Defining and identifying potentially morally injurious experiences for secure mental healthcare workers: a Delphi study
| Date | 26 December 2024 |
| Pages | 64-80 |
| DOI | https://doi.org/10.1108/JCRPP-03-2024-0021 |
| Published date | 26 December 2024 |
| Author | Elanor Lucy Webb,Jane L. Ireland,Michael Lewis |
Defining and identifying potentially morally
injurious experiences for secure mental
healthcare workers: a Delphi study
Elanor Lucy Webb, Jane L. Ireland and Michael Lewis
Abstract
Purpose –Staff in secure mental health-care settings face unique occupational challenges that may
conflict with their personal or professional moral code. Initial research has established the presence of
moral injury in this population, thoughinsight into the specific sources and driving factors at the root of
this syndrome is limited.The purpose of this study was to identify potentiallymorally injurious events and
associatedrisk factors for secure mental healthcarestaff.
Design/methodology/approach –To address this gap, a three-round expert Delphi survey was
conducted to gain consensuson the conceptualisation, types and driversof potentially morally injurious
experiences(PMIEs) for secure mental health-careworkers. Health-care professionals andacademics in
the field wererecruited.
Findings –A high level of consensus (¼80%) was achievedon several sources of moral injury, which
related to aspects of the health-care system, the secure context, relational dynamics and individual
practices, behaviours and attitudes. Experts also 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
developmentof moral injury.
Practical implications –The findings suggest thatcurrent definitions of PMIEs may, in isolation, be too
narrow, promptingthe need to attend to the broad range of PMIEs experiencedby secure mental health-
care staff. In addition, recommendations for the primary and secondary prevention of moral injury in
secure mental health-carestaff are offered, recognising theparticular need for intervention at a systemic
level.
Originality/value –To the best of the authors’ knowledge,this study is the first to consider the range of
sources of moral injury faced by staff providing for people with complex forensic and mental health
needs.
Keywords Moral injury, Mental healthcare, Staff well-being, PMIEs, Secure care, Delphi
Paper type Research paper
Introduction
Secure mental health-care settings afford a range of challenges and stressors for staff
operating within such an environment, who face the risk of direct exposure to several
potentially traumatic experiences. This occupational group is frequently subject to displays
of aggression by patients, with 67–70% of secure mental health-care staff being the victim
of physical violence (Newman et al., 2023a) and up to 99% being subject to verbal assault
(Kelly et al., 2015). Exposure to self-harming behaviours and attempted and completed
suicide by patients are also common experiences for staff (Chammas et al., 2022;Newman
et al., 2023a) and can be experienced as traumatic (Sandford et al., 2020).Furthermore, the
risk for indirect, or “secondary”, trauma is also notably pertinent in secure mental health-
care workers, by nature of caring for people with some of the most pervasive trauma and
criminal offending histories (Newman et al., 2023b). By consequence of their increased risk
Elanor Lucy Webb is based
at Centre for
Developmental and
Complex Trauma,
St Andrew’s Healthcare,
Northampton, UK and
School of Psychology and
Humanities, University of
Central Lancashire,
Preston, UK.
Jane L. Ireland and Michael
Lewis are both based at
School of Psychology and
Humanities, University of
Central Lancashire,
Preston, UK and Ashworth
Research Centre,
Liverpool, UK.
Received 28 March 2024
Revised 5 December 2024
Accepted 5 December 2024
Declaration: The authors
received no financial support
for the research, authorship
and/or publication of this
paper. The authors have no
conflict of interest to declare.
PAGE 64 jJOURNAL OF CRIMINOLOGICAL RESEARCH, POLICY AND PRACTICE jVOL. 11 NO. 1 2025, pp. 64-80, ©EmeraldPublishi ng Limited, ISSN 2056-3841 DOI 10.1108/JCRPP-03-2024-0021
for trauma exposure, presentations of trauma symptomology are also noted to be elevated
in secure mental health-care workers. Examination of the prevalence of post-traumatic
stress disorder (PTSD) in secure mental health-care staff indicates that almost a quarter
(22%) meet diagnostic criterion for a probable diagnosis, which is two times greater than
the prevalence rate seen in staffworking in general mental health services (11%; Rodrigues
et al., 2021) and five times greater than rates reported for the general UK population
(McManus et al., 2016). Thus, the additional “secure” element of health care appears to
bring additional challengesfor staff and their well-being.
In addition to the traumatic experiences faced by staff in secure mental health care,
however, there are also several ethical tensions brought about by working in this context
that may contribute to distress in the workforce. Secure mental health-care workers provide
care to patients who are detained against their will and whose freedoms are restricted,
navigating inherent power imbalances in their relationships with those that they care for.
They also contend with the demand of balancing care and managingrisk, meeting both the
forensic and mental health needs of patients. Such events may not always fit with the
“Criterion A” requirement of PTSD [DSM-5; American Psychiatric Association (APA), 2013],
which recognises traumatic events as those involving “death, threatened death, actual or
threatened serious injury, or actual or threatened sexual violence”. However, the effects of
such experiences may be well accountedfor through a “moral injury” framework.
In accordance with dominant definitions, moral injury defines the distress resulting from
exposure to “potentially morally injurious events” (PMIEs) in which an individual
“perpetrates, fails to prevent, witnesses, or learns about acts that transgress deeply held
moral beliefs” (Litz et al.,2009, p. 700). Initial research by Morris et al. (2022) exploring
PMIE exposure and subsequent distress in secure mental health-care staff has noted
scores that exceed those reported in other health-care sectors (e.g. Lamb et al.,2021)and
parallel those reported in military populations (e.g. Forkus et al.,2019). The impacts of
moral injury are multifaceted, including depression and anxiety (Benatov et al., 2022;Saba
et al., 2022), as well as sleep disorders, social withdrawal, alcohol and substance use and
suicidal ideation (e.g. Boscarino et al.,2022;Hall et al.,2022;Padmanathan et al., 2023).
Moral injury has also been linked to workplace absenteeism and intention to leave the
health-care profession (Rabin et al.,2023;Sert-Ozen and Kalaycioglu, 2023). Thus,
prevention and management strategies that mitigate risk for moral injury in secure mental
health-care staff are warranted, with potential benefits for workforce well-being as well as
the quality and continuity of care provided.
To inform the development of such strategies, an understanding of the events and
experiences underlying and providing the foundations for moral injury is warranted.
Nevertheless, whilst the relevance and prevalence of moral injury in secure mental health-
care staff have been noted (Morris et al., 2022), investigation of the PMIEs and driving
factors at the root of such distress is lacking. Thus far, only one study has considered the
potentially morally injurious effect of practices pertinent to the secure mental health-care
setting, with an association between exposure to violence and moral injury reported in
a sample of secure mental health-care workers (Webb et al., 2023). Nevertheless, the
cross-sectional, correlational design and narrow focus of this study limit the ability to draw
substantive conclusions regarding the range of morally injurious experiences that occur in
this environment.
In recognition of the limited evidence base, an earlier systematic review of the PMIEs faced
by staff in forensic and mental health settings was conducted (Webb et al.,2024). The
review highlighted a broad range of experiences and practices relevant to the secure
mental health setting that may bare the potential to result in moral injury for staff. However,
the literature included in the review was primarily focused on ethical dilemmas and morally
distressing experiences, as opposed to sources of moral injury specifically. In addition,
included studies were conducted in forensic or mental health settings, separately, and thus
VOL. 11 NO. 1 2025 jJOURNALOF CRIMINOLOGICAL RESEARCH, POLICY AND PRACTICE jPAGE 65
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