Professor Neil Greenberg discusses the concept of 'moral injury' as a result of working in difficult circumstances - and how to manage it.

There can be little doubt that for the majority of 2020, and probably before then too, many healthcare workers (HCWs) have worked long hours in high-pressured environments characterised by exposure to traumatic events and moral dilemmas. Healthcare staff who have not been on the 'COVID frontline' have also had to adapt to new ways of working, and all have had to contend with a wide range of non-work stressors that have affected the rest of society as well.

These situations place HCWs at risk of suffering 'moral injuries'. This term describes the distress experienced when circumstances clash with one's moral or ethical code. The sorts of situations that may lead to moral injury are varied, but in broad terms consist of the following:

  • acts of commission: eg, silencing the alarm on a ventilator and then getting called away to an emergency with a bad outcome for the patient whose alarm was silenced
  • omission: eg, not speaking with a clearly distressed junior staff member as you felt the need to get home to your own family
  • feeling betrayed, often by a higher authority: eg, not being provided with safety equipment, forcing you to choose between delivering poor care or risking your own life.

While our understanding of moral injury remains somewhat underdeveloped, staff who suffer with moral injuries are at risk of developing a range of mental health issues.

Without doubt, some HCWs will have thrived since the onset of the pandemic, but it is inevitable that some will suffer a range of mental health issues including depression, post-traumatic-stress-disorder (PTSD) and substance misuse, to name but a few.

As such, it is imperative that healthcare organisations be aware of the wealth of evidence that exists about how to protect the mental health of staff carrying out psychologically risky roles, and how to identify those staff who do become unwell to ensure they are provided with timely and effective evidence based support.

Supporting healthcare workers

Preventative medicine provides a useful structure for understanding how best to support HCWs. First, prevent ill-health onset (primary prevention). Next, identify early indicators of impending ill-health and intervene (secondary prevention). Finally, if illness does occur, provide early treatment to optimise rapid recovery (tertiary prevention).

These principles have guided the way the armed forces have supported their staff for decades, and while HCWs and military personnel are different in many ways, the principles of supporting them effectively are remarkably similar.

Primary prevention

Primary prevention is best achieved through thoroughly preparing staff with good role-specific training, sufficient equipment and supervision, as well as fostering strong, supportive relationships between team members especially between staff members and their supervisors.

Supervisors should ensure that staff take an active interest in their colleagues' psychological wellbeing. Depending on the setting, it may also be appropriate to 'buddy up' shift staff and ensure team leaders conduct end-of-shift check-ins with staff - with a specific focus on their psychological health.

Secondary prevention

Secondary prevention is dependent on supervisors - and indeed all team members - feeling confident to have a psychologically knowledgeable and understanding conversation with potentially distressed staff members.

There is very good evidence that brief active listening skills training can help supervisors have meaningful conversations with team members which consequently protect their mental health. Such conversations need not focus on psychological topics; distress can often be best alleviated through helping a colleague to problem-solve an issue.

For example, the best 'treatment' for a staff member who is petrified that they will make a mistake at work may well be further training or mentoring rather than psychotherapy or time off.

MDU app

It is important to note that psychological debriefing techniques should not be used, as they have been conclusively found to be unhelpful and may cause harm; the National Institute for Health and Care Excellence (NICE) specifically warns against their use. However, it is equally important to note that well-run post-shift, or post-incident, leader-led operational debriefings are a good thing to do. These provide an opportunity for staff to reflect on what has happened, which may help prevent moral injuries; and they are also a demonstration that someone's manager is interested in changing things for the better.

Basic needs

Managers should also ensure that HCWs' basic needs are met, including arranging for reasonable shift patterns, rest areas, and suitable safety equipment as well as ensuring that up-to-date and accurate information on local and national supportive services are well advertised.

Although many 'wellness' approaches are promoted as being stress-busting, or are seen as fashionable - such as mindfulness or remote yoga classes - it is notable that while they are unlikely to cause harm, evidence of them being beneficial for the majority of staff is often lacking.

Professional help

Whatever the cause of someone's mental health problems, commonly they fail to seek professional help. This may result from someone failing to recognise their difficulties as a mental health disorder, concerns about how others will see them (often termed stigma) or worries about the impact of help-seeking on their career.

Because of poor autonomous help-seeking, it is vital that supervisors, and trained peers, should be alert for early signs of distress. There is good evidence that many staff are more comfortable sharing concerns with their peers; especially if the concerns are related to a perceived poor relationship with their bosses.

There are a number of peer-support programmes - such as the TRiM (Trauma Risk Management) programme developed by the UK military - now used within the NHS and many other emergency services, which can be beneficial. TRiM is not 'penicillin for trauma', but it is well-evidenced 1, 2, 3 and has been shown to improve social support, reduce sickness and facilitate access to professional care.

It is imperative that healthcare organisations be aware of the wealth of evidence that exists about how to protect the mental health of staff carrying out psychologically risky roles.

However, despite the provision of good primary and secondary prevention, some HCWs will need professional assessment and care. Ideally, this approach should be carried out by 'frontline' mental health professionals who focus on helping staff to return to duty wherever possible.

This can be achieved through use of the four PIES principles of Proximity, Immediacy, Expectancy, and Simplicity.

  • Proximity refers to keeping people at work wherever possible, possibly in a lower stress role along with good support.
  • Immediacy refers to adopting a 'nip it in the bud approach', which relies on having a meaningful, psychologically savvy conversation with colleagues, rather than accepting that 'fine' really means that someone's mental health is good.
  • Expectancy refers to reassuring staff that their reactions are likely to improve and are not indicative of illness; or if they do not resolve, then professional support will be provided.
  • Simplicity refers to the benefits of practical, real world-solutions, the benefits of a listening ear and adopting basic healthy habits such as getting good sleep, eating well and enjoyable physical activity.

Importantly, these approaches can often be implemented by supervisors with an interest in their staff's wellbeing. The use of a PIES approach has been shown to both help conserve staffing levels and protect staff's longer-term mental health. One study found that the more PIES principles applied at the time someone was distressed, the better their outcome 20 years later on.

Finally, it is noteworthy that NICE recommends active monitoring of trauma-exposed staff in order that the minority who need formal, rather than PIES, treatment can access it in a timely fashion. The earlier such treatment commences, the greater the likelihood that long term disability will be avoided.


Paying proper attention to HCWs mental health is not just legally required and morally justified. It is also an effective way to ensure that staff are psychologically well enough to provide high quality care.

At a time when the future is uncertain, taking good care of HCWs' mental health should be seen as a priority, alongside high quality research to identify which interventions work best and for whom.


  1. Whybrow D, Jones N and Greenberg N., Promoting organizational well-being: a comprehensive review of Trauma Risk Management. Occup Med (Lond) (2015) 65 (4): 331-336.doi: 10.1093/occmed/kqv024
  2. Greenberg N, Langston V, Jones N., Trauma risk management (TRiM) in the UK Armed Forces. J R Army Med Corps. 2008 Jun;154(2):124-7.
  3. Jones N, Burdett H, Green K & Greenberg N., Trauma Risk Management (TRiM): Promoting Help Seeking for Mental Health Problems Among Combat-Exposed U.K. Military Personnel, Psychiatry, 2017, 80:3, 236-251.

This page was correct at publication on 07/10/2020. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.