Leading civilian UK centre of excellence for military health research

From the military to the NHS

When the pandemic occurred in 2020, understandably, much focus was quickly directed to healthcare workers (HCWs) and their mental well-being. Many war-like terms were used in the media when describing the scene in hospitals, such as ‘frontline’ and ‘fighting an unknown enemy’. However, there are many differences between Armed Forces personnel’s deployment experiences of military personnel and what HCWs faced during the pandemic. Nevertheless, the research conducted in the military sphere has helped us understand how HCWs may be impacted and how best to support them.

For example, we know that at the height of the pandemic, HCWs had to make difficult decisions due to scant resources and high patient numbers. In addition, they may have witnessed an unusual number of fatalities and may have known colleagues who died from COVID-19. Such decisions or events may cause ‘Moral Injury’ and are therefore described as potentially morally injurious events (PMIEs).

The term Moral Injury originated in a military context; such injuries can occur when someone experiences events which strongly clash with their moral beliefs and values [1]. PMIEs have been associated with Post-Traumatic Stress Disorder (PTSD), depression and suicidal ideation in military veterans [2]. A similar association has been found in HCWs during COVID-19 in that PMIEs were significantly associated with adverse mental health symptoms across HCWs [3].

What do we know so far?

The NHS CHECK study is the UK’s largest study (n = 23,462) of the mental health and wellbeing of HCWs through the COVID-19 pandemic and beyond. The NHS CHECK study comprised of four online surveys disseminated at different time points (starting in April 2020 and the latest in February 2023). All NHS staff in the participating 18 Trusts were eligible, from cleaners to consultants. In addition, a sample of staff were interviewed about their experiences at work and their wellbeing.

The initial findings from the baseline survey (April 2020 to June 2020) revealed that many staff appeared to be experiencing probable common mental disorders such as anxiety and depression (58.9%) and PTSD (30.2%) [4]. However, much like other studies, NHS CHECK surveys used screening tools which are designed to identify potential mental disorders, not diagnose them.

The prevalence estimates of common mental disorders (21.5%) in HCWs were considerably lower when assessed using diagnostic interviews (considered the gold standard for diagnosing mental conditions) compared with screening tools [5]. However, the fact that 1 in 5 HCWs would benefit from mental health care is a stark finding given that it is well established that people with mental health problems perform less well [6].

Further survey results suggested that particular HCWs may be at higher risk of poor mental health outcomes. Younger, female, lower paid staff (Agenda for Change Pay Band 5 (£34,581) or below [7]), those who felt poorly supported by colleagues/managers, and those who experienced PMIEs were most at risk of adverse mental health outcomes.

There’s lots more research to read about from the NHS CHECK study. Please visit nhscheck.org to read more.

My PhD

My PhD, which I started in October 2022, aims to understand:

  1. the impact of the COVID-19 pandemic on the mental health, occupational and wellbeing outcomes and associated determinants of lower-paid NHS staff,
  2. how this impact may change over the course of the COVID-19 pandemic,
  3. what existing support has helped promote positive outcomes and mitigate negative outcomes in these staff groups.

I want to focus on those in Agenda for Change bands (2-4); the full-time salaries for these bands range from £22,383 to £27,596 outside of London [7]. This includes staff such as healthcare assistants, porters and administrators. It is important to draw attention to non-clinical staff members not only because they play a vital role in the running of the NHS but also because, as aforementioned, there is some evidence to suggest they may be at risk of poorer outcomes. In addition, the ‘cost of living crisis’ is likely to have affected those on lower incomes more severely and subsequently have a detrimental impact on their wellbeing.

How will I do this?

  1. I will use the NHS CHECK survey data to compare lower-paid staff to other staff to see if they differ on specific outcomes, including adverse mental health.
  2. Using all four waves of the NHS CHECK survey data, I will explore whether this impact has changed over time.
  3. The third aim will be assessed using secondary analysis of qualitative interview data. The NHS CHECK team has already carried out several interviews. I will use these to explore what support has been helpful, what individuals would like to see going forward, facilitators and barriers to access and whether lower-paid staff have unique needs or require tailored support.

I have already completed a four-month placement at NHS England with the Insights and Evaluation team, where I learnt how they gather staff feedback and use it to shape policy. I joined the team on listening exercises where they spoke to staff in the ward and community to hear about current challenges and suggestions on how their Trust can best support them. I used data collected on these visits and conducted remote interviews with staff in bands 1-4 to understand how best to support staff in these bands. I hope these findings will be published in due course.

If you want to hear more about my PhD, please get in touch and watch this space.


  1. Litz, B.T., et al., Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 2009. 29(8): p. 695-706.
  2. Frankfurt, S. and P. Frazier, A Review of Research on Moral Injury in Combat Veterans. Military Psychology, 2016. 28(5): p. 318-330.
  3. Williamson, V., et al., Moral injury and psychological wellbeing in UK healthcare staff. Journal of Mental Health, 2023. 32(5): p. 890-898.
  4. Lamb, D., et al., 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.Occupational and Environmental Medicine, 2021. 78(11): p. 801.
  5. Scott, H.R., et al., 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. The Lancet Psychiatry, 2023. 10(1): p. 40-49.
  6. de Oliveira, C., et al., The Role of Mental Health on Workplace Productivity: A Critical Review of the Literature. Applied Health Economics and Health Policy, 2023. 21(2): p. 167-193.
  7. NHS. Agenda for change - Pay Rates. Health Careers. 2020 [cited 2022 27 July]; Available from: https://www.healthcareers.nhs.uk/working-health/working-nhs/nhs-pay-andbenefits/agenda-change-pay-rates.
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