By Dr Gabrielle Pendlebury, Medicolegal Consultant
The term ‘moral injury’ describes the suffering experienced by doctors and healthcare practitioners who face experiences which strongly clash with their ethical and moral values. Providing care in such situations can be difficult due to complex feelings of guilt, remorse and shame; for some staff, this can lead to burnout and mental health issues.
The concept of moral injury has been especially relevant during the COVID-19 pandemic. Many doctors have reported a negative impact on their wellbeing, with inexperienced or poorly supported staff particularly at risk due to being psychologically and practically ill-prepared for the tough situations and difficult choices confronting them.
Dr Derek Tracy and colleagues have written extensively on moral injury and discussed their experiences of it whilst working in the London Nightingale hospital in our webinar: How to survive a pandemic.
Specific challenges during COVID-19
Staff reported insufficient personal protective equipment (PPE) to protect themselves and do their job effectively. Conversely, those who did have access to full PPE were unable to easily communicate with patients or colleagues while wearing it.
Many were working in an unfamiliar clinical environment, caring for large numbers of very unwell patients, at times leading them to question their competency and training for the role.
What can organisations do to support their staff?
Primary prevention: Transparency and communication
A first step is an honest appraisal of the situation so that staff expectations are realistic. At the London Nightingale hospital, a welcome letter was sent to prospective staff congratulating them on undertaking a rewarding role and assuring them of appropriate support, but also directly noting that the work would be challenging, that people may die despite staff’s best efforts and that the environmental situation could be uncomfortable.
Dr Tracy notes that induction, or early briefings, should not sugar coat what staff will face. Frank preparation allows for honest reflection about role-suitability, taking one’s own vulnerabilities and personal-life responsibilities into account to ensure the individual is able and prepared to take on that role.
It is important to properly prepare people for the tasks ahead, ensuring that everyone, but most importantly supervisors, are able to have supportive conversations. Tiered levels of appropriate support are also key.
At the London Nightingale, staff were encouraged to support each other: from ‘buddying’ systems to shift-end supervisor-led reviews (quite different from ‘psychological debriefing’ for which there is little convincing evidence of benefit). The environment was adapted to the need: from the basics of adequate nutrition, rest gaps and furnishings, to easily located, up-to-date local and national support offerings—whether posters, phonelines, apps or other digital resources.
Secondary prevention: Identification of those at risk
After these initial efforts (sometimes known as ‘primary prevention’), which aim to stop problems developing, a ‘secondary’ level of prevention then aimed to identify those who may be developing problems and intervene accordingly.
Approaches to secondary prevention included supervisors having psychologically savvy supportive conversations with team members or peer supporters directly tasked with ‘walking the floor’ to offer a chance to chat and access informal assistance. There are evidenced peer-to-peer protocols; an example is the “TRiM” (Trauma Risk Management) programme developed by the UK military that teaches awareness of stigma, recognition of signs of mental ill-health, and pathways to care.
Tertiary prevention: Access to professional help
The final step in this tiered approach was access to professional help for some if distress progressed to mental illness.
With the right support, doctors facing such situations can overcome trauma and avoid mental health issues. Now that a second lockdown is in effect, it is a sensible time for employers to consider how they can support their staff to avoid illness and experience post-traumatic growth.