Developing a Biopsychosocial-Spiritual Framework to Prevent Moral Suffering (Moral Injury) in Trauma-Exposed First Responder Communities

Research output: ThesisDoctoral Thesis

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In Australia there are over 140,000 full-time first responders (police, fire, ambulance, emergency, and intensive care medical staff) who are reported to have increased rates of psychological distress. Currently, there is narrow focus on the traumatic content of first responder work as the cause of increased distress. Current interventions strategies are built on a biopsychosocial framework that largely provides secondary and tertiary prevention strategies for individual workers and include resilience training, mindfulness, and therapeutic regimes. The strategies used largely overlook the moral, religious, and spiritual elements of distress. However, research is increasingly reporting that distress can arise in high-risk occupations from non-traumatic, moral, and organisational stressors that include moral dissonance, organisational injustice, perceptions of betrayal, and unsupportive leadership.
Utilising abductive reasoning, this thesis offers a reconsideration of the cause and prevention of distress through the lens of moral suffering to develop a biopsychosocial-spiritual (BPSS) framework. Current moral models of distress such as moral injury, moral distress, and perceived injustice are aggregated into a larger anthropological model called moral suffering. The BPSS framework addresses the omission of religious and spiritual elements of moral suffering to produce holistic organisational and leadership interventions as primary prevention strategies.
Mixed methods research utilised Bayesian Network (BN) analysis to report on surveys from first responders (n = 229). Two narrative oriented inquiries (NOI) of 21 auto/biographies (n = 24) and interviews of some of those authors (n = 16) were conducted. A practical theological reflection (PTR) was then utilised to develop the BPSS framework and practical interventions.
The BN analysis reported that all three moral models of suffering are relevant constructs across all first responder occupations. Moral injury was significantly higher than in combat veterans and moral distress at comparable levels to nursing groups, while levels of the blame factor of perceived injustice were comparable with those suffering musculoskeletal injuries. Police consistently reported the highest levels of distress. The NOI reported six major themes contributed to moral suffering. Two of those stressors (death and injustice) arose from the content of the work, while the other four (poor leadership, organisational injustice, lack of resources, and inappropriate recognition) are contextual workplace stressors. These contextual stressors align closely with psychosocial hazard categories in emerging regulations and standards.
To comply with psychosocial safety regulations several changes to organisational culture and leadership practices are recommended. Recommendations are made to four tiers of first responder organisations. At an organisational level, implementation of just culture algorithms is recommended to prioritise organisational learning and restoration of staff across all sectors of the business. Multiple discipline wellbeing teams (MDWTs) are encouraged to develop programs that are based on a collaborative approach to provide holistic and person-centred prevention programs to address moral suffering from organisational stressors. Leaders are encouraged to forge a “shepherd” identity through the application of nine key behaviours. Finally, workers themselves are encouraged to develop a “guardian” identity and exercise their moral imagination to make their moral expectations explicit and develop strategies to prevent moral disengagement.
Original languageEnglish
QualificationDoctor of Philosophy
Awarding Institution
  • Charles Sturt University
  • Cameron, Andrew, Principal Supervisor
  • Shaw, Rhonda, Principal Supervisor
  • de Almeida Neto, Abilio, Co-Supervisor, External person
Place of PublicationAustralia
Publication statusPublished - 2023


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