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PMIEs have been a feature of work within much of the National Health Service (NHS) for many years, and the understanding of MI is now more commonplace, having been highlighted during the COVID-19 pandemic; however, understanding of how such events affect workers over the long term is lacking.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To understand the development of healthcare workers\u2019 (HCWs) experiences of PMIEs over a period of 3 years.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design and participants<\/jats:title>\n                    <jats:p>We carried out follow-up semistructured qualitative interviews with 15 NHS staff who were previously interviewed on the same topic in 2021. All interviews were recorded, transcribed and analysed using reflexive thematic analysis following an inductive approach.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Three main themes and six subthemes were identified: (1) internal context and subjective experiences, (1.i) control in a rigid system, (1.ii) psychosocial dynamics, (2) external context and the moral cost of culture, (2.i) organisational culture, (2.ii) sources of MI, (3) responses to PMIEs, (3.i) maladaptive responses, (3.ii) adaptive responses. Key issues identified included perceptions of insufficient control over their work and work environment, low psychological safety and perceived misunderstanding of the value of their work from patients and colleagues, leading to a challenging organisational culture. We found that in the 3 years between the interviews many staff reported developing \u2018secondary\u2019 feelings of betrayal as a result of perceived ongoing governmental neglect of recognition for HCWs\u2019 sacrifices during the pandemic and a lack of acknowledgement of governmental mistakes made in the acute period.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Findings show an interplay between individual and organisational factors that HCWs faced while working in the NHS, underlining the need for wide-ranging intervention strategies. Since the HCWs\u2019 original interviews in 2021, a secondary betrayal has developed, emphasising the need for interventions that can restore trust in the system.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-115402","type":"journal-article","created":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T11:50:30Z","timestamp":1787053830000},"page":"e115402","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["NHS healthcare worker experiences of moral injury: a follow-up qualitative study in England using reflexive thematic analysis"],"prefix":"10.1136","volume":"16","author":[{"given":"Erin","family":"Higginbottom","sequence":"first","affiliation":[{"name":"University College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Friederike","family":"Stoeck","sequence":"additional","affiliation":[{"name":"University College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7655-7986","authenticated-orcid":false,"given":"Sharon","family":"Stevelink","sequence":"additional","affiliation":[{"name":"King\u2019s College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Siobhan","family":"Hegarty","sequence":"additional","affiliation":[{"name":"King\u2019s College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0904-749X","authenticated-orcid":false,"given":"Rosalind","family":"Raine","sequence":"additional","affiliation":[{"name":"University College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anne Marie","family":"Rafferty","sequence":"additional","affiliation":[{"name":"King\u2019s College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4550-2971","authenticated-orcid":false,"given":"Neil","family":"Greenberg","sequence":"additional","affiliation":[{"name":"King\u2019s College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6743-9929","authenticated-orcid":false,"given":"Simon","family":"Wessely","sequence":"additional","affiliation":[{"name":"King\u2019s College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-6549-0078","authenticated-orcid":false,"given":"Hassan","family":"Rahman","sequence":"additional","affiliation":[{"name":"University College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1526-9793","authenticated-orcid":false,"given":"Danielle","family":"Lamb","sequence":"additional","affiliation":[{"name":"University College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,8,18]]},"reference":[{"key":"2026081804501751000_16.8.e115402.1","doi-asserted-by":"publisher","DOI":"10.1016\/j.cpr.2009.07.003"},{"key":"2026081804501751000_16.8.e115402.2","doi-asserted-by":"publisher","DOI":"10.1080\/09638237.2023.2182414"},{"key":"2026081804501751000_16.8.e115402.3","doi-asserted-by":"publisher","DOI":"10.1037\/trm0000069"},{"key":"2026081804501751000_16.8.e115402.4","doi-asserted-by":"crossref","DOI":"10.3390\/ijerph20136300","article-title":"The Association of Moral Injury and Healthcare Clinicians\u2019 Wellbeing: A Systematic Review","volume":"20","author":"Thibodeau","year":"2023","journal-title":"Int J Environ Res Public Health"},{"key":"2026081804501751000_16.8.e115402.5","doi-asserted-by":"publisher","DOI":"10.1016\/j.pnpbp.2021.110247"},{"key":"2026081804501751000_16.8.e115402.6","unstructured":"Office for National Statistics . 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