felt so bad for this kid… he was in lots of pain and just basically lying on the floor and we couldn't do anything. I felt bad’.
In line with cognitive processing models, they found the clinical debrief to be useful, whether with a paramedic or physician who had also been on the scene:
‘They know exactly what happened and you can say, well why did we decide to do this…then suddenly there is some kind of scientific underpinning, understanding that helps you process what's happened’.
Equally, they also talked about the need for emotional processing, ‘Just sit down and understand and go, yeah, that's crap… talk me through it. Get everything out’. even when this was hard to do: ‘You've got to make the effort, I find I have to make the effort. If I'm going to talk about it, I need to talk about it properly’.
Interestingly, this population did not talk about failures of leadership, or poor decisions made by leaders, but had unstinting admiration for their seniors and their extensive experience:
‘he (the doctor) was like, okay, let's look for injury patterns because that's quite useful. I just remember thinking, oh my God … Obviously I was feeling a lot more than he was but that's just by virtue of him having – that's his job and that's his life’.
It was not until I started talking to other groups that I began to understand the issues that were arising with leadership, and also, that I had actually begun my exploration of moral injury in healthcare in the wrong place.
The research I undertook with students in pre‐hospital care was meant to be the first step in a series of studies about whether moral injury was a concept that resonated with healthcare professionals. Once it was complete, I presented it with my collaborator, Charlotte Krahe, at a symposium in June 2017, two weeks after the fire at Grenfell Tower. I was overwhelmed by the response. I had thought there would be some interest in the topic, but I had not anticipated the number of people who would want to talk to me about their experiences, and their concern for themselves and their colleagues. It was this event that meant that I began to understand the extent of distress in paramedics and other ambulance staff, and in specialties such as intensive care, critical care, and, of course, emergency department staff.
Those who had not spoken to me at the time often wrote to me later, many were educators who wanted to know how to protect the students in their care:
‘I actually think there is huge potential for use of the term “moral injury” to describe the feelings arising in clinicians and students from seeing patients in situ where there is severe deprivation, isolation, poverty, squalor, and sadness ‐ a large part of what paramedics do and probably more frequently encountered than significant trauma, disturbing violence and serious illness.
‘The themes it (the published paper) has highlighted are the exact same that resonate across the entire student cohort and it's such a positive thing to see it professionally worked up. It points me in the right direction as to the best and better ways to keep our boys and girls as safe as possible’.
Others sent me long emails about how moral injury resonated with their experiences, either because of the kinds of jobs they had seen, or the way they felt the system had treated them. At a conference, one physician told me: ‘I just feel like a piece of meat on a conveyer belt. One day I'll fall off and they'll just put another piece of meat on’. It is clear that staff are feeling unsupported at work and we know from recent surveys that the degree to which staff will identify themselves as burnt out and stressed beyond their capacity to deal with it is worryingly high [1]. Since that first presentation of the research in June 2017, I have been invited to speak about moral injury at conferences, symposia and study days both in the United Kingdom and abroad. Clearly there is an appetite for discussion about moral injury and the psychosocial effects of working in healthcare more broadly.
FUTURE DIRECTIONS FOR RESEARCH AND INTERVENTION
There is no clear, recognised treatment for moral injury at the time of writing. There is speculation about the use of Acceptance and Commitment Therapy [19] given its focus on accepting the world as it is, with the good and the bad, and the equal emphasis on psychological flexibility. Treatments which focus on psychological flexibility are useful because they remind people that they are not their thoughts, that their thoughts occur independent of them and need not be engaged with, and if they are engaged with, their options for action and engagement can be of their own choosing. The ability to notice a world in which terrible things can happen and in which wonderful things also happen and not become fixated on either of these may be why this type of cognitive behavioural therapy would work.
There is a move among healthcare professionals to talk about preventing moral injury, which of course is not possible. The recent COVID pandemic has meant that the conditions for moral injury are all present – poor decisions made by leaders are causing death and post‐viral disability, as well as economic devastation and healthcare workers are powerless to provide sufficiently ‘good’ care because they lack the resources to do so. While this experience is probably more pronounced in the United Kingdom and the United States, high death tolls among healthcare workers are common across the world which further adds to the sense of being put in harm's way. So, the moral injury is inevitable, and we need to plan for understanding how to support people through the grieving and meaning‐making processes which might alleviate it.
Work is underway to develop questionnaires to understand moral injury in healthcare, with a view to mapping the problem and developing strategies to address it. Especially during the COVID‐19 pandemic it has gained a great deal of traction and been mentioned in the popular press (Gerada, 16 October 2020) [20]. It has become clear that the incident which might be considered morally injurious differs greatly from one person to another. It is likely that the most effective interventions for managing harm will be those with which we are already familiar, that is, peer support, having time to talk, to debrief cases together, mapping both the clinical decisions and thinking about the feelings which these provoked. Healthcare professionals should be supported in finding solutions which work in their own settings and there will need to be a recognition of the structural issues that are affecting spaces for peer support.
REFERENCES
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