Moral injury

Moral Injury (MI) is the signature wound of service. In defining moral injury, there are two levels. At an individual level, it occurs when a person perpetuates, fails to prevent or bears witness to a serious act that transgresses their deeply held moral beliefs and expectations. This leads to inner conflict, because the experience is at odds with their personal core ethical and moral beliefs. At an organisational level, it occurs when serious acts of transgression have been caused by or resulted in a betrayal of what is culturally held to be morally right in a ‘high-stakes’ situation by those who hold legitimate authority.

In systems that are dominated by managerialism and financial considerations devoid of leadership, there is a high risk of moral injury. There can be a real mismatch between the values of the management within caring organisations, such as the NHS, and the values of people who have sacrificed their lives to pursue their vocation in serving the needs of their patients: this mismatch can lead to mental health issues, burnout and an increasing level of suicide. This was acknowledged at the recent NHS Wounded Healer Conference, where the effects of the pandemic on health professionals were discussed.

Dr Margaret McKinnon, the Homewood Chair of Mental Health at McMasters University, and Ruth Lanius, Professor of Psychiatry and the director of PTSD research unit at the University of Western Ontario, have highlighted the levels of moral injury amongst health workers as a result of Covid-19. These include:

• Individual or collective circumstance can cause moral distress: for example, not being able to do the right thing due to financial and institutional constraints.
• A rapid response to a crisis is needed in the absence of an evidence-based solution.
• Staff are unable to meet the needs of patients.
• Decisions have to be taken quickly as to who lives and who dies.
• Staff are with dying patients alone.
• Individuals are forced to balance the physical and mental wellbeing of their patients with those of themselves and their families.
• The fabric of personal and professional identity can be torn, resulting in a sense of guilt and shame.
• There exists an accumulation of things experienced under pressure in a climate of uncertainty.

In order to address this crucial issue, myself and two other Churchill Fellows, Dr Sophie Redlin and Alison O’Connor, came together using funding generously granted from the Churchill Fellowship Covid-19 Action Fund to run a retreat for NHS and care home workers. The retreat took place in Oxfordshire in late March 2022. It set out to:

• Challenge the way we view and manage emotional distress within the health and social care setting, shifting the paradigm within which we treat mental health.
• Bring an awareness of moral injury into the UK discourse on health care workers' mental health and prototype treatment for it.
• Integrate the concept of post-traumatic growth into all mental health interventions, understanding that the individual can transform the deepest of struggles into the greatest of strengths.
• Rebuild community support networks, including the use of peer mentoring to create ongoing and sustainable support.
• Use creative therapies including self-compassion and forgiveness.
• Begin the process of transition ‘back to me’ with the opportunity to ‘tell my story’.
• Acknowledge the power of group-based approaches and 'talking circles', built on a foundation of transparency, honesty and mutuality in the treatment of mental health and wellbeing.

The feedback we received was universally positive:

“I feel able to use the skills learned to face challenges in a more positive, understanding way. I feel refreshed and able to make informed choices that I wouldn’t have had the courage to face before attending.” - Care Home Manager.

“I don’t fear the future now. I found who I used to be and realised I am brave, strong, loving and compassionate." - Senior Nurse.

“I am leaving with a feeling of gratitude and peace. My spirit feels energised and I feel much more optimistic.” - Senior Sister.

Moral injury is a spiritual wound demanding a spiritual response. Spirituality is at the heart of all those who serve, whatever the context, since it sacrifices self-interest to the greater good in a way that leaves the individual vulnerable. In understanding this, we open the door to understanding the interaction between body, soul and spirit using holistic solutions, which can be extended into all areas of wellbeing and mental health treatment.

We are now trying to raise the funds to run more retreats to consolidate the project and to carry out more detailed evaluation. If this is successful, we plan to establish a social enterprise to widen and deepen this approach across a range of contexts.