Moral injury
It’s sad that as a Society we feel the need to have a page on our website to address this but this is becoming an increasing focus of the questions that we are asked as a Society. Our members are asking for both support and also what we are doing as a Society.
Vicky Price - SAM President Elect
Recently I had to have a few minutes in my office to regroup after I’d seen a patient. I didn’t quite know how to process my feelings. I was feeling ashamed and upset.
My patient had been in our waiting room for over 18 hours. He was a bilateral amputee and a wheelchair user.
His medical problem was not life threatening and easy to treat but was affecting his arm and so affected his ability to care for himself, hence the need for admission. He was usually normally independent, worked full time, headed up a local charity but now suddenly found himself incredibly vulnerable.
He’d not want to make a fuss and he was unable to get out of his wheelchair to get to a toilet. He had been incontinent and had no food or drink for fear of needing the toilet again.
As I took him into a room to assess him, he grabbed hold of my hand, sobbed and begged me not to abandon him in “that place”. I couldn’t look him in the eyes, I was so ashamed of how we’d treated him this far. I managed to get him into a bed space, and as we undressed him, myself and the nurses were horrified how he’d already got excoriations from sitting in urine in his wheelchair for 18 hours.
His story is one of many happening all over the country. We all know how hard it is to sit in a waiting room for hours when transport gets delayed etc, but this is people who are unwell, in pain and already suffering.
The ED waiting room is a difficult and busy place to be. The corridor where patients wait is a busy chaotic environment with very little dignity. Both these areas are exactly the opposite of where we’d want our patients to be and almost the perfectly designed area to promote delirium.
How do staff feel when they are faced with this? I talked about this recently at a The Society for Acute Medicine conference in Belfast and lots of people spoke to me privately afterwards. All had some story where they had experienced something that had left them with similar emotions, of anger but also shame, guilt, embarrassment and failure. One doctor told me that they hadn’t had a DNAR conversation with the patient as they felt that the corridor wasn’t an appropriate place. There were visibly upset as they described arriving at a resuscitation attempt on this frail patient who had clearly been dying.
One doctor told me that a patient had asked them to go to the toilet and they’d spoken to the nurse. When they later returned to take more blood tests the patient was sobbing in distress after being incontinent as the nurse hadn’t yet had time and they felt wracked with guilt.
Another told me that they’d taken time off unwell and had now agreed not to see patients outside of the ward anymore as it had just become intolerable.
Lynsey Alexander - SAM AHP Lead
‘Get some rest you look exhausted’, a well meaning colleague says as they leave the office. Meant kindly I know. I also know: I am completely knackered. It’s Winter and our AMU is chaos. Whatever your profession, the pressure is only ramping up and finding the physical and mental energy needed to keep going is really tough. The sheer relentlessness of our AMUs coupled with bed pressures and the constant battle to provide good quality care is overwhelming. Precious days off are spent doing the bare essentials (dog walk, food shop, clean), trying to conserve some energy and readying myself for the next working week. This is a vicious cycle whereby resentment creeps in because work becomes the focus and I can’t remember the last time I did something for me.
The word Wellbeing is one we have heard much more often over the past few years. It means to be in a state of being comfortable, healthy or happy. At work we are encouraged to think about our wellbeing and to prioritise it. This is easier said than done, more often than not it falls somewhere near the bottom of the list of things to do. Until I hit that ever familiar brick wall and kick myself for allowing things to fall into a cycle of eat, sleep, work, repeat.
I am in a team lead position and was embarrassed to say I was finding things hard. I let things fall behind. I put work first. I chose not to do the things I wanted for fear of not coping at work, of being too tired, of not being able to support my team. I forgot the fundamental thing that I tell so many other people- If you don’t look after yourself, how will you look after others?
Acute Medicine is one of the most difficult jobs I have had but it is also the one where I feel most valued and where my contribution is celebrated. If you have other responsibilities on top of work such as looking after kids, or parents or others- you do not get to switch off when you get home.
Wellbeing will not be the same for everyone. And those little acts of self- care, that help us reach that state of wellbeing will also be different. What I have found useful is starting small. When things are overwhelming, don’t overwhelm yourself more, don’t set yourself unrealistic goals and do be kind to yourself for trying. ‘Comparison is the thief of joy’- do your thing, whatever that may be and remember consistency is key.
I am passionate about my job and I am passionate about Acute Medicine. I imagine anyone who works within healthcare, with that underlying volition to help others is equally as passionate. Putting yourself first does not mean failure to cope, nor does it mean you are not a compassionate person or a driven professional. I have a strong sense of purpose and remembering why I do what I do can really help on the harder days. So can tapping into the resource you do have-family, your colleagues, your friends, your Multi-disciplinary team.
Despite all of this there are times where things will still feel overwhelming and it’s difficult to know where to start. While we have come a long way when it comes to talking about our mental health, unfortunately there can still be a stigma attached that can stop us reaching out for help or reaching out to help someone else. SAM have compiled a list of resources that people may find useful. If you are reading this and you wish to share an idea that helps you and or something you think would help others then please get in touch 😊
What is Moral Injury?
The BMA published a report into moral injury after a survey in 2021 which outlines this nicely “Moral distress is defined as the psychological unease generated where professionals identify an ethically correct action to take but are constrained in their ability to take that action”.
We are feeling this increasingly whilst working in Acute Medicine. We know on a basic level that corridor care and leaving patients in the waiting room for hours is not the right care that they need, but we are powerless to change this on an individual level. Dr Trimble and I have written an editorial below and discussed some of the recent stories we have been told by members.
We are aware of the profound effect this can have on our members. It can cause a host of emotions including anger which can then be misplaced on colleagues or family members once we’ve left work. This combined with the guilt, shame and powerlessness can then contribute to mental health issues.
Editorial - Vicky Price & Michael Trimble
All UK based doctors will be familiar with the GMC’s instruction to ‘make the care of your patient your first concern’. Care is an interesting to word; it can mean to care for others or a degree of troubling anxiety, as in ‘worries and cares’. This ambiguity goes as far back as the word’s Latin origins in the 1st century AD. i It is ironic in the setting of 21st century health care to find that those who try to care for others are so burdened in their endeavours. Why should this be so? For most of us, from the day we enter medical school, and often long before, we hope to do something good, something to help people. At medical school and during training we are encouraged to ‘aspire to excellence.’ ii But then in our working life we find that the systems and structures of our institutions do not allow us to do so. Instead of aspiring to excellence, we instead find ourselves working with the normalization of deviance.iii This term was coined by sociologist Diane Vaughan when reviewing the Challenger space shuttle disaster. She used it to describe a situation where people within an organization become so accustomed to deviant behaviour that they don’t consider it as deviant; even though they far exceed their own rules for elementary safety. With safari ward rounds, patients in outlying wards, borders, and corridor beds now so routine practice as to be unremarkable, we are surely living with the normalization of deviance. There is tension between how we wish to practice and how we actually practice. Moral dilemmas arise when a caregiver must choose between incompatible courses of action, each of which has ethical justification; moral distress is the psychological impact which arises when the agent is clear about the ethically appropriate course of action, but institutional constraints make it difficult to implement. iv Beyond this is moral injury – the point is reached where individuals who are exposed to events that violate their moral values experience severe distress and even functional impairment.v
Though less often discussed than individual or professional ethics, institutions too have their ethical attributes.vi Pellegrino and Thomasma contrast commercially driven health care systems with those based on fiduciary trust and note how this can influence the practice of the clinicians working within. vii We could add to these bureaucratic systems, with a focus on the achievement of certain targets and this is perhaps more representative of the UK situation.
What can we do to change this? Ideally, a change in working environment and practices is required. We need adequately staffed units with physical and functional capacity for the work that is to be done. The Society is lobbying for this at every opportunity. As his been highlighted in recent political debate the model of healthcare delivery needs to be reviewed. However, even with political will and a well thought out plan, this is a long-term matter. In the meantime, we must support each other.
So how can we help each other? Somebody reaching out with kindness and compassion can be essential. The most basic way of listening to someone with cup of tea may sound painfully old fashioned and British, but it is understated in the importance of allowing someone some time to help someone make sense of their feelings. As outlined above, when faced with these working conditions, individuals can face a wide range of emotions and may not even recognise they are struggling.
In a system where there is increasing numbers of patients in increasingly more areas with increasingly more paperwork and administration, time is one thing that is getting hard to find, but so important to allow ourselves and others. As leaders we should be providing a role model in listening to concerns and providing support whilst simultaneously continuing to raise these issues.
As well as looking at what is provided by the local trusts, some people prefer to seek help elsewhere.
Nationally the following organisations all provide support to staff are;
- BMA counselling and support servicesviii
- NHS Practitioner Health (England only)ix
- National Wellbeing hub (Scotland)x
- Canopi (Wales)xi
- MDTA Northern Ireland, medical and training agency, support servicesxii
1 Encyclopedia of Bioethics. Revised edition. Edited by Warren Thomas Reich. 5 Volumes. New York: Simon & Schuster Macmillan, 1995. Pages 319-331.
2 Tooke, J. Aspiring to Excellence. Final Report of the Independent Inquiry into Modernising Medical Careers https://www.medschools.ac.uk/media/1934/aspiring-to-excellence.pdf
3 Price, MR. and Williams, TC. When Doing Wrong Feels So Right: Normalization of Deviance. Journal of Patient Safety 14(1):p 1-2, March 2018. | DOI: 10.1097/PTS.0000000000000157
4 Rorty, MV., Mills, AE., and Werhane, PH Institutional Practices, Ethics, and the Physician, in Rhodes, R., Francis, L. P., & Silvers, A. (Eds.). (2007). The blackwell guide to medical ethics. John Wiley & Sons
5 Griffin, B.J., Purcell, N., Burkman, K., Litz, B.T., Bryan, C.J., Schmitz, M., Villierme, C., Walsh, J. and Maguen, S. (2019), Moral Injury: An Integrative Review. JOURNAL OF TRAUMATIC STRESS, 32: 350-362. https://doi.org/10.1002/jts.22362
6 https://www.cambridge.org/core/services/aop-cambridge-core/content/view/BC197E7289B68C3169822D36890ED82D/S0963180100902032a.pdf/ethics-and-the-structures-of-healthcare.pdf
7 Pellegrino ED, Thomasma DC. For the patient’s good: the restoration of beneficence in health care, Oxford: Oxford University Press; 1988. p. 101
8 https://www.bma.org.uk/advice-and-support/your-wellbeing/wellbeing-support-services/counselling-and-peer-support-services
9 https://www.practitionerhealth.nhs.uk/
10 https://wellbeinghub.scot/
11 https://canopi.nhs.wales/
12 https://www.nimdta.gov.uk/professional-support-wellbeing/professional-support-wellbeing-contact-information/
What is SAM doing?
SAM continues to raise both the issue of corridor care and also the impact this has on all staff in national statements as well as in meetings with department of Health and NHS England.
We will use this website to highlight links to information on this topic as well as links to support services.
We are keen to hear from you if you have any suggestions for other ways SAM can help with this issue.
What can I do?
Whilst we do feel powerless to immediately alter the situation for patients in corridor care. It is important that we recognise the amazing care that we are still providing. Acute medicine is a specialty that looks after patients at the very beginning of their emergency attendance. They are often frightened, unwell and unsure of what will happen. Thanks to the skill and compassion of people working within acute medicine across the country we are often able to avoid admission, using Ambulatory pathways/ Same Day emergency Care, or for those needing admission, get rapid diagnosis (often using POCUS) and compassionately address their concerns. We may not be able to always control the location, we can control the conversation and patients will always appreciate that care and compassion no matter where they are located.
Other practical ways, continue to recognise that this is not normal and raise it whenever you can or feel able. Keep talking and get support fro yourself and others who need it. Help develop local support networks. Complete surveys that are sent out and be honest with your feelings on how this is affecting you. Let us know of any ideas you have that we can support from our National platform.
How to get support?
There are lots of articles describing this and organisations nationally that offer support
Keeping Yourself Well
Heading | Summary | Link |
Headspace app | Mindfulness app | Free until March 2025 for NHS staff |
NHS, Check my emotional and mental wellbeing | A self assessment for NHS staff that offers direct links to mental health support | Check my wellbeing – Self-assess your psychological and emotional wellbeing |
Work life central app | Positive and practical network to aim support a healthy work life balance | Free until March 2025 |
Calm app | Meditation and sleep support app | Blue light discount |
Active 10 | Track walking and earn rewards, sets goals to keep motivated | Free |
Couch to 5k | Running programme for absolute beginners | Free |
Couch to fitness | 9 week fitness plan, 30 minute sessions suitable for beginners with no equipment needed | Free |
NHS Quit Smoking app | Track progress, see how much your saving | Free |
Better Health – Healthier families – Healthier recipes | Recipe ideas for all the family to support a balanced diet | |
Runna app | Running and fitness personalised programme for all abilities | 2 weeks free trial with discount code – NHS2 |
Youtube Yoga BOHO Beautiful | Free yoga programes for all abilities | |
Youtube 5 minute medication you can do anywhere | Easy way to reset with 5 minute meditation | |
Tea and Empathy | National informal peer to peer support network on facebook |
Engaging in Support
Heading | Summary | Link |
#StayAlive | Suicide prevention recourse | |
Mind: What can I do to help myself cope | Different methods offered to help regain control well feeling overwhelmed. | |
Bright Sky | Support and information for anyone in a abusive relationship or concerned about someone who they know | |
Unmind app | Platform to empower staff to practically improve their mental health | |
Cruse Bereavement support | Support for people going through grief | |
GLADD | Association of LGBTQ+ Doctors and Dentists support page | |
Barclays money mentors | Learn new ways to save budget and make plans | |
British Nursing Association – mental health matters | Focus’s on mental health, healthy minds and coping mechanisms. Offers a free mind plan | |
RCN- Telephone counselling service | Offer short term brief therapy for members | Getting telephone counselling with the RCN | Royal College of Nursing |
Doctors support network | Free to join with a donation of choice- offers support to doctors, dentists and students | |
DocHealth | Psychotherapists support for doctors- offer confidential service | |
NHS Practitioner Health | Free and confidential NHS primary care mental health and addiction service | |
BMA wellbeing support | Offer a range of support including Vicarious trauma coping strategies and burnout questionnaires | |
The sick doctors trust | Offer support for doctors, dentists and students who are concerned about their sue of drugs and alcohol | |
Pharmacy Support | Provide guidance and advice on staying mentally healthy and reducing stress for pharmacists | Mental health and wellbeing in the pharmacy - Pharmacist Support |
Financial wellbeing support | NHS England support page for NHS employees seeking financial support |
Managers & Leaders Support/Education
Heading | Summary | Link |
NHS England: Looking after your teams health and wellbeing guide | Offers a guide to supporting your team to develop a wellbeing culture,- great for managers and leaders | NHS England » Looking after your team’s health and wellbeing guide |
NHS Employers: Supporting our NHS staff with burnout and stress | Webinar inline with “time to talk day”. Hear from industry experts and NHS organisations to gain a deeper understanding of burnout and stress. | Supporting our NHS staff with burnout and stress | NHS Employers |
Cruse: Greif first aid training | 3 module course to empower your workforce with tools and techniques. | |
NHS leaders and executive leaders wellbeing programme 2025 | In partnership with NHS England programme to enhance wellbeing of leaders, two different programmes available | NHS Leaders and Executive Leaders Wellbeing Programmes 2025 | NHS Employers |
Mental Health First Aid courses (MHFA) | Offers courses to workplaces, managers and individuals |