This follow-up qualitative study identified an internal domain of experience that shaped how NHS healthcare workers processed potentially morally injurious events. Participants described a pervasive sense of limited control over their work and working environment. That perceived lack of agency was experienced against a backdrop of a generally rigid system, which exacerbated distress around morally challenging decisions and constrained responses to ethically troubling situations.
Psychosocial dynamics formed a second subtheme in the internal domain. Interviewees reported interactions with colleagues, expectations from patients, and interpersonal climates that affected their moral and emotional responses. Low psychological safety and perceptions that the value of their work was misunderstood by patients and colleagues contributed to ongoing strain and complicated processing of PMIEs.
These subjective, intrapersonal experiences were not static; participants described how their feelings and interpretations evolved over the three-year interval between interviews. The study documents continuity and change in internal reactions to earlier events, highlighting the long-term nature of moral distress when organisational context remains unchanged.
Participants located much of the moral cost of their experiences in organisational and systemic culture. An organisational culture perceived as unsupportive or dismissive amplified the impact of PMIEs and hindered recovery. Specific cultural features cited included poor acknowledgement or recognition of staff contributions and a lack of visible organisational responsibility for mistakes made during acute periods.
Sources of moral injury identified by staff were often external to individual clinical encounters and included system-level failures, perceived policy shortcomings, and broader societal or governmental responses. Notably, many participants described the emergence of a secondary sense of betrayal since their original 2021 interviews. This secondary betrayal centered on a perception of ongoing governmental neglect: insufficient recognition of healthcare sacrifices during the pandemic and a lack of apology or acknowledgement for governmental errors in the acute response.
Such external attributions underscore how organisational and political contexts intersect with personal moral appraisals and sustain injury beyond the initial morally injurious events themselves.
The study differentiated participant responses into maladaptive and adaptive categories. Maladaptive responses included prolonged distress, erosion of trust in institutions, and lingering negative emotions tied to both the original PMIEs and to perceived subsequent betrayals. These responses risk ongoing harm to staff well-being and retention if left unaddressed.
Adaptive responses were also observed, although the source article does not enumerate specific strategies in detail. The thematic structure implies that some participants engaged in meaning-making or coping processes that mitigated harm. The authors emphasise the interplay of individual coping and organisational support: adaptive outcomes are more likely where systems provide psychological safety, recognition, and avenues to address wrongdoing or systemic failure.
Fifteen NHS staff who had been interviewed previously in 2021 participated in semistructured follow-up interviews. All interviews were recorded and transcribed. The research team applied reflexive thematic analysis using an inductive approach to identify patterns in participants’ accounts. Analysis yielded three overarching themes and six subthemes reflecting internal and external contexts and response patterns.
The paper reports qualitative, in-depth exploration of longitudinal changes in HCWs’ experiences of PMIEs rather than quantitative prevalence estimates.
Findings indicate that addressing moral injury among NHS staff requires interventions beyond individual-level supports. The interplay between personal experiences and organisational culture suggests that multi-level strategies are necessary, including measures to increase psychological safety, acknowledge and recognise staff sacrifices, and formally address systemic failures when they occur.
The emergence of secondary betrayal linked to perceived governmental neglect highlights a need for actions that restore trust in institutions. This may include transparent acknowledgement of mistakes and meaningful recognition of staff contributions, although the source article does not prescribe specific programmes or policies.
The study’s longitudinal, qualitative design offers insight into how experiences of PMIEs and moral injury can evolve over multiple years. Using reflexive thematic analysis allowed researchers to inductively generate themes grounded in participant accounts.
Limitations inherent to the reported work include the small sample (15 participants) and the qualitative focus, which limits generalisability; the source article does not provide further demographic details or procedural specifics in this brief summary. The authors conclude that moral injury among NHS workers reflects an interplay of individual and organisational factors and that wide-ranging interventions are needed to restore trust and support staff recovery.
Overall, the follow-up interviews document persistent moral harm, the development of secondary feelings of betrayal, and the ongoing influence of organisational and governmental contexts on healthcare workers’ moral and psychological wellbeing.