Psychiatric Services

Australasian Psychiatry

Moral injury and psychiatrists in 2022, Vol. 30(3) 326–329

© The Royal Australian and
New Zealand College of Psychiatrists 2022

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DOI: 10.1177/10398562211062464
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Paul A Maguire and Jeffrey CL Looi Academic Unit of Psychiatry and Addiction Medicine, Canberra Hospital, The
Australian National University Medical School, Canberra, ACT, Australia; Consortium of Australian-Academic Psychiatrists for
Independent Policy and Research Analysis (CAPIPRA), Canberra, ACT, Australia

Abstract
Objectives: This study aims to provide a clinical update on moral injury from the perspective of a public sector
community psychiatrist, and to outline approaches to addressing the issues raised.
Conclusions: Although not considered a mental illness, moral injury is an important condition for psychiatrists to
have an awareness of, as it is associated with psychological distress and/or impairments in emotional, social or be-
havioural functioning. Potentially morally injurious events (PMIEs) for community psychiatrists may include staff
shortages and deficient resources rendering it difficult to provide an acceptable standard of professional care; time
constraints negatively impacting teaching, supervising and mentoring medical students; cost-prohibition regarding
preferred medication choices; lack of gender and cultural diversity of available psychiatrists; and work environments
not conducive to psychiatrists speaking out about their concerns. The COVID-19 pandemic has exposed and exac-
erbated PMIEs for some community psychiatrists. Whether or not a PMIE transitions to a moral injury may be
influenced by the individual’s resilience and the quality of emotional, psychological and administrative support they
receive before, during and after the potentially precipitating event. Preventative strategies to mitigate susceptibility to
a moral injury may be implemented at both a systems level and individual level, and include collective healthcare
advocacy action.

Keywords: moral injury, moral distress, potentially morally injurious event

he term ‘moral injury’ remains relatively unfamiliar development of shame, guilt and lack of self-forgiveness.5

T to many within the medical profession.1 Moral

injury is an occupational health hazard and may be
particularly germane for psychiatrists due to the nature of
our work, especially regarding the challenges in the public
sector.2 We focus here on the moral injury challenges for
public sector community psychiatrists and how they
might be addressed and prevented.
Definition
Moral injury comprises two core components: (1) expo-
sure to a potentially morally injurious event (PMIE) such
as observing, causing or failing to prevent adverse out-
comes which transgress core moral and ethical values and
beliefs3 and (2) development of psychological distress
and/or negative effects on emotional, social or behav-
ioural functioning.4 Some definitions view moral injury as
arising solely from shortcomings within the system in
which the person works, whereas broader definitions
accept that moral injury may relate to an individual’s
perceived own breach of responsibility, with subsequent
Whether or not a PMIE results in a moral injury may be
influenced by the person’s resilience and how well they
are supported emotionally, psychologically and admin-
istratively before, during and after the precipitating
event.6 Moral injury can co-occur with, and exacerbate,
PTSD and depression, with PMIEs accounting for 9.4%
and 5.2% of the variance in these disorders, respectively.4
A related term is ‘moral distress’, which denotes a sense
of psychological unease which arises when an individual
is unable to carry out what they view as the correct
ethical action, due to constraints within their work
environment.1
Corresponding author:
Paul A Maguire, Academic Unit of Psychiatry and Addiction
Medicine, The Australian National University Medical School,
Building 4, Level 2, Canberra Hospital, PO Box 11, Woden, ACT
2605, Australia.
Email: Paul.Maguire@act.gov.au

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Maguire and Looi
Moral injury to medical practitioners
Causes of moral distress and associated PMIEs, which
predispose to the development of moral injury, vary
across professions. However, there exist several factors
which are specific for medical practitioners, including
psychiatrists. These include inadequate, deficient or ab-
sent resources (including staffing shortages) necessary to
provide an acceptable standard of professional care (often
related to inadequate funding); disparity between a doc-
tor’s own ethical standards and those practised in the
work environment; observing poor standards of care;
a sense of having colluded in, or abetted, ethically or
professionally wrong decisions; and absence of appro-
priate professional structures needed to make optimal
decisions for best patient outcomes.1
Moral injury and PMIEs to community psychiatrists in
the public sector
The community psychiatrist working in the public mental
health system may face almost daily PMIEs. Many of these
relate to scant resources in the face of ever-burgeoning
demands placed upon the clinician, from both within and
without the service.2 However, other PMIEs are related to
the model of care, rigid operational protocols, workplace
culture, and organisational attitudinal factors.
Recruitment and retention challenges. Ongoing chal-
lenges with recruitment and retention in Australia and
abroad mean that at any one time, there are likely to be
shortages in the optimal number of psychiatrists sup-
porting a community mental health team (https://www.
ranzcp.org/news-policy/news/psychiatry-workforce-
shortage-top-priority). This may have several unfavourable
consequences and associated PMIEs. The waiting time for
public health patients to access their psychiatrist may
exceed what is viewed by most (including patients and
their families or carers) as reasonable. This may result in
an unnecessary exacerbation of their mental illness and
associated risks, distress, and possible preventable hos-
pital admission. Time constraints arising from staff
shortages may act as catalysts for a moral injury due to the
psychiatrist’s experience of frustration and guilt associ-
ated with a compromised ability to properly assess, reflect
on, and manage patients with a severe mental illness and
comorbidities (medical and/or drug and alcohol). Sub-
optimal recruitment and retention of clinical staff is not
limited to mental health services. A recent survey of doctors
from all disciplines revealed that the most commonly
identified contributor to moral distress is insufficient staff
to adequately treat all patients.1
Supervision, teaching and mentoring. The community
mental health service may host medical students on their
clinical rotations. The psychiatrist may be assigned to
deliver supervision and teaching, which further impacts
limited working time. When a psychiatrist wishes to
provide more in-depth teaching, and mentoring, for an
enthusiastic student (who may have expressed interest in
pursuing a career in psychiatry) but is unable to deliver
due to time constraints, a sense of guilt, frustration and
missed opportunity may lead to moral injury.
Inequities in subsidised medication and cost-prohibition. A
PMIE often encountered in community psychiatry re-
lates to medication cost-containment by pharmaceutical
services. If a patient has a diagnosis of bipolar 1 affective
disorder and is currently suffering from a major de-
pressive episode (MDE) with psychotic features, they are
eligible to receive a subsidised Authority script for an
evidence-based second-generation antipsychotic medi-
cation. However, if this patient were, instead, suffering
from an MDE within a diagnosis of major depressive
disorder, they are not eligible to receive such a pre-
scription (https://www.pbs.gov.au/pbs/home). This in-
equity, which could render a trial of evidence-based
preferred medication being cost-prohibitive to the pa-
tient, may result in a PMIE for the psychiatrist.
Lack of allied health support services within community
mental health services may present another PMIE. People
with schizophrenia are more likely to be overweight or
obese compared with their counterparts in the general
population.7 Prescription of antipsychotic medication
causing increased hunger and reduced satiety is a key
iatrogenic contributor to the problem. Access to a di-
etician or personal trainer may help reduce the risk of
future cardiometabolic complications, but is often lack-
ing, either within the community public mental health
service, or privately for patients due to financial disad-
vantage and social impoverishment.
Racial and gender diversity among psychiatric staff. Moral
distress and potential for a moral injury may be associ-
ated with lack of diversity among available psychiatric
staff, again due to funding-related shortages. When
a patient, particularly one who has been a victim of
sexual abuse by a male perpetrator, strongly requests
a female psychiatrist, it can be morally distressing for
a psychiatrist to be working in a system which is unable
to honour this preference. Similarly, a lack of cultural
diversity within a community mental health team may
be a PMIE. For instance, an Aboriginal patient from the
stolen generation or a patient from an ethnic minority
with significant cultural sensitivities related to their
presentation may request a culturally aligned psychia-
trist, who may not be able to be provided.
Lack of administrative support. Organisational admin-
istrative attitudinal factors may be associated with moral
distress and risk of moral injury. A workplace culture
which does not encourage, or even permit, staff members
‘speaking up’ about important but potentially conten-
tious issues has been identified as a contributor to moral
distress among medical practitioners.1 Psychiatrists who
seek to advocate for improved healthcare and safety may
experience workplace bullying and harassment as an or-
ganisational response, leading to moral and likely psy-
chological injury.8
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 Australasian Psychiatry 30(3)

Table 1. Preventative strategies against the development of a moral injury

Systems Level Concern relating to moral distress
• Provision of adequate funding and staffing • Unacceptable waiting times leading to preventable relapse or
exacerbation of illness
• Allow adequate time for clinical, administrative and • Inability to provide quality care to patients, leading to frustration
teaching duties and guilt in clinicians. Inability to carry out quality teaching and
supervision of medical students
• Foster a diverse and tolerant workplace culture which • Lack of ability to provide culturally aligned clinicians or choice of
encourages clinicians to express, and enact, their values clinician gender when appropriate. Transgression of core values
and beliefs in day-to-day work
• Educative programs to increase awareness of moral injury • In the absence of awareness, clinicians may be less able to seek
and effect change, and to protect themselves from a moral injury
Individual Level
• Discuss PMIEs and moral distress at peer review meetings • Lack of psychological support, and a sense of professional
• Seek psychological support if required when exposed to isolation or not being heard, is likely to exacerbate the distress and
PMIE reduced function associated with a moral injury
• Advocate for flexible and supportive interface with
administrators
• Develop a self-care plan1

Effect of COVID-19 on moral injury
The COVID-19 pandemic has exposed and sometimes
exacerbated existing PMIEs for community psychia-
trists, as well as engendering some unique PMIEs re-
lated to the pandemic itself. The issue of staff shortages
has been aggravated by some medical and allied health
staff needing to self-isolate and quarantine. Some
teams have been reduced to a small core of residual
clinicians in this context with heightened risk of moral
distress due to increase workloads. In addition, staff
have had to deal with increased COVID-19 related
anxiety and sometimes despair, among their patient
base, placing further pressure on the system in terms of
extra time and resources to manage this. Some staff
members, including psychiatrists, have lost close rel-
atives to COVID-19, resulting in need for time off to
grieve and make funeral arrangements. Lockdown
protocols have (necessarily) caused delays associated
with COVID-19 screening procedures and resulted in
a need for telehealth, making psychiatric assessment
more challenging.9
PMIEs may arise from awareness of disruptions to crucial
mental health care services during the COVID-19 out-
break. A survey among 130 countries found significant
disruptions to mental health provision for vulnerable
people including children and adolescents, older persons,
and antenatal and post-natal services, as well as reduced
psychotherapy provision generally (https://www.who.
int/news/item/05-10-2020-covid-19-disrupting-mental-
health-services-in-most-countries-who-survey). PMIEs may
also relate to disproportionate levels of stigmatisa-
tion, poverty, unhealthy lifestyle factors, residential
instability and social isolation, among people with
severe mental illness, which may worsen their vul-
nerability during the COVID-19 pandemic (https://
jamanetwork.com/journals/jamapsychiatry/fullarticle/
2767721).
Managing and preventing moral injury for
community psychiatrists
Effective action on preventing exposure to PMIEs requires
healthcare advocacy by psychiatrists and trainees to ad-
dress systemic and individual issues outlined in Table 1.
Healthcare advocacy is best approached by psychiatrists
and trainees through collective action, in partnership
with medico-political organisations such as Unions and
the AMA.10 Steps to effective advocacy have been de-
scribed previously by Looi et al.10 Doctors advocating
individually may be subject to bullying and harassment,
particularly when they raise concerns about which an
organisation and its administrators are sensitive to dis-
sent, as well as public exposure.8 Perhaps the RANZCP
could consider including a position statement on moral
injury with the aim of improving awareness, manage-
ment and prevention, providing definitions and strategies
outlined in Table 1, as well as key references from the
literature, including the systematic review and meta-
analysis by Barnes et al.5
As moral injury may cause significant psychological dis-
tress, psychiatrists and trainees should seek support from
their peer review group, and consult their GP to seek
mental healthcare as needed, including accessing specific

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Maguire and Looi
services such as Drs4Drs (https://www.drs4drs.com.au/)
and The Essential Network for healthcare workers for the
COVID-19 pandemic (https://www.blackdoginstitute.org.
au/the-essential-network/).
Future research is required to better characterise moral
injury, including exploring cultural dimensions, and to
assess the efficacy of measures to improve awareness and
management and support of those suffering from it.
Conclusion
Although not a mental illness, moral injury is associated
with significant psychological distress and reduced
level of functioning, especially in public sector com-
munity psychiatry. Moral injury needs to be recognised,
managed appropriately and preferably prevented by
healthcare advocacy at both at a systems level and in-
dividual level.
Disclosure
The authors report no conflict of interest. The authors alone are responsible for the content and
writing of the paper.
Funding
The authors received no financial support for the research, authorship, and/or publication of
this article.
ORCID iDs
Paul A Maguire  https://orcid.org/0000-0001-5002-9918
Jeffrey CL Looi  https://orcid.org/0000-0003-3351-6911
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