The differential and accumulative impacts of self and other sources of moral injury on well-being in mental healthcare staff

• Date: 26 April 2024
• Pages: 139-155
• DOI: https://doi.org/10.1108/IJWHM-10-2023-0155
• Published date: 26 April 2024
• Subject Matter: Health & social care,Healthcare management,HR & organizational behaviour,Human resource policy,Employee welfare
• Author: Elanor Lucy Webb,Deborah J. Morris,Benedetta Lupattelli Gencarelli,Jemima Worsfold

The differential and accumulative

impacts of self and other sources

of moral injury on well-being

in mental healthcare staff

Elanor Lucy Webb and Deborah J. Morris

Centre for Developmental and Complex Trauma, St Andrew’s Healthcare,

Northampton, UK and

Faculty of Medicine and Health Sciences, The University of Buckingham,

Buckingham, UK, and

Benedetta Lupattelli Gencarelli and Jemima Worsfold

Centre for Developmental and Complex Trauma, St Andrew’s Healthcare,

Northampton, UK

Abstract

Purpose –Research has established the prevalence and relevance of moral injury in healthcare workers,

though less attention has been paid to the different classes of potentially morally injurious events (PMIEs)

experienced by this population and their impact. This exploratory study sought to examine the frequency of

self- and other-generated PMIE classes and their associations with demographic characteristics and well-being

outcomes among mental healthcare staff.

Design/methodology/approach –Secondary analysis of data drawn from two cross-sectional surveys of

267 frontline and leadership staff from mental healthcare settings in the UK was conducted. Responses on the

Moral Injury Events Scale and the Short Professional Quality of Life Scale were extracted for analysis.

Findings –Betrayal by others was most frequently endorsed (61.8%), whilst self-transgressions were least

frequently reported (25.5%). After controlling for the number of PMIE classes experienced, betrayal

significantly predicted secondary traumatic stress (p50.01) and burnout (p50.04). Additionally, other

transgressions significantly predicted secondary traumatic stress (p50.008). The predictive effects of self-

transgressions on burnout, secondary traumatic stress and compassion satisfaction were all nonsignificant

after controlling for the number of PMIE classes experienced.

Practical implications –Findings highlight differences in the frequency and impact of self and other PMIEs

experienced by healthcare professionals. Reducing cumulative exposure to differential PMIE classes appears

to be of critical importance to improving occupational well-being in this group.

Originality/value –To ourknowledge, this studyis the first to explorethe associations betweenPMIE classes

and occupational well-beingin a mental healthcare population, inclusive of frontlineand leadership staff.

Keywords Healthcare, Moral injury, Mental health, Betrayal, Transgression, Transgressions

Paper type Research paper

Introduction

Moral injury describes the psychological, spiritual, social and existential impacts of exposure

to situations that violate a person’s deeply held moral values, referred to as “potentially

morally injurious events”(PMIEs). Original definitions confined moral injury as a response to

experiences of betrayal by authority figures in “high stakes”situations (Shay, 1994,2003).

However, more contemporary definitions propose differential classifications of PMIEs that

include and extend beyond betrayal events (Litz et al., 2009), including transgressions by the

self and by others, inclusive of nonauthority figures. Accordingly, dominant measures of

PMIE exposure, such as the Moral Injury Events Scale (MIES; Nash et al., 2013), capture

exposure to these three differential types of PMIEs, namely, (1) betrayal by others,

Moral injury

and mental

healthcare staff

139

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Received 17 October 2023

Revised 9 February 2024

13 March 2024

Accepted 18 March 2024

InternationalJournal of Workplace

Health Management

Vol. 17 No. 2, 2024

pp. 139-155

© Emerald Publishing Limited

1753-8351

DOI 10.1108/IJWHM-10-2023-0155

(2) transgressions by others and (3) self-transgressions. These different types of PMIEs are

referred to as “classes”.

Whilst the origins of moral injury are firmly rooted in the experiences of military

personnel, investigation of this construct in other occupational groups has burgeoned

(ter Heide and Olff, 2023). In particular, focus has been on the application of moral injury in

describing the experiences and distress of staff working in healthcare settings in the context

of the COVID-19 pandemic (Hegarty et al., 2022). Data gathered from frontline workers during

this period indicates that approximately half of healthcare professionals have experienced a

PMIE (Borges et al., 2021;Maftei and Holman, 2021). Furthermore, exposure to PMIEs has

been associated with a plethora of psychological, physiological and social adversities,

including depression and anxiety, suicidal behaviour, social withdrawal, substance use and

sleep disturbances (Fani et al., 2021;Hall et al., 2022). Thus, minimising their occurrence and

subsequent impacts reflects an important priority in healthcare.

The prevalence and impact of PMIE classes in healthcare

Whilst research has largely focused on the overall incidence of PMIE exposure in healthcare,

a more recent investigation has identified discrepancies in the prevalence of individual PMIE

classes. Self-transgressions have been found to be the least commonly endorsed PMIE class

for healthcare professionals, with betrayal being most frequently reported (Borges et al., 2021;

Brennan et al., 2022;Greene et al., 2023;Nieuwsma et al., 2022;Williamson et al., 2023). Parallel

trends have also been noted in veterans (Maguen et al., 2020), indicating a tendency for

exposure to PMIEs stemming from external sources. Accordingly, strategies that seek to

minimise exposure to specific PMIE classes may have differential effects on reducing the

prevalence of moral injury, dependent on the class of PMIE experienced.

Initialexamination of the individualimpacts of PMIEs in healthcareworkers has notedself-

transgressions, which are reported less commonlythan betrayal, to have a greater bearingon

an individual’s work functioning (Weber et al., 2023). Whilst strategies that target the most

prevalent sourcesof moral injury, namely betrayal,may be of some benefit, interventionsthat

target the most impactful PMIEs are arguably the most important. Accordingly, this finding

contests thenotion of frequency as a proxy forimpact and suggests that the effectsof a PMIE

are likely to be in part driven by the natureof the morally injurious experience.

That said, the relative contribution of self-transgressions, other-transgressions and

betrayals, above the effects of cumulative exposure to differential PMIE classes, has been

subject to limitedempirical exploration. Previous research has indicated the overall frequency

and intensityof experienced PMIEs to be a strong driverof well-being outcomes (Ehman et al.,

2023). Furthermore, Saba et al. (2022) found that well-being was more strongly driven by the

overall intensity of PMIEs experienced than by exposure to any specific PMIE class.

Establishingthe role ofspecific PMIE classesas well as the effectsof exposure to multiplePMIE

classes, is key to developing both preventative and managementapproaches for moral injury.

Besides gaining insight into the frequency and impact of PMIE classes, exploration of

sociodemographic differences within healthcare remains an important research priority

(Borges et al., 2022). Initial research in veteran samples has noted a greater tendency for non-

white and female veterans to report other-directed PMIEs, both alone (e.g. Maguen et al., 2020)

and when exploring differences intersectionality, between gendered ethnic groups

(Nieuwsma et al., 2022). Additionally, the odds of exposure to multiple PMIE classes are

also noted to be higher in female and non-white veterans (Saba et al., 2022). Of the limited

research on healthcare staff, the results are mixed. When examining profiles on the MIES of

mental healthcare staff, similarity in average exposure and impact scores for all PMIE classes

was noted between gender and ethnic groups, both separately and at their intersection

(Morris et al., 2022). In contrast, Nieuwsma et al. (2022) found that non-white participants were

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