Moral Injury

Since the pandemic started, I have been offering psychological support to staff working on Covid19 wards in the local hospitals, as well as speaking to friends and family on the ‘frontline’.

 “I feel like a bad nurse”, or a variation on this theme, is probably the most common sentiment expressed – be it nurse, doctor, physio or whoever. These staff are out of their comfort zones, working in ways that can feel inhumane.

The nurse in question was not a bad nurse at all, but she was having to do things in a way that went against so much that she had learnt in her training and valued as a professional. In particular, she was struggling with the instruction to minimise the time spent in contact with the patients because of the risk of infection. Dressed in PPE, there’s no popping your head round the door to check someone’s ok, chat with them about their family, and give them a reassuring smile. Infection control is everything. Contact with the patient is reduced to carrying out key tasks, as your vulnerability to becoming infected yourself and the severity of infection is thought to be ‘dose’ related.  PPE makes communication difficult in any case: with the muffling caused by the uniform and the constant beeping of technology, it is hard to hear and vision can be restricted; and with a mask covering your lower face, the patient can only see your eyes, and these are behind the visor. It is not only hard to make meaningful contact with the patient, but it can be difficult to make yourself heard and call out to colleagues, and there can be a sense of isolation, a feeling of loneliness.

I imagine many of you have already read moving accounts of what staff in Covid-19 areas are up against in the alienating, depersonalising environments of adapted ITU wards,  looking after the most ill patients.  It would seem gratuitous for me to go into too much detail. Most people I’ve spoken to mention the overwhelming heat and sense of claustrophobia, the fact that once you’re in PPE, you can’t have a drink or nip off for a pee, the discomfort of wearing a properly fitting mask that sometimes cause facial sores, and the fact that you can’t touch your face, or wipe away the sweat and the tears.  ‘Donning and doffing’ often gets mentioned. This is the procedure of dressing oneself in the PPE, and –  even more complicated – removing it at the end of the shift, taking scrupulous care not to spread the virus, recognising that it will be present on every external surface of the protective gear. I find it hard enough to remember to keep two metres away from others and follow the one-way system in the supermarket, but these staff are having to remember hundreds of new rules and highly technical rituals that have to be followed if they are to keep their patients, their colleagues and themselves safe.

One of the most upsetting features of looking after Covid19 patients is the fact that families cannot be allowed in to see them. The staff find this heart-breaking and are full of poignant stories of acting as conduits between the dying patient and their loved ones, sometimes facilitating a telephone or video link for the last good-bye.  Such memories will haunt them.

Probably most difficult for clinical managers at the start of the pandemic was the responsibility for allocating inadequate resources to equally needy patients in the absence of sophisticated data about who would most benefit. Sadly, as most people now realise, the pandemic has caught the UK unprepared and years of austerity have resulted in us having many fewer hospital beds, including ITU beds, and, indeed medical staff, in relation to our population than almost any country in Europe. At a human level, this unprecedented crisis meant senior clinicians asking the staff in their teams – some of them very frightened – to undertake tasks for which they were poorly prepared, and, particularly at the start of the pandemic, poorly protected. A huge number of staff working on ITU at the peak of the crisis had been redeployed from other areas, what would normally be thorough specialist training condensed into one or two days. But even for permanent ITU staff, the nature of this virus, its high infectivity, the constant changing of procedures as people learned on their feet, meant that many of the tasks were unfamiliar and often counterintuitive.

The characteristics of this disease have horrified and taken even our most experienced and toughened health-workers by unpleasant surprise. Maybe it is always like this with a new entity: the sense of the unknown, learning on the job in real time, with real patients, with baffling questions emerging at a rate much higher than the answers.  Sudden unexplained death when the patient had seemed to be improving can be shocking and very frightening, with well-practiced ways of supporting life in the critically ill not having the same effect as they would in other disorders. It is difficult to hang on to therapeutic optimism and the fact that one is doing one’s best when there are so many deaths, some of them relatively young, some of them healthcare colleagues.

Until recently, I was not familiar with the concept of moral injury. It is a concept that comes from the military and aptly describes some of the deep conflicts that frontline healthcare workers have been experiencing during this pandemic. It describes the psychological distress that results from actions, or lack of them, which violate someone’s moral or ethical code.  It has been shown to be a major contributor to stress, as people struggle with negative thoughts about themselves – ‘I’m a bad nurse’ – as well as intense feelings of shame, guilt  or disgust.  If left to fester, these can lead to long standing mental health problems, PTSD, depression and even suicidal feelings. Sometimes the negativity and ‘immorality’ is attributed to someone in authority rather than themselves, but I must say, I haven’t come across this very much in the clinicians I’ve been working with – I guess a lot of it has been channelled into anger with the government and campaigning for more PPE. Most of the clinicians I’ve talked to say they couldn’t have got through it without the extraordinary selfless hard work of their teams, or the support of their clinical managers: and perhaps surprisingly, certainly impressively, most continue to say they love their job. But the costs to them will live on for a long time.

It is not by any means over. Most healthcare staff fear a second wave. Extra staff deployed from other areas have returned to the hard work of getting their abandoned services up and running and coping with the backlog and consequences of putting so many patients on hold. The staff in ITU are left with more patients than usual and trying to sort the complicated logistics of managing both Covid positive and Covid negative patients in their units. Resources, including drugs and PPE, are still scarce. Everyone is deeply tired.  Very few are sleeping well. Hospital managers are panicking about money and already talking about cutting clinical posts and other resources. Although there has already been much planning for a second wave, there is little energy for this, and I don’t think it’s an exaggeration to say that it is feared and dreaded.

“I just can’t face it,” one senior nurse told me. She will face it, of course, if she has to. In the meantime, the country needs to move on from clapping our frontline workers, to a more nuanced understanding of what these jobs entail. Collectively, we need to ask ourselves how we can contribute to developing our health service to support and value the thousands of clinicians who courageously return to this physically gruelling and emotionally costly labour each day?  We need to address the health of the system in which they work and ensure that they have the resources they need to do the job – and not just during a pandemic.