Moral Injury: Understanding the causes, processes, and consequences in the UK Ambulance Service

Moral Injury (MI) is a form of psychological distress that usually presents after being involved in or witnessing events that contradict a person's moral or ethical values. This can lead to experiences such as emotional numbing, avoidance, and demoralisation. While much of the previous research has been undertaken within a military context, and more recently within hospital environments, Ambulance Service employees are at high risk of MI due to the nature of their work. Ambulance staff make ethical decisions in high-intensity situations as part of their role, making them vulnerable to psychological distress.
Through a partnership with the North West Ambulance Service (NWAS), this research will develop the existing theoretical framework of MI. A combination of semi-structured interviews and daily diaries will be used to gather qualitative data to identify how MI manifests both psychologically and behaviourally over time and what influences the experiences of MI.
The Critical Decision Method will be used to design the interviews. This methodology allows for insight as to the goals and decision methods which are used in high-intensity work environments and has previously been used to research the Emergency Services. Data will be analysed using template and thematic analysis, allowing for identification and organisation of common themes within the data.
A 4-week daily diary study will be conducted after the interviews. This study will focus on participants who present with the highest level of exposure to potentially morally injurious events. Participants will be asked to complete the diary after each shift, where they will answer questions in relation to MI connected to their work experiences that day. Data will be analysed using thematic trajectory analysis (TTA), which is an extended form of template analysis. This methodology is optimal for diary data which often consists of fluid and variable qualitative data. Following on from this study, a second stage of interviews will be conducted to further understand the results of the diaries. As such, the direction of these interviews will be informed by the content of their diary and will also be analysed using TTA.
The results will provide insight as to what events are likely to lead to MI and which personnel are at high risk. The combination of methods will provide data on both retrospective reflections on past events, and the psychological processes involved in real time reactions to recent events. The diary data will be able to inform on how personnel cope with experiencing a morally distressing event over time, and whether these coping strategies or psychological processes lead to beneficial or harmful outcomes.
Such data should lead to the development of a theoretical framework of MI within ambulance service personnel, using the rich and meaningful data on the acquirement and progression of MI. Further, this project will provide practical recommendations for at-risk organisations which can be included in training or support initiatives. This may include structured debriefs to promote emotional reassurance and validation after distressing events, and prevent the progression of MI.