself.

The pandemic has only exacerbated Moral Injury and Moral stress. The lack of access to face-to-face mental health support during the pandemic made moral injury to citizens something to be taken seriously too.

Apart from pandemic-caused injury, we all experience or witness injustices, cruelty, status degradation or profound breaches of moral expectations. Bewilderment, humiliation, and resentment of any kind experienced by anyone are also classed as moral-philosophical injuries.

Establishing Change

How the government can mitigate the risk of moral distress in Healthcare

In a paper published by the APA journal Psychological Trauma: Theory, Research, Practice, and Policy, researchers from the University of Surrey NHS should prioritise “moral repair” to avoid a longer-term fractured relationship with the organisation.

The BMA recommendations are to ensure adequate funding and resourcing; increase staffing; empower doctors; develop an open and sharing workplace culture; provide support for employees and streamline NHS bureaucracy.

What clinicians can do to Help

Re-frame the problem

A recent editorial in the BMJ by Prof. Neil Greenberg and colleagues (2020), talked about the positive effects of crises – Psychological growth – a dramatic improvement in psychological resilience, esteem and outlook. This can be achieved when leaders lead effectively. Below are some tips to help:

Education, Awareness and Support systems

Managers need to become familiar with, comfortable discussing, and able to spot psychological stressors. Front line staff need to be educated about the risks of MI and what emotions they will experience. Understanding and being to pinpoint symptoms helps prepare psychologically. Make staff aware of moral injury stressors, causes and symptoms and encourage the use of a support network or peer support programs.

Psychological support should be prioritized and made readily accessible.

Talk openly about feelings of guilt and shame

Be aware of reticence to speak about guilt or shame. Treatment for moral injuries should include discussion of shame and guilt.

Protect the Vulnerable

No matter what the lockdown rules are, vulnerable groups, such as survivors of domestic violence, and those with serious mental illnesses should access treatment and support networks. One can remotely, check on vulnerable individuals via zoom etc.

Engender a culture of openess

Use frank, open and honest dialogue, encourage emotional ‘off-loading’ and self-disclosure of experiences of moral challenges.

How Key-workers can help themselves

Talk about it, develop support networks, speak out (whenever possible), seek advice – from peer supporters, managers, colleagues’ chaplains, other welfare provision or get professional help if necessary.

How we can Help

Our team at the Brain Collective can help with a range of mental health symptoms and conditions such as Moral Injury and PTSD using a range of neurofeedback methods. We work best with clients who can conveniently commute to and from Harrogate on the same day. To learn more about Neurofeedback therapy, explore our process and discover who we help, visit us at thebraincollective or book a free telephone consultation on 01423 565522.


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