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

道德伤害（MI）是一种心理困扰的形式，通常出现在参与或目睹违背个人道德或伦理价值观的事件之后。这可能会导致情绪麻木、逃避和士气低落。虽然之前的许多研究都是在军事背景下进行的，最近在医院环境中进行的，但救护车服务人员由于其工作性质而处于心肌梗死的高风险中。救护人员在高强度的情况下做出道德决定，这是他们职责的一部分，使他们容易受到心理困扰。通过与西北救护车服务（NWAS）的合作，本研究将发展MI的现有理论框架。半结构化访谈和日常日记的结合将用于收集定性数据，以确定MI随着时间的推移在心理和行为上是如何表现的，以及影响MI经历的因素。关键决策方法将用于设计访谈。这种方法使人们能够深入了解在高强度工作环境中使用的目标和决策方法，这些方法以前曾用于研究应急服务。数据将使用模板和专题分析进行分析，以便识别和组织数据中的共同主题。访谈结束后将进行为期4周的每日日记研究。这项研究将重点关注那些暴露于潜在道德伤害事件的最高水平的参与者。参与者将被要求在每次轮班后完成日记，在那里他们将回答与当天工作经历相关的MI问题。数据将使用专题轨迹分析（TTA）进行分析，这是模板分析的扩展形式。这种方法对于日记数据是最理想的，日记数据通常由流动和可变的定性数据组成。在这项研究之后，将进行第二阶段的访谈，以进一步了解日记的结果。因此，这些访谈的方向将由他们日记的内容决定，也将使用TTA进行分析。结果将提供关于哪些事件可能导致MI以及哪些人员处于高风险中的见解。这些方法的结合将提供对过去事件的回顾性反思以及对最近事件的实时反应所涉及的心理过程的数据。日记数据将能够告知员工如何随着时间的推移应对道德上的痛苦事件，以及这些应对策略或心理过程是否会导致有益或有害的结果。这样的数据应该导致在救护车服务人员中MI理论框架的发展，使用关于MI获取和进展的丰富而有意义的数据。此外，该项目将为处于风险中的组织提供实用的建议，这些建议可以包括在培训或支持计划中。这可能包括结构化的汇报，以促进痛苦事件后的情感安慰和确认，并防止心肌梗死的进展。

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.