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Moral injury insights into supporting front-line workers during and after the COVID-19 pandemic

Those providing mental health support for front-line workers during and after the COVID-19 pandemic should consider the unprecedented challenges these people will face to their moral and ethical beliefs, according to a new article by King’s College London researchers.

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Published in the journal Occupational Medicine, the article proposed using the framework of ‘moral injury’ as a means to understand the experiences undergone by frontline workers during the COVID-19 pandemic and set out recommendations for working with those whose mental health has been affected.

The article was a collaboration between King's Centre for Military Health Research and Combat Stress.

A term that originated from research with 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 highlight that moral injury is a particularly relevant concept in understanding the psychological impact of frontline workers having to take certain decisions or actions due to the circumstances of the current COVID-19 pandemic.

COVID-19 is already placing a substantial demand on the National Health Service (NHS) and those who work within it. The researchers also noted that other essential workers in non-healthcare related roles such as the justice system, national defence, media workers, social workers, etc .may also feel the profound effects of being required to perform already highly challenging duties in a more constrained manner which may lead to risks being more difficult to manage.

Similar challenges may also be experienced by other essential workers such as supermarket workers or delivery drivers, who routinely would not have considered themselves as providing critical services to the public.

Essential workers during the COVID-19 pandemic may be particularly vulnerable to experiencing moral injury and, whilst moral injury is not a mental illness, it is significantly associated with PTSD, depression and suicidal ideation. – Lead author, Dr Victoria Williamson, from the Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King’s College London

Morally injurious events can lead to negative thoughts about oneself or others as well as deep feelings of shame, guilt, anger or disgust. These feelings, in turn, can contribute to the development of mental health problems, including depression, PTSD and anxiety. How such events will impact front-line, key worker teams remains unclear, but it is likely that many will experience a degree of moral distress.

Lead author, Dr Victoria Williamson, from the Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King’s College London said: ‘Historically, moral injury was first described in military personnel but previous work has shown moral injury is not limited by context or profession. Essential workers during the COVID-19 pandemic may be particularly vulnerable to experiencing moral injury and, whilst moral injury is not a mental illness, it is significantly associated with PTSD, depression and suicidal ideation. Our article aims to highlight this topic for occupational health staff, discuss possible risk factors for moral injury and provide useful information about how moral injury might be avoided.’

In order to inform the support given to front-line workers during and after the COVID-19 pandemic the authors made a number of evidence-based recommendations for both employers and clinicians working with those workers who have developed mental health problems. These included increasing awareness of the likelihood of experiencing moral injury in the current COVID-19 pandemic; improving informal support through trained peer supporters, managers etc.; making professional psychological support readily accessible; and ensuring that support addresses feelings of guilt or shame which, due to their nature, may be difficult to access.

Healthcare staff are not the only essential workers currently undertaking challenging, but vital, duties and having to make unusually difficult decisions which they are not ordinarily part of their day to day work. Moral injuries may occur when employees are forced to make important decisions which have ‘no right answer’ and when staff feel that they have been placed in an ‘impossible’ situation. – Senior author, Professor Neil Greenberg from the Institute of Psychiatry, Psychology & Neuroscience, King’s College London

Senior author, Professor Neil Greenberg from the IoPPN, King’s College London said: ‘The current COVID19 crisis has rightly highlighted the vital work that the NHS are doing to save lives. However, healthcare staff are not the only essential workers currently undertaking challenging, but vital, duties and having to make unusually difficult decisions which they are not ordinarily part of their day to day work. Moral injuries may occur when employees are forced to make important decisions which have ‘no right answer’ and when staff feel that they have been placed in an ‘impossible’ situation. We hope our paper provides employers with some advice about how to address this problem and clinicians with advice about how they take account of moral injury when providing mental healthcare for essential workers in the months and years ahead.’

The article was a collaboration between King's Centre for Military Health Research and Combat Stress.

The research providing this insight was funded by Forces in Mind Trust.

Reference: Williamson, V. et al. (2020) COVID-19 and experiences of moral injury in front-line key workers. Occupational Medicine. http://doi.org/10.1093/occmed/kqaa052

Contact: Franca Davenport, Interim Senior Press Officer, IoPPN: franca.davenport@kcl.ac.uk / +44 +44 7718 697176