Moral injury and psychological wellbeing in UK healthcare staff.

BACKGROUND: Potentially morally injurious events (PMIEs) can negatively impact mental health. The COVID-19 pandemic may have placed healthcare staff at risk of moral injury. AIM: To examine the impact of PMIE on healthcare staff wellbeing. METHODS: Twelve thousand nine hundred and sixty-five healthcare staff (clinical and non-clinical) were recruited from 18 NHS-England trusts into a survey of PMIE exposure and wellbeing. RESULTS: PMIEs were significantly associated with adverse mental health symptoms across healthcare staff. Specific work factors were significantly associated with experiences of moral injury, including being redeployed, lack of PPE, and having a colleague die of COVID-19. Nurses who reported symptoms of mental disorders were more likely to report all forms of PMIEs than those without symptoms (AOR 2.7; 95% CI 2.2, 3.3). Doctors who reported symptoms were only more likely to report betrayal events, such as breach of trust by colleagues (AOR 2.7, 95% CI 1.5, 4.9). CONCLUSION: A considerable proportion of NHS healthcare staff in both clinical and non-clinical roles report exposure to PMIEs during the COVID-19 pandemic. Prospective research is needed to identify the direction of causation between moral injury and mental disorder as well as continuing to monitor the longer term outcomes of exposure to PMIEs.

Multicentre, England-wide randomised controlled trial of the 'Foundations' smartphone application in improving mental health and well-being in a healthcare worker population.

BACKGROUND: Healthcare workers (HCWs) have faced considerable pressures during the COVID-19 pandemic. For some, this has resulted in mental health distress and disorder. Although interventions have sought to support HCWs, few have been evaluated. AIMS: We aimed to determine the effectiveness of the 'Foundations' application (app) on general (non-psychotic) psychiatric morbidity. METHOD: We conducted a multicentre randomised controlled trial of HCWs at 16 NHS trusts (trial registration number: EudraCT: 2021-001279-18). Participants were randomly assigned to the app or wait-list control group. Measures were assessed at baseline, after 4 and 8 weeks. The primary outcome was general psychiatric morbidity (using the General Health Questionnaire). Secondary outcomes included: well-being; presenteeism; anxiety; depression and insomnia. The primary analysis used mixed-effects multivariable regression, presented as adjusted mean differences (aMD). RESULTS: Between 22 March and 3 June 2021, 1002 participants were randomised (500:502), and 894 (89.2%) followed-up. The sample was predominately women (754/894, 84.3%), with a mean age of 44⋅3 years (interquartile range (IQR) 34-53). Participants randomised to the app had a reduction in psychiatric morbidity symptoms (aMD = -1.39, 95% CI -2.05 to -0.74), improvement in well-being (aMD = 0⋅54, 95% CI 0⋅20 to 0⋅89) and reduction in insomnia (adjusted odds ratio (aOR) = 0⋅36, 95% CI 0⋅21 to 0⋅60). No other significant findings were found, or adverse events reported. CONCLUSIONS: The app had an effect in reducing psychiatric morbidity symptoms in a sample of HCWs. Given it is scalable with no adverse effects, the app may be used as part of an organisation's tiered staff support package. Further evidence is needed on long-term effectiveness and cost-effectiveness.

'You get looked at like you're failing': A reflexive thematic analysis of experiences of mental health and wellbeing support for NHS staff.

Staff in the National Health Service (NHS) are under considerable strain, exacerbated by the COVID-19 pandemic; whilst NHS Trusts provide a variety of health and wellbeing support services, there has been little research investigating staff perceptions of these services. We interviewed 48 healthcare workers from 18 NHS Trusts in England about their experiences of workplace health and wellbeing support during the pandemic. Reflexive thematic analysis identified that perceived stigma around help-seeking, and staffing shortages due to wider socio-political contexts such as austerity, were barriers to using support services. Visible, caring leadership at all levels (CEO to line managers), peer support, easily accessible services, and clear communication about support offers were enablers. Our evidence suggests Trusts should have active strategies to improve help-seeking, such as manager training and peer support facilitated by building in time for this during working hours, but this will require long-term strategic planning to address workforce shortages.

Prevalence of post-traumatic stress disorder and common mental disorders in health-care workers in England during the COVID-19 pandemic: a two-phase cross-sectional study.

BACKGROUND: Previous studies on the impact of the COVID-19 pandemic on the mental health of health-care workers have relied on self-reported screening measures to estimate the point prevalence of common mental disorders. Screening measures, which are designed to be sensitive, have low positive predictive value and often overestimate prevalence. We aimed to estimate prevalence of common mental disorders and post-traumatic stress disorder (PTSD) among health-care workers in England using diagnostic interviews. METHODS: We did a two-phase, cross-sectional study comprising diagnostic interviews within a larger multisite longitudinal cohort of health-care workers (National Health Service [NHS] CHECK; n=23 462) during the COVID-19 pandemic. In the first phase, health-care workers across 18 NHS England Trusts were recruited. Baseline assessments were done using online surveys between April 24, 2020, and Jan 15, 2021. In the second phase, we selected a proportion of participants who had responded to the surveys and conducted diagnostic interviews to establish the prevalence of mental disorders. The recruitment period for the diagnostic interviews was between March 1, 2021 and Aug 27, 2021. Participants were screened with the 12-item General Health Questionnaire (GHQ-12) and assessed with the Clinical Interview Schedule-Revised (CIS-R) for common mental disorders or were screened with the 6-item Post-Traumatic Stress Disorder Checklist (PCL-6) and assessed with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) for PTSD. FINDINGS: The screening sample contained 23 462 participants: 2079 participants were excluded due to missing values on the GHQ-12 and 11 147 participants due to missing values on the PCL-6. 243 individuals participated in diagnostic interviews for common mental disorders (CIS-R; mean age 42 years [range 21-70]; 185 [76%] women and 58 [24%] men) and 94 individuals participated in diagnostic interviews for PTSD (CAPS-5; mean age 44 years [23-62]; 79 [84%] women and 15 [16%] men). 202 (83%) of 243 individuals in the common mental disorders sample and 83 (88%) of 94 individuals in the PTSD sample were White. GHQ-12 screening caseness for common mental disorders was 52·8% (95% CI 51·7-53·8). Using CIS-R diagnostic interviews, the estimated population prevalence of generalised anxiety disorder was 14·3% (10·4-19·2), population prevalence of depression was 13·7% (10·1-18·3), and combined population prevalence of generalised anxiety disorder and depression was 21·5% (16·9-26·8). PCL-6 screening caseness for PTSD was 25·4% (24·3-26·5). Using CAPS-5 diagnostic interviews, the estimated population prevalence of PTSD was 7·9% (4·0-15·1). INTERPRETATION: The prevalence estimates of common mental disorders and PTSD in health-care workers were considerably lower when assessed using diagnostic interviews compared with screening tools. 21·5% of health-care workers met the threshold for diagnosable mental disorders, and thus might benefit from clinical intervention. FUNDING: UK Medical Research Council; UCL/Wellcome; Rosetrees Trust; NHS England and Improvement; Economic and Social Research Council; National Institute for Health and Care Research (NIHR) Biomedical Research Centre at the Maudsley and King's College London (KCL); NIHR Protection Research Unit in Emergency Preparedness and Response at KCL.

'It hurts your heart': frontline healthcare worker experiences of moral injury during the COVID-19 pandemic.

Background: Moral injury is defined as the strong emotional and cognitive reactions following events which clash with someone's moral code, values or expectations. During the COVID-19 pandemic, increased exposure to Potentially Morally Injurious Events (PMIEs) has placed healthcare workers (HCWs) at risk of moral injury. Yet little is known about the lived experience of cumulative PMIE exposure and how NHS staff respond to this. Objective: We sought to rectify this knowledge gap by qualitatively exploring the lived experiences and perspectives of clinical frontline NHS staff who responded to COVID-19. Methods: We recruited a diverse sample of 30 clinical frontline HCWs from the NHS CHECK study cohort, for single time point qualitative interviews. All participants endorsed at least one item on the 9-item Moral Injury Events Scale (MIES) [Nash et al., 2013. Psychometric evaluation of the moral injury events scale. Military Medicine, 178(6), 646-652] at six month follow up. Interviews followed a semi-structured guide and were analysed using reflexive thematic analysis. Results: HCWs described being routinely exposed to ethical conflicts, created by exacerbations of pre-existing systemic issues including inadequate staffing and resourcing. We found that HCWs experienced a range of mental health symptoms primarily related to perceptions of institutional betrayal as well as feeling unable to fulfil their duty of care towards patients. Conclusion: These results suggest that a multi-facetted organisational strategy is warranted to prepare for PMIE exposure, promote opportunities for resolution of symptoms associated with moral injury and prevent organisational disengagement. HIGHLIGHTS Clinical frontline healthcare workers (HCWs) have been exposed to an accumulation of potentially morally injurious events (PMIEs) throughout the COVID-19 pandemic, including feeling betrayed by both government and NHS leaders as well as feeling unable to provide duty of care to patients.HCWs described the significant adverse impact of this exposure on their mental health, including increased anxiety and depression symptoms and sleep disturbance.Most HCWs interviewed believed that organisational change within the NHS was necessary to prevent excess PMIE exposure and promote resolution of moral distress.

Antecedentes: El daño moral se define como las fuertes reacciones emocionales y cognitivas que siguen a los eventos que chocan con el código moral de una persona, sus valores o expectativas. Durante la pandemia de COVID-19, el aumento de la exposición a Eventos Potencialmente Dañinos para la Moral (PMIEs, por su sigla en inglés) ha puesto a los trabajadores de la salud (HCWs, por su sigla en inglés) en riesgo de daño moral. Aún se conoce poco sobre la experiencia vivida de la exposición acumulada a PMIE y cómo el personal del Servicio Nacional de Salud de Inglaterra (NHS en su sigla en inglés) responde a esto.Objetivo: Buscamos rectificar esta brecha de conocimiento a través de la exploración cualitativa de las experiencias vividas y perspectivas del personal clínico de primera línea de NHS que respondió al COVID-19.Métodos: Reclutamos una muestra diversa de 30 HCWs clínicos de primera línea de la cohorte del estudio CHECK del NHS, para entrevistas cualitativas de una sola vez. Todos los participantes aprobaron al menos un ítem de los 9 de la Escala de Eventos de Daño Moral (MIES) [Nash y cols., 2013. Psychometric evaluation of the moral injury events scale. Military Medicine, 178(6), 646­652] en el seguimiento a los 6 meses. Las entrevistas siguieron una guía semi-estructurada y fueron analizadas utilizando análisis temático reflexivo.Resultados: Los HCWs describieron estar expuestos de forma rutinaria a conflictos éticos, creados por exacerbación de problemas sistémicos pre-existentes que incluían falta de personal y de recursos. Encontramos que los HCWs experimentaron un rango de síntomas de salud mental primariamente relacionados a percepciones de traición institucional y al sentirse incapaces de cumplir con su deber de cuidado hacia los pacientes.Conclusión: Estos resultados sugieren que se requiere una estrategia organizacional multifacética para preparar para la exposición a PMIE fomentar oportunidades de resolución de los síntomas asociados al daño moral y prevenir la separación organizacional.

‘It hurts your heart’: frontline healthcare worker experiences of moral injury during the COVID-19 pandemic ‘Duele tu corazón’: experiencias de daño moral durante la pandemia de COVID-19 en trabajadores de la salud de primera línea ‘它伤了你的心’：在 COVID-19 疫情期间一线医护人员的道德伤害经历

Background: Moral injury is defined as the strong emotional and cognitive reactions following events which clash with someone’s moral code, values or expectations. During the COVID-19 pandemic, increased exposure to Potentially Morally Injurious Events (PMIEs) has placed healthcare workers (HCWs) at risk of moral injury. Yet little is known about the lived experience of cumulative PMIE exposure and how NHS staff respond to this. Objective: We sought to rectify this knowledge gap by qualitatively exploring the lived experiences and perspectives of clinical frontline NHS staff who responded to COVID-19. Methods: We recruited a diverse sample of 30 clinical frontline HCWs from the NHS CHECK study cohort, for single time point qualitative interviews. All participants endorsed at least one item on the 9-item Moral Injury Events Scale (MIES) [Nash et al., 2013. Psychometric evaluation of the moral injury events scale. Military Medicine, 178(6), 646–652] at six month follow up. Interviews followed a semi-structured guide and were analysed using reflexive thematic analysis. Results: HCWs described being routinely exposed to ethical conflicts, created by exacerbations of pre-existing systemic issues including inadequate staffing and resourcing. We found that HCWs experienced a range of mental health symptoms primarily related to perceptions of institutional betrayal as well as feeling unable to fulfil their duty of care towards patients. Conclusion: These results suggest that a multi-facetted organisational strategy is warranted to prepare for PMIE exposure, promote opportunities for resolution of symptoms associated with moral injury and prevent organisational disengagement. HIGHLIGHTS Clinical frontline healthcare workers (HCWs) have been exposed to an accumulation of potentially morally injurious events (PMIEs) throughout the COVID-19 pandemic, including feeling betrayed by both government and NHS leaders as well as feeling unable to provide duty of care to patients. HCWs described the significant adverse impact of this exposure on their mental health, including increased anxiety and depression symptoms and sleep disturbance. Most HCWs interviewed believed that organisational change within the NHS was necessary to prevent excess PMIE exposure and promote resolution of moral distress.

Capturing the experiences of UK healthcare workers during the COVID-19 pandemic: A structural topic modelling analysis of 7,412 free-text survey responses.

BACKGROUND: Healthcare workers (HCWs) have provided vital services during the COVID-19 pandemic, but existing research consists of quantitative surveys (lacking in depth or context) or qualitative interviews (with limited generalisability). Structural Topic Modelling (STM) of large-scale free-text survey data offers a way of capturing the perspectives of a wide range of HCWs in their own words about their experiences of the pandemic. METHODS: In an online survey distributed to all staff at 18 geographically dispersed NHS Trusts, we asked respondents, "Is there anything else you think we should know about your experiences of the COVID-19 pandemic?". We used STM on 7,412 responses to identify topics, and thematic analysis on the resultant topics and text excerpts. RESULTS: We identified 33 topics, grouped into two domains, each containing four themes. Our findings emphasise: the deleterious effect of increased workloads, lack of PPE, inconsistent advice/guidance, and lack of autonomy; differing experiences of home working as negative/positive; and the benefits of supportive leadership and peers in ameliorating challenges. Themes varied by demographics and time: discussion of home working decreasing over time, while discussion of workplace challenges increased. Discussion of mental health was lowest between September-November 2020, between the first and second waves of COVID-19 in the UK. DISCUSSION: Our findings represent the most salient experiences of HCWs through the pandemic. STM enabled statistical examination of how the qualitative themes raised differed according to participant characteristics. This relatively underutilised methodology in healthcare research can provide more nuanced, yet generalisable, evidence than that available via surveys or small interview studies, and should be used in future research.

UK veterans’ mental health and well-being before and during the COVID-19 pandemic: a longitudinal cohort study

ObjectiveTo investigate the impact of the COVID-19 pandemic on the health and well-being of UK ex-service personnel (veterans) before and during the pandemic, and to assess associations of COVID-19 experiences and stressors with mental health, alcohol use and loneliness.DesignAn additional wave of data was collected from a longitudinal cohort study of the UK Armed Forces.SettingOnline survey June–September 2020.ParticipantsCohort members were included if they had completed a questionnaire at phase 3 of the King’s Centre for Military Health Research health and well-being study (2014–2016), had left the Armed Forces after regular service, were living in the UK, had consented to follow-up and provided a valid email address. Invitation emails were sent to N=3547 with a 44% response rate (n=1562).Primary outcome measuresCommon mental health disorders (CMDs) (measured using the General Health Questionnaire, 12 items—cut-off ≥4), hazardous alcohol use (measured using the Alcohol Use Disorder Identification Test, 10 items—cut off ≥8) and loneliness (University of California, Los Angeles, Loneliness Scale— 3 items-cut-off ≥6).ResultsVeterans reported a statistically significant decrease in hazardous drinking of 48.5% to 27.6%, while CMD remained stable (non-statistically significant increase of 24.5% to 26.1%). 27.4% of veterans reported feelings of loneliness. The COVID-19 stressors of reporting difficulties with family/social relationships, boredom and difficulties with health were statistically significantly associated with CMD, hazardous drinking and loneliness, even after adjustment for previous mental health/hazardous alcohol use.ConclusionsOur study suggests a COVID-19 impact on veterans’ mental health, alcohol use and loneliness, particularly for those experiencing difficulties with family relationships. Veterans experienced the pandemic in similar ways to the general population and in some cases may have responded in resilient ways. While stable levels of CMD and reduction in alcohol use are positive, there remains a group of veterans who may need mental health and alcohol treatment services.

Why did some parents not send their children back to school following school closures during the COVID-19 pandemic: a cross-sectional survey.

Background: On 23 March 2020, schools closed to most children in England in response to COVID-19 until September 2020. Schools were kept open to children of key workers and vulnerable children on a voluntary basis. Starting 1 June 2020, children in reception (4-5 years old), year 1 (5-6 years old) and year 6 (10-11 years old) also became eligible to attend school. Methods: 1373 parents or guardians of children eligible to attend school completed a cross-sectional survey between 8 and 11 June 2020. We investigated factors associated with whether children attended school or not. Results: 46% (n=370/803) of children in year groups eligible to attend school and 13% (n=72/570) of children of key workers had attended school in the past 7 days. The most common reasons for sending children to school were that the child's education would benefit, the child wanted to go to school and the parent needed to work. A child was significantly more likely to attend if the parent believed the child had already had COVID-19, they had special educational needs or a person in the household had COVID-19 symptoms. Conclusions: Following any future school closure, helping parents to feel comfortable returning their child to school will require policy makers and school leaders to communicate about the adequacy of their policies to: (A) ensure that the risk to children in school is minimised; (B) ensure that the educational potential within schools is maximised; and (C) ensure that the benefits of school for the psychological well-being of children are prioritised.

Factors affecting healthcare workers' compliance with social and behavioural infection control measures during emerging infectious disease outbreaks: rapid evidence review.

OBJECTIVE: The 2019-2020 outbreak of novel coronavirus has raised concerns about nosocomial transmission. This review's aim was to explore the existing literature on emerging infectious disease outbreaks to identify factors associated with compliance with infection control measures among healthcare staff. METHODS: A rapid evidence review for primary studies relevant to healthcare workers' compliance with infection control measures. RESULTS: Fifty-six papers were reviewed. Staff working in emergency or intensive care settings or with contact with confirmed cases appeared more likely to comply with recommendations. There was some evidence that anxiety and concern about the risk of infection were more associated with compliance, and that monitoring from superiors could improve compliance. Observed non-compliance of colleagues could hinder compliance. Staff identified many barriers to compliance related to personal protective equipment, including availability, perceived difficulty and effectiveness, inconvenience, discomfort and a negative impact on patient care. There were many issues regarding the communication and ease of understanding of infection control guidance. CONCLUSION: We recommend provision of training and education tailored for different occupational roles within the healthcare setting, managerial staff 'leading by example', ensuring adequate resources for infection control and timely provision of practical evidence-based infection control guidelines.

Health-protective behaviour, social media usage and conspiracy belief during the COVID-19 public health emergency.

BACKGROUND: Social media platforms have long been recognised as major disseminators of health misinformation. Many previous studies have found a negative association between health-protective behaviours and belief in the specific form of misinformation popularly known as 'conspiracy theory'. Concerns have arisen regarding the spread of COVID-19 conspiracy theories on social media. METHODS: Three questionnaire surveys of social media use, conspiracy beliefs and health-protective behaviours with regard to COVID-19 among UK residents were carried out online, one using a self-selecting sample (N = 949) and two using stratified random samples from a recruited panel (N = 2250, N = 2254). RESULTS: All three studies found a negative relationship between COVID-19 conspiracy beliefs and COVID-19 health-protective behaviours, and a positive relationship between COVID-19 conspiracy beliefs and use of social media as a source of information about COVID-19. Studies 2 and 3 also found a negative relationship between COVID-19 health-protective behaviours and use of social media as a source of information, and Study 3 found a positive relationship between health-protective behaviours and use of broadcast media as a source of information. CONCLUSIONS: When used as an information source, unregulated social media may present a health risk that is partly but not wholly reducible to their role as disseminators of health-related conspiracy beliefs.

Experiences of supported isolation in returning travellers during the early COVID-19 response: a qualitative interview study.

OBJECTIVES: (1) To understand the experiences and perceptions of those who underwent supported isolation, particularly in relation to factors that were associated with improved compliance and well-being; (2) to inform recommendations for the management of similar supported isolation procedures. DESIGN: We carried out a qualitative study using semistructured interviews to capture participants' experiences and perceptions of supported isolation. Data were analysed using the framework approach, a type of thematic analysis that is commonly used in research that has implications for policy. SETTING: Telephone interviews carried out within approximately 1 month of an individual leaving supported isolation. PARTICIPANTS: 26 people who underwent supported isolation at either Arrowe Park Hospital (n=18) or Kents Hill Park Conference Centre (n=8) after being repatriated from Wuhan in January to February 2020. RESULTS: Six key themes were identified: factors affecting compliance with supported isolation; risk perceptions around catching COVID-19; management of supported isolation; communication with those outside supported isolation; relationship with others in supported isolation; and feelings on leaving supported isolation. Participants were willing to undergo supported isolation because they understood that it would protect themselves and others. Positive treatment by staff was fundamental to participants' willingness to comply with isolation procedures. Despite the high level of compliance, participants expressed some uncertainty about what the process would involve. CONCLUSIONS: As hotel quarantine is introduced across the UK for international arrivals, our findings suggest that those in charge should: communicate effectively before, during and after quarantine, emphasising why quarantine is important and how it will protect others; avoid coercion if possible and focus on supporting and promoting voluntary compliance; facilitate shared social experiences for those in quarantine; and ensure all necessary supplies are provided. Doing so is likely to increase adherence and reduce any negative effects on well-being.

NHS CHECK: protocol for a cohort study investigating the psychosocial impact of the COVID-19 pandemic on healthcare workers.

INTRODUCTION: The COVID-19 pandemic has had profound effects on the working lives of healthcare workers (HCWs), but the extent to which their well-being and mental health have been affected remains unclear. This longitudinal cohort study aims to recruit a cohort of National Health Service (NHS) HCWs, conducting surveys at regular intervals to provide evidence about the prevalence of symptoms of mental disorders, and investigate associated factors such as occupational contexts and support interventions available. METHODS AND ANALYSIS: All staff, students and volunteers working in the 18 participating NHS Trusts in England will be sent emails inviting them to complete a survey at baseline, with email invitations for the follow-up surveys sent 6 months and 12 months later. Opening in late April 2020, the baseline survey collects data on demographics, occupational/organisational factors, experiences of COVID-19, validated measures of symptoms of poor mental health (eg, depression, anxiety, post-traumatic stress disorder), and constructs such as resilience and moral injury. These surveys will be complemented by in-depth psychiatric interviews with a sample of HCWs. Qualitative interviews will also be conducted, to gain deeper understanding of the support programmes used or desired by staff, and facilitators and barriers to accessing such programmes. ETHICS AND DISSEMINATION: Ethical approval for the study was granted by the Health Research Authority (reference: 20/HRA/210, IRAS: 282686) and local Trust Research and Development approval. Cohort data are collected via Qualtrics online survey software, pseudonymised and held on secure university servers. Participants are aware that they can withdraw from the study at any time, and there is signposting to support services if participants feel they need it. Only those consenting to be contacted about further research will be invited to participate in further components. Findings will be rapidly shared with NHS Trusts, and via academic publications in due course.

Psychosocial impact of the COVID-19 pandemic on 4378 UK healthcare workers and ancillary staff: initial baseline data from a cohort study collected during the first wave of the pandemic.

OBJECTIVES: This study reports preliminary findings on the prevalence of, and factors associated with, mental health and well-being outcomes of healthcare workers during the early months (April-June) of the COVID-19 pandemic in the UK. METHODS: Preliminary cross-sectional data were analysed from a cohort study (n=4378). Clinical and non-clinical staff of three London-based NHS Trusts, including acute and mental health Trusts, took part in an online baseline survey. The primary outcome measure used is the presence of probable common mental disorders (CMDs), measured by the General Health Questionnaire. Secondary outcomes are probable anxiety (seven-item Generalised Anxiety Disorder), depression (nine-item Patient Health Questionnaire), post-traumatic stress disorder (PTSD) (six-item Post-Traumatic Stress Disorder checklist), suicidal ideation (Clinical Interview Schedule) and alcohol use (Alcohol Use Disorder Identification Test). Moral injury is measured using the Moray Injury Event Scale. RESULTS: Analyses showed substantial levels of probable CMDs (58.9%, 95% CI 58.1 to 60.8) and of PTSD (30.2%, 95% CI 28.1 to 32.5) with lower levels of depression (27.3%, 95% CI 25.3 to 29.4), anxiety (23.2%, 95% CI 21.3 to 25.3) and alcohol misuse (10.5%, 95% CI 9.2 to 11.9). Women, younger staff and nurses tended to have poorer outcomes than other staff, except for alcohol misuse. Higher reported exposure to moral injury (distress resulting from violation of one's moral code) was strongly associated with increased levels of probable CMDs, anxiety, depression, PTSD symptoms and alcohol misuse. CONCLUSIONS: Our findings suggest that mental health support for healthcare workers should consider those demographics and occupations at highest risk. Rigorous longitudinal data are needed in order to respond to the potential long-term mental health impacts of the pandemic.