Two in three UK doctors suffer ‘moral distress’ due to overstretched NHS, study finds

Denis Campbell

The Guardian

Originally posted 28 Dec 23

Two in three UK doctors are suffering “moral distress” caused by the enfeebled state of the NHS and the damage the cost of living crisis is inflicting on patients’ health, research has found.

Large numbers are ending up psychologically damaged by feeling they cannot give patients the best possible care because of problems they cannot overcome, such as long waits for treatment or lack of drugs or the fact that poverty or bad housing is making them ill.

A new survey found that 65% of doctors overall, including nearly four in five (78%) GPs and more than half (56%) of hospital doctors, have experienced “moral distress” as a direct result of situations they have encountered working in the NHS.

Seeing patients with malnutrition or hypothermia, or stuck on trolleys in A&E corridors asking for help or forced to choose between heating their home or getting a prescription dispensed are among the events triggering their distress, medics said.

“There’s barely a doctor at work in the NHS today who doesn’t see or experience this distress on a daily basis,” said Prof Philip Banfield, the leader of the British Medical Association.

The NHS is “impossibly overstretched”, has thousands of vacancies for doctors and has a quarter fewer doctors a head of population than Germany, he added.

“In practice that means we can almost never give the standard of care we would want, only ever the care we can manage. That takes its toll, as we see here,” Banfield said.

The info is here.

Key points:

The study also found that:

• Nearly half (47%) of doctors believe the cost of living crisis is contributing to their moral distress.
• 72% of doctors say being unhappy at work has affected their mental health.
• 85% of doctors have experienced fatigue as a result of their work.

Causes of moral distress:

• Doctors are often in situations where they have to make difficult decisions about who to treat first, or whether they can afford to give a patient the treatment they need.
• They may also feel that they are not able to provide the level of care that they would like to because of the lack of resources in the NHS.

Impact of moral distress:

• Moral distress can lead to burnout, depression, and anxiety.
• It can also make it difficult for doctors to continue working in the NHS.

The Moral Crisis of America’s Doctors

Wendy Dean & Elisabeth Rosenthal

The New York Times

Orignally posted 15 July 23

Here is an excerpt:

Some doctors acknowledged that the pressures of the system had occasionally led them to betray the oaths they took to their patients. Among the physicians I spoke to about this, a 45-year-old critical-care specialist named Keith Corl stood out. Raised in a working-class town in upstate New York, Corl was an idealist who quit a lucrative job in finance in his early 20s because he wanted to do something that would benefit people. During medical school, he felt inspired watching doctors in the E.R. and I.C.U. stretch themselves to the breaking point to treat whoever happened to pass through the doors on a given night. “I want to do that,” he decided instantly. And he did, spending nearly two decades working long shifts as an emergency physician in an array of hospitals, in cities from Providence to Las Vegas to Sacramento, where he now lives. Like many E.R. physicians, Corl viewed his job as a calling. But over time, his idealism gave way to disillusionment, as he struggled to provide patients with the type of care he’d been trained to deliver. “Every day, you deal with somebody who couldn’t get some test or some treatment they needed because they didn’t have insurance,” he said. “Every day, you’re reminded how savage the system is.”

Corl was particularly haunted by something that happened in his late 30s, when he was working in the emergency room of a hospital in Pawtucket, R.I. It was a frigid winter night, so cold you could see your breath. The hospital was busy. When Corl arrived for his shift, all of the facility’s E.R. beds were filled. Corl was especially concerned about an elderly woman with pneumonia who he feared might be slipping into sepsis, an extreme, potentially fatal immune response to infection. As Corl was monitoring her, a call came in from an ambulance, informing the E.R. staff that another patient would soon be arriving, a woman with severe mental health problems. The patient was familiar to Corl — she was a frequent presence in the emergency room. He knew that she had bipolar disorder. He also knew that she could be a handful. On a previous visit to the hospital, she detached the bed rails on her stretcher and fell to the floor, injuring a nurse.

In a hospital that was adequately staffed, managing such a situation while keeping tabs on all the other patients might not have been a problem. But Corl was the sole doctor in the emergency room that night; he understood this to be in part a result of cost-cutting measures (the hospital has since closed). After the ambulance arrived, he and a nurse began talking with the incoming patient to gauge whether she was suicidal. They determined she was not. But she was combative, arguing with the nurse in an increasingly aggressive tone. As the argument grew more heated, Corl began to fear that if he and the nurse focused too much of their attention on her, other patients would suffer needlessly and that the woman at risk of septic shock might die.

Corl decided he could not let that happen. Exchanging glances, he and the nurse unplugged the patient from the monitor, wheeled her stretcher down the hall, and pushed it out of the hospital. The blast of cold air when the door swung open caused Corl to shudder. A nurse called the police to come pick the patient up. (It turned out that she had an outstanding warrant and was arrested.) Later, after he returned to the E.R., Corl could not stop thinking about what he’d done, imagining how the medical-school version of himself would have judged his conduct. “He would have been horrified.”

The info is here, paywalled.

Summary: The article explores the moral distress that many doctors are experiencing in the United States healthcare system. Doctors are feeling increasingly pressured to make decisions based on financial considerations rather than what is best for their patients. This is leading to a number of problems, including:

• Decreased quality of care: Doctors are being forced to cut corners on care, which is leading to worse outcomes for patients.
• Increased burnout: Doctors are feeling increasingly stressed and burned out, which is making it difficult for them to provide quality care.
• Loss of moral compass: Doctors are feeling like they are losing their moral compass, as they are being forced to make decisions that they know are not in the best interests of their patients.

The article concludes by calling for a number of reforms to the healthcare system, including:

• Paying doctors based on quality of care, not volume of services: This would incentivize doctors to provide the best possible care, rather than just the most profitable care.
• Giving doctors more control over their practice:This would allow doctors to make decisions based on what is best for their patients, rather than what is best for their employers.
• Supporting doctors' mental health: Doctors need to be supported through the challenges of providing care in the current healthcare system.

Moral Shock

Stockdale, K. (2022).

Journal of the American Philosophical

Association, 8(3), 496-511.

doi:10.1017/apa.2021.15

Abstract

This paper defends an account of moral shock as an emotional response to intensely bewildering events that are also of moral significance. This theory stands in contrast to the common view that shock is a form of intense surprise. On the standard model of surprise, surprise is an emotional response to events that violated one's expectations. But I show that we can be morally shocked by events that confirm our expectations. What makes an event shocking is not that it violated one's expectations, but that the content of the event is intensely bewildering (and bewildering events are often, but not always, contrary to our expectations). What causes moral shock is, I argue, our lack of emotional preparedness for the event. And I show that, despite the relative lack of attention to shock in the philosophical literature, the emotion is significant to moral, social, and political life.

Conclusion

I have argued that moral shock is an emotional response to intensely bewildering events that are also of moral significance. Although shock is typically considered to be an intense form of surprise, where surprise is an emotional response to events that violate our expectations or are at least unexpected, I have argued that the contrary-expectation model is found wanting. For it seems that we are sometimes shocked by the immoral actions of others even when we expected them to behave in just the ways that they did. What is shocking is what is intensely bewildering—and the bewildering often, but not always, tracks the unexpected. The extent to which such events shock us is, I have argued, a function of our felt readiness to experience them. When we are not emotionally prepared for what we expect to occur, we might find ourselves in the grip of moral shock.

There is much more to be said about the emotion of moral shock and its significance to moral, social, and political life. This paper is meant to be a starting point rather than a decisive take on an undertheorized emotion. But by understanding more deeply the nature and effects of moral shock, we can gain richer insight into a common response to immoral actions; what prevents us from responding well in the moment; and how the brief and fleeting, yet intense events in our lives affect agency, responsibility, and memory. We might also be able to make better sense of the bewildering social and political events that shock us and those to which we have become emotionally resilient.

The info is here.

This appears to be a philosophical explication of "Moral Injury", as can be found multiple places on this web site.

How Bullying Manifests at Work — and How to Stop It

Ludmila N. Praslova, Ron Carucci, & Caroline Stokes

Harvard Business Review

Originally posted 4 NOV 22

While the organizational costs of incivility and toxicity are well documented, bullying at work is still a problem. An estimated 48.6 million Americans, or about 30% of the workforce, are bullied at work. In India, that percentage is reported to be as high as 46% or even 55%. In Germany, it’s a lower but non-negligible 17%. Yet bullying often receives little attention or effective action.

To maximize workplace health and well-being, it’s critical to create workplaces where all employees — regardless of their position — are safe. Systemic, organizational-level approaches can help prevent the harms associated with different types of bullying.

The term workplace bullying describes a wide range of behaviors, and this complexity makes addressing it difficult and often ineffective. Here, we’ll discuss the different types of bullying, the myths that prevent leaders from addressing it, and how organizations can effectively intervene and create a safer workplace.

The Different Types of Bullying

To develop more comprehensive systems of bullying prevention and support employees’ psychological well-being, leaders first need to be aware of the different types of bullying and how they show up. We’ve identified 15 different features of bullying, based on standard typologies of aggression, data from the Workplace Bullying Institute (WBI), and Ludmila’s 25+ years of research and practice focused on addressing workplace aggression, discrimination, and incivility to create healthy organizational cultures.

These 15 features can be mapped to some of the common archetypes of bullies. Take the “Screamer,” who is associated with yelling and fist-banging or the quieter but equally dangerous “Schemer” who uses Machiavellian plotting, gaslighting, and smear campaigns to strip others of resources or push them out. The Schemer doesn’t necessarily have a position of legitimate power and can present as a smiling and eager-to-help colleague or even an innocent-looking intern. While hostile motivation and overt tactics align with the Screamer bully archetype and instrumental, indirect, and covert bullying is typical of the Schemer, a bully can have multiple motives and use multiple tactics — consciously or unconsciously.

Caroline mediated a situation that illustrates both conscious and unconscious dynamics. At the reception to celebrate Ewa’s* national-level achievement award, Harper, her coworker, spent most of the time talking about her own accomplishments, then took the stage to congratulate herself on mentoring Ewa and letting her take “ownership” of their collective work. But there had been no mentorship or collective work. After overtly and directly putting Ewa down and (perhaps unconsciously) attempting to elevate herself, Harper didn’t stop. She “accidentally” removed Ewa from crucial information distribution lists — an act of indirect, covert sabotage.  

In another example, Ludmila encountered a mixed-motive, mixed-tactic situation. Charles, a manager with a strong xenophobic sentiment, regularly berated Noor, a work visa holder, behind closed doors — an act of hostile and direct bullying. Motivated by a desire to take over the high-stakes, high-visibility projects Noor had built, Charles also engaged in indirect, covert bullying by falsifying performance records to make a case for her dismissal.

The info is here.

What to Do If Your Job Compromises Your Morals

R. Carucci and L. N. Praslova

Harvard Business Review

Originally posted 29 APR 22

Here are two excerpts:

The emerging scholarship on reconciling the various terms used to describe responses to moral events points toward a continuum of moral harm. Of course, the complexity and variety of moral situations make any classification imperfect. Situations involving committing moral transgressions are more likely to lead to shame and guilt, while being a victim of betrayal is more likely to result in anger or sadness. In addition, there are also individual differences in sensitivity to morally distressing events, which can be determined by both biology and experience. Nevertheless, here is a useful summary:

• Moral challenges are isolated incidents of relatively low-stakes transgressions. For example, workers might be instructed to use lower-quality materials in creating a product (e.g., substituting a non-organic product when running out of organic). A manager may require an employee to stay late, as a rare exception. This may result in a somewhat distressing but transitory “moral frustration,” with moderate levels of anger or guilt.
• Moral stressors can lead to more significant moral distress. This may involve more substantial and/or regular moral transgressions — for example, a manager pushing employees to stay late several times every month, or an HR professional administering a morale survey knowing that the results will never be used, just like all the previous surveys. A dental practice may upsell patients on unnecessary, but not harmful treatments. This may result in negative moral emotions that are bothersome and might be lasting, but do not interfere with daily functioning. (However, in some nursing research, the experience referred to as “moral distress” is seen as very intense, possibly meeting the criteria for moral injury).
• Injurious events are the most egregious. Executives could pressure a manager into manipulating burned-out employees to regularly sacrifice their time off and well being, while the organization intentionally keeps positions open for months. A health care worker might be required to provide medical treatments that are likely to lead to more treatments even though a cure is available. Situations like these could result in a highly distressing moral injury in which negative moral emotions are sufficiently intense and frequent to interfere with daily functioning. In particular, a person may experience intense shame leading to self-isolation or self-harm, or may quit their job in disgust. This level of moral stress response is similar to and at least partially overlaps with post-traumatic stress disorder (PTSD).

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Moral injuries can leave lasting impacts on our psyche, but they don’t have to remain debilitating. Like other trauma and hurt, we can grow from them. We can find the resilience we need to rise above the injury and restore our moral centers. Sometimes we’re able to take the environments along on that journey, and sometimes we have to leave them. Either way, if you’re carrying the weight of moral injury, don’t wait until it overtakes your whole outlook on life, and yourself. Find the courage to face what you’ve experienced and done, and with it, reclaim the values you hold most dear.

The info is here.

Why nurses are raging and quitting after the RaDonda Vaught verdict

B. Kelman & H. Norman

www.npr.org

Originally published 5 APR 22

Emma Moore felt cornered. At a community health clinic in Portland, Ore., the 29-year-old nurse practitioner said she felt overwhelmed and undertrained. Coronavirus patients flooded the clinic for two years, and Moore struggled to keep up.

Then the stakes became clear. On March 25, about 2,400 miles away in a Tennessee courtroom, former nurse RaDonda Vaught was convicted of two felonies and now faces eight years in prison for a fatal medication mistake.

Like many nurses, Moore wondered if that could be her. She'd made medication errors before, although none so grievous. But what about the next one? In the pressure cooker of pandemic-era health care, another mistake felt inevitable.

Four days after Vaught's verdict, Moore quit. She said the verdict contributed to her decision.

"It's not worth the possibility or the likelihood that this will happen," Moore said, "if I'm in a situation where I'm set up to fail." In the wake of Vaught's trial ― an extremely rare case of a health care worker being criminally prosecuted for a medical error ― nurses and nursing organizations have condemned the verdict through tens of thousands of social media posts, shares, comments and videos. They warn that the fallout will ripple through their profession, demoralizing and depleting the ranks of nurses already stretched thin by the pandemic. Ultimately, they say, it will worsen health care for all.

Statements from the American Nurses Association, the American Association of Critical-Care Nurses, and the National Medical Association each said Vaught's conviction set a "dangerous precedent." Linda Aiken, a nursing and sociology professor at the University of Pennsylvania, said that although Vaught's case is an "outlier," it will make nurses less forthcoming about mistakes.

"One thing that everybody agrees on is it's going to have a dampening effect on the reporting of errors or near misses, which then has a detrimental effect on safety," Aiken said. "The only way you can really learn about errors in these complicated systems is to have people say, 'Oh, I almost gave the wrong drug because ...'"

"Well, nobody is going to say that now."

The info is here.

Moral Injury, Traumatic Stress, and Threats to Core Human Needs in Health-Care Workers: The COVID-19 Pandemic as a Dehumanizing Experience

Hagerty, S. L., & Williams, L. M. (2022)

Clinical Psychological Science. 

https://doi.org/10.1177/21677026211057554

Abstract

The pandemic has threatened core human needs. The pandemic provides a context to study psychological injury as it relates to unmet basic human needs and traumatic stressors, including moral incongruence. We surveyed 1,122 health-care workers from across the United States between May 2020 and August 2020. Using a mixed-methods design, we examined moral injury and unmet basic human needs in relation to traumatic stress and suicidality. Nearly one third of respondents reported elevated symptoms of psychological trauma, and the prevalence of suicidal ideation among health-care workers in our sample was roughly 3 times higher than in the general population. Moral injury and loneliness predict greater symptoms of traumatic stress and suicidality. We conclude that dehumanization is a driving force behind the psychological injury resulting from moral incongruence in the context of the pandemic. The pandemic most frequently threatened basic human motivations at the foundational level of safety and security relative to other higher order needs.

From the General Discussion

A subset of respondents added context to their experiences of moral injury in the form of narrative responses. These powerful accounts of the lived experiences of health-care workers provided us with a richer understanding of the construct of moral injury, especially as it relates to the novel context of the pandemic. Although betrayal is a known facet of moral injury from prior work (Bryan et al., 2016), our qualitative analysis suggests that dehumanization may also be a key phenomenon that underlies pandemic-related moral injury. Given our findings, we suggest that it may be important to attend to both betrayal and dehumanization when researching or intervening on the psychological sequelae of the pandemic. Our results support this because experiences of dehumanization in our sample were associated with greater symptoms of traumatic stress.

Another lens through which to view the experiences of health-care workers in the pandemic is through unsatisfied basic human motivations. Given the obvious barriers the pandemic presents to human connection (Hagerty & Williams, 2020), we had an a priori interest in studying loneliness. Our results indeed suggest that need of social connection appears relevant to the mental-health experiences of health-care workers during the pandemic such that loneliness was associated with greater traumatic stress, moral injury, and suicidal ideation. Echoing the importance of this social factor are findings from prior research suggesting that social connectedness buffers the association between moral injury and suicidality (Kelley et al., 2019) and buffers the impact of PTSD symptoms on suicidal behavior (Panagioti et al., 2014). Thus, our work further highlights lack of social connection as possible risk factor among individuals who face moral injury and traumatic stress and demonstrates its relevance to the mental health of health-care workers during the pandemic.

The research is here.

The Moral Injury of COVID: How Will Nurses Survive?

Diane M. Goodman

MedScape.com

Originally posted 11 FEB 22

Here are some excerpts:

According to recent statistics, 1 in 5 nurses have retired from active duty since the pandemic began. Far from feeling like heroes, nurses now feel exhausted, demoralized, underappreciated, and severely overworked. They are broken in ways that cannot be repaired.

Recently, an intensive care unit nurse abandoned his shift in the middle of the night and walked off into the unknown only to be found deceased 2 days later. What happened to this caregiver? Was his distress so severe he could not communicate pain? One can only wonder.

Nurses across the country are suffering from moral injury.

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This is what nurses feel prepared to do, but it violates their moral code.

Nurses may be unfamiliar with the process of rationing care, but the pandemic has changed that perspective. Nurses are now dealing with a form of rationing that leaves them miserable, in tears, and in persistent distress.

Providing care for 10 patients as opposed to a maximum of five forces nurses to make appalling decisions. Which patient needs my attention now? Will another patient die while I am in this room? How can I choose without suffering lasting trauma from my decisions?

Nurses have repeatedly been placed in impossible situations throughout the pandemic.

Remember the early days of PPE shortages? Nurses went without appropriate attire to protect their peers, at times with fatal results. 

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The profession prides itself on delivering the highest quality care it can. But when was the last time nurses felt that they were meeting this standard? How can they? They are working in a system where their own needs are minimized to meet the demands of an ongoing COVID patient population.

Moral injury, which can lead to moral trauma if unresolved, is different from burnout. 

Moral injury affects our sense of right and wrong. Moral injury is different because it represents a situation of witnessing care or offering care that conflicts with our internal compass. It is witnessing patients die without loved ones, repeatedly, or instituting a crisis standard of care that feels endless, although no earthquake, tornado, or bus accident has occurred. It is a feeling of running behind without the possibility of ever getting a break.

Moral injury is lasting distress that leads to feelings such as guilt, anger, and shame. There are true psychological implications for this type of angst. 

The info is here.

Moral Injury During the CDOVID-19 Pandemic

Borges LM, Barnes SM,  et al. 

Psychol Trauma. 2020 Aug;12(S1):S138-S140. 

doi: 10.1037/tra0000698. Epub 2020 Jun 4. PMID: 32496101.

Here is an excerpt:

Moral injury in COVID-19 may be related to, but is distinct from: 1) burnout, 2) adjustment disorders, 3)

depression, 4) traumatic stress/PTSD, 5) moral injury in the military, and 6) moral distress. Moral injury

may be a contributing factor to burnout, adjustment disorders, or depression, but they are not equivalent. The diagnosis of PTSD requires a qualifying exposure to a traumatic stressor, whereas experiencing a moral injury does not. Moral injury in the military has been addressed in a different population and particularly after deployment, and its lessons may not be generalizable to moral injury during COVID-19, which we are seeing acutely among healthcare workers. Finally, moral distress may be a precursor to moral injury, but the terms are not interchangeable. Previous literature has noted that moral distress signals a need for systemic change because it is generated by systemic issues. Thus, moral distress can serve as a guide for healthcare improvement, and rapid systemic interventions to address moral distress may help to prevent and mitigate the impact of moral injury.

While not a mental disorder itself, moral injury undermines core capacities for well-being, including a

sense of ongoing value-laden actions, competence to face and meet challenges, and feelings of belonging and meaning. Moral injury is associated with strong feelings of shame and guilt and with intense self-condemnation and a shattered core sense of self. Clinical observations suggest that uncertainty in decision-making may increase the likelihood or intensity of moral injury.

In the context of a public health disaster such as the COVID-19 pandemic, acknowledgement of the need

to transition from ordinary standards of care to crisis standards of care can be both necessary and helpful to 1) provide a framework upon which to make difficult and ethically fraught decisions and 2) alleviate some of moral distress and indeed moral injury that may otherwise be experienced in the absence of such guidance. The pandemic forces us to confront challenging questions for which there are no clear answers, and to make “lose-lose” choices in which no one involved ends up feeling satisfied or even comfortable. 

The info is here.

On Top of Everything Else, the Pandemic Messed With Our Morals

Jonathan Moens

The Atlantic

Originally posted 8 June 21

Here is an excerpt:

The core features of moral injury are feelings of betrayal by colleagues, leaders, and institutions who forced people into moral quandaries, says Suzanne Shale, a medical ethicist. As a way to minimize exposure for the entire team, Kathleen Turner and other ICU nurses have had to take on multiple roles: cleaning rooms, conducting blood tests, running neurological exams, and standing in for families who can’t keep patients company. Juggling all those tasks has left Turner feeling abandoned and expendable. “It definitely exposes and highlights the power dynamics within health care of who gets to say ‘No, I'm too high risk; I can't go in that patient's room,’” she said. Kate Dupuis, a clinical neuropsychiatrist and researcher at Canada’s Sheridan College, also felt her moral foundations shaken after Ontario’s decision to shut down schools for in-person learning at the start of the pandemic. The closures have left her worrying about the potential mental-health consequences this will have on her children.

For some people dealing with moral injury right now, the future might hold what is known as “post-traumatic growth,” whereby people’s sense of purpose is reinforced during adverse events, says Victoria Williamson, a researcher who studies moral injury at Oxford University and King’s College London. Last spring, Ahmed Ali, an imam in Brooklyn, New York, felt his moral code violated when dead bodies that were sent to him to perform religious rituals were improperly handled and had blood spilling from detached IV tubes. The experience has invigorated his dedication to helping others in the name of God. “That was a spiritual feeling,” he said.

But moral injury may leave other people feeling befuddled and searching for some way to make sense of a very bad year. If moral injury is left unaddressed, Greenberg said, there’s a real risk that people will develop depression, alcohol misuse, and suicidality. People suffering from moral injury risk retreating into isolation, engaging in self-destructive behaviors, and disconnecting from their friends and family. In the U.K., moral injury among military veterans has been linked to a loss of faith in organized religion. The psychological cost of a traumatic event is largely determined by what happens afterward, meaning that a lack of support from family, friends, and experts who can help people process these events—now that some of us are clawing our way out of the pandemic—could have serious mental-health repercussions. “This phase that we’re in now is actually the phase that’s the most important,” Greenberg said.

The article is here.

Betrayal vs. Nonbetrayal Trauma: Different Effects of Social Support & Emotion Regulation on PTSD Symptom Severity

N. Kline & K.M. Palm Read

Psychological Trauma: 

Theory, Research, Practice, and Policy. 

Abstract

Objective: Betrayal Trauma Theory posits that interpersonal traumas are particularly injurious when the perpetrator is a person that the victim previously trusted and was close to. A relevant protective factor to examine is social support, which may influence PTSD symptomology through its influence on emotion regulation. The aim of the current study was to examine differences in the associations between social support, emotion regulation, and PTSD symptom severity for survivors of betrayal trauma and nonbetrayal trauma. 

Method: Two hundred and 73 trauma survivors (age: M = 25.96 years, SD = 9.42 years; 80.2% female; 63.7% White) completed the anonymous, online survey. Results: Across both groups, emotion regulation mediated the relationship between social support and PTSD symptom severity. A multiple-samples SEM analysis showed that the betrayal group evidenced a weaker relationship between social support and emotion regulation. 

Conclusions: Findings suggest that survivors of high betrayal trauma may not engage with their social support in ways that foster emotion regulation skills. Therefore, for high betrayal trauma survivors specifically, group interventions that involve the survivor and close contact(s), may be particularly beneficial in enhancing emotion regulation and decreasing PTSD symptomology.

Impact Statement

Findings suggest social support may influence the impact of trauma through improving survivors’ ability to regulate emotions. Survivors of betrayal trauma may not seek out social support to the same extent or manner as nonbetrayal trauma survivors, limiting opportunities for beneficial emotional regulation practices and support. Clinicians should consider focusing on how interpersonal processes can facilitate greater understanding, acceptance, and regulation of emotions following betrayal trauma. 

The article is here.

Reframing Clinician Distress: Moral Injury Not Burnout

W. Dean, S. Talbot, and A. Dean
Fed Pract. 2019 Sep; 36(9): 400–402.

For more than a decade, the term burnout has been used to describe clinician distress. Although some clinicians in federal health care systems may be protected from some of the drivers of burnout, other federal practitioners suffer from rule-driven health care practices and distant, top-down administration. The demand for health care is expanding, driven by the aging of the US population. Massive information technology investments, which promised efficiency for health care providers, have instead delivered a triple blow: They have diverted capital resources that might have been used to hire additional caregivers, diverted the time and attention of those already engaged in patient care, and done little to improve patient outcomes. Reimbursements are falling, and the only way for health systems to maintain their revenue is to increase the number of patients each clinician sees per day. As the resources of time and attention shrink, and as spending continues with no improvement in patient outcomes, clinician distress is on the rise. It will be important to understand exactly what the drivers of the problem are for federal clinicians so that solutions can be appropriately targeted. The first step in addressing the epidemic of physician distress is using the most accurate terminology to describe it.

Freudenberger defined burnout in 1975 as a constellation of symptoms—malaise, fatigue, frustration, cynicism, and inefficacy—that arise from “making excessive demands on energy, strength, or resources” in the workplace. The term was borrowed from other fields and applied to health care in the hopes of readily transferring the solutions that had worked in other industries to address a growing crisis among physicians. Unfortunately, the crisis in health care has proven resistant to solutions that have worked elsewhere, and many clinicians have resisted being characterized as burned out, citing a subtle, elusive disconnect between what they have experienced and what burnout encapsulates.

In July 2018, the conversation about clinician distress shifted with an article we wrote in STAT that described the moral injury of health care. The concept of moral injury was first described in service members who returned from the Vietnam War with symptoms that loosely fit a diagnosis of posttraumatic stress disorder (PTSD), but which did not respond to standard PTSD treatment and contained symptoms outside the PTSD constellation. On closer assessment, what these service members were experiencing had a different driver. Whereas those with PTSD experienced a real and imminent threat to their mortality and had come back deeply concerned for their individual, physical safety, those with this different presentation experienced repeated insults to their morality and had returned questioning whether they were still, at their core, moral beings. They had been forced, in some way, to act contrary to what their beliefs dictated was right by killing civilians on orders from their superiors, for example. This was a different category of psychological injury that required different treatment.

The article is here.

Suicides of two health care workers hint at the Covid-19 mental health crisis to come

Wendy Dean
statnews.com
Originally posted 30 April 2020

Here is an excerpt:

Denial, minimizing, and compartmentalizing are essential strategies for coping with a crisis. They are the psychological tools we reach for over and over to get through harrowing situations. Health care workers learn this through experience and by watching others. We learn how not to pass out in the trauma bay. We learn to flip into “rational mode” when a patient is hemorrhaging or in cardiac arrest, attending to the details of survival — their vital signs, lab results, imaging studies. We learn that if we grieve for the 17-year-old gunshot victim while we are doing chest compressions we will buckle and he will die. So we shut down feeling and just keep doing.

What few health care workers learn how to do is manage the abstractness of emotional recovery, when there is nothing to act on, no numbers to attend, no easily measurable markers of improvement. It is also hard to learn to resolve emotional experiences by watching others, because this kind of intense processing is a private undertaking. We rarely get to watch how someone else swims in the surf of traumatic experience.

Those on the frontlines of the Covid-19 pandemic, especially those in the hardest-hit areas, have seen conditions they never imagined possible in the country with the most expensive health care system in the world. Watching patients die alone is traumatic. Having to choose your own safety over offering comfort to the dying because your hospital or health care system doesn’t have enough personal protective equipment to go around inflicts moral injury. When facing the reality of constrained resources and unthinkable choices, working to exhaustion, and caring for patients at great personal risk, the only way to get through each shift is to do what is immediately at hand.

The info is here.

Hospitals prepare for wave of mental health disorders among their workers

Del Quentin Wilber
The Los Angeles Times
Originally posted May 6, 2020

Here is an excerpt:

Mental health practitioners pointed to the suicide late last month of Dr. Lorna Breen as a warning flare. Colleagues said the 49-year-old Breen, an emergency room physician at NewYork-Presbyterian Allen Hospital in Manhattan, took her life after becoming overwhelmed by the volume of coronavirus patients who died on her watch.

“People at these elite medical institutions are talented, disciplined, strong and resilient,” said Dr. Jeffrey Lieberman, the chair of psychiatry at Columbia University Medical Center, where Breen was an assistant professor of emergency medicine. “But everyone has a breaking point. Tragically, in her case, her dedication pushed her past the breaking point.”

Healthcare professionals said the potential for trouble is particularly acute in New York, which has emerged as ground zero in the U.S. for COVID-19, the disease caused by the coronavirus.

Its hospitals have been crushed by an onslaught of severely ill patients. With no proven treatments or cures, physicians and nurses say they have often felt powerless to prevent the sickest from dying. Nearly 14,000 people have perished from the disease in the city, health officials say. During the height of the outbreak a month ago, doctors at Mt. Sinai Hospital were reporting at least 20 deaths a day. Typically, the hospital has one or two.

“The mortality that even veteran clinicians are witnessing has been massive and devastating to healthcare workers,” Lieberman said.

The info is here.

COVID-19 Is Making Moral Injury to Physicians Much Worse

Wendy Dean
Medscape.com
Originally published 1 April 20

Here is an excerpt:

Moral injury is also coming to the forefront as physicians consider rationing scarce resources with too little guidance. Which surgeries truly justify use of increasingly scarce PPE? A cardiac valve replacement? A lumpectomy? Repairing a torn ligament?

Each denial has profound impact on both the patients whose surgeries are delayed and the clinicians who decide their fates. Yet worse decisions may await clinicians. If, for example, New York City needs an additional 30,000 ventilators but receives only 500, physicians will be responsible for deciding which 29,500 patients will not be ventilated, virtually assuring their demise.

How will physicians make those decisions? How will they cope? The situation of finite resources will force an immediate pivot to assessing patients according to not only their individual needs but also to society's need for that patient's contribution. It will be a wrenching restructuring.

Here are the essential principles for mitigating the impact of moral injury in the context of COVID-19. (They are the same as recommendations in the time before COVID-19.)

1. Value physicians

a. Physicians are putting everything on the line. They're walking into a wildfire of a pandemic, wearing pajamas, with a peashooter in their holster. That takes a monumental amount of courage and deserves profound respect.

The info is here.

Treating “Moral” Injuries

Anna Harwood-Gross
Scientific American
Originally posted 24 March 20

Here is an excerpt:

Though PTSD symptoms such as avoidance of reminders of the traumatic event and intrusive thought patterns may also be present in moral injury, they appear to serve different purposes, with PTSD sufferers avoiding fear and moral injury sufferers avoiding shame triggers. Few comparison studies of PTSD and moral injury exist, yet there has been research that indirectly compares the two conditions by differentiating between fear-based and non-fear-based (i.e., moral injury) forms of PTSD, which have been demonstrated to have different neurobiological markers. In the context of the military, there are countless examples of potentially morally injurious events (PMIEs), which can include killing or wounding others, engaging in retribution or disproportionate violence, or failing to save the life of a comrade, child or civilian. The experience of PMIEs has been demonstrated to lead to a larger range of psychological distress symptoms, including higher levels of guilt, anger, shame, depression and social isolation, than those seen in traditional PTSD profiles.

Guilt is difficult to address in therapy and often lingers following standardized PTSD treatment (that is, if the sufferer is able to access therapy). It may, in fact, be a factor in the more than 49 percent of veterans who drop out of evidence-based PTSD treatment or in why, at times, up to 72% of sufferers, despite meaningful improvement in their symptoms, do not actually recover enough after such treatment for their PTSD diagnosis to be removed. Most often, moral injury symptoms that are present in the clinic are addressed through traditional PTSD treatments, with thoughts of guilt and shame treated similarly to other distorted cognitions. When guilt and the events it relates to are treated as “a feeling and not a fact,” as psychologist Lisa Finlay put it in a 2015 paper, there is an attempt to lessen or relieve such emotions while taking a shortcut to avoid experiencing those that are legitimate and reasonable after-wartime activities. Continuing, Finlay stated that “the idea that we might get good, as a profession, at talking people out of guilt following their involvement in traumatic incidents is frighteningly short-sighted in more ways than one.”

The info is here.

Managing mental health challenges faced by healthcare workers during COVID-19 pandemic

Greenberg N., & others
BMJ 2020; 368 :m1211

Here is an excerpt:

Moral injury

Moral injury, a term that originated in the military, can be defined as the psychological distress that results from actions, or the lack of them, which violate someone’s moral or ethical code.1 Unlike formal mental health conditions such as depression or post-traumatic stress disorder, moral injury is not a mental illness. But those who develop moral injuries are likely to experience negative thoughts about themselves or others (for example, “I am a terrible person” or “My bosses don’t care about people’s lives”) as well as intense feelings of shame, guilt, or disgust. These symptoms can contribute to the development of mental health difficulties, including depression, post-traumatic stress disorder, and even suicidal ideation. Equally, some people who have to contend with significant challenges, moral or traumatic, experience a degree of post-traumatic growth,3 a term used to describe a bolstering of psychological resilience, esteem, outlook, and values after exposure to highly challenging situations. Whether someone develops a psychological injury or experiences psychological growth is likely to be influenced by the way that they are supported before, during, and after a challenging incident.

Moral injury has already been described in medical students, who report great difficulty coping with working in prehospital and emergency care,4 where they were exposed to trauma that they felt unprepared for. This may be similar to the unprecedented nature of the challenges healthcare staff are currently facing. In the UK, most NHS staff may have felt, with some justification, that with all its faults, the NHS gives the sickest people the greatest chance of recovery. As such, staff should and usually do feel that it is something to be proud of.

The huge current effort to ensure adequate staffing and resources may be successful, but it looks likely that during the covid-19 outbreak many healthcare workers will encounter situations where they cannot say to a grieving relative, “We did all we could” but only, “We did our best with the staff and resources available, but it wasn’t enough.” That is the seed of a moral injury. Not all staff members will be adversely affected by the challenges ahead (table 1) but no one is invulnerable, and some healthcare workers will hurt, perhaps for a long time, unless we begin now to prepare and support our staff.

The info is here.

Italian nurse with coronavirus dies by suicide over fear of infecting others

Yaron Steinbuch
nypost.com
Originally published 25 March 20

A 34-year-old Italian nurse working on the front lines of the coronavirus pandemic took her own life after testing positive for the illness and was terrified that she had infected others, according to a report.

Daniela Trezzi had been suffering “heavy stress” amid fears she was spreading the deadly bug while treating patients at the San Gerardo Hospital in Monza in the hard-hit region of Lombardy, the Daily Mail reported.

She was working in the intensive care unit while under quarantine after being diagnosed with COVID-19, according to the UK news site.

The National Federation of Nurses of Italy expressed its “pain and dismay” over Trezzi’s death, which came as the country’s mounting death toll surged with 743 additional fatalities Tuesday.

“Each of us has chosen this profession for good and, unfortunately, also for bad: we are nurses,” the federation said.

The info is here.

Docs Decry ‘Moral Injury’ From Financial Pressures Of Health Care

Melissa Bailey
Kaiser Health News
Originally published 4 Feb 20

Here are two excerpts:

But “the real priority is speed and money and not our patients’ care,” Corl said. “That makes it tough for doctors who know they could be doing better for their patients.”

Dean said people often frame burnout as a personal failing. Doctors get the message: “If you did more yoga, if you ate more salmon salad, if you went for a longer run, it would help.” But, she argued, burnout is a symptom of deeper systemic problems beyond clinicians’ control.

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“The health system is not set up to help patients. It’s set up to make money,” he said.

The best way to approach this problem, he said, is to help future generations of doctors understand “how decisions made at the systems level impact how we care about patients” — so they can “stand up for what’s right.”

Whether these experiences amount to moral injury is open for discussion.

Cynda Rushton, a nurse and professor of clinical ethics at Johns Hopkins University, who has studied the related notion of “moral distress” for 25 years, said there isn’t a base of research, as there is for moral distress, to measure moral injury among clinicians.

But “what both of these terms signify,” Rushton said, “is a sense of suffering that clinicians are experiencing in their roles now, in ways that they haven’t in the past.”

Dean grew interested in moral injury from personal experience: After a decade of treating patients as a psychiatrist, she stopped because of financial pressures. She said she wanted to treat her patients in longer visits, offering both psychotherapy and medication management, but that became more difficult. Insurers would rather pay her for only a 15-minute session to manage medications and let a lower-paid therapist handle the therapy.

The info is here.

Autonomy, mastery, respect, and fulfillment are key to avoiding moral injury in physicians

Simon G Talbot and Wendy Dean
BMJ blogs
Originally posted 16 Jan 20

Here is an excerpt:

We believe that distress is a clinician’s response to multiple competing allegiances—when they are forced to make a choice that transgresses a long standing, deeply held commitment to healing. Doctors today are caught in a double bind between making patients’ needs the top priority (thereby upholding our Hippocratic Oath) and giving precedence to the business and financial frameworks of the healthcare system (insurance, hospital, and health system mandates).

Since our initial publication, we have come to believe that burnout is the end stage of moral injury, when clinicians are physically and emotionally exhausted with battling a broken system in their efforts to provide good care; when they feel ineffective because too often they have met with immovable barriers to good care; and when they depersonalize patients because emotional investment is intolerable when patient suffering is inevitable as a result of system dysfunction. Reconfiguring the healthcare system to focus on healing patients, rebuilding a sense of community and respect among doctors, and demonstrating the alignment of doctors’ goals with those of our patients may be the best way to address the crisis of distress and, potentially, find a way to prevent burnout. But how do we focus the restructuring this involves?

“Moral injury” has been widely adopted by doctors as a description for their distress, as evidenced by its use on social media and in non-academic publications. But what is at the heart of it? We believe that moral injury occurs when the basic elements of the medical profession are eroded. These are autonomy, mastery, respect, and fulfillment, which are all focused around the central principle of purpose.

The info is here.