AimsMoral injury (MI) refers to psychological distress resulting from witnessing or participating in events which violate an individual's moral code. Originating from military experiences, the phenomenon also has relevance for healthcare professionals dealing with wars, natural disasters and infectious diseases. The deontological basis of medicine prioritises duty to the individual patient over duty to wider society. These values may place healthcare professionals at increased risk of moral injury, particularly in crisis contexts where they may be party to decisions to withdraw or divert care based on resource availability.We conducted a systematic review of medical literature to understand the extent and clinical and socio-demographic correlates of moral injury during the COVID-19 pandemic.MethodWe conducted a systematic review of reports included in MEDLINE, PsycINFO, BNI, CINAHL, EMBASE, EMCARE and HMIC databases using search terms: “moral injury” AND “covid” OR “coronavirus” OR “pandemic”. We also searched Google Scholar and Ovid Database and conducted reference searching. We searched for published quantitative primary research as well as advance online publications and pre-print research. Findings are reported in line with Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA). Two authors independently assessed the included studies’ methodological quality using a seven-item checklist.ResultOur databases search identified 498 records and other sources identified 4 records. We screened 391 records after removing duplicates. 4 reports met our protocol requirements.Three papers used cross-sectional designs. One reported longitudinal outcomes of their sample already described in one of the three papers. Only one study used a MI scoring system validated for healthcare professionals. Others used scoring validated in military populations. These papers reported outcomes from 3334 subjects, with a higher proportion of females. The largest study (3006 subjects) reported MI in 41.3% of their sample. Overall, factors associated with greater MI included: providing direct care to COVID-19 patients; sleep troubles; being unmarried; aged <30 years; female gender; and Buddhist/Taoist faith. Nurses reported a greater severity of MI than physicians. MI significantly correlated with anxiety, depression and burnout. The longitudinal study reported that more stressful and less supportive work environments predicted greater MI at 3 months follow-up.The average quality assessment score of these studies was 4/7.ConclusionIt is important that we are able to address moral injury awareness training as part of workforce preparedness and burnout prevention during the COVID-19 pandemic and other disaster responses across the globe.

AimsTo ensure that patients who are high intensity users of acute mental health services (136 suite, Liaison, and inpatient admissions) have a ‘safety plan’ in place .This should contain person centred and specific recommendations to avert crisis and guide acute clinicians in managing care in a crisis situation.MethodsAudit of electronic health care records of top 10 patients who most frequent attend each of s136 suite, LPS and inpatient wards (26 in total) in the period 05/2021 to 04/2022.Process mappingDriver diagramCoproduction via patient engagement teamFocus group-across care groups and lived experienceResults-Audit of 26 identified HIU – whilst most (>80%) had a ‘safety plan’ in place, these lacked sufficient detail to avert ‘crisis’ and guide appropriate treatment should the situation escalate. The most frequent diagnosis was EUPD (77%). Most (93%) were open to CPA pathway. •Process mapping – visual representation of crisis planning process within CPA process.•Driver Diagram – primary and secondary drivers leading to change ideas of: additional ‘HIU response plan’ template; best practice example to guide care coordinators; process of flagging up HIU to community mental health services.•Focus group – themes included the importance of : joint working across care groups’ transparency with patients regarding professional opinion; consistency of interventions during a ‘crisis’; and coproduction of safety plans.•HIU response plans are incorporated into the safety plans of 20/26 HIUs.•PDSA process ongoing – quality assurance and clinical effectiveness of changes to be reviewed. Further change ideas sought through QI process.ConclusionHigh intensity users who often present in ‘crisis’ to acute mental health services, have unmet needs.This cohort require an additional framework to meet their needs.When patients experience a mental health ‘crisis’, a consistent and clear treatment response is experienced as helpful.Safety/crisis planning is thus an important aspect of meeting needs.HIU response plans’ can be incorporated into a patients ‘safety plan’ to ensure that individualised and specific guidance is available.Best practice example of ‘HIU response plans’ can empower community mental health colleagues to co-produce such plans.

AimsUK medical students report high levels of stress, in particular within the coronavirus pandemic: 46% have a probable psychiatric disorder; almost 15% consider suicide; 80% describe support as poor or moderately adequate. Our aim was to propose a novel conceptual framework for the implementation of effective interventions to reduce their stress and support wellbeing.MethodA systematic review of MEDLINE, PsycINFO and CINAHL databases was undertaken with appropriate search terms, supplemented by reference searching. Published quantitative and qualitative primary research was included. Findings were reported in line with Preferred Reporting Items for Systematic Reviews and MetaAnalyses.ResultRecords identified through database searching 2,347; additional records 139; records following removal of duplicates 1,324. Full text studies included 41: ‘Curriculum and Grading’ (n = 4); ‘Mindfulness and Yoga’ (n = 11); ‘Stress Management/Relaxation’ (n = 13); ‘Behavioural Interventions’ (n = 3); ‘Cognitive & Self-awareness Interventions’ (n = 2); Mentorship (n = 3); ‘Education, Screening and Access to care’ (n = 3); ‘Multifaceted Interventions’ (n = 2).Effective interventions include those that reduce academic stress through grading changes and supporting transition to clinical training; resilience enhancing interventions such as mindfulness, yoga, CBT, group based exercise and relaxation; peer mentorship; faculty mentorship when actively engaged by the mentor; reducing stigma; improving detection; and improving access to treatment.Outcomes for clinical year students were less promising, suggesting interventions may be insufficient to combat clinical stressors.ConclusionWe propose a framework for implementing these effective interventions through ‘Ecological and Preventative’ paradigms. The former highlights an individual's interaction with their sociocultural environment, recognising multiple levels of influence on health: individual, interpersonal, institutional, community, and national. At each level the framework of primary, secondary and tertiary prevention can be applied.Primary Prevention (intervening before health is impacted): reducing academic stress; resilience interventions; mentorship; peer support; brief interventions to avoid progress to established disorders.Secondary Prevention (reducing prevalence of disorder): early detection through staff training and screening; treatment referral pathways; reciprocal arrangements if peers are placed within local settings.Tertiary Prevention (reducing impairment): reasonable adjustments, communicated between placementsThis recognises that medical students require a range of interventions at multiple levels to reduce stress, promote wellbeing and manage the spectrum of mental health difficulties they may encounter. The ecological framework also acknowledges the reciprocity of individuals being influenced by and influencing their environment, which aligns with the concept of co-production.