Writing in a new analysis piece in The BMJ Professor Neil Greenberg, and his co-authors applied the concept of ‘moral injury’ to provide insight into the mental health challenges faced by healthcare workers during the COVID-19 pandemic and to identify approaches to help prevent negative impacts on their mental health.

A term that originated in the military, moral injury is the psychological distress which results from actions, or lack of them, which violate someone’s moral or ethical code. The authors outlined the relevance and value of this concept as a framework to understand the mental health challenges that healthcare workers face in the current crisis and find ways to help overcome these.

Such challenges may include: how to allocate scant resources to equally needy individuals, how to balance one’s own physical and mental healthcare needs with those of patients, how to align one’s desire and duty to patients with those to family and friends and, how to provide care for all severely unwell patients with constrained or inadequate resources.

In The BMJ analysis the authors said: ‘It is still possible that the huge current effort in ensuring adequate staffing and resources is successful, but it remains more probable that during the COVID 19 outbreak many healthcare workers will encounter situations where they cannot say to a grieving relative “we did all we could”, but only “ we did the best we could with the staff and resources available,  it wasn’t enough”. That is the seed of a moral injury. It will hurt, and perhaps hurt for a long time, unless we now start to prepare and support our staff who will have to face this challenge.’

The authors set out six ways to potentially mitigate the negative moral impact of the COVID-19 outbreak for healthcare workers:

• Healthcare workers should be prepared to face moral dilemmas during the pandemic, which means they should be given a full and realistic assessment of what they will face.
• Team leaders should help staff make sense of morally challenging decisions they have to make, perhaps through a Schwartz-round style of discussion.
• The routine support processes, such as peer support programmes, for healthcare staff should include a briefing on moral injuries, as well as an awareness of other causes of mental ill-health, and what to look out for.
• All team leaders should be aware that no one is invulnerable. Even the most resilient team members may become overwhelmed by situations.
• There is a need to ensure all those who are supervising others are also supported as they may be affected by being part of any difficult decision-making.
• After the pandemic is over, supervisors should ensure that time is made to reflect on and learn from the extraordinarily difficult experiences to create a meaningful, rather than traumatic, narrative.

The analysis article suggests that some people who have to contend with significant challenges, moral or traumatic, experience some level of increase in esteem, outlook and values after exposure to highly challenging situations. Whether someone develops a psychological injury, or experiences psychological growth, is likely to be influenced by the way that they are supported before, during and after a challenging incident.

Lead author on the article, Professor Greenberg from the Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King’s College London said: ‘There is a real and pressing need to acknowledge the mental health challenges that healthcare workers will face over the coming months in order that the right support is made available to them in a timely fashion. We will need a psychologically healthy, and highly functional workforce in order to successfully win the battle against COVID 19. My co-authors and I hope this article provides both a call to arms and a set of practical mitigations measure which will help protect the valiant heroes of the moment so they remain resilient as they save lives in these extraordinary times.’

The research was funded by the National Institute for Health Research (NIHR) Health Protection Research Unit in Emergency Preparedness and Response at King’s College London, in partnership with Public Health England, and in collaboration with the University of East Anglia and Newcastle University.

 

Article originally published on The BMJ.

Reference: Greenberg, N. et al (2020) Managing the mental health challenges faced by healthcare workers during the COVID-19 pandemic. The BMJ

Contact: Louise Pratt, Head of Communications, IoPPN: louise.a.pratt@kcl.ac.uk / +44 7850 919020