The COVID-19 virus outbreak was declared a pandemic by the WHO on 12 March 2020. Whilst
the infection mortality rate is not fully understood, it appears to be considerably
higher than that of other recent pandemics (e.g. H1N1 pandemic, mortality rate 0.02%)
[1]. Furthermore, several groups of people, such as the elderly and those with some
pre-existing medical conditions, appear to be particularly vulnerable to the disease
[1,2].
International evidence, and the public health messaging put forward by Public Health
England, suggests that COVID-19 may place a substantial demand on an overstretched
National Health Service (NHS). A lack of specific resources—such as a lack of beds
in Intensive Care Units, essential medicines and ventilators—and increased demand
on the NHS may mean that front-line workers, such as clinicians, paramedics and other
care staff, may be unable to provide adequate treatment to all patients, as seen in
Italy [3]. Additionally, current guidance recommends that anyone who is showing signs
of a potential COVID-19 infection (e.g. new persistent cough, fever), or who lives
in a house with someone who shows such signs, must self-quarantine at home [2] meaning
that some clinicians will be unable to return to their ‘front-line’ responsibilities
at a time when their colleagues are working exceptionally hard. As a result of these
exceptional challenges, lives will inevitably be lost that could, in other circumstances,
have been saved. Non-clinical professionals in other essential roles, such as the
justice system, 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. 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 and some moral injuries [4].
Moral injury is defined as the profound psychological distress which results from
actions, or the lack of them, which violate one’s moral or ethical code [5]. Morally
injurious events can include acts of perpetration, acts of omission or experiences
of betrayal from leaders or trusted others. Unlike post-traumatic stress disorder
(PTSD), moral injury is not a mental illness. Although experiences of potentially
morally injurious events (PMIEs) can lead to negative thoughts about oneself or others
(e.g. “I am a monster” or “my colleagues don’t care about me”) as well as deep feelings
of shame, guilt or disgust. These, in turn, can contribute to the development of mental
health problems, including depression, PTSD and anxiety [6].
Moral injury is not limited by context or profession. For example, a recent review
found that exposure to moral injury was significantly associated with PTSD, depression
and suicidal ideation across a range of professions (e.g. teacher, military personnel,
journalists) across a variety of countries (e.g. USA, Australia, Israel) [6].
Currently, there are no manualized approaches to treat moral injury-related mental
health difficulties. In fact, some standardized treatments for PTSD (e.g. prolonged
exposure) may potentially be harmful and worsen patient feelings of guilt and shame.
Some emerging US evidence suggests that Adaptive Disclosure (where forgiveness is
received from a benevolent moral authority) may be helpful [7]. UK clinicians also
report using an amalgamation of validated treatments (e.g. compassion-focused therapy,
schema therapy, etc.) to treat patients affected by moral injury [8].
Much of the research in moral injury at this stage has been carried out in military
personnel and veterans. However, several potential risk factors for moral injury have
been identified [9,10] that may be applicable to other professions during the COVID-19
Pandemic (Table 1):
Table 1.
Potential risk factors for moral injury
1. Increased risk of moral injury if there is loss of life to a vulnerable person
(e.g. child, woman, elderly);
2. Increased risk of moral injury if leaders are perceived to not take responsibility
for the event(s) and are unsupportive of staff;
3. Increased risk of moral injury if staff feel unaware or unprepared for emotional/psychological
consequences of decisions;
4. Increased risk of moral injury if the PMIE occurs concurrently with exposure to
other traumatic events (e.g. death of loved one);
5. Increased risk of moral injury if there is a lack of social support following the
PMIE.
Front-line key workers, such as healthcare providers and emergency first responders
but also other non-healthcare-related staff (e.g. social workers, prison staff), may
be especially vulnerable to experiencing moral injuries during this time. A lack of
resources may mean they are unable to adequately care for those they are responsible
for which may result in great suffering or a loss of life. A lack of resources, clear
guidance or training may also mean staff perceive that their own health is not being
properly considered by their employers and feel at increased risk of disease exposure.
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.
It is important to note, just as not all individuals who experience trauma necessarily
develop PTSD, exposure to PMIEs does not automatically result in moral injury. Nonetheless,
the following practical recommendations may be beneficial:
Front-line staff should be made aware of the possibility of PMIE exposure in their
role, and the emotions, thoughts and behaviours that might be experienced as a result.
Discussing this topic in advance of exposure to a PMIE, most probably facilitated
by supervisory level leaders, may help develop psychological preparedness and allow
staff to understand some inevitable symptoms of distress.
Front-line staff should be encouraged to seek informal support, from trained peer
supporters, managers, colleagues, chaplains or other welfare provision provided by
their employer, early on and take a ‘nip it in the bud’ approach—rather than dwelling
on the PMIEs they have been exposed to. There is good evidence that social support
is generally protective for mental health.
If informal support does not help, professional help should be sought early on. Professional
support is likely to be needed when difficulties relating to the PMIE become persistent
and impair an individual’s daily functioning. Sources of confidential help, which
should be rapidly accessible, should be well advertised within organizations. Those
providing such support should be aware of the concept of moral injury and also that
those suffering with such difficulties may often fail to talk about them because of
intense feelings of shame and guilt.
Those in leadership roles should be encouraged to proactively ‘check in’ with their
teams, offer empathetic support and encourage help-seeking where necessary. It is
vital that managers feel comfortable in having psychologically informed conversations
with their staff, or if they do not possess such skills, they should ensure that someone
else (e.g. trained peer supporter) checks in with their staff on a regular basis instead.
Employers of essential staff should be aware that psychological debriefing techniques
and psychological screening approaches are ineffective. Instead, it is imperative
that organizations actively monitor staff exposed to PMIEs, facilitate effective team
cohesion and make informal, as well as professional, sources of support readily available
to their employees. Furthermore, exposure to PMIEs should be frankly discussed and
efforts should be made to ensure that staff understand the potential for their work
during the COVID-19 outbreak to impact on their mental health, whilst ensuring they
are also aware that psychological growth can also be expected if staff ‘do their best’.
Recommendations for clinicians providing psychological support during and after the
COVID-19 Pandemic include:
Psychological support for those in front-line roles and affected by the COVID-19 should
be prioritized and made more readily accessible. Lengthy waiting lists for care are
a key reason why many individuals do not seek formal psychological help post-trauma.
Clinicians should also be aware that individuals who develop moral injury-related
mental health disorders are often reticent to speak about guilt or shame and may instead
focus on more classically traumatic elements of their presentation. As such, clinicians
should make sufficient sensitive enquiries about PMIEs in anyone who presents with
mental health difficulties having been an essential worker during the COVID-19 Pandemic.
Clinicians offering psychological treatment to patients should continue to do so,
taking precautionary measures where needed—such as offering treatment via Skype, Zoom,
telephone or similar. Useful information on this subject can be found at https://www.rcpsych.ac.uk/about-us/responding-to-covid-19/guidance-for-clinicians/digital-covid-19-guidance-for-clinicians.
Steps should be taken by clinical care teams to ensure that vulnerable groups, such
as survivors of domestic violence, and those with serious mental illnesses continue
to be able to access treatment and support networks. This is likely to require local
mental health services to proactively, most probably remotely, check on vulnerable
individuals and remind them of effective psychological coping strategies and possibly
‘top up’ their psychological therapy provision where that would be helpful.
Clinicians should encourage patients to take practical steps to manage anxiety during
this time, including limiting time spent accessing media and news outlets, seeking
COVID-19-related information from trusted sources (i.e. Public Health England, NHS),
and encouraging the use of evidence-based coping resources (i.e. https://www.nhs.uk/oneyou/every-mind-matters/).
Funding
This research was funded by the Forces in Mind Trust grant (FiMT17/0920E).
Competing interests
None declared.