Injuries of the moral kind

For many of us, confronting images of exhausted and distressed frontline workers during the height of the COVID-19 pandemic remain seared into our memory.

This group was called on to make countless life-or-death decisions every day. They were applauded for putting themselves at risk to keep others safe. But ANU experts warn their experiences could have a long-lasting impact on their mental health.

“These workers may have had to do things they understood to be a requirement of their job, but that went against how they’d act under their own volition,” PhD scholar Victoria Thomas, from the ANU School of Medicine and Psychology, says.

“In a hospital that can include denying care to people because there aren’t enough ventilators. In the moment you have to get on with it and make the best decision possible. But, after the dust settles you can be left with some very difficult feelings about the choices you had to make.”

The profound suffering that can occur when someone is forced to make impossible choices that conflict with their core values has a name: moral injury. And Thomas believes it needs our urgent attention.

“It can cause a range of difficult emotional experiences — a loss of trust in the organisation, existential conflict about your life or a loss of the sense that your work has meaning, as well as debilitating feelings of anger, guilt and shame,” she says.

“It’s made worse when you feel like the workplace or system you’re a part of doesn’t have your back or is treating you like you’re just a number — that’s when you start to see moral injury occur.”

Other recent Australian research on moral injury by Reverend Dr Mark Layson, from Charles Sturt University, supports this idea. Layson was inspired by his service as a former police officer, former firefighter, and current work as an ambulance and disaster chaplain.

Layson’s research found that a sense of betrayal by your workplace leads to greater distress than exposure to traumatic experiences alone.

“While there is increasing evidence that moral injury exists, deeper exploration of it in civilian populations is an urgent priority,” Layson says.

Thomas adds that traditionally our understanding of moral injury has come from looking at the experiences of soldiers returning home from war, but now workers in more and more occupations are suffering from it.

“The pandemic showed there’s a desperate need to understand what it looks like outside the military,” she says. “If a doctor wants to check for a broken bone they can do an X-ray. For other illnesses, there’s blood tests. We need equally good measurement tools for psychological injuries.”

Thomas is taking matters into her own hands. She’s come up with one of the first psychometric measurement tools for moral injury in occupational settings beyond the military. The project was inspired by Thomas’ own experience of working with refugees, and the pain and frustration she felt at not being able to help them as much as she would’ve liked to.

“My tool captures the situations that can lead to moral injury and the key symptoms that we need to look out for,” she says.

“The fact it can be used in any setting will allow for comparison across groups of workers for the first time, helping us to screen for those who are most at risk and pinpoint the situations causing the most distress.”

The Occupational Moral Injury Scale is a 20-item questionnaire, tested on a group of more than 1,400 frontline workers and first responders, including nurses, police, paramedics, triple-zero call operators and people working behind the desk in emergency departments.

It is now being translated into other languages. Thomas is also expanding it for use in a range of other professions, including the public service.

“Once you explain the concept a lot of people say, ‘oh my god, I have experienced that’,” Thomas says. “The individual situations can look really different, but there are some pretty reliable themes.”

Thomas hopes her work will help normalise this kind of psychological response.

“We have these natural impulses to feel things like guilt and shame and sadness in response to moral violations for a reason,” she says. “It doesn’t mean there’s something wrong with you — it means you’ve been put in a really difficult situation.

“We know workers in certain occupations are more prone to moral injury and when you throw something like COVID into the mix it takes that to another level, because the pressure people are operating under and the lack of resources.”