Neil Greenberg
Professor of Defence Mental Health
King’s College London Twitter: @Profngreenberg
Moral Injury, Mental Health and
Healthcare Staff
Who am I? Twitter: @Profngreenberg
Psychiatrist and Professor at King’s College London
RC Psychiatrists Chair of Occupational Psychiatry SIG and Lead for Trauma
Served in the Royal Navy for 23+ years
Managing Director of March on Stress Ltd
Part of NHSE/I Wellbeing Team & Recovery Commission
Set up the MH staff support strategy at London Nightingale Hospital
Main Sources of www. Information
www.ukpts.co.uk
http://epr.hpru.nihr.ac.uk/
www.marchonstress.com/
www.kcl.ac.uk/kcmhr
Risks to mental health during COVID 19
Traumatic exposure
Workload and shift patterns
Home life stressors
Moral injury
What is Moral Injury?
Profound distress following a transgressive act that violates one’s moral or ethical
code
well - moral distress – moral injury - illness
Potential Morally Injurious Events
Commission
I did things I should not have done
I am a monster
My team did things they should never have done
Omission
I froze and people died
I just let it happen
Betrayal by a higher authority
My supervisor had no interest in my safety
They lied to cover up their errors
MIES (six response option strongly disagree to strongly agree)
I saw things that were morally wrong
I am troubled by having witnessed others’ immoral acts
I acted in ways that violated my own moral code or values
I am troubled by having acted in ways that violated my own morals or values
I violated my own morals by failing to do something that I felt I should have done
I am troubled because I violated my morals by failing to do something that I felt I should
have done
I feel betrayed by my supervisors/managers who I once trusted
I feel betrayed by co-workers who I once trusted
I feel betrayed by others outside the health service who I once trusted
Potentially morally injurious event and mental health
outcomes in HCWs
% m
eeti
ng
case
nes
s
31.1
28.0
40.8
24.6 24.3
51.1
25.8 24.9
49.3
21.5
24.6
53.9
0.0
10.0
20.0
30.0
40.0
50.0
60.0
Low Moderate High
Exposure to moral injury
GHQCommon mental disorders
GAD-7Anxiety
PHQ-9Depression
PCL-6PTSD
Morally injurious events and MH disorders
Who is at risk of suffering a moral injury?N n (%) Mean[SD] n (%) meeting MIES cut-off Chi2
p value
Sex 26,112
Female 20,990 (81) 2,630 (24)p<0.001
Male 4,819 (19) 698 (31)
Role 25,899
Doctor 1,872 (7) 237 (27)
p<0.001Nurse 6,674 (26) 1,065 (30)
Other clinical 7,824 (31) 945 (25)
Non-clinical staff 9,304 (36) 1,096 (23)
Relationship status 26,015
In a relationship 19,267 (74) 2,440 (25)p=0.001
Single 6,748 (26) 900 (28)
Ethnicity 26,055
White 22,476 (86) 2,920 (25)
p<0.001
Black 1,066 (4) 101 (32)
Asian 1,640 (6) 196 (33)
Mixed ethnicity 626 (2) 93 (32)
Other ethnicity 247 (1) 34 (38)
Changed role due to CV19 25,880
Yes 3,266 (13) 460 (30)p<0.001
No 22,614 (87) 2,885 (25)
In contact with CV19 patients 25,446
Yes 11,958 (47) 1,940 (31)p<0.001
No 13,488 (53) 1,406 (21)
Adequate PPE 21,987
Yes 20,025 (91) 2,523 (24)p<0.001
No 1,962 (9) 458 (46)
Types of moral injury and MH disorders
Moral injury, teams and support
N n (%)
Mean[SD]
n (%) meeting MIES
cut-off
Chi2
p value
Feel you have adequate support from:
Line managers 25,331
Yes 21,167 (84) 2,068 (19)p<0.001
No 4,164 (16) 1,275 (55)
Colleagues 25,357
Yes 23,359 (92) 2,759 (23)p<0.001
No 1,998 (8) 586 (53)
Friends/family 25,301
Yes 24,137 (95) 3,061 (25)p<0.001
No 1,164 (5) 279 (43)
Colleague died from CV19 13,877
Yes 892 (6) 324 (39)p<0.001
No 12,985 (94) 3,028 (25)
Staff groups and moral injury items
What to do about moral injury
Reduce exposure
Prepare – “realism and a chance to speak about the challenge”
- Evidence from medics (Kisely et al. 2020)
- Evidence from military (Iversen et al. 2008]
Post-exposure validation
- thank you (a proper one)
- reflective practice
What to do about moral injury? - Reflective Practice
• Meaningful, leader-led, open discussion
• Discussion about: Facts, Impact, functioning Now & Education
• Aims to:
• Create ‘a meaningful narrative’
• Reduce stress
• Improve working relationships
Conclusion
Moral injury is not a mental illness
It is linked with mental health disorders, inc. in healthcare staff
Some groups more at risk (e.g. nurses, change of role, more exposed to challenge)
Betrayal is the most impactful type of PMIE
Nurses mostly from managers, doctors mostly from the 'health service'
Evidence informed ideas about how to mitigate the impact of MI but more research is
needed
Any Questions?- Fire Away!
[email protected]: @profngreenbergwww.kcl.ac.uk/kcmhrhttp://epr.hpru.nihr.ac.uk/