Staff wellbeing

Understanding and addressing moral injury in essential workers during the pandemic

What is moral injury?

“Distress that results from actions (or inaction) which violate a person’s moral/ethical code. It may involve negative thoughts about themselves or others (for example, ‘I am a terrible person’ or ‘They don’t care about people’s lives’) as well as intense feelings of shame, guilt, or disgust.”

Greenberg and colleagues

Moral Injury is not a mental illness but it can lead to mental ill health. With the right support, it can also lead to psychological growth such as increased resilience or confidence.

Understanding and addressing moral injury in essential workers is important as it may be a common issue during the pandemic with significant effect on their wellbeing.

Moral injury outside of the military is an emerging area and the pandemic is an unusual situation. It is therefore important to seek staff views to identify actual need so that interventions are more likely to be successful.

Staff survey

A local multiagency project group, including Tees, Esk and Wear Valley NHS Foundation Trust, County Durham and Darlington NHS Foundation Trust, Durham County Council and Public Health England, developed a survey to understand moral injury amongst essential workers defined by government as “critical to the COVID-19 response” during the first wave of the COVID-19 pandemic.

The survey involved self-administered questions which asked staff across County Durham and Darlington about their experiences during the first wave of the pandemic as well as and what they feel would help address these issues. It also asked about wellbeing and some issues which may be risk factors for moral injury.

The survey was disseminated to staff across all sectors of essential workers by staff bulletins, multiagency groups and partner emails.

Watch our video below:

Findings

What troubled respondents

Respondents were asked to describe actions they felt were wrong or against good practice and any impact on them. Common themes included:

Others not obeying rules & social distancing (including other staff, managers, the public and people in authority):

• “Government and other people in the public eye not following guidance. This leads to frustration, anger. People in the community not wearing masks leads to a sense of futility on the actions we are trying to take as individuals. We depend on each other ultimately.”
• “Colleagues not adhering to the guidance and rules, distancing. Also the public.”
• “Whilst working from home I could see that people within my street were ignoring the rules and allowing people in their homes on a number of  occasions. This made me so frustrated and impacted my mental health as I felt they were stopping me and my family from being able to do things.”
• “Staff not wearing appropriate face masks… including senior staff.”

Not sharing workload fairly, not being allowed to work from home and fast redeployment with limited preparation for a long, or uncertain, time:

• “I felt the… service was abandoned by other services suddenly deciding they were unable to perform home visits.”
• “Being asked to go into base to work alone in an office when work can be 100% carried out at home. Increased risk to myself and family needlessly.”
• “I felt bullied into volunteering just so I wouldn’t end up working somewhere else.”
• “… others stating that they will work remotely. This can then put extra work to those left in bases.”
• “All our young managers started to work from home and left our 50+ employs to face the pandemic. They looked after themselves. All the… teams felt let down, it was like no one cared.”
• “I had not worked on a ward environment for over… years. I was instructed that I would be expected to practice on a ward as a registered nurse from day one, which would include IV antibiotics and drug rounds, which made me feel very uneasy.”
• “The hesitancy in allowing home working – I was made to feel I was abandoning my post when asked to work from home.”

Access to PPE, equipment, uniform, safe changing/ break area and changing PPE rules or safety concerns:

• “Working in reception area and have still not had Perspex screens fitted – continuously having to e-mail management to ask them to have this chased up. Feel that is not being seen as high priority.”
• “The total lack of consistency with regards to PPE rules. Following WHO advice initially, then PHE advice when PPE ran short. The use of out of date face masks. The regularity of policy changes was difficult to keep track of.”

Lack of kindness & supervisor check-ins:

• “The public perception that nurses are dirty and carrying disease. The GP practices… treating us like we are dirty.”
• “Colleagues not adhering to the guidance and rules, distancing. Also the public.”
• “I already felt that I was letting the team down, this was emphasised by my manager saying “poor … is rushed off her feet because … is isolating”, this really upsets me.”
• “A phone call every now and again would have been nice to see how we were all doing.”

Care of patients/residents/ clients/others (including care home residents not appropriate receiving care and patient flow/safety):

• “I did feel some of the doctors palliated patients too early just because they were elderly and Covid positive… I felt Covid was a very “hands off” approach… I therefore felt I was not a good nurse during this time and did not give the care and psychological support the patient should have had.”
• “Actively denied access to patients who had requested specifically our (chaplaincy) care; denial of visitors to EOL care patients by some members of staff.”
• “The residents felt they were given up on purely over a positive test, they felt abandoned by the NHS.”
• Very elderly mother-in-law who lives alone feeling very isolated – makes me feel guilty because there’s little I can do about it except to telephone her at regular intervals.”
• “Our care team felt the residents were written off and disregarded, we felt they were being sacrificed for a presumed influx at the NHS of younger people.”
• “Advised I cannot maintain face-to-face contact with clients who suffer from mental health and rely on that support. I have felt immense guilt for not providing the support my role requires me to.”

Fairness, or lack of it, seemed to be a common thread across multiple themes.

Condensed table of key survey themes:

Download key survey themes (604.44kB)

Respondent suggestions

Respondents were asked whether there was anything that could help prevent a similar situation or reduce the impact. Suggestions from respondents included:

Quick win actions

Given the pressure on essential workers during the pandemic and the rapidly changing situation some quick win actions were shared with local organisations and systems by PowerPoint and an infographic designed. These quick wins may be helpful for other local, or national, systems.

Quick win actions included:

1. Ensuring regular supportive supervisor check-ins (at all levels)
2. Encouraging kindness (to self & others)
3. Ensuring rules are seen to be fair & enforced (e.g. re PPE, social distancing, homeworking, sharing workload and HR/shielding/absence policies)
4. Clear communication (of guidance, plans, understanding of challenges staff face and action taken to address any feedback)

Addressing moral injury across the whole system

Addressing moral injury requires a systems based approach that recognises the impact of team dynamics, organisational factors, societal attitudes and beliefs as well as government policy and strategy. Without considering this efforts to address moral injury are at risk of being tokenistic and not tackling the underlying causes of the issue. Moral injurious environments have a greater role to play in the genesis of moral injury and resolving it than the individual factors. Whilst the individual approaches may be seen as the easiest to implement they should not be at the expense of team, organisation, societal and government policy interventions. Systems could aim to not just treat moral injury and any resultant effects on wellbeing but also reduce events that cause moral injury  By combining the survey results, existing literature and expert opinion a framework for action at all levels of the system could be developed, improved through feedback,  agreed and implemented across the system.

Potential actions at all levels of the system to reduce moral injury and its consequences:

Download Moral Injury Table of Interventions (414.44kB)

If you are concerned about moral injury the North East & North Cumbria Staff Wellbeing Hub has several wellbeing offers that you may find beneficial including a free online compassionate minds course and a coaching offer for mangers and leaders.

For more information, please email the Hub on: [email protected] or use the button below to visit the website.