Moral injury in secure mental healthcare: Conceptualisation, causes and cognitions

Abstract

This PhD aimed to explore the conceptualisation of moral injury, and the sources leading to and increasing risk for the development of moral injury in healthcare staff working in secure mental health settings. The program of work also sought to explore a series of cognitive-emotional pathways linking exposure to a potentially morally injurious event (PMIE) with the development of moral injury, and subsequent psychological and somatic adversities.

In line with the first aim, a systematic literature review and meta-ethnography was firstly conducted. Thirty qualitative and quantitative papers identifying potential sources of moral injury for healthcare workers in forensic and mental health settings were identified. Meta-ethnographic synthesis of the findings across papers yielded three third-order factors reflecting a series of moral dichotomies; (i) ‘between profession and system’, (ii) ‘between relations with patients and relations with others’, and (iii) ‘between principles and practices’. The line of argument that developed from the synthesis described the hierarchical relationships between such dichotomies, with discordance between values of the healthcare profession and features of the healthcare system primarily providing the conditions for PMIEs to occur.

Following this, the first study involved the recruitment of 46 experts to partake in a Delphi survey of sources of moral injury, over three successive rounds. A number of PMIEs were identified, which related to aspects of the healthcare system, the secure context, relational dynamics, and individual practices, behaviours and attitudes. Experts also identified and agreed on several items relating to the definition of a PMIE, the factors driving the occurrence of PMIEs, and the factors increasing risk for the subsequent development of moral injury.

In line with the second aim, a cross-sectional study of the risk factors and cognitive mechanisms implicated in the development of moral injury (study two) was conducted. Data was collected from 545 healthcare professionals working in secure mental health settings. In the first instance, the results indicated high rates of exposure to moral transgressions and betrayals, and such events were experienced as impactful by participants. Furthermore, findings supported a developmental-cognitive pathway underlying moral injury. Specifically, a partially mediating serial effect of childhood trauma symptoms, early maladaptive schemas, and maladaptive metacognitions in the pathway between moral injury exposure and distress was found.

Finally, the contributions of moral injury to secondary psychological, somatic, physiological and functional sequalae, and the cognitive-emotional mechanisms linking these facets (study three) was explored. Analyses of data collected from 385 healthcare professionals working in secure mental healthcare organisations indicated moral injury symptoms to be a positive predictor of psychological distress, somatic symptoms, nightmare-related difficulties, and impairments in personality functioning, and contributed to the regression models beyond the effects of burnout. Additionally, findings indicated a mediating role for negative emotional schema in the pathways between moral injury and these adverse well-being outcomes.

This programme of research indicates that secure mental healthcare settings provide many of the conditions for moral injury to occur at an organisational, relational, and individual level. Additionally, the findings support the conceptualisation of moral injury through an intergrated framework that considers developmental, cognitive, emotional and social processes. From the findings, a theoretical model that attempts to explain how moral injury occurs and leads to subsequent adverse well-being outcomes in secure mental healthcare staff is proposed.