Defining and identifying potentially morally injurious experiences for secure mental healthcare workers: a Delphi study

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, though insight into the specific sources and driving factors at the root of this syndrome is limited. The purpose of this study was to identify potentially morally injurious events and associated risk factors for secure mental healthcare staff. Design/methodology/approach To address this gap, a three-round expert Delphi survey was conducted to gain consensus on the conceptualisation, types and drivers of potentially morally injurious experiences (PMIEs) for secure mental health-care workers. Health-care professionals and academics in the field were recruited. Findings A high level of consensus (= 80%) was achieved on 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 development of moral injury. Practical implications The findings suggest that current definitions of PMIEs may, in isolation, be too narrow, prompting the need to attend to the broad range of PMIEs experienced by secure mental health-care staff. In addition, recommendations for the primary and secondary prevention of moral injury in secure mental health-care staff are offered, recognising the particular 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.