Moral injury: the effect on mental health and implications for treatment

Workshop on hastened death as "space for an appreciative discussion": A qualitative study

AIM

To evaluate the suitability of a drama-based workshop as a method for ethical deliberation.

BACKGROUND

Nurses worldwide are inadequately prepared to care for people who desire hastened death, which can lead to ethical and moral dilemmas. To address this problem, we developed a drama-based ethical deliberation workshop to assist nurses in these situations. Senghor and Racine's three moments of ethical deliberation and their quality criteria served as basis for evaluation.

DESIGN

Qualitative descriptive study design.

METHODS

Non-participant observations and a survey with incomplete sentences to be completed by nursing students were used. Data analysis followed Mayring's deductive content analysis approach.

RESULTS

All three moments of ethical deliberation according to Senghor and Racine were identified. Participants recognised hastened death as morally problematic, shared their experiences and gained a deeper understanding of the problem. They reported feeling better prepared for encounters with persons seeking assisted suicide. In terms of its quality, the drama-based workshop achieved good and partial ethical deliberation.

CONCLUSIONS

The workshop has demonstrated its suitability as a method for ethical deliberation. The workshop should be complemented by specific modules, such as communication skills and be tailored to other professional groups. A validated instrument is needed to ensure a more comprehensive assessment of the quality.

Examining moral distress and injury resulting from the COVID-19 pandemic: Insights from the Ghanaian radiography workforce

BACKGROUND

Moral distress has been an issue under consideration in healthcare practice. The COVID-19 pandemic became a critical factor that contributed to heightened moral distress and injury among healthcare professionals, including radiographers. Despite the substantial engagement of radiographers in the management of COVID-19 patients, the consequent moral distress and injury states experienced by this critical frontline workforce have not been widely explored. This study investigated the level of moral distress and the coping mechanisms employed by radiographers in Ghana during the pandemic to provide valuable information to support radiographers and prepare the workforce better against any future pandemics.

METHODS

Utilising a cross-sectional design, a survey approach was employed for data collection between June 2023 and August 2023 from clinically-active radiographers who worked before and during the pandemic in Ghana. Both descriptive and inferential statistics were generated using Microsoft Excel 2019 and the Statistical Package for the Social Sciences (v.26).

RESULTS

Hundred (100) radiographers participated in the study. The result demonstrated that the COVID-19 pandemic escalated the risk of moral distress among radiographers from 22 % (n = 22) to 43 % (n = 43), with 33 % (n = 33) exhibiting signs of moral injury. This escalation impacted the mental health of 12 % (n = 12) of respondents and was reported as a contributor to career-changing decisions among radiographers. Notably, many of those affected did not seek formal support but relied on personal coping strategies and family support. Inadequate resources (69 %, n = 69), particularly regarding consumables, emerged as the primary cause of moral distress. The study underscored that the most effective means of mitigating moral distress in radiographers was through the provision of resources and additional staff support (66 %, n = 66).

CONCLUSION

This study sheds light on the state of moral distress and injury among radiographers during the COVID-19 pandemic, impacting the mental health of a minority and contributing to career-changing decisions. The findings emphasise the importance for healthcare institutions to proactively implement systems, such as resource provision, improved staffing, and emotional support, now and during similar future pandemics. This is crucial to address moral distress and cater to the mental health needs of radiographers, ensuring a resilient clinical radiography workforce.

'It was horrible to watch, horrible to be a part of': Midwives' perspectives of obstetric violence

BACKGROUND

Obstetric violence, including unconsented interventions, coercion and disrespect, violates human rights; impacting the physical and psychosocial health of women. The perspective and experience of midwives related to obstetric violence have been explored in low and middle-income countries, with limited research into the experience of midwives in high income nations.

AIM

To explore Australian midwives' perspectives of obstetric violence.

METHODS

Thematic analysis of qualitative in-depth interviews with 15 midwives experienced in supporting women during birth. Critical feminist theory underpinned each stage of the research.

FINDINGS

Interviews with 15 Australian midwives from diverse care settings were analysed thematically. Four key themes were developed from the data: 'the operationalisation of obstetric violence', 'the impact of obstetric violence' 'the historical and situational context' and 'hope for the future'. Midwives considered entrenched patriarchal structures and gender inequity as fundamental to the occurrence of obstetric violence. This societal scaffold is intensified within health care systems where power imbalances facilitate maternal mistreatment through coercion and grooming women for compliance in the antenatal period. Fragmented care models expose women to mistreatment with continuity models being protective only to a point. Midwives experience their own trauma, as a result of what they have witnessed, and due to the lack of support they receive when advocating for women.

CONCLUSIONS

Obstetric violence occurs in Australian maternity systems with unconsented interventions, overmedicalisation, coercion, and disrespect observed by midwives. Care-related trauma impacts on the mental health of midwives, raising workforce concerns for policy makers, consumer advocates and professional bodies.

Psychological endurance: how grit, resilience, and related factors contribute to sustained effort despite adversity

Many concepts describe how individuals sustain effort despite challenging circumstances. For example, scholars and practitioners may incorporate discussions of grit, hardiness, self-control, and resilience into their ideas of performance under adversity. Although there are nuanced points underlying each construct capable of generating empirically sound propositions, the shared attributes make them difficult to differentiate. As a result, substantial confusion arises when debating how these related factors concomitantly contribute to success, especially when practitioners attempt to communicate these ideas in applied settings. The model proposed here-psychological endurance-is a unified theory to explore how multiple concepts contribute to sustained goal-directed behaviors and individual success. Central to this model is the metaphor of a psychological battery, which potentiates and sustains optimal performance despite adversity. Grit and hardiness are associated with the maximum charge of the psychological battery, or how long an individual could sustain effort. Self-control modulates energy management that augments effort required to sustain endurance, whereas resilience represents the ability to recharge. These factors are constrained by both psychological and physiological stressors in the environment that drain the psychology battery. Taken together, these ideas form a novel framework to discuss related psychological concepts, and ideally, optimize intervention to enhance psychological endurance.

Psychiatry as a vocation: Moral injury, COVID-19, and the phenomenology of clinical practice

In this article, we focus on a particular kind of emotional impact of the pandemic, namely the phenomenology of the experience of moral injury in healthcare professionals. Drawing on Weber's reflections in his lecture Politics as a Vocation and data from the Experiences of Social Distancing during the COVID-19 Pandemic Survey, we analyse responses from healthcare professionals which show the experiences of burnout, sense of frustration and impotence, and how these affect clinicians' emotional state. We argue that this may relate to the ethical conflicts they experience when they are forced to make clinical decisions where there are no optimal outcomes, and how in turn that impacts on their own emotional state. We then further examine the notion of 'burnout' and the phenomenology of 'moral injury'. Our argument is that these experiences of moral injury across a range of clinicians during the pandemic may be more prevalent and long-standing in psychiatry and mental health than in other areas of healthcare, where ethically difficult decisions and resource constraints are common outside times of crisis. Hence, in these clinical arenas, moral injury and the phenomenology of emotional changes may be independent of the pandemic. The insights gained during the pandemic may provide wider insights into the challenges of developing services and training the workforce to provide appropriate mental health care.

Reflections: When Moral Injury and Compassion Fatigue Strike: Apologize to Patients, Forgive Ourselves

This pandemic has caused trauma to so many, including professionals who stand guard ready to handle crises, such as child and adolescent psychiatrists like me working in the emergency department. We have seen acuity increase in emergency rooms across the country2; boarders are waiting longer for beds on inpatient units3-all while the country has been systematically shutting down alternative levels of care, closing doors to alternative options to decant our already straining emergency rooms.4.

The role of psychologists in supporting illness-related dying and death: A systematic mixed studies review

Psychologists remain underrepresented in end-of-life care, and there is limited understanding of their role among healthcare professionals, patients, and caregivers. This systematic mixed-studies review, prospectively registered on PROSPERO (CRD42020215775), explored the role of psychologists, and the facilitators and barriers they experience, in supporting clients with illness-related dying and death. A search of six research databases was conducted in October 2023. Fifty-one studies, mainly qualitative and from the perspectives of psychologists, met inclusion criteria. Thematic synthesis highlighted how psychologists provided expertise across various contexts. They supported clients with preparing for death, and adjusting to dying, provided professional consultancy and support, and undertook leadership in enhancing psychological end-of-life care. Results illustrated the sustaining factors and ongoing challenges working in end-of-life care, namely, the unique nature of navigating the death space, recognition and awareness of psychologists' contribution, and the support, training and development required. Given the universality of dying and death, this review is relevant to psychologists working within and beyond more traditional end-of-life care contexts, such as employee assistance programs, private practice, schools, and other psychological services. Policy, clinical and research implications are discussed, including the need for greater engagement and training of psychologists in the dying and death space.

Restore and Rebuild (R&R): a protocol for a phase 2, randomised control trial to compare R&R as a treatment for moral injury-related mental health difficulties in UK military veterans to treatment as usual

BACKGROUND

Exposure to potentially morally injurious events is increasingly recognised as a concern across a range of occupational groups, including UK military veterans. Moral injury-related mental health difficulties can be challenging for clinicians to treat and there is currently no validated treatment available for UK veterans. We developed Restore and Rebuild (R&R) as a treatment for UK veterans struggling with moral injury-related mental health difficulties. This trial aims to examine whether it is feasible to conduct a pilot randomised controlled trial (RCT) of R&R treatment compared with a treatment-as-usual (TAU) control group.

METHODS

We will use a feasibility single-blind, single-site RCT design. The target population will be UK military veterans with moral injury-related mental health difficulties. We will recruit N=46 veteran patients who will be randomly allocated to R&R (n=23) or TAU (n=23). Patients randomised to R&R will receive the 20-session one-to-one treatment, delivered online. Veterans allocated to TAU, as there are currently no manualised treatments for moral injury-related mental health problems available, will receive the one-to-one treatment (online) typically provided to veterans who enter the mental health service for moral injury-related mental health difficulties. We will collect outcome measures of moral injury, post-traumatic stress disorder (PTSD), alcohol misuse, common mental disorders and trauma memory at pretreatment baseline (before randomisation), end of treatment, 12 weeks and 24 weeks post-treatment. The primary outcome will be the proportion of patients who screen positive for PTSD and moral injury-related distress post-treatment.

ETHICS AND DISSEMINATION

This trial will establish whether R&R is feasible, well-tolerated and beneficial treatment for veterans with moral injury-related mental health difficulties. If so, the results of the trial will be widely disseminated and R&R may improve access to effective care for those who struggle following moral injury and reduce the associated negative consequences for veterans, their families and wider society.

TRIAL REGISTRATION NUMBER

ISRCTN99573523.

Moral Injury Among Interventional Radiologists

RATIONALE AND OBJECTIVES

To evaluate moral injury (MI) among interventional radiologists using validated assessment tools.

MATERIALS AND METHODS

An anonymous 29-question online survey was distributed to interventional radiologists using the Society of Interventional Radiology Connect Open Forum website, Twitter, Facebook, LinkedIn, and electronic mail. The survey consisted of demographic and practice environment questions, a global quality of life (QoL) scale (scored 1-100), the MI Symptom Scale‑Healthcare Professional (MISS-HP) (scored 1-100), and two open-ended questions. A MISS-HP score ≥ 36 was indicative of experiencing MI. P < .05 was considered statistically significant for all two-sided tests.

RESULTS

Beginning on March 30, 2023, 365 surveys were completed over 5 days. Of the respondents, 299 (81.9%) were male, 65 (17.8%) were female, and one preferred not to disclose gender. The respondents included practicing interventional radiologists (299; 81.9%) and interventional radiologists-in-training (66; 18.1%). Practice settings included academic (146; 40.0%), community (121; 33.2%), hybrid (84; 23.0%), or other (14; 3.8%) centers. Mean QoL was 71.1 ± 17.0 (range: 0-100) suggestive of "good" QoL. Mean QoL in the MI subgroup was significantly different from that for the rest of the group (67.6 ± 17.0 vs. 76.6 ± 16.0; P < 0.05). 223 (61.1%) respondents scored ≥ 36 on the MISS-HP, and thus were categorized as having profession-related MI. Mean MISS-HP was 39.9 ± 12.6 (range: 10-83). Mean MISS-HP in the MI subgroup was significantly different from that for the rest of the group (47.4 ± 9.6 vs. 28.0 ± 5.7; P < 0.05). There was a negative correlation between MI and QoL (r = -0.4; P < 0.001). Most common themes for greatest contribution to MI were ineffective leadership, barriers to patient care, corporatization of medicine, non-physician administration, performing futile procedures, turf battles, and reduced resources. Most common themes for ways to reduce MI were more autonomy, less bureaucracy, more administrative support, physician-directed leadership, adequate staffing, changes to the medical system, physician unionization, transparency with insurance companies, more time off, and leaving medicine/retirement.

CONCLUSION

MI is prevalent among interventional radiologists, and it negatively correlates with QoL. Future work should investigate causative factors and mitigating solutions.

Trauma-Informed Care in Psychedelic Therapy Research: A Qualitative Literature Review of Evidence-Based Psychotherapy Interventions in PTSD and Psychedelic Therapy Across Conditions

Introduction

Post-traumatic stress disorder (PTSD) is associated with significant patient burden. While pharmacotherapies and evidence-based psychotherapy interventions (EBPI) are effective, studies consistently highlight inadequate outcomes and high treatment dropout. Psychedelic therapy (PT) has shown preliminary promise across difficult-to-treat conditions, including MDMA-assisted therapy for PTSD, however trials of classical psychedelics in PTSD are lacking. Understanding patients' experiences of EBPI could help promote safety in PT.

Aim

To systematically review qualitative research on patients' subjective experience of EBPI for PTSD, and of PT, and examine areas of overlap and divergence between them.

Methods

Systematic literature searches for studies published between 2010 and 2023 were conducted on OVID, PubMed, Web of Science, and PsycInfo. Included were original studies in English that presented qualitative data of patient experiences of EBPI in PTSD, or PT for any indication. Extracted data from included studies were analysed using thematic synthesis. Syntheses were completed separately for EBPI and PT, before similarities and differences between the therapies were identified.

Results

40 research articles were included for review: 26 studies on EBPI for PTSD, and 14 studies on PT. EBPI studied were CBT, EMDR, CPT and PE. Psychedelic compounds studied were psilocybin, ibogaine, LSD, MDMA and ketamine, for treatment of substance use disorders, anxiety relating to physical illness, depression, and PTSD. Core themes from patient experiences of EBPI: 1) patient burden in PTSD treatment; 2) readiness; 3) key mechanisms of change; 4) psychological safety and trust. Themes identified in the review of PT: 1) indirect trauma processing; 2) reorganisation of self-narratives via processes of relatedness and identification; 3) key treatment characteristics.

Conclusion

This study suggests overlap between patients' experience of EBPI and PT in terms of key mechanisms of change, the importance of psychological safety and readiness to engage in treatment. Trauma-informed care paradigms and practices may improve safety and acceptability of PT research.

Moral injury and mental health among health-care workers during the COVID-19 pandemic: meta-analysis

Background: During the COVID-19 pandemic, health-care workers (HCWs) may have been confronted with situations that may culminate in moral injury (MI). MI is the psychological distress that may result from perpetrating or witnessing actions that violate one's moral codes. Literature suggests that MI can be associated with mental health problems.Objective: We aimed to meta-analytically review the literature to investigate whether MI is associated with symptoms of posttraumatic stress disorder (PTSD), anxiety, depression, burnout, and suicidal ideation among active HCWs during the COVID-19 pandemic.Method: We searched eight databases for studies conducted after the onset of the COVID-19 pandemic up to 18 July 2023, and performed random-effects meta-analyses to examine the relationship between MI and various mental health outcomes.Results: We retrieved 33 studies from 13 countries, representing 31,849 individuals, and pooled 79 effect sizes. We found a positive association between MI and all investigated mental health problems (rs = .30-.41, all ps < .0001). Between-studies heterogeneity was significant. A higher percentage of nurses in the samples was associated with a stronger relationship between MI and depressive and anxiety symptoms. Samples with a higher percentage of HCWs providing direct care to patients with COVID-19 exhibited a smaller effect between MI and depressive and anxiety symptoms. We observed a stronger effect between MI and PTSD symptoms in US samples compared to non-US samples.Conclusion: We found that higher MI is moderately associated with symptoms of PTSD, anxiety, depression, burnout, and suicidal ideation among HCWs during the COVID-19 pandemic. Our findings carry limitations due to the array of MI scales employed, several of which were not specifically designed for HCWs, but underscore the need to mitigate the effect of potentially morally injurious events on the mental health of HCWs.

Understanding Moral Injury in Frontline Health Care Professionals 2 Years After the Onset of COVID-19

ABSTRACT

Throughout the COVID-19 pandemic, health care professionals have worked in morally challenging situations. The aim of this research was to investigate the predictors of moral injury in United Kingdom frontline health care professionals working in a variety of roles 2 years after the onset of the pandemic. A cross-sectional survey was conducted January 25-February 28, 2022. A total of 235 participants answered sociodemographic, employment, health, COVID-19-related questions, and the 10-item Moral Injury Symptom Scale-Healthcare Professional version. Nearly three quarters had experienced moral injury. Twelve significant predictors of moral injury were entered into a backward elimination binominal logistic regression. The final model included five independent predictors that explained 25.4% variance in moral injury (χ 2 [5, N = 235] = 45.7, p < 0.001). Odds of moral injury were significantly raised in young health care professionals (<31 years), smokers, and those reporting low workplace confidence, not feeling appreciated, and feeling burned out. The findings support interventions to relieve moral injury in frontline health care professionals.

Moral injury and its mental health consequences among protesters: findings from Israel's civil protest against the government's judicial reform

Background: Government actions and participating in protracted-duration protests against it affect protesters' mental health, leading to high distress levels, such as posttraumatic and depressive symptoms. Aside from exposure to violence and other issues, protest participation can pose unique challenges to the protesters as they may be exposed to potentially morally injurious events (PMIEs), such as the betrayal of leaders they once trusted. This study's primary objective was to examine the extent of psychological difficulties among civilians participating in long-duration protests in Israel. More specifically, the study aimed to understand the contribution of exposure to protest-related PMIEs to psychological difficulties such as posttraumatic and depressive symptoms.Method: Participants comprised 4036 Israelis who were actively involved in the unfolding civil protest movement against the government-led judicial overhaul between January 2023 and August 2023. The protesters completed validated self-report questionnaires that included measures of PMIE exposure, PTSD and depressive symptoms.Results: About half (44.3%) of the sample met the criteria for self-report diagnosis of major depression and 10.6% for PTSD. Most of the protesters indicated their exposure to at least one moral injury event, with 63.9% reporting exposure to PMIE-Betrayal. Protesters exposed to PMIEs reported significantly higher levels of both PTSD and depression than non-PMIE-exposed protesters. Hierarchical regression analyses revealed that, beyond demographics and protest-related characteristics such as exposure to violence, PMIE dimensions significantly contributed to both PTSD and depression levels.Conclusions: The findings highlight the mental burden of protesters during the civil protests against the judicial overhaul in Israel. More central to the present research, the findings highlight the critical contribution of PMIEs exposure to this burden. Clinicians treating protesters coping with depression and PTSD following the civil actions should attend to their exposure to PMIEs, which may relate to the deleterious psychological effects among protesters.

Exploring nurses' well-being and strategies to support self-care

Nurses experience a range of challenges in their practice that can adversely affect their well-being, for example work-related stress and workforce issues. These challenges may have been intensified by various factors, such as the coronavirus disease 2019 (COVID-19) pandemic and shift working. This article considers the concept of well-being and explores nurses' well-being in the context of ongoing stressors and workforce issues. It also examines some of the effects of shift work on nurses' well-being and how these could be mitigated. The authors outline a range of self-care practices that nurses could engage in and consider how they may be supported in this by their line managers and healthcare organisations.

Moral injury in a global health emergency: a validation study of the Italian version of the Moral Injury Events Scale adjusted to the healthcare setting

Background: When exposed to events that transgress one's moral beliefs, a plethora of negative consequences may follow, which are captured by the concept of moral injury (MI). Despite its relevance to experiences of healthcare workers during a global health emergency, there is lack of validated MI instruments adapted to the healthcare setting.Objective: The present study aims to provide a validation of the Italian version of the Moral Injury Events Scale (MIES) adjusted to the healthcare setting by assessing its factor structure, internal consistency and construct validity.Methods: A sample of 794 healthcare workers (46% nurses, 51% female) engaged in hospital facilities during the COVID-19 pandemic in Italy completed measures of MI, PTSD, anxiety, depression, burnout, meaning in life and positive affect.Results: Using an exploratory structural equation modelling (ESEM) we assessed the scale factor structure for the entire sample and separately for nurse professional and female healthcare worker groups. Findings support a three-factor solution: Factor 1 'perceived transgressions by others'; Factor 2 'perceived transgressions by self'; and Factor 3 'perceived betrayals by others'. Findings also indicate some level of convergence with measures of PTSD, anxiety, depression and burnout.Conclusion: Results suggest that the MIES may be useful in capturing unique experiences of moral injury amongst healthcare workers engaged in a global health emergency. The low range correlations with measures of psychological distress might potentially indicate that MI, which captures cognitive value judgements rather than manifest symptomatology, may uniquely explain a certain amount of variance. Implications for the development of new empirically derived and theoretical guided tools are discussed, highlighting the need for future research to examine the role of individualising and social binding moral principles in gaining a more nuanced understanding of moral injury experiences amongst healthcare professionals across different socio-cultural settings.

Focusing a realist evaluation of peer support for paediatric mental health

OBJECTIVE

Mental health problems are a leading and increasing cause of health-related burden in children across the world. Peer support interventions are increasingly used to meet this need using the lived experience of people with a history of mental health problems. However, much of the research underpinning this work has focused on adults, leaving a gap in knowledge about how these complex interventions may work for different children in different circumstances. Realist research may help us to understand how such complex interventions may trigger different mechanisms to produce different outcomes in children. This paper reports on an important first step in realist research, namely the construction of an embryonic initial programme theory to help 'focus' realist evaluation exploring how children's peer support services work in different contexts to produce different outcomes in the West Midlands (UK).

METHODS

A survey and preliminary semi-structured realist interviews were conducted with 10 people involved in the delivery of peer support services. Realist analysis was carried out to produce context-mechanism-outcome configurations (CMOC).

RESULTS

Analysis produced an initial programme theory of peer support for children's mental health. This included 12 CMOCs. Important outcomes identified by peer support staff included hope, service engagement, wellbeing, resilience, and confidence; each generated by different mechanisms including contextualisation of psychoeducation, navigating barriers to accessing services, validation, skill development, therapeutic relationship, empowerment, and reducing stigma.

CONCLUSION

These data lay the groundwork for designing youth mental health realist research to evaluate with nuance the complexities of what components of peer support work for whom in varying circumstances.

Post-traumatic Stress Disorder and Moral Injury Among Ukrainian Civilians During the Ongoing War

While severity of post-traumatic stress disorder (PTSD) symptoms and moral injury among civilians affected by armed conflicts is generally understudied, even less research exists on civilian populations during an active war. This paper reports a large-scale study that administered standard assessments of PTSD and moral injury severity, as well as rich demographic questionnaires, to nearly 1300 Ukrainian civilians during the ongoing Russian invasion. Analyses revealed an extremely high prevalence of severe PTSD symptoms and moral injury, relative to both proposed clinical cut-offs and to earlier measurements from a similar population. Further regression analyses identified risk factors and protective factors. Greater severity of PTSD symptoms was observed among women, older and forcibly displaced individuals, and individuals from geographic regions under Russian occupation. Higher education correlated with milder PTSD symptoms. Moral injury was particularly strong in younger individuals. The present study is one of the first to report a large scale set of psychological data collected from the civilian population of Ukraine during the ongoing Russian invasion. It is obvious from the scope and long-term nature of the atrocities that psychological treatment of the civilian population will be required both presently, while the hostilities are ongoing, and in the future. This data contributes to a detailed understanding of the psychological response to traumatic stress, including its overall prevalence and presence in specific demographically and geographically defined civilian groups.

Restore and Rebuild (R&R) - a feasibility pilot study of a co-designed intervention for moral injury-related mental health difficulties

BACKGROUND

Moral injury can significantly negatively impact mental health, but currently no validated treatment for moral injury-related mental health difficulties exists in a UK context. This study aimed to examine whether the Restore and Rebuild (R&R) treatment was feasible to deliver, acceptable and well tolerated by UK military veterans with moral injury related mental health difficulties.

METHOD

The R&R treatment was delivered to 20 patients who reported distress related to exposure to a morally injurious event(s) during military service. R&R is a 20-session psychotherapy with key themes of processing the event, self compassion, connecting with others and core values. Treatment was delivered online, weekly, one-to-one by a single therapist. Qualitative interviews with patients and the therapist who delivered R&R were conducted to explore acceptability and analysed using thematic analysis.

RESULTS

Following treatment, patients experienced a significant reduction in symptoms of post-traumatic stress disorder, depression, alcohol misuse and moral injury related distress. R&R was found to be well tolerated by patients and improved their perceived wellbeing.

CONCLUSIONS

These results provide preliminary evidence that veterans struggling with moral injury related mental ill health can benefit from R&R treatment.

Providing immediate digital mental health interventions and psychotrauma support during political crises

We describe the development and provision of a digital mental health intervention and trauma support platform for victims of political and social repression in Belarus. The Samopomoch platform provides secure and effective support tailored to the needs of such victims, and individuals are provided with access to the service via a modern, encrypted, and protected communication platform. The service involves personal health tracking (e-mental health self-screening), targeted and untargeted client communication (psychoeducation and self-help information), and psychological counselling sessions. The Samopomoch platform is also collecting evidence to show the effectiveness of the service and proposes a model for replication in similar settings. To our knowledge, this is the first immediate digital mental health-care response to a political crisis, and the high needs and increasing demand for this service within the targeted population indicate the necessity for its continuation and scaling-up. We urge policy makers to provide immediate responses for establishing digital mental health interventions and psychological trauma support.

'Thrown in at the deep end': a qualitative analysis into the transition from trainee to consultant during the COVID-19 pandemic and lessons for the future

Background

Sustained crises such as the COVID-19 pandemic would be expected to impact the transition from trainee to consultant for anaesthetists or intensivists, but limited research exists on this important topic. This study aimed to examine the social context of this crucial career transition during the pandemic and post-pandemic periods.

Methods

We conducted semi-structured interviews with anaesthetists and intensivists who became consultants after the first UK lockdown. Thematic analysis was used and data saturation was reached at 33 interviews.

Results

The pandemic substantially impacted the transition to consultant role in various ways, including professional identity, clinical and non-clinical responsibilities, and wellbeing. Participants experienced identity confusion, self-doubt, and moral injury, resulting in intense emotional distress, feelings of guilt and helplessness, which persisted beyond the pandemic. They also felt unprepared for their consultant roles because of disruptions in training. The pandemic exaggerated the vulnerability of those transitioning to consultants, because of increased clinical uncertainties, and pressures of the growing backlog. Additionally, the pandemic impacted on the wellbeing of those transitioning to consultants, intensifying feelings of anxiety and stress. We also identified unique opportunities presented by the pandemic, which accelerated learning and encouraged post-traumatic growth. Our study identified practical solutions that may improve transition experience at individual, organisational, and national levels.

Conclusions

Persistent crises significantly impact the transition from trainee to consultant. Our findings generated insights into the challenges of this critical career transition and staff wellbeing, and serve to inform approaches of ongoing support for those transitioning to consultants.

Veterans' experiences of moral injury, treatment and recommendations for future support

INTRODUCTION

Moral injury (MI) significantly impacts the lives of many UK military veterans however, there is a lack of manualised treatment to address the needs of this population. To develop future treatments that are acceptable and well tolerated, veterans should be consulted on their experiences of existing psychological treatments and suggestions for future treatments.

METHODS

10 UK military veterans were interviewed about their experiences of receiving treatment for psychological difficulties after MI, and beliefs about core components of future treatments. Thematic analysis of these interviews were conducted.

RESULTS

2 superordinate themes were identified: experiences of previous mental health treatment and perceptions of the proposed treatments. Reflections on cognitive behavioural therapy were mixed, with some describing that it did not ameliorate their guilt or shame. In future treatments, focusing on values, using written letters and including therapy sessions with close companions were considered beneficial. Veterans reported that a strong rapport with therapist was key for MI treatment.

CONCLUSION

Findings provide a useful account of how current post-trauma treatments may be experienced by patients with MI. Although limited by sample size, the results highlight therapeutic approaches that may be helpful in future and provide important considerations for therapists treating MI.

Meaning(s) of transition(s) from military to civilian life at the intersection with mental health: implications for clinical settings

The experiences of military personnel moving into civilian life can be varied for the individual, families and communities. This paper aims to shed light on the various meanings of the multiple and "nested" transitions of military personnel to civilian life in the context of attending a mental health service in the UK. This was achieved through secondary analysis of semi-structured interviews with veterans who were engaging with a mental health service in the UK and a further interview with the mental health service lead. A thematic analysis was employed based on a descriptive phenomenological approach. Results indicate that an appropriate support infrastructure needs to be put in place for veterans prior to, during and after the transition to civilian life. The support appropriateness includes themes specific to connectedness to others, support service accessibility, mental health professionals' military culture awareness and mental health stigma. Although the findings suggest that community services need an awareness of veterans' specific needs, many of the themes are similar to those of the general population. Therefore, the need for an integrated healthcare system is essential in the transition of military service personnel to civilian life. Drawing on international evidence as well as the current findings, implications for policy and practice are highlighted throughout.

Repairing moral injury takes a team: what clinicians can learn from combat veterans

Moral injury results from the violation of deeply held moral commitments leading to emotional and existential distress. The phenomenon was initially described by psychologists and psychiatrists associated with the US Departments of Defense and Veterans Affairs but has since been applied more broadly. Although its application to healthcare preceded COVID-19, healthcare professionals have taken greater interest in moral injury since the pandemic's advent. They have much to learn from combat veterans, who have substantial experience in identifying and addressing moral injury-particularly its social dimensions. Veterans recognise that complex social factors lead to moral injury, and therefore a community approach is necessary for healing. We argue that similar attention must be given in healthcare, where a team-oriented and multidimensional approach is essential both for ameliorating the suffering faced by health professionals and for addressing the underlying causes that give rise to moral injury.

Moral injury and suicidal ideation among health professionals: The role of mental health

BACKGROUND

The prolonged COVID-19 pandemic has burdened health professionals mentally and physically. This study aims to explore the relationship between moral injury (MI) and suicidal ideation (SI), and the role of mental health conditions in this relationship.

METHODS

Three-wave repeated online cross-sectional study with a total of 10,388 health professionals were conducted in different stages (2020-2022) of the COVID-19 pandemic in mainland China. Participants completed the Chinese version of the Moral Injury Symptoms Scale-Health Professional, Post-Traumatic Stress Disorder (PTSD) Checklist for DSM-5 coupled with a blanket of scales.

RESULTS

The prevalence of SI and MI among health professionals was 9.8 % and 40.2 %, respectively. The prevalence risk of SI was lower in wave 2 (OR = 0.64, 95 % CI: 0.54-0.77) and wave 3 (OR = 0.71, 95 % CI: 0.60-0.84) when compared with wave 1. MI (OR = 4.66, 95 % CI: 3.99-5.43), medical error (OR = 1.15, 95 % CI: 1.00-1.32), workplace violence (OR = 1.13, 95 % CI: 0.97-1.32), depression (OR = 94.08, 95 % CI: 63.37-139.69), anxiety (OR = 25.54, 95 % CI: 21.22-30.74), PTSD (OR = 24.51, 95 % CI: 19.01-31.60) were associated with a higher risk of SI. The mediation model revealed that depressive, anxiety, and PTSD symptoms explained 90.6 % of the total variance in the relationship between MI and SI.

CONCLUSIONS

The risk of SI has reduced among health professionals since the first peak of the COVID-19 pandemic in China. MI may contribute to prevalent SI, and mental health conditions, especially depressive symptoms, play a significant role as mediators.

LIMITATIONS

Cross-sectional design precludes the investigation of casual relationships. The nonrandom sampling method limits the generalization.

Conceptualization of moral injury: A socio-cognitive perspective

LAY SUMMARY

This article looks at how moral injury (MI) may develop by considering what event features may be especially salient and cause MI and what experiences an individual may have after an event that might lead to the occurrence of a MI. It proposes that the beliefs someone has about themselves, others, and the world can be shaped by experiences in childhood and early life. Once an individual has experienced a potentially morally injurious event (PMIE) — for example, witnessing something that violates deeply held moral or ethical codes but being unable to stop it, doing something that violates these ethical codes, or experiencing a significant betrayal — they may try to make sense of it by changing the way they see the world, themselves, and others. This can lead to problems in the individual’s relationship with themselves and others, leading to feelings of shame and guilt and withdrawal from other people. More important, for an event to be a PMIE, it must significantly challenge strongly held moral beliefs and a sense of right and wrong.

Environmental Factors Impacting Wellness in the Trauma Provider

Purpose of Review

The purpose of this review is to evaluate the recent literature on environmental factors impacting wellness for the acute care surgeon. This includes factors influencing physical, mental, and emotional well-being.

Recent Findings

Recent studies have identified challenges to surgeon wellness including increased incidence of sleep deprivation, musculoskeletal pain and injuries, pregnancy complications, moral injury, posttraumatic stress disorder (PTSD), and burnout. Qualitative studies have characterized the surgeon's emotional response to occupational stress, adverse events, and surgical complications. Further descriptive studies offer interventions to prevent moral injury after adverse events and to improve surgeon work environment.

Summary

Acute care surgeons are at increased risk of sleep deprivation, musculoskeletal pain and injury, pregnancy complications, moral injury, PTSD, and burnout. Surgeons experience feelings of isolation and personal devaluation after adverse events or complications, and this may lead to practice limitation and progression to PTSD and/or burnout. Interventions to provide mentorship, peer support, and education may help surgeons recover after adverse events. Further study is necessary to evaluate institution-driven interventional opportunities to improve surgeon well-being and to foster an inclusive and supportive environment.

Veterinary professionals' experiences of moral injury: A qualitative study

BACKGROUND

Exposure to potentially morally injurious events (PMIE) has been found to be associated with negative mental health outcomes. Veterinary professionals (VPs) often experience challenging workplace events, but whether they experience PMIEs and the impact of exposure on their wellbeing is poorly understood. The objective of the study was to explore UK VPs experiences of PMIEs, the impact of PMIEs on VPs' wellbeing and beliefs about factors that influence VPs' exposure to PMIEs.

METHODS

Ten VPs were recruited. Semi-structured interviews were carried out, and data were analysed using thematic analysis.

RESULTS

VPs were found to experience PMIEs, including transgressive acts of commission or omission (e.g., being involved in or witnessing convenience euthanasia) or betrayal by trusted colleagues (e.g., bullying). Experiences of PMIEs evoked considerable psychological distress, including guilt, shame and loss of confidence in one's abilities. Several risk factors for experiencing psychological distress following a PMIE were described.

CONCLUSIONS

This study provides some of the first evidence that VPs may be vulnerable to moral injury and illustrates the impact that PMIEs may have on VPs' wellbeing.

LIMITATIONS

Future studies are needed to design and evaluate effective pathways for the prevention of and intervention for VPs who experience moral injury.

The lived experiences of health care professionals regarding visiting restrictions in the emergency department during the COVID-19 pandemic: A multi-perspective qualitative study

AIMS

To explore the lived experiences of emergency department (ED) healthcare professionals regarding visiting restrictions during the COVID-19 pandemic.

DESIGN

A qualitative phenomenology study.

METHODS

Semi-structured interviews were undertaken. Participants consisted of 10 physicians, 20 clinical nurses, and three managers, who were purposefully selected from two EDs in China between April and July 2021. Colaizzi's approach guided data analysis.

RESULTS

Four themes arose: (i) burden moral injury, (ii) higher workload to provide and support patient- and family-centered care, (iii) dissatisfied and unsafe healthcare service for patients and families, and (iv) tailoring strategies to provide family-centered care.

PATIENT OR PUBLIC CONTRIBUTION

This study explored the lived experiences of ED health care professionals regarding visiting restrictions during the COVID-19 pandemic. Noted challenges included communicating with families and ethical decision making. Strategies that support ED clinician welfare, and communication with families are warranted if visiting policy restrictions are continued or re-introduced.

Development of an intervention for moral injury-related mental health difficulties in UK military veterans: a feasibility pilot study protocol

Background: Experiencing potentially morally injurious events (PMIEs) has been found to be significantly associated with poor mental health outcomes in military personnel/veterans. Currently, no manualised treatment for moral injury-related mental health difficulties for UK veterans exists. This article describes the design, methods and expected data collection of the Restore & Rebuild (R&R) protocol, which aims to develop procedures to treat moral injury related mental ill health informed by a codesign approach. Methods: The study consists of three main stages. First, a systematic review will be conducted to understand the best treatments for the symptoms central to moral injury-related mental ill health (stage 1). Then the R&R manual will be co-designed with the support of UK veteran participants with lived experience of PMIEs as well as key stakeholders who have experience of supporting moral injury affected individuals (stage 2). The final stage of this study is to conduct a pilot study to explore the feasibility and acceptability of the R&R manual (stage 3). Results: Qualitative data will be analysed using thematic analysis. Conclusions: This study was approved by the King's College London's Research Ethics Committee (HR-20/21-20850). The findings will be disseminated in several ways, including publication in academic journals, a free training event and presentation at conferences. By providing information on veteran, stakeholder and clinician experiences, we anticipate that the findings will not only inform the development of an acceptable evidence-based approach for treating moral injury-related mental health problems, but they may also help to inform broader approaches to providing care to trauma exposed military veterans.

Associations between psychosocial stressors at work and moral injury in frontline healthcare workers and leaders facing the COVID-19 pandemic in Quebec, Canada: A cross-sectional study

Healthcare workers (HCWs) on the frontline of the COVID-19 pandemic exhibit a high prevalence of depression and psychological distress. Moral injury (MI) can lead to such mental health problems. MI occurs when perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations. Since the start of the pandemic, psychosocial stressors at work (PSWs) might have been exacerbated, which might in turn have led to an increased risk of MI in HCWs. However, research into the associations between PSWs and MI is lacking. Considering these stressors are frequent and most of them are modifiable occupational risk factors, they may constitute promising prevention targets. This study aims to evaluate the associations between a set of PSWs and MI in HCWs during the third wave of the COVID-19 pandemic in Quebec, Canada. Furthermore, our study aims to explore potential differences between urban and non-urban regions. The sample of this study consisted of 572 HCWs and leaders from the Quebec province. Prevalence ratios (PR) of MI and their 95% confidence intervals (CI) were modelled using robust Poisson regressions. Several covariates were considered, including age, sex, gender, socio-economic indicators, and lifestyle factors. Results indicated HCWs exposed to PSWs were 2.22-5.58 times more likely to experience MI. Low ethical culture had the strongest association (PR: 5.58, 95% CI: 1.34-23.27), followed by low reward (PR: 4.43, 95% CI: 2.14-9.16) and high emotional demands (PR: 4.32, 95% CI: 1.89-9.88). Identifying predictors of MI could contribute to the reduction of mental health problems and the implementation of targeted interventions in urban and non-urban areas.

Testifying after an Investigation: Shaping the Mental Health of Public Safety Personnel

In this editorial, we draw on two Canadian cases to interrogate how mass causality events and investigations consume many responders before (e.g., public safety communicators, detachment service assistants), during (e.g., police, fire, paramedics), and after the incident (e.g., coroners, correctional workers, media coverage). Their well-being may suffer from the associated processes and outcomes. In the current article, we focus on the mass causality incident of 2020 in Nova Scotia, Canada, and the investigation following a prisoner death in 2019 in Newfoundland, Canada, to explore how testifying post-incident can be made more palatable for participating public safety personnel (PSP). Specifically, we study how testifying after an adverse event can affect PSP (e.g., recalling, vicarious trauma, triggers) and how best to mitigate the impact of testimony on PSP well-being, with a lens to psychological "recovery" or wellness. We focus here on how to support those who may have to testify in a judicial proceeding or official inquiry, given being investigated for best-intended actions can result in moral injury or a posttraumatic stress injury, both exacerbated by judicial review, charge, accusation, or inquiry.

Longitudinal comparisons of mental health, burnout and well-being in patient-facing, non-patient-facing healthcare professionals and non-healthcare professionals during the COVID-19 pandemic: findings from the CoPE-HCP study

BACKGROUND

The COVID-19 pandemic may disproportionately affect the mental health of healthcare professionals (HCPs), especially patient-facing HCPs.

AIMS

To longitudinally examine mental health in HCPs versus non-HCPs, and patient-facing HCPs versus non-patient-facing HCPs.

METHOD

Online surveys were distributed to a cohort at three phases (baseline, July to September 2020; phase 2, 6 weeks post-baseline; phase 3, 4 months post-baseline). Each survey contained validated assessments for depression, anxiety, insomnia, burnout and well-being. For each outcome, we conducted mixed-effects logistic regression models (adjusted for a priori confounders) comparing the risk in different groups at each phase.

RESULTS

A total of 1574 HCPs and 147 non-HCPs completed the baseline survey. Although there were generally higher rates of various probable mental health issues among HCPs versus non-HCPs at each phase, there was no significant difference, except that HCPs had 2.5-fold increased risk of burnout at phase 2 (emotional exhaustion: odds ratio 2.50, 95% CI 1.15-5.46, P = 0.021), which increased at phase 3 (emotional exhaustion: odds ratio 3.32, 95% CI 1.40-7.87, P = 0.006; depersonalisation: odds ratio 3.29, 95% CI 1.12-9.71, P = 0.031). At baseline, patient-facing HCPs (versus non-patient-facing HCPs) had a five-fold increased risk of depersonalisation (odds ratio 5.02, 95% CI 1.65-15.26, P = 0.004), with no significant difference in the risk for other outcomes. The difference in depersonalisation reduced over time, but patient-facing HCPs still had a 2.7-fold increased risk of emotional exhaustion (odds ratio 2.74, 95% CI 1.28-5.85, P = 0.009) by phase 3.

CONCLUSIONS

The COVID-19 pandemic had a huge impact on the mental health and well-being of both HCPs and non-HCPs, but there is disproportionately higher burnout among HCPs, particularly patient-facing HCPs.

Exploring the psychological impact of working during COVID-19 on medical and nursing students: a qualitative study

OBJECTIVES

To identify the psychological impact of working during the COVID-19 pandemic on medical and nursing students' psychological well-being. To inform recommendations for the provision of future student well-being support.

DESIGN

An interpretative qualitative, semistructured interview study employing maximum variation sampling, snowball sampling and a thematic analysis.

SETTING

A large West Midlands (UK) university with medical and nursing undergraduate and postgraduate programmes. Study undertaken between January and May 2020.

PARTICIPANTS

A purposive sample of eight medical (six women and two men) and seven nursing (all women) students who worked >2 weeks in a healthcare setting during the COVID-19 pandemic (from 1 March 2020 onwards).

RESULTS

Four core themes with corresponding subthemes were identified: (1) COVID-19 sources of distress-working conditions, exposure to suffering, death and dying, relationships and teams, individual inexperience and student identity, (2) negative impact on mental health and well-being-psychological and emotional distress, delayed distress, exhaustion, mental ill health, (3) protective factors from distress-access to support, environment, preparation and induction, recognition and reward, time for breaks and rest and (4) positive experiences and meaningful outcomes.

CONCLUSIONS

Student pandemic deployment has had a significant negative impact on students' psychological well-being, as a result of demanding working conditions, unprecedented exposure to death and suffering and lack of preparation for new job roles. Universities and healthcare organisations must formally acknowledge this impact and provide well-being support for distressed students working in such challenging contexts. They must also establish more supportive and inclusive healthcare environments for medical and nursing students in future pandemic and postpandemic circumstances, through the implementation of support systems and adequate preparation.

Impact on staff of providing non-invasive advanced respiratory support during the COVID-19 pandemic: a qualitative study in an acute hospital

OBJECTIVES

To explore the experiences of healthcare workers providing non-invasive advanced respiratory support (NARS) to critically unwell patients with COVID-19.

DESIGN

A qualitative study drawing on a social constructionist perspective using thematic analysis of semistructured interviews.

SETTING

A single acute UK National Health Service Trust across two hospital sites.

PARTICIPANTS

Multidisciplinary team members in acute, respiratory and palliative medicine.

RESULTS

21 nurses, doctors (juniors and consultants) and physiotherapists described the provision of NARS to critically unwell COVID-19 patients as extremely challenging. The main themes were of feeling ill prepared and unsupported, a need to balance complex moral actions and a sense of duty to patients and their families. The impact on staff was profound and findings are discussed via a lens of moral injury. Injurious events included staff feeling they had acted in a way that caused harm, failed to prevent harm or had been let down by seniors or the Trust. Participants identified factors that mitigated adverse impact.

CONCLUSIONS

Although many of the issues described by participants are likely immutable components of healthcare in a pandemic, there were several important protective factors that emerged from the data. Experience, debriefing and breaks from COVID-19 wards were valuable to participants and successfully achieving a peaceful death for the patient was often viewed as compensation for a difficult journey. These protective factors may provide modelling for future education and support services to help prevent moral injury or aide in its recovery.

TRIAL REGISTRATION NUMBER

Registered on the Open Science Framework, DOI 10.17605/OSF.IO/TB5QJ.

Supporting Aboriginal and Torres Strait Islander Families to Stay Together from the Start (SAFeST Start): Urgent call to action to address crisis in infant removals

Reducing the rate of over-representation of Aboriginal and Torres Strait Islander children in out-of-home care (OOHC) is a key Closing the Gap target committed to by all Australian governments. Current strategies are failing. The "gap" is widening, with the rate of Aboriginal and Torres Strait Islander children in OOHC at 30 June 2020 being 11 times that of non-Indigenous children. Approximately, one in five Aboriginal and Torres Strait Islander children entering OOHC each year are younger than one year. These figures represent compounding intergenerational trauma and institutional harm to Aboriginal and Torres Strait Islander families and communities. This article outlines systemic failures to address the needs of Aboriginal and Torres Strait Islander parents during pregnancy and following birth, causing cumulative harm and trauma to families, communities and cultures. Major reform to child and family notification and service systems, and significant investment to address this crisis, is urgently needed. The Family Matters Building Blocks and five elements of the Aboriginal and Torres Strait Islander Child Placement Principle (Prevention, Participation, Partnership, Placement and Connection) provide a transformative foundation to address historical, institutional, well-being and socioeconomic drivers of current catastrophic trajectories. The time for action is now.

The wounded helper: moral injury contributes to depression and anxiety among Israeli health and social care workers during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic can affect the mental health of health and social care workers (HSCWs) who are frontline workers in this crisis. The pandemic poses unique challenges to HSCWs as they face morally daunting decisions while working with limited knowledge and resources. This study examined the relationships between exposure to potentially morally injurious events (PMIEs) and depression and anxiety among HSCWs.

METHOD

A sample of 243 Israeli HSCWs completed validated self-report questionnaires that include measures of depression, anxiety, exposure to PMIEs, perceived stress, and moral injury symptoms.

RESULTS

About one-third (33.6%) of the sample met the criteria for major depressive disorder, 21.5% met the criteria for generalized anxiety disorder, and 19.1% reported comorbidity of depression and anxiety. Beyond demographic, COVID-19, and work-related characteristics, PMIEs contributed to depression and anxiety among HSCWs. The integrative model indicated the mediating role of perceived stress and moral injury symptoms in the associations of PMIEs with depression and anxiety.

CONCLUSIONS

The study's findings highlight HSCWs' mental burden during the COVID-19 pandemic and the important contribution of exposure to PMIEs to this burden. Clinicians treating HSCWs coping with depression and anxiety following the COVID-19 should also attend to moral injury symptoms.

"It Is Difficult to Always Be an Antagonist": Ethical, Professional, and Moral Dilemmas as Potentially Psychologically Traumatic Events among Nurses in Canada

AIMS

We explore social and relational dynamics tied to an unexplored potentially psychologically traumatic event (PPTE) that can impact nurses' well-being and sense of their occupational responsibilities: namely, the moral, ethical, or professional dilemmas encountered in their occupational work.

DESIGN

We used a semi-constructed grounded theory approach to reveal prevalent emergent themes from the qualitative, open-ended component of our survey response data as part of a larger mixed-methods study.

METHODS

We administered a national Canadian survey on nurses' experiences of occupational stressors and their health and well-being between May and September 2019. In the current study, we analyzed data from four open text fields in the PPTE section of the survey.

RESULTS

In total, at least 109 participants noted that their most impactful PPTE exposure was a moral, professional, and/or ethical dilemma. These participants volunteered the theme as a spontaneous addition to the list of possible PPTE exposures.

CONCLUSIONS

Emergent theme analytic results suggest that physicians, other nurses, staff, and/or the decision-making power of patients' families can reduce or eliminate a nurse's perception of their agency, which directly and negatively impacts their well-being and may cause them to experience moral injury. Nurses also report struggling when left to operationalize patient care instructions with which they disagree.

IMPACT

Nurses are exposed to PPTEs at work, but little is known about factors that can aggravate PPTE exposure in the field, impact the mental wellness of nurses, and even shape patient care. We discuss the implications of PPTE involving moral, professional, and ethical dilemmas (i.e., potentially morally injurious events), and provide recommendations for nursing policy and practice.

Experiences and impact of moral injury in U.K. veterinary professional wellbeing

BACKGROUND

Veterinary professionals (VPs) are often exposed to distressing and ethically challenging events in their line of work, yet little is known about whether they may experience moral injury and the impact potentially morally injurious events (PMIEs) may have on their wellbeing. This cross-sectional study aimed to examine the association between PMIEs and the mental health outcomes of U.K. VPs.

METHOD

Assessments of PMIE exposure and self-report measures of common mental disorders were administered using an anonymous online questionnaire to 90 U.K. VPs between December 2020 and May 2021.

RESULTS

Exposure to PMIEs was reported by almost all VPs (89.0%), with acts of omission most frequently reported. Experiences of PMIEs were significantly associated with symptoms of PTSD (p < 0.01) and experiencing a betrayal event was significantly associated with PTSD symptoms (p<0.05). However, there was no significant association found between PMIE exposure and alcohol misuse or CMD (p > 0.05).

CONCLUSIONS

This study provides some of the first evidence that experiences of moral injury are significantly associated with adverse mental health outcomes in U.K. VPs. Future work is needed to design effective pathways for prevention and intervention for VPs exposed to highly challenging events.

HIGHLIGHTS

U.K. veterinary professionals were found to experience moral injury.Experiences of moral injury were significantly associated with symptoms of PTSD.

"It's Been Ugly": A Large-Scale Qualitative Study into the Difficulties Frontline Doctors Faced across Two Waves of the COVID-19 Pandemic

This study aimed to gain an uncensored insight into the most difficult aspects of working as a frontline doctor across successive COVID-19 pandemic waves. Data collected by the parent study (CERA) was analysed using conventional content analysis. Participants comprised frontline doctors who worked in emergency, anaesthetic, and intensive care medicine in the UK and Ireland during the COVID-19 pandemic (n = 1379). All seniority levels were represented, 42.8% of the sample were male, and 69.2% were white. Four themes were identified with nine respective categories (in parentheses): (1) I'm not a COVID hero, I'm COVID cannon fodder (exposed and unprotected, "a kick in the teeth"); (2) the relentlessness and pervasiveness of COVID ("no respite", "shifting sands"); (3) the ugly truths of the frontline ("inhumane" care, complex team dynamics); (4) an overwhelmed system exacerbated by COVID (overstretched and under-resourced, constant changes and uncertainty, the added hinderance of infection control measures). Findings reflect the multifaceted challenges faced after successive pandemic waves; basic wellbeing needs continue to be neglected and the emotional impact is further pronounced. Steps are necessary to mitigate the repeated trauma exposure of frontline doctors as COVID-19 becomes endemic and health services attempt to recover with inevitable long-term sequelae.

A longitudinal analysis of the role of potentially morally injurious events on COVID-19-related psychosocial functioning among healthcare providers

Medical leaders have warned of the potential public health burden of a "parallel pandemic" faced by healthcare workers during the COVID-19 pandemic. These individuals may have experienced scenarios in which their moral code was violated resulting in potentially morally injurious events (PMIEs). In the present study, hierarchical linear modeling was utilized to examine the role of PMIEs on COVID-19 pandemic-related difficulties in psychosocial functioning among 211 healthcare providers (83% female, 89% White, and an average of 11.30 years in their healthcare profession [9.31]) over a 10-month span (May 2020 -March 2021). Reported exposure to PMIEs was associated with statistically significant poorer self-reported psychosocial functioning at baseline and over the course of 10-months of data collection. Within exploratory examinations of PMIE type, perceptions of transgressions by self or others (e.g., "I acted in ways that violated my own moral code or values"), but not perceived betrayal (e.g., "I feel betrayed by leaders who I once trusted"), was associated with poorer COVID-19 related psychosocial functioning (e.g., feeling connected to others, relationship with spouse or partner). Findings from this study speak to the importance of investing in intervention and prevention efforts to mitigate the consequences of exposure to PMIEs among healthcare providers. Interventions for healthcare providers targeting psychosocial functioning in the context of moral injury is an important area for future research.

Moral Injury and Light Triad Traits: Anxiety and Depression in Health-Care Personnel During the Coronavirus-2019 Pandemic in Honduras

The purpose of the current study was to determine the influence of moral injury and Light Triad (LT) personality traits on anxiety and depression symptoms of health-care personnel during the coronavirus-2019 pandemic. A quantitative, cross-sectional research design was used, the study included a sample of 169 health-care workers from Honduras. Data was gathered through the Moral Injury Symptom Scale for Health Professionals (MISS-HP), Light Triad Scale (LTS), the Generalized Anxiety Disorder-7, and the Patient-Health Questionnaire-9. Results suggest that almost 9 out of 10 respondents experienced at least one potentially morally injurious event, 45.6% were at significant risk of impairment related to moral injury. Working with limited staff and resources, and the implications of it, was the most common potentially morally injurious situation reported by the respondents. Results suggest that MISS-HP Mistrust has significant negative correlations with LT traits. A hierarchical regression model determined that Moral Injury, but not LT traits, significantly affected depression symptoms. On the other hand, anxiety symptoms were significantly predicted by Moral Injury, as did LTS-Humanism. The results were discussed according to their implications for public health policy in Latin America.

Moral Injury, Australian Veterans and the Role of Chaplains: An Exploratory Qualitative Study

Military personnel deployed to war zones or assigned to other morally challenging military duties are likely to be exposed to potentially morally injurious events (PMIE) that may inflict a moral injury (MI). This qualitative study formed 'Phase 1' of a larger study into PMIEs experienced by Australian veterans and the potential pastoral/spiritual care role of chaplains. Two seminars were conducted that involved 10 veterans being interviewed and audio recorded about their deployment experiences to evaluate whether there was any evidence among Australian veterans of a PMIE. Narrative data analysis indicated that all participants had been exposed to, or were involved in, a PMIE of one kind or another. Seven key themes were identified from the analyzed qualitative data: (i) immoral acts, (ii) death and injury, (iii) betrayal, (iv) ethical dilemmas, (v) disproportionate violence, (vi) retribution and (vii) religious/spiritual issues. Given this preliminary PMIE evidence identified, there is a need for further research, as well as the development of a suitable moral injury assessment scale appropriate for Australian veterans. Furthermore, given the ethical, moral, and spiritual issues involved, the implementation of a rehabilitation program suitable for Australian veterans which can be provided by chaplains is also suggested-namely 'Pastoral Narrative Disclosure.' It is argued that moral injury needs to be recognized, not just as an issue affecting individual personnel and their families, but is also a community health, organizational and government responsibility.

Supporting Primary Care Professionals to Stay in Work During the COVID-19 Pandemic: Views on Personal Risk and Access to Testing During the First Wave of Pandemic in Europe

Background: Minimising primary care professionals' (PCPs) risk of SARS-CoV-2 infection is crucial to ensure their safety as well as functioning health care system. PCPs' perspectives on the support they needed in the early stages of a public health crisis can inform future preparedness. Aim: To understand PCPs' experiences of providing care during the COVID-19 pandemic, with focus on personal risk from COVID-19 and testing. Design and Setting: Qualitative study using semi-structured interviews with PCPs in England, Belgium, the Netherlands, Ireland, Germany, Poland, Greece and Sweden, between April and July 2020. Method: Interviews were analysed using a combination of inductive and deductive thematic analysis techniques. Results: Eighty interviews were conducted, showing that PCPs tried to make sense of their risk of both contracting and severity of COVID-19 by assessing individual risk factors and perceived effectiveness of Personal Protective Equipment (PPE). They had limited access to PPE yet continued providing care as their "duty." Some PCPs felt that they were put in high-risk situations when patients or colleagues were not flagging symptoms of COVID-19. Not having access to testing in the initial stages of the pandemic was somewhat accepted but when available, was valued. Conclusion: Access to adequate PPE and testing, as well as training for staff and education for patients about the importance of ensuring staff safety is crucial. Given PCPs' varied response in how they appraised personal risk and their tolerance for working, PCPs may benefit from the autonomy in deciding how they want to work during health emergencies.