I remember the exact moment when the enormity of the Covid-19 crisis dawned on me. In the days before the pandemic was even called a pandemic, I was sitting in a hastily organised meeting of senior hospital colleagues. We were thrashing out how we might respond if the terrifying scenes emerging from northern Italy were to be replicated in our hospital. A critical care consultant stood up and said: “People have to understand that we are entering a war zone – we have to adapt accordingly.” There was a moment of stunned silence in the room. From somebody else these words might have seemed melodramatic, but from this wise, well-respected doctor, they struck a sobering chord.
With the latest UK government figures showing that there have been nearly 150,000 deaths where Covid-19 was mentioned on the death certificate, it’s understandable why some people compare the pandemic with a war. Indeed, daily life in the NHS is now peppered with military language: the frontline, gold command calls, redeployment, buddy systems. As a psychiatrist, the term that has resonated with me the most is “moral injury”.
Moral injury can be defined as the distress that arises in response to actions or inactions that violate our moral code, our set of individual beliefs about what is right or wrong. In the medical literature, moral injury has historically been associated with the mental health needs of military personnel, arising from their traumatic experiences during active service.
Moral injury is generally thought to arise in high-stakes situations so it’s no surprise that the term has gained traction in healthcare settings over the course of the pandemic, given that healthcare staff have been faced with extreme and sustained pressure at work. In many ways, working in the NHS over the past year has felt like being some sort of circus acrobat, contorting ourselves to balance various competing realities: the desire to provide high-quality care for all our patients in the context of limited resources, looking after our own health needs alongside those of our patients, trying to make peace with the responsibility we feel towards our loved ones while still upholding our duty of care to patients.
If we fail to deliver, particularly in high-stakes situations where we think things should have been done differently, it can shake us to our core. Our moral code transcends the relatively superficial responsibilities of our professional role: it gets to the heart of who we are as human beings. If we feel like our core values have been attacked, it can leave us feeling devastated and disillusioned.
Many people who have experienced moral injury describe a sense of powerlessness and betrayal. The latter is often cited by healthcare staff in relation to the government’s handling of the pandemic, be that over inadequate supplies of PPE, the perceived failure to enter lockdown soon enough or the real-terms pay cut for many NHS staff.
There is a genuine fear that, once the dust begins to settle on the pandemic, there will be an exodus of NHS staff who feel too broken by their experiences over the past year to continue in their role.
It’s important to recognise that moral injury is not a mental illness. Most people who experience moral injury will recover without the need for formal help. However, research tells us that moral injury can be associated with the development of serious mental health problems such as depression, post-traumatic stress disorder and suicidal behaviour – this is more likely to occur if people feel unprepared and unsupported.
We know that moral injury can result in various powerful feelings, primarily shame, guilt and anger. We can often tell if someone is feeling angry but it can be much harder to recognise those individuals who have become overwhelmed with shame or guilt. There can be a tendency for such individuals to disconnect from those around them and disengage from the task at hand. The danger of not recognising when people are finding things difficult, is that there can be a delay in getting appropriate help. Like many health issues, the longer that mental distress is left unaddressed, the harder it can then be to tackle. I’ve lost count of the times that people have told me that they’re “fine” when it turns out that they’re anything but.
From what we know so far, it appears a tiered support system that enables people to make sense of their experiences can be beneficial to those who have experienced moral injury – most will be helped by the simple act of a supportive conversation with somebody they trust, while others will require the expertise of specialist mental health services.
It’s also worth keeping in mind that, as well as causing injury, trauma can be responsible for growth, too. For some of us, meeting the challenges of the pandemic has helped us to increase our sense of professional competence and confidence. While it remains unclear exactly why some of us will be injured but others will thrive, we do know that we can encourage professional growth by optimising our levels of preparedness and support before, during and after high-stakes situations.
We’ve now been fighting the war against Covid-19 for more than a year. We are not soldiers, or heroes, or angels. We are healthcare professionals who are trying our best to do the job that we have been trained to do. But we cannot achieve this without adequate support and resources. We have a moral duty to minimise the risk of moral injury to healthcare staff. Not only because we want a sustainable workforce and an effective healthcare system but also because it’s simply the right thing to do.