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!

Neil.greenberg@kcl.ac.ukTwitter: @profngreenbergwww.kcl.ac.uk/kcmhrhttp://epr.hpru.nihr.ac.uk/