“It haunts me still”: Exposure to potentially morally injurious events in first responders

Moral injury is a biopsychosocial, behavioral, and spiritual consequence that may occur for individuals in high-risk occupations after acting, failing to prevent, or witnessing events that go against their deeply held morals or values. While there has been extensive research on the types of events that may lead to moral injury for veterans, and a growing literature on healthcare workers, limited research has explored the experiences of first responders. This study builds on a multi-year participatory action research study with a large fire department in northern California aimed at understanding and mitigating moral injury among first responders. The present article explores the types of potentially morally injurious events that firefighters, paramedics, and emergency medical technicians experienced through their work. Participants (n=122) responding to a department-wide survey described the event that was most troubling to them that went against their morals or values. Using a constructivist, reflexive approach, we identified seven themes to these potentially morally injurious exposures: (1) Witnessing suffering, (2) Concerns about not saving a patient or that actions may have harmed someone, (3) Witnessing harmful, unprofessional, or biased behavior towards a patient, (4) Witnessing colleagues behaving poorly towards self or other colleagues, (5) Acting unprofessionally or unethically, (6) Feeling implicated by system failures, and (7) Tensions between professional and personal values. We contextualize these findings within the growing moral injury literature, including emerging theory. We share recommendations based on these findings for how organizations may reduce exposure to potentially morally injurious events and foster support to mitigate distress. • We indexed potentially morally injurious event types reported by first responders. • Our sample included firefighters, paramedics, and emergency medical technicians. • Seven moral injury themes were reported using a constructivist, reflexive approach. • Some themes were: witnessing suffering, concerns about not saving/harming patients. • Recommendations focus on reducing exposure and fostering organizational support.