Last week I was asked to talk at the Severn Deanery regional paediatric training day and I spoke to the doctors in training about “Thinking about what we do in Paediatrics: talking, debriefing and moral injury.” This got me thinking more carefully about the term ‘moral injury’, what it means, whether we should be doing more to understand it and what, if anything, we should be doing to make provision for it in our clinical practice.
It is important for all of us in healthcare to think about the effects of our work on our emotional and psychological wellbeing - a simple acknowledgment of the fact that as doctors, nurses and allied healthcare professionals working in paediatrics and emergency medicine, we see and are exposed to things that are sometimes hard to witness and can affect us very deeply, not just as professionals but as parents and as human beings.
Moral injury is a term that emerged from work with military veterans in the context of post-traumatic stress disorder and a number of definitions exist including: “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Despite the emergence of military colloquialisms in our medical language - NHS emergency staff ‘on the front lines’ - most of us are fortunately not actually working in an armed conflict. So is moral injury a real thing for us?
Certainly we know that our staff in paediatrics and emergency medicine are experiencing significant challenges with burnout and that the narrative around resilience is problematic (1). The BMJ piece ’60 seconds on…moral injury” (2) highlights the potential problems with words like burnout and resilience in the context of looking at staff wellbeing and improving working environments: namely that medical staff are somehow complicit in the environmental or professional exposures that can injure them. A common and reasonable opinion is that there is some sense in moving staff to being the ‘recipients’ of this kind of injury (rather than looking at how staff can better themselves) so that efforts can be firmly aimed at improving the system and where and how staff work. In a recent paper looking at whether medical students might experience moral injury during their pre-hospital training exposure (3) the authors stated ‘the term moral injury may be useful in conceptualising the negative psychological effects of delivering emergency and prehospital medicine as it provides a non-pathological framework for understanding these effects.’
But this has provoked some important discussion, including some strong views that grouping moral injury and burnout together is incorrect (4). A view that there is something about moral injury that is just part of ‘what we do’ and can be experienced even in a perfect system, whereas burnout arises through broken systems and inadequate provision for medical staff. The implication is that separating the two terms allows us – on the one hand – to focus on the things that we can control such as rota patterns, the working environment and rest facilities – and on the other hand – to focus on the inevitable exposure to distressing and traumatic events that comes with caring for sick and injured people.
This debate, in my view, is probably about people’s views on whether the things we experience as health professionals really do “transgress deeply held moral beliefs and expectations.” For most, the death of a child, for example, is one of the most distressing experiences we encounter in paediatric emergency medicine. The discussion about whether this is something that anybody ‘should have to witness’ is probably of academic value because it is part of our job. But neither can we ignore the detrimental effects this can have on the human condition. In our emergency department we are using TRiM (Trauma Risk Management) to support staff (5) and I like the idea of going even further to bring trained, dedicated psychology support into the team for the staff. But at the very least I think we should be speaking openly about the risk of ‘injury’ to our colleagues and the key is that we focus on 3 things:
1. Acknowledging openly that, on a human level, our clinical experiences can be emotionally and psychologically challenging
2. Understanding that interventions are useful for supporting staff in processing distressing events
3. Ensuring that, in addition to support for traumatic clinical experiences, we improve staff wellbeing by optimising: the work environment; working patterns; provision for rest and sleep; physical and psychological health
When writing this, I wanted to ask Esther Murray what she thought. Esther is a Health Psychologist working at Barts and The London School of Medicine and Dentistry and something of an expert on moral injury. To conclude, she summarises the issue brilliantly:
“Even if experiencing distressing events is part of the job, and what upsets one person is not what upsets another, we can still recognise the need in all of us to take a minute after some events. It can be necessary in emergency medicine to push the feelings aside and crack on because it’s so busy, but that doesn’t mean the feelings are gone. Just letting them be could be the most useful thing you can do, just letting yourself acknowledge to yourself that a particular incident was rough. We know from work in the area of moral injury that peer support is hugely beneficial, that doesn’t have to be a long talk, it can be a quick acknowledgement that you both saw something difficult and you’re feeling it. One of the effects of moral injury can be shame, guilt and a desire to isolate so it’s important to know that and try not to do it.”
Dan Magnus (@drdanmagnus)
Consultant in Paediatric Emergency Medicine, Bristol Royal Hospital for Children
With special thanks to Esther Murray (@EM_HealthPsych)
1. Is it time to stop talking about resilience?: https://www.yougotthiswellness.com/single-post/2018/07/14/Is-it-time-to-stop-talking-about-Resilience
2. 60 seconds on…moral injury: BMJ 2019;365:l1933 doi: 10.1136/bmj.l1933
3. Murray E, Krahé C, Goodsman D. Are medical students in prehospital care at risk of moral injury? E. June 2018:emermed-2017-207216. doi:10.1136/emermed-2017-207216
4. Moral injury and burnout are not the same: https://blogs.bmj.com/bmj/2019/06/06/joshua-parker-moral-injury-and-burnout-are-not-the-same/