Category Archives: The world

stethoscope and pen on medical chart

An Explanation of Moral Injury

Moral injury is defined as the profound psychological distress which results from actions, or the lack of them, which violate one’s moral or ethical code.

All in the medical profession sign up to a moral code that promises beneficence and non-maleficence. To not only do good for those in their care but to do no harm. The covid-19 pandemic as called on many frontline workers to push themselves to the brink. Previously called burnout, it is now recognised that when clinicians are asked, repeatedly, to act in a way, in a top-down administration, that is in opposition to their moral compass, it can cause untold damage.

Lack of resources such as beds, ventilators or medicines can mean frontline workers are unable to give the care they know can save lives, having to self-isolate while colleagues are stretched beyond capacity, knowing you’re not able to provide care for those with life limiting conditions because you’ve been re-deployed to give life-saving treatment or being involved in any keyworker roles under extreme pressure may lead to unnecessary risks being taken.

Ambulance technicians sitting in a queue instead of taking the next call, palliative care nurses preventing relatives from sitting with their loved ones as they die, admin staff sending out letters to push back patients’ outpatient appointments/surgery or any staff trying to follow policies set out by management that don’t appear to be patient centred are all events that could be considered potentially morally injurious. While in themselves, the worker may manage each individual event, it might be the build up or it might be the lack of support that can cause the most damage.

Man in scrubs looking depressed

Experience of potentially morally injurious events can lead to negative thoughts about oneself such as “I’m a terrible person” or “I’m not good enough” which can lead to shame and guilt. Although moral injury itself is not a mental illness, it can lead to symptoms of post-traumatic stress disorder when the sufferer can have flash back, lack of sleep and anxiety.

There is an increased risk of moral injury if the following occurs:

  1. Loss of life to a vulnerable person (e.g. child, elderly);
  2. Leaders are perceived to not take responsibility for the event(s) and are unsupportive;
  3. Staff feel unaware or unprepared for emotional/psychological consequences of decisions;
  4. The potentially morally injurious event occurs concurrently with exposure to other traumatic events (e.g. death of loved one);
  5. A lack of social support following the potentially morally injurious event.

Moral injury may not be restricted to frontline healthcare workers but can also be experienced by shop workers, teachers, social workers or prison staff for example. A lack of clear guidelines, training and resources mean they feel their own health is at risk and their unable to adequately care for those entrusted to them.

Man in scrubs sitting on the floor

Guilt or shame surrounding this issue can mean staff are reluctant to talk about it. Lack of support and a belief that it’s “all in a day’s work” means staff can turn to unhealthy coping mechanisms to manage the impact of moral injury.

It has been found that psychological screening or de-briefing is ineffective but the following may be beneficial for anyone exposed to potentially morally injurious events:

  1. Education and being made aware of the thoughts and feelings that could arise from the events and discussing the topic in advance to ensure staff are psychologically prepared;
  2. Seek informal support from colleagues, peer supporters, chaplains, managers etc as early as possible;
  3. If informal support doesn’t help and the events appears to be impacting the individuals daily life, professional help should be sought early. Sources of confidential support should be advertised within organisations so that it’s easily accessible.
  4. Those in leadership should have psychologically informed conversations upon checking in with their staff regularly. If they don’t poses the skills, trained peer-supporters could take on this role. These “check-ins” should involve encouraging staff to seek help whenever necessary.
  5. Frank discussion of events and team cohesion can help. It’s important to understand the impact on mental health as well as being aware psychological growth can be expected if staff do their best.
  6. Limiting exposure to media and unreliable news outlets and instead seeking information from trusted sources such as public health England and finding evidence-based coping resources (i.e. https://www.nhs.uk/oneyou/every-mind-matters/).

Experiencing moral injury and/or needing informal or professional support doesn’t make one person stronger or weaker than another.

Control, influence or concern—understanding these circles could transform your life!

In some ways I feel incredibly fortunate to have gone through some dark times, when I’ve been mentally ill, I’ve had access to therapy that’s taught me, not only how to manage my mental illness, but how to cope with all sorts of nasty things that are thrown at us over time! Don’t get me wrong, I don’t have it all sussed, but I noticed something being passed around on social media, I’d completely forgotten I’d learnt in therapy that people might find helpful in times like these.

woman sitting in front of computer head in hands worrying

Do you find yourself worrying about other people not wearing face masks properly? Or feeling that you’re not doing a good enough job home schooling your children because everyone else appears to have it more together than you? Does it feel like you’re winding yourself up into a frenzy but there isn’t really anything you can really do about it?! This could be because you’re spending energy in the wrong place.

Everything in our lives can be separated into circles depending on how much control, or influence we have over them. Click here to see a visual representation, below is a description of why it helps to do this:

Circle of control

These are the things you have full control over; spending time and energy on these things will have the biggest benefit on your life.

Circle of influence

These are things within your influence, there’s something you can do to have some impact on the outcome but that doesn’t mean the outcome will always be in your favour. You may gain some benefit but don’t spend too much energy on these things.

Circle of concern

Most people find themselves spending time worrying most about these things but is there any point expecting energy when there’s nothing you can do to really have much influence? There’s no harm in feeling concerned that there’s a global pandemic, this is called “being human” but put the concern in the right place—you can wash your hands after you’ve been the supermarket, you can remember to wash your face masks so you have a clean one ready to go out, you can ensure you’re leaving enough space when you’re in the post office queue but you can’t do anything about the R number!

If you find yourself feeling hopeless about everything, as seems to be quite common at the moment, please be reassured that this won’t last forever. Turn your eyes to the small things you are in control of and you’ll feel more empowered. Don’t worry about the bigger picture, that can feel quite daunting.

For each worry you have, think to yourself “how much control do I have?”, if it’s something you have full control over, put it in the centre circle, if you realise you have no control over it, put it in the outside circle and let go of worrying about it. If, however, you realise that you have some influence over it, it’s ok to put it in the middle circle but keep your concern in proportion. Don’t spend too much time worrying about it if there’s not really much you can do about it.

This technique is well known to help people in the general population as well as people struggling with mental illness. However, if you feel your anxiety might be out of proportion to size of the concern, it’s impacting your sleep or it’s preventing you from going about your everyday life, it’s important to seek professional support.

Partially empty Christmas table

It’s ok–Christmas hasn’t been cancelled!

Across the world many will be experiencing a different kind of Christmas this year. The Covid-19 pandemic has shocked the world. In the UK, it’s been announced that many cannot spend it with anyone outside their household. I’ve heard people say “Christmas is cancelled” so I’ve felt moved to respond.

This year, people have been hit with loss beyond anything anyone expected, we’re beginning to try and pick up the pieces, hoping Christmas will help, then we’ve been told, a week before Christmas that we need to change our plans. Some will be feeling frustrated about the guidelines “constantly changing” or anxiety about spending Christmas in an unplanned way, some will be annoyed at the Big Brother treatment or overwhelmed with managing last minute changes. Personally, I’m angry and sad at people who’re incapable at following simple guidance, it’s the small minority spoiling it for the majority who’re now having to follow more stringent rules.

What’s important is, whatever you’re feeling, it’s valid and you give yourself space to feel what you’re feeling, while also understanding what you can and can’t control.

Let me explain

Your feelings are your feelings and no one can tell you what you’re feeling. You might even be feeling relieved—sometimes it can help to write down how you’re feeling or talk about them with a trusted friend.

Problems come when you deny your feelings, push them down or try to swallow them, they’ll come out eventually; you or those around you will suffer. We can’t control the virus or the guidelines set out by the government. What we can control is how we respond and keeping a positive attitude helps makes it easier to cope. A positive attitude doesn’t mean, pretending everything is fine!

Perhaps this year, we can learn from the first Christ-mas…

During her last trimester, the government ordered Jesus’ mum to take a long journey. How unsettling would this have felt?! But she didn’t complain, she just did as she was told. Does this remind you of anything?

Joseph considers leaving Mary as he thought she’d been unfaithful but he didn’t, he trusted God. How many people are angry at God, just now? Blaming him and asking “how”? Or “why”? Perhaps, instead, we can say, “please be with us in our troubles”? For he will be there in a heart beat, as soon as we reach out.

There was no room for Mary and Joseph but an inn keeper let them stay in his cattle shed. This year, how will you help the homeless or those less fortunate?

Jesus was born and laid in an animal’s feeding trough. At this time of year, it’s usually a time of plenty where food and materialism takes centre stage. Some people, this year won’t have enough food, How great would it be if our children grew up appreciating the smaller things in life instead of ‘needing’ the lasting gadget due to FOMO?

Mug of hot chocolate with marshmallows and ginger bread biscuit

Christmas isn’t about presents, decorations or even about friends and family. This year, some people won’t be able to afford presents, may have lost their home and may not be spending it with anyone they choose but Christmas can be what you make it. Perhaps a lie-in, a spot of yoga, a walk and a Christmas movie while enjoying a some cheese and crackers will be what works this year? Perhaps you’d rather play an album of heavy rock a full volume while head banging and playing air guitar is your thing? This year is about doing what works!

It may not be possible to be with our loved ones this year but technology may bring us together. A short zoom call could bring some important connectivity.

Some thing good that occurred when the church building doors shut in March this year. Many churches are continuing the live stream all of the services. Perhaps this Christmas you could check out one of these? You’ll be able to find the Arch Bishop of Canterbury Justin Welby on Facebook by using this link. My local church St Mark’s will be live on YouTube with all the links accessible from the website.

Family decorating Christmas tree

But what about all those traditions?! Maybe this is the year you re-evaluate whether you really want to continue all those traditions, is it time for new traditions? This is a great time to have a good think about what’s really important, have you been doing things the same every year just because that’s what you’ve always done? If you come to the conclusion that you really want to stick with everything you’ve always done, there’s always next year; but maybe you’ll see things with fresh eyes and realise that you don’t have to do things the same every year!

Remember this is just one year, one day, don’t put so much pressure on it that it’s spoilt. Be honest with yourself and those around you about how you’re feeling but don’t let those feelings control you. You can chose how you respond.