Towards a Holistic Model of Care for Moral Injury: An Australian and New Zealand Investigation into the Role of Police Chaplains in Supporting Police Members following exposure to Moral Transgression

Police members can be exposed to morally transgressive events with potential for lasting psychosocial and spiritual harm. Through interviews with police members and police chaplains across Australia and New Zealand, this qualitative study explores the current role that police chaplains play in supporting members exposed to morally transgressive events. The availability of chaplains across police services and the close alignment between the support they offer, and the support sought by police, indicates they have an important role. However, a holistic approach should also consider organizational factors, the role of leaders, and access to evidence-based treatment in collaboration with mental health practitioners.


Introduction
Policing is a highly dynamic occupation which involves exposure to potentially psychologically traumatic events (Carleton et al., 2019), occupational stressors (Carleton, Afifi, Taillieu, Carleton et al., 2020a), and ethical or moral dilemmas (Lentz et al., 2021).Ethical and moral dilemmas are particularly pertinent for policing which is based on codes of conduct and ethical standards grounded in morality and with a focus on ethics of care (Lentz et al., 2021).Police members are often required to make quick decisions in high risk and unpredictable environments, sometimes resulting in actions that go against their own moral code to protect themselves or others (Angehrn et al., 2020).More broadly there is increasing recognition that police members can be exposed to a range of events that transgress their moral values (Blumberg, 2022) and can be associated with poor mental health outcomes (Chan & Andersen, 2020;Demou et al., 2020;Simmons-Beauchamp & Sharpe, 2022).
The construct of moral injury (MI) has gained increasing attention from researchers and clinicians since Litz's seminal paper (Litz et al., 2009), but has primarily been explored within a military and Veteran context to date (Papazoglou et al., 2020;Phelps et al., 2022).MI is not a mental health disorder, but can be associated with disorders such as posttraumatic stress disorder (PTSD) and major depressive disorder (Phelps et al., 2022).MI refers to the lasting psychological, social, and spiritual harms which may result from exposure to betrayal by authority in high-stakes situations (Bikos, 2023;Shay, 2014) or transgression of deeply held moral beliefs of right or wrong (Litz et al., 2009).For police, this might include behaving (or witnessing others behave) in a way that goes against personal values; for example, witnessing family violence or child exploitation.
These events are referred to as potentially morally injurious events (PMIEs) and fall on the severe end of a continuum of morally transgressive events (Litz & Kerig, 2019).At the other end of the continuum lies relatively minor and common moral challenges of daily life, and between the two extremes lies a range of mid-severity moral stressors.This range of morally transgressive events vary in their potential for lasting and impairing harm.Events on the less severe end of the continuum are more likely to be associated with transient feelings of moral frustration, whereas PMIEs increase likelihood of experiencing an enduring MI (Litz & Kerig, 2019).The aetiology of MI is exposure to a PMIE (Hall et al., 2022), but exposed individuals will be differentially impacted, with some unaffected by the event and others experiencing differing degrees of distress and other symptoms (Jones et al., 2022).Further, morally transgressive events experienced in an organisational setting can cause moral distress that, even at low levels, can be harmful for the individual, their work performance, and their organisational commitment (Chan & Andersen, 2020;Phelps et al., 2022).
MI may be distinct from PTSD with respect to neurophysiology (Barnes et al., 2019) and symptom profiles (Bryan et al., 2018), but the co-occurrence of MI and PTSD is high (Koenig et al., 2020).The concurrence makes intuitive sense given the probability of moral transgressions being associated with potentially psychologically traumatic events and therein posttraumatic stress injuries (Carleton et al., 2019), including PTSD.PMIEs exposures have also been associated with increased risk of symptoms related to major depressive disorder (Nazarov et al., 2018), generalized anxiety disorder (Lee et al., 2022), and self-injurious thoughts and behaviours (Jamieson et al., 2023;Zerach & Levi-Belz, 2019).As such, addressing the causes and outcomes of MI and moral distress is important, particular among police members who are on the frontline and are at high-risk of exposure to PMIEs.
Research into moral injury in policing is in its infancy, and greater understanding is of utmost importance for ensuring that police member wellbeing is at the forefront and that operational readiness is maintained.A whole-of-organisation approach is recommended to address moral injury that occurs in an organisational setting (Phelps et al., 2022), but chaplains play a potentially important part for several reasons.First, within a policing context, chaplains fulfil the role of offering informal care to staff and other members of the public who are both religious or non-religious, through various methods such as respectful listening, pastoral counselling, or, when appropriate, prayer (Layson et al., 2023).Moreover, police chaplains have the opportunity to support staff at all times, including before during and after critical incidents (Tunks Leach et al., 2020).Research showing that harm to one's religious beliefs and spirituality may lead to poorer mental health outcomes among those exposed to PMIEs (Hall et al., 2022;Evans et al., 2018) supports the potential importance of chaplainled pastoral models of care to address the spiritual impacts of moral transgressions (Carey et al., 2016;Koenig & Al Zaben, 2021).Lastly, the ready availability of chaplains within police organisations across Australia and New Zealand supports the feasibility of chaplains playing a key role.However, empirical evidence on the nature of support provided by chaplains in routine practice, and the extent to which that support is considered helpful by police members, is currently lacking.

Aim
The current study was designed to use qualitative methods to capture the perspectives of both police members and police chaplains to better understand the current and potential role of chaplains in supporting police members exposed to PMIEs.

Procedure
Qualitative interview questions see Appendix 1 were developed by the project team in consultation with an advisory group comprising chaplains, mental health experts in MI, and people with lived experience.Interview questions for police members who had sought support following exposure to moral transgressions explored: PMIE exposures, sources of support that were accessed, anticipated outcomes, actual outcomes, and intended sources of support in the future.For police members who had not sought support, questions explored PMIE exposures, reasons for not seeking support, and intended sources of support for future help-seeking.Police members who did not mention chaplains as a source of support were explicitly prompted regarding willingness to engage with a chaplain for support.Interview questions for chaplains explored the types of PMIE for which police have sought chaplain support, the methods or approaches chaplains used to offer support, factors underlying selected methods of support, and observed outcomes (see Appendix 1).
Qualitative interview data were collected between February and September 2022.Police members and police chaplains were recruited through participating police services, using targeted emails and flyers, as well as social media advertisements.Police chaplains were also recruited through the National Police Chaplaincy Group.All advertising materials contained a link to the online screening survey that included the measures (for police members only), assessed eligibility, and obtained participant personal and demographic information.Prior to accessing the survey questions, participants were informed that clicking through to the next page indicated they consented to participate and have their data published in a journal article.Eligible police members were current serving and indicated that they had experienced a PMIE event according to the description of PMIEs in the MIOS.All chaplains currently employed (paid or volunteer) by a police service were eligible.
In an effort to collect a representative sample across Australia and New Zealand, the current study was designed to solicit four to five police member participants and two to three police chaplain participants from each Australian state, Australian territory, and New Zealand.Participants were contacted via phone or email, depending on their indicated preference, and were invited to attend an interview.Invitations to complete an interview were sequentially made to participants who expressed interest in participating in the study, except where several expressions of interest were submitted over a short period of time and there was an oversupply of potential participants from a particular area.In such cases, participants were selected based on their screening survey indicating a PMIE exposure or other disparate event relative to previously interviewed participants.Other participants were informed via email that they had been waitlisted for an interview.Some waitlisted participants were invited to attend an interview when other participants could not be contacted within three attempts.Interviewing continued until saturation was reached, with no new salient information emerging from interviews.
All interviews were completed via Zoom or Microsoft Teams and were audio recorded.Interviews typically lasted 30 to 60 min.De-identified audio recordings were sent to a confidential, Australian-based, third-party transcription service who adhered to the Commonwealth Privacy Act.
The current study was approved by the University of Melbourne Human Research Ethics Committee (reference number 2021-22399-22447-2).Further approval was sought from police services across all states of Australia and New Zealand and were subsequently provided by Western Australia (WA) Police Force Research Governance; Northern Territory (NT) Police, Fire and Emergency Services; Queensland (QLD) Police Service Research Committee; New South Wales (NSW) Police Force; Victoria (VIC) Police Research Coordination Committee; Australian Federal Police (AFP); Tasmanian (TAS) Institute of Law Enforcement Studies; and New Zealand (NZ) Evidence Based Policing Centre.

Participants
A total of 121 police members and thirteen police chaplains completed the online expression of interest survey.There were 13 chaplains and 47 police members invited to attend a semi-structured qualitative interview.A total of 35 police members (see Table 1) and 11  chaplains (see Table 2

Data Analysis
Transcripts underwent thematic analysis via NVivo (version 12) using Braun and Clarke's (2006) recommended methods.Transcripts were analysed by one researcher and a second researcher completed a fidelity check on 10% of the transcripts.Following the fidelity check, 70% of codes and themes were consistent between transcripts and over 80% agreement was achieved through discussion.The researchers familiarised themselves with the data before generating initial codes using an inductive approach.When half of the transcripts had been coded and grouped into initial themes, the data was presented to the study team and advisory group for input into how codes had been grouped to produce each theme.The remainder of the transcripts were coded and grouped into themes and subthemes and the final dataset was discussed with the study team and advisory group to ensure specifics of each theme were accurate and theme labels were refined.The MIOS description of PMIEs was used to classify events as PMIEs or less severe moral transgressions.Throughout the thematic analysis process, codes and themes were repeatedly cross-examined and refined to suit the developing narrative of the dataset.

Demographics, Service-Related Characteristics
Police members and police chaplains were predominantly male (68.6% of police members and 81.8% of chaplains  Police members described moral transgressions that varied along a continuum of severity (Litz & Kerig) (see Table 3).The severity of around half of these transgressions (55%) was consistent with a PMIE.Of note, level of distress did not necessarily correlate with severity of the moral transgression, and for the purpose of this study, the full range of moral transgressions were thus considered relevant.Moral transgressions could be aggregated into three categories: (1) 60% reported witnessing moral transgressions on the part of others; (2), 46% reported betrayal; and (3) 9% reported having perpetrated moral transgressions themselves.Around half (51%) reported having had several exposures to diverse moral transgressions during their police service.The majority of police members (66%) had sought support following exposure to moral transgression.Chaplains reported that the most common types of PMIEs for which members sought their support were: (1) workplace and role related issues (e.g., having to reconcile other's mistakes, male-female pay gap, mandatory vaccinations), reported by 64%; (2) deaths, reported by 55%; (3) incidents involving children, reported by 45%; and (4) motor vehicle accidents, reported by 36%.Note that the events reported by chaplains also represent moral transgressions of varying severity, including but not limited to, PMIEs.

Domains, Themes and Subthemes
The current study goals were addressed through five domains of enquiry for police members who had sought support, three domains of enquiry for police members who had not sought support (see Fig. 1), and six domains of enquiry for police chaplains.Themes and subthemes that emerged within each domain and are presented in Tables 4, 5 and 6 and summarised below.

Police Members who had Sought Support
The most frequently reported source of support (78%) was an external mental health practitioner (e.g., psychologists, counsellors, psychiatrists, Employee Assistance Programs).Mental health practitioners were not interviewed for the current study,    relatively fewer seeking resolution of the issue (22%).The police members reported outcomes of seeking support including improved symptoms and functioning (39%), feeling that they "got it off their chest" (22%), as well as feeling reassured and validated (17%).
Most police members (70%) reported their next help-seeking efforts would include addressing the stressor sooner (31%), going to an external mental health practitioner (19%), not going to the same internal person again (19%), and reporting the transgression (19%).Most (62%) were open to speaking to a chaplain but a third of that group would only do so if they were approached by the chaplain.In this context it is interesting to note that 86% of police members who had spoken to a chaplain initiated the contact themselves.

Police Members who had not Sought Support
The most common reason (50%) police members gave for not seeking support was preference for using informal supports.Other reasons included not recognising MI as a mental health issue (33%), thinking that exposure to moral transgressions was just part of the job (33%), mistrust or scepticism (25%), or passively self-managing (25%).When asked what could have changed their mind about help-seeking, police members nominated the need for greater confidentiality and trust (33%), better support from management (25%), ensuring the right support is available (25%), and greater education and understanding of MI (25%).
Police members who had not previously sought support indicated future helpseeking would include speaking to a spouse (58%), a chaplain (42%), a peer or colleague (43%), a civilian friend (33%), or an external mental health practitioner (33%).Members who had not mentioned chaplaincy (n = 7) were specifically asked whether they would seek support from a chaplain in the future and almost all (n = 6) indicated that they would.

Police Chaplains
Police chaplains reported using several support strategies for police exposed to moral transgressions.All reported listening and providing a safe space for police members and almost all (91%) reported using flexible spiritual guidance rather than no spiritual focus.Most chaplains (73%) endorsed referral or encouragement to access support, as well as developing trust and rapport (73%), as important components of their role.Approximately half (55%) of chaplains reported offering encouragement and rein-Domain 8: What approach do you take when helping a police member?Theme: Move forward (36%) "Helping them understand and help them deal with it and go forward.""Some have been able to go back to work."Theme: They feel supported (36%) "Feeling like someone's genuinely interested in them.""'I couldn't have done it without people like you just supporting, loving, encouraging.'" 1 3 forcement of actions being taken or providing coping strategies (45%), and several reported offering a different perspective (36%).
Police chaplains reported that their goal in supporting police members was to facilitate member recovery pathways (73%) or increased member self-awareness about why a given event may have impacted the member (45%).Approximately half of chaplains reported using a person-centred approach for everyone (55%), and more than half indicated each member's spiritual or religious beliefs impacted their approach (64%).Chaplains felt that it was unhelpful to take too much of a religious approach (64%), or think you've got all the answers (45%).Chaplains reported outcomes including having seen police members experience relief from "getting it off their chest" (73%), moving forward (36%), and having a sense of feeling supported (36%).

Discussion
Several previous studies have reported on MI interventions developed and delivered by chaplains (see the scoping review from Jones et al., 2022 andCurrier et al., 2023) but we believe that this is the first to use a qualitative methodology to explore the support provided by chaplains in routine practice and how this support is received by police members.The initial scope of enquiry was the nature of support sought and provided following the experience of a PMIE but as noted in the results, the types of moral transgressions described by both police members and police chaplains varied on a continuum of severity, which included, but was not limited to, PMIEs.For the purpose of this study, the full continuum of moral transgressions was considered relevant, with the severity of impact, as measured by the MIOS, unrelated to the severity of the event.Incidentally, this is not dissimilar to studies in the PTSD field that have found PTSD severity to be unrelated to severity of the Criterion A stressor, or indeed to be more severe in some cases following a non-Criterion A stressor (Gold et al., 2005;Long et al., 2008).It is beyond the scope of this paper to explore this in depth, but the finding highlights the need for further research into the impacts of moral transgressions beyond those considered PMIEs.
The most common type of moral transgression reported by police members involved witnessing another person act in a way that transgressed the individual's beliefs of right and wrong or feeling betrayed.Such moral transgressions were not uncommon with half of respondents reporting exposure to several such events.Support was most commonly sought from mental health practitioners outside of the police service.Satisfaction was markedly higher for external mental health practitioners (relative to internal mental health practitioners).The discrepant satisfaction reports are partially explained by police members feeling a greater sense of confidentiality and trust when accessing an external health service provider.Indeed, participants reported feeling like they could talk about things more freely and be open and honest when seeking support externally to their organisation.Through facilitating confidentiality, external health service providers may enable trust.This may also be true for chaplains who use approaches which aim to facilitate trust (Tunks Leach et al., 2023).This was supported by the current findings whereby police felt that chaplains were trusting, understanding, and made police feel cared for.This facilitation of trust has the potential to be particularly beneficial for police members who had experienced betrayal-based moral stressors and PMIEs and had lost trust in their organisation.
Only a third of police members sought support from chaplains.A preference for support from mental health practitioners over support from chaplains has been noted in previous research with public safety personnel (Carleton, Afifi, Turner et al., 2020).However, a notable finding in the current study was that satisfaction with support was highest for chaplains.All police who sought support from chaplains reported being satisfied with the support they received.This may be attributed to close alignment between support that police members indicated they were looking for (have feelings validated and come to reconcile their experience) and the support that chaplains indicated they provide (listening, providing safe spaces, and seeking to validate members' feelings).It is also possible that police members with more severe symptoms were more likely to seek support from mental health practitioners than those who sought support from chaplains and that symptom severity had an influence on satisfaction with support.This was not tested in the current study.
The potential importance of chaplains in providing support was further highlighted by evidence that, among police members who had not yet sought support, most were open to speaking with a chaplain for future support, preferring the chaplain to initiate the approach.This result suggests greater chaplaincy outreach could be an effective proactive approach to mitigating MI and supporting mental health.There was also a small proportion of members who were not open to chaplaincy support, the reasons for which warrant further attention.
While the support currently provided by chaplains aligns closely with what police members say that they need, this should be considered one component of an holistic approach that also involves evidence-based care from mental health practitioners for MI and related mental health injuries such as PTSD (Koenig et al., 2020), major depressive disorder (Nazarov et al., 2018), generalized anxiety disorder (Lee et al., 2022), as well as self-injurious thoughts and behaviours (Zerach & Levi-Belz, 2019).It has been previously reported that police chaplains can potentiate beneficial spiritual interventions for directly improving MI outcomes (Currier et al., 2023) as well as facilitating access to psychological services as a function of regular, direct engagements with members and outreach opportunities.Both of these were observed in the current study with the majority of chaplains describing their approach as offering flexible spiritual guidance alongside referral or encouragement to access other forms of support, thus demonstrating an appreciation of their role within the holistic model of care.
Although not a key focus of the current research, it was noteworthy that only 2 in 5 police members reported improvement in their symptoms or level of functioning after seeking support from either an internal or external mental health practitioner or a chaplain.We have a significant challenge ahead to develop, evaluate and implement organisation-wide and evidence-based approaches to prevention and support for workers likely to be exposed to moral transgressions in the course of their work (Phelps et al., 2022).

Strengths and Limitations
The current study has several strengths and limitations that contextualise the results and can help inform future research.The qualitative methodology was an important strength, providing more nuanced insights about the unique moral stressors and PMIEs experienced by police members and chaplains, as well as the help-seeking attitudes and behaviours of police members.With better understanding of police member and police chaplains' experiences, attitudes and behaviours, future research using quantitative methodologies will strengthen and broaden this understanding and allow for comparison between different demographic groups within the police force.
The diversity of study participants may have been limited by using a recruitment strategy which included promotion through chaplains.The recruitment strategy may have facilitated a sampling bias for police member participants who were open to chaplaincy, though promotion through other channels such as social media and advertisements hopefully helped to mitigate the likelihood of bias.Future research using broader recruitment strategies may help mitigate against such biases and produce more representative results.The participants were also predominantly older men, which does not accurately reflect contemporary police demographics that include a higher proportion of young women members.This warrants additional research with a larger cohort of both police members and police chaplains.

Conclusion
Despite the limitations, the results provide evidence that police members experience frequent exposures to moral transgressions associated with mental health challenges, and highlight the importance of police organisations addressing MI.The current results suggest four potential foci.First, in addition to the traditional focus on mental health service providers, organisations should recognise the potential role of chaplains in supporting members who have experienced PMIEs and facilitating access to mental health service providers.Second, many police members did not recognise that exposure to moral transgressions as potentially injurious, highlighting the importance of increasing awareness and education about risks, symptoms, and sources of support.Third, several of the moral transgressions that were reported were associated with organisational factors, and participating police members suggested resolutions required organisational change.The feedback highlights the importance of recognising the impact of organisational culture, policies, and practices, on individual member wellbeing.Finally, participating police members reported that perceiving higher levels of confidentiality and trust, better supports from management, and access to the right supports, would all have facilitated their help-seeking.The suggestions underscore the importance of organisational strategies to promote helpseeking through supportive management, and ready access to evidenced-based, high quality, and confidential holistic care.
In sum, this research contributes to our increased appreciation that wellbeing strategies within policing jurisdictions need to accommodate a biopsychosocial-spiritual framework to assist police members in looking after their holistic wellbeing, as the 6.What did that support involve?
• Prompt: how long were you engaged in support?6.What was the outcome or outcomes?7. Did you receive all the support you needed and for as long as you needed?
• Prompt: were you left with any unmet needs?8. Would you do anything different if the need arose again in the future to seek support for moral injury?
• Prompt: would you seek support from a Chaplain or would you be open to speaking to a chaplain if they were to approach you?Why/why not?
If NO: 3. Why is that? 4. What, if anything, could have changed your mind so that you would have sought support? 5.If you were to seek support, who do you think you would be most likely to see and why/why not? 6. E.g., mental health practitioner.
• Prompt: did you speak to an internal or external mental health practitioner, chaplain, peer, family member etc.

Fig. 1
Fig. 1 Flow chart of themes and subthemes for police members

Table 2
Police chaplain (n = 11) demographics ' service and served in metropolitan locations (62.9%).All reported exposure to PMIEs on the MIOS, and the majority reported moral injury in the moderate to severe range (88% scored 29 or above on the MIOS).Police members were equally likely to have (40.0%) or not have (45.7%) a religious affiliation.Chaplains had also commonly served over 20 years (27.3%),though some had been in service for 5 years or less (27.3%).Most worked in metropolitan locations (58.3%), and they were predominantly Christian (90.9%).

Internal mental health practitioner (48%)
"The psychologists that [the police service] had employed, they were very au fait with it.""Ihave seen [mental health practitioners] internal."Subtheme:Not supported as hoped (73%)"I didn't -I received hardly any support.""The psychs that are attached to the [police service], they have a very blanket view of things."Subtheme:

Felt they got the support they needed (27%
) "Yeah, I think the department's quite good with support."Yes, from our health and welfare.""" Theme: Chaplain (30%) "I went to the police chaplain.""On multiple occasions [I got support] from a priest."Subtheme: Felt they got the support they needed (100%) "[The chaplain] has supported me previously.I'm not religious, but she's incredible.""[The chaplain] just cared.Not because I was a police officer, just because I'm a human."

Subtheme: Actively reached out to the chaplain (86%)
"[Needing to speak with a person] made me approach him.""I usually reach out to the chaplain.I have known the chaplain for a very long time."

Theme: Open to speaking to a chaplain (62% of participants assessed for this domain)
"I would probably go and talk to him because he seems really nice.""Yes.I actually think that they have a really valuable space within the police force."Subtheme

: Would only speak to a chaplain if they were approached by one (38%)
"If they were to approach me, I'd be open in liaising.""I wouldn't have initiated [a conversation]."

When seeking support, what outcomes were you hoping for? Theme: symptoms to improve and increased functioning (48%)
"I knew I wasn't coping and that I needed better strategies.""To figure out what was going on with me because I had no idea what was going on."Theme: Validation (35%) "Having the sounding board just to go, 'am I crazy for thinking this yet again?'"

Table 4
Domains, sub-domains, and themes for police members who had sought support

What were the outcomes of seeking support? Theme: symptoms to improve and increased functioning
"Being able to vent, to not bottle anything up, just get it all off the chest.""A lot of it was just about listening.Me being able to unload."Theme: Felt reassured and validated (17%) "Validation, reassurance, support.""The outcome you get is the validation… you've acted in line with your morals and values."

Domain 7: Would you do anything differently if they need arose again? Theme: Would do it differently (70%
) "I would now.Well, now I know what it is.""I wouldn't bother going down that avenue."Subtheme: Would address it sooner (31%) "I probably should have taken time off earlier and had an extended break.""have a lot more understanding about it now… I would see [the MI] earlier."Subtheme:

Would go to an external mental health practitioner (19%)
"I would go straight to private psychologists and psychiatrists.""I'd seek someone like [private psychologist], so someone independent of the organisation."

Subtheme: Would not go to the same internal person again (19%)
"I wouldn't go to [police service].I wouldn't go to any of my managers.""I would not go through police welfare, I wouldn't speak to a manager."

Subtheme: Would report it or call it out (19%)
"I'd probably escalate it higher than what I did.""Be upfront and just say, 'listen, this is not acceptable,' and be the noisemaker."Table 4 (continued)

Table 5
Domains, sub-domains, and themes for police members who had not sought support

What could have changed your mind? Theme: More confidentiality and trust (33%)
"It is such a small area, [there's] confidentiality issues.""Imean confidentiality is important."Theme:Better support from management (25%)"Being supported by the police hierarchy might add to that weight of feeling it's okay.' "If that was to be supported… then it's going to be a lot easier [to seek support]."Theme:

Greater education and understanding of MI (25%)
"Go read it on a board in a GP's office and go, 'hey, that's me.'""More discussion around moral injury as something that police experience."

Domain 3: Who would you seek support from if you were to seek support? Sub-domain 3.1: Would you go to a chaplain? Theme: Spouse (58%) "
My wife would be my first port of call.""Well family members definitely, because my husband is also in the job.""[I] would probably use [the employee assistance program] as my initial go-to.""I'd probably pick someone through the EAP, because again, it's anonymous."