The area of moral injury and staff distress is seldom discussed within the fields of drugs and alcohol, homelessness, and mental health services. Moral injury and moral distress are often mislabelled as PTSD, and while the symptomology may be similar, the process which the distress stems from is very different.
While PTSD is usually the result of fear-based events – abuse, a car crash, a near-death experience – moral injury stems from being prevented from doing what you believe is ethically and morally right.
Those working with clients who have experienced multiple disadvantage can often encounter traumatic situations, so understanding and recognising the signs and symptoms of moral injury is important for ensuring the wellbeing of staff and the efficacy of services provided to those with multiple and complex needs.
A 2009 article in Clinical psychology review describes moral injury as occurring when individuals are prevented from acting in ways that align with their ethical and moral beliefs. Moral distress refers to the repeated exposure to potentially morally injurious events, and is a recognised clinical term. Moral distress creates a sense of frustration and emotional pain when individuals recognise the right course of action yet feel powerless to overcome the barriers to following that course.
Moral injury and distress may also contribute to feelings of fatigue or hopelessness. Staff can experience a sense of detachment from their client, creating barriers to the delivery of effective interÂventions and care. Emotional numbness, or cynicism towards the work, can also develop as a way of self-protection from further distress and injury. This can create an internal psychological discourse leading to feelings of guilt and shame – for example, staff can experience dilemmas when faced with service criteria and thresholds which lead to the exclusion of those with comÂplex needs (for example, dual diagnosis).
So what can be done? We can tackle moral injury and moral distress by taking a multi-tier approach. At the individual level, monitor your own wellbeing when you may feel that your values and your actions are misaligned. When feeling that they’re prevented from following the right course of action, people can become cynical, experience feelings of guilt or shame, or withdraw from usual interactions. Seeking out a trusted colleague and spaces for reflection is essential to explore these feelings and possible different perspectives.
Intervention at a team level, meanwhile, is a wonderful opportunity to promote healthy daily habits that can be shared amongst the team. Check-ins with each other are key to fostering a cohesive, supportive, working environment. These check-ins also help people to notice if a colleague is struggling, and to provide support in a non-judgmental environment. Organisations may wish to consider group reflective practice as a standard provision to help staff discuss the emotional impact and sources of moral injury in a supportive atmosphere.
At leadership level, supervision with staff serves as a point of contact for staff to reflect and manage their own wellbeing. It’s also an opportunity to discover possible organisational factors or workplace cultures that may be hindering an individual’s ability to act in line with their own and organisational values.
Finally, at system level, those with multiple needs require multi-professional and multi-agency approaches to support their care and recovery. It’s in this space, however, where moral distress can be most experienced. Working in partnership around a person is essential yet is not without its own challenges. Systems such as charities, local authorities and the NHS must work together with potentially incongruent rules and policies – this requires an open and honest dialogue at a strategic governance level to facilitate changes and enable excellent quality of care.
When staff are supported and skilled to notice and manage their emotional health, they’re less likely to experience burnout. It’s important to recognise that eradication of moral injury cannot be achieved – the focus should be on reducing the sources of moral injury and having the opportunity to discuss these issues in a non-judgmental space.
By recognising the signs of moral distress, promoting constructive dialogues, and providing support, organisations can become healthier work environments that prioritise the mental health and the moral and ethical values of their staff. It’s through this recognition and proactive response that real change can be achieved.
Steven Batten is clinical psychologist in training, Humber Teaching NHS Foundation Trust. Dr Stephen Donaldson is consultant clinical psychologist, REACH team/professional lead for psychological professions, Tees Esk and Wear Valleys NHS Foundation Trust.