Addressing Moral Injury – Caring for the Carers

March 5, 2021 Phil Taylor, Chief Digital Officer, RLDatix and Dr. Tim McDonald, Chief Patient Safety and Risk Officer, RLDatix

Caption: Recent data reveals that doctors suffering far worse from depression, anxiety, stress, burnout or emotional distress than before the start of the pandemic.

This article originally appeared in the Clinical Services Journal (CSJ)

Clinicians and caregivers are facing unprecedented levels of extreme emotional stressors during the pandemic with moral injuries triggering acute levels of staff burnout. Phil Taylor and Dr. Timothy McDonald at RLDatix discuss what we can learn from past traumatic events and how they can be applied to healthcare to help safeguard the mental wellbeing of clinical staff during COVID-19 and beyond.

Staff burnout has long been an issue in healthcare and is now being exacerbated by the pandemic. Clinicians are seeing patients die, having to make heart-breaking decisions about who to treat, coping with lack of resources, shortages of ICU units and oxygen supplies, fearful of contracting the virus and infecting family, working long hours and treating extremely poorly patients. This is leading to increased depression, post-traumatic stress disorder and even suicides. Staff are suffering from significant ‘moral injuries’ which, if left untreated, may threaten the long-term capacity of the healthcare service. Research indicates that while for many people symptoms of PTSD resolve within several weeks between 10% and 20% of individuals exposed to trauma experience PTSD symptoms that persist and are associated with impairment. In military populations the rate for lifetime symptoms is estimated at about 8%[i], a significant figure.  

Recent data from the BMA reveals that 45.69% of the 7,000 doctors surveyed are suffering far worse from depression, anxiety, stress, burnout or emotional distress than before the start of the pandemic while 62.20% say they are overcome by far higher levels of fatigue and exhaustion.[ii]

In ‘Preventing a Parallel Pandemic – A National Strategy to Protect Clinicians’ Well-Being’[i] the authors make the point that we could be facing a parallel pandemic where, although those working on the frontline are remembered as heroes, the trauma they have lived through could mean a surge of emotional harm that equates to another pandemic. Just as patient safety has been a top priority for healthcare organisations for many years, the authors (all Doctors of Medicine) make the case for immediate action to address caregiver safety and wellbeing, bringing it equally to the top of the agenda. PTSD can be difficult to treat, and is extremely difficult to live with, and while it may not be possible to avoid the traumatic aspects of being a frontline clinician, we can at least ensure that every effort is made to provide the support and care for those affected.

Appropriate emotional support for caregivers

Research[ii] has found that an organisational approach to improving clinician well-being is more effective than strategies focusing on personal resilience. However, the design of initiatives to improve emotional well-being, which are often based on mental health models, can see low uptake due to deeply entrenched views about what is expected of clinicians. Many caregivers feel under pressure to live up to an unrealistic image of doctors and nurses where there is an expectation of personal sacrifice due to the general culture where self-care is seen as selfish and that physical and emotional exhaustion are part of the job.

A recently published article that appeared in the New England Journal of Medicine by Jo Shapiro, M.D., and Timothy B. McDonald, M.D., J.D.[iii] suggests some proactive steps healthcare organisations can take, that have been proven to support staff that are suffering stress, emotional exhaustion and burnout.

Peer-support programmes

Stigma and isolation can be barriers to staff asking for help, as vulnerability can been seen as a sign of weakness. Therefore, programmes that rely on self-referral often fail because clinicians are understandably reluctant to admit they need help. Introducing a peer-support model into the healthcare organisation frames emotional fallout as an occupational hazard, rather than a mental health problem, thereby reducing the stigma associated with receiving support. 

Introducing a peer-support model into the healthcare organisation frames emotional fallout as an occupational hazard, rather than a mental health problem, thereby reducing the stigma associated with receiving support. 

A peer-support model recognises that most caregivers prefer to confide in and receive support from their colleagues[iv] rather than from mental health professionals simply because peers understand their specific emotional stressors or ‘moral injuries’. Peer support also fosters a sense of camaraderie that is crucial to sustaining joy at work. Seeing that colleagues understand their emotional responses and have had similar experiences reduces the feelings of isolation and self-recrimination associated with distress

Funding for peer-support programme should cover adequate training, marketing internally and externally to attract the attention of those that could benefit from the service, and ideally, deploying personnel who can lead, dedicate time and act as an important ‘go to’ liaison for the programme.  

Safeguarding staff from moral injury   

In order to safeguard staff from moral injury, healthcare organisations need to focus on providing outreach to caregivers that may be in need of help and ensure that easily accessible ‘reach in’ services are also available. Regulators could help to make this happen with Duty of Care type legislation.

Healthcare leaders can prioritise reaching out to staff who may benefit from receiving help by developing systems for offering support to clinicians rather than relying on self-referral. Even when emotional support programmes exist, caregivers may avoid them because of barriers including concerns about confidentiality, stigma, and access.

Good outreach initiatives have a robust component that involves proactively reaching out to staff, taking away the stigma of receiving support and facilitating easy access to the programme. Stressful events such as the occurrence of medical errors can be used as triggers for peer-support[i]. Open and honest engagement encourages staff to come forward for support. Outreach triggers specific to COVID-19 might include clinical service on a coronavirus ward or the death of a patient with COVID-19, particularly if the patient was the caregiver’s colleague.

Although some emotional stress can be mitigated by means of preventive approaches such as peer-support programmes, some caregivers will need professional mental health services. These supplemental services must be confidential and accessible at any time. In these cases, having peer supporters make initial contact with affected caregivers has the advantage of normalising and facilitating connections to professional mental health resources in a discrete, sympathetic and constructive way.

Leadership accountability  

Emotional stress often comes from workplace issues that teams feel should be mitigated promptly and where leaders are not sufficiently sensitive to operations to effectively utilise the control invested in their role to reduce or mitigate these issues. These include the perception of inadequate or poorly distributed resources; unsustainable or unmanaged seasonal clinical volume; or even other colleagues’ unprofessional and problematic behaviour, including racist and sexist behaviour. Given that some situations cannot be simply or rapidly mitigated, such as the current situation with COVID-19, these need to be addressed by open and transparent communication with teams about the situation involving expert members of the team in informing the decision-making process and sharing details of what is being done, and what can be achieved. 

Healthcare leaders can demonstrate accountability for caregiver wellbeing by showing they are taking realistic and meaningful steps to assess and address concerns in order to treat the causes of emotional stress rather than merely the symptoms.

In these actions, even small actions, speak louder than words - statements from leaders about their desire to reduce burnout, in the absence of efforts to engage with staff in addressing its underlying causes, erode rather than build trust. Healthcare leaders can demonstrate accountability for caregiver wellbeing by showing they are taking realistic and meaningful steps to assess and address concerns in order to treat the causes of emotional stress rather than merely the symptoms.

Systems can highlight the risk of moral injuries

Leaders can empower clinicians to speak up about unsafe, highly stressful, or morally challenging workplace conditions and ensure that concerns are listened to and, wherever possible, acted on.

As part of this effort, processes can be developed that actively solicit feedback and suggestions for improvement from caregivers on the frontline, as well as channels through which staff can safely and anonymously report concerns.  Accountability among organisational leaders for support initiatives with sufficient investment of resources, elimination of access barriers, articulation of this accountability among executives and stakeholders, goes a long way towards the development of effective systems with mechanisms to measure and track the progress.

Results shared with staff and the Executive Board can demonstrate the systems effectiveness and leadership accountability. Leaders could also look at how they assess individual ward or departmental performance through consistent, Trust-wide accreditation schemes that promote self-assessment and self-improvement at all levels. This close involvement of caregivers increases a sense of self-worth and belonging, and boosts morale.

Steps to support well-being initiatives  

Systems, processes and frameworks can make a huge difference to the effectiveness of well-being, staff and patient safety initiatives. These are some practices that have proven to be highly effective, both in healthcare and other industries, and may help support current well-being initiatives.  

  • A CANDOR framework – healthcare organisations can earn trust through the Communication and Optimal Resolution (CANDOR) framework, which encourages open, honest, and clear communication that leads to deep, meaningful relationships with patients and their family members as they cope with the mental and emotional impact of a safety event. This dovetails well with the Duty of Candour ethos introduced by the Care Quality Commission (CQC) in 2014.  Additionally, CANDOR focuses on providing care for the caregiver through emotional first aid when an unexpected or traumatic event occurs.  
  • High Reliability attributes – traditional High Reliability organisations are airline companies or the oil and gas sector where the consequences of any errors are fatal.  Healthcare organisations too address life and death situations and can benefit from becoming High Reliability organisations themselves.  According to the Health & Safety Executive (HSE), High Reliability organisations share five distinct characteristics.[ii]  They all focus on:
    • Successful containment of unexpected events – having robust back-up systems in place in the event of failures and allowing people of expertise, irrespective of rank, to make important safety-related decisions.
    • Effective anticipation of potential failures – through engagement with  frontline staff to gain the ‘bigger picture’ of operations. 
    • Just Culture – High Reliability organisations understand the importance of speaking openly about problems and fixing them without blame. 
    • Learning orientation – a focus on continuous technical training, open communications of accident investigation outcomes and regularly updating procedures in line with the organisational knowledge base.
    • Mindful leadership - encourages regular engagement with staff and investing resources in safety management that balances profits with safety successfully. 
  • Introduce a Just Culture – Listed above as one of the attributes of a high reliability organisation, this resonates particularly at a time when leading healthcare organisations have written to Government Ministers, fearing the rise in litigation from COVID-19 deaths. They rightly argue it is fundamentally wrong that “healthcare professionals should suffer from the moral injury and long-term psychological damage that could result from having to make decisions on how limited resources are allocated, while at the same time being left vulnerable to the risk of prosecution for unlawful killing."[iii]

Caption: Healthcare professionals shouldn’t suffer from the moral injury and long-term psychological damage that could result from having to make decisions on how limited resources are allocated. 

A Just Culture is fair treatment of staff that supports a culture of fairness, openness and learning by making staff feel confident to speak up when things go wrong, rather than fearing blame.[i]  Supporting staff to be open about mistakes allows valuable lessons to be learnt so the same errors can be prevented from being repeated. 

Leaders who introduce a Just Culture strive to lead from the front with compassion, are visible – even virtually in these socially-distanced times - and make time to communicate change and help staff understand the reasons for change.

Hardwiring theory into everyday practice

Safeguarding caregivers requires investment in systems and processes that enable staff. For example, technology that automates processes to make life easier for clinicians while accurately recording patient incidents and successes. Leveraging the power of data is an ideal way to apply safety intelligence while driving high reliability and predictability around important caregiver safety processes.

The latest patient safety technology is ideally situated to identify when a clinician is likely to be suffering from ‘moral injury’ that may lead to burnout. This gives leaders the intelligence they need to proactively, sensitively and appropriately reach out to caregivers while providing the hard evidence to track the effectiveness of their support programmes. Data powers the systems and workflows that hardwire safeguarding theory into everyday practice.

In caring for the carers, regulators can take a pivotal role in ensuring that healthcare organisations apply the same processes, best practice principles and regulations of patient safety to the emotional wellbeing of clinicians and caregivers everywhere. If we want to avoid the predicted parallel pandemic of healthcare professionals that are too traumatised to carry on, as an industry, we need to act now.


[i] ‘A just culture guide’ published by NHS Improvement: https://improvement.nhs.uk/resources/just-culture-guide/#h2-about-our-guide

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