Moral injury and the current crisis in healthcare

In 2012, former soldier Simon Edwards was approached by Help for Heroes. The organisation wanted him to design a programme to help injured military veterans return to civilian life. When they discussed the emotional and psychological difficulties that many veterans experienced, the phrase on everyone’s lips was post-traumatic stress disorder – PTSD. But, says Edwards, ‘it became very apparent to me that there was something more profound going on.’

Many years later, Edwards came across the concept of moral injury. In psychological literature, this is described as the deep distress that people feel when they are obliged to act in a way that runs counter to their values; to how they see themselves. As an idea, he says, ‘it made perfect sense.’

Moral injury was first observed in veterans. An article by psychologist Brett Litz describes it as what happens when people perpetrate, fail to prevent, bear witness to or learn about acts that transgress moral beliefs or expectations. For example, moral injury is what happens when people who have authority over you require you to do things that you believe are fundamentally wrong.

Since 2012, Edwards had received a Churchill Fellowship to investigate treatments for PTSD, and had founded a charity, Serve On, to support former military personnel. Now, he became interested in moral injury in healthcare settings. He felt called on to help healthcare workers who were experiencing this life-altering injury to their sense of self. And he had an idea.

He remembered two other people he’d met through his Churchill Fellowship. Alison O’Connor was a clinical supervisor for therapists whose Fellowship investigated creative approaches to addressing trauma. Sophie Redlin was a GP whose Fellowship explored ways for communities to support people with mental health issues.

Edwards contacted them to ask if they were interested in collaborating on a project that addressed moral injury in healthcare settings. Maybe they could apply for Churchill Fellowship funding as a trio? As it turned out, they were the first group of people who had ever contacted the Churchill Fellowship to ask about working together.

‘I wasn’t that familiar with the idea of moral injury, despite being a medic working in the pandemic,’ Redlin explains. ‘Now I see the ways in which I was affected. It’s such a big thing that people don’t realise is going on for them.’

The pandemic had exacerbated existing issues in healthcare. NHS staff had been put in situations that they didn’t feel they’d been trained for. Huge numbers of staff were experiencing burnout; having to take time off; quitting healthcare for good. At the heart of the problem was a type of moral distress that nobody seemed to be talking about.

When the charity founder, GP, and therapist began to discuss the situation, something seemed to click. An idea came together. Inspired by his experience leading peer support groups, Edwards wanted to create a three-day retreat, where healthcare workers could begin to heal together. In her Churchill Fellowship, Redlin had studied the concept of the ‘talking circle’ within Native American and Alaska Native communities, a way of harnessing community to tackle individual distress. O’Connor wanted to invite a music therapist to run a session, to provide a different way for people to access what they were feeling. She says, ‘There was something about each of our individual approaches that, when we came together as a three, felt really special.’

As they envisioned it, the retreat would be a place where healthcare workers could make sense of their experience of moral injury during the pandemic, and of continuing to work in a sector where individuals face mounting pressures. It would be a space where individuals could begin to forgive themselves for the ways in which, in an impossible situation, they felt they had failed their own moral values.

The trio felt that gathering as a group was key to the process of healing. ‘Moral injury is a very human response to systemic failings. Working in a group creates more opportunity to normalise experience,’ says O’Connor. ‘Witnessing is part of recovery.’ Edwards adds, ‘It’s about individuals realising they’re not on their own and that they can talk about stuff they can’t even talk to their families about – in fact, especially can’t talk to their families about.’

The healthcare workers whom they invited to join the retreat were strangers to each other, but a feeling of trust and rapport quickly developed. On the second day, they held a talking circle about forgiveness. Each person in the circle named something they wanted to be forgiven for, and the group affirmed that they were forgiven. ‘I had not anticipated how powerful that would be,’ says Redlin.

The trio wanted to share the possibility of self compassion with the group. In times of stress, they encouraged participants to develop an inner voice, a way of talking to oneself, that was nurturing rather than critical. When people returned to their workplaces, the hope was that they would be equipped with new ways of coping.

The retreat participants stayed in touch using a WhatsApp group, and Edwards, Redlin and O’Connor organised online gatherings over Zoom. They’ve received multiple messages from participants describing how the retreat changed their perspectives on work and how they felt about themselves. One of the nurses got in touch to tell them that the ongoing relationships with people she’d met on the retreat had had a huge impact on her life.

‘She said, I know now that if I have a day where I’m struggling, or a shift that’s really tough, there is somewhere I can reach out to and I know somebody will respond. I’m not on my own with it,’ O’Connor relates.

The three Churchill Fellows have now set up a Community Interest Company together, Moral Injury Partnership. The first step is to run more retreats, so that more people can experience the benefits of their approach. They intend to gather more robust evidence that their methods work. They also hope that people who take part in the retreats will share the coping strategies they’ve learned within their workplaces. ‘It’s about empowering a community to support each other,’ says Redlin.

For the trio, NHS and care homes can do more, and intervene earlier, to prevent moral injury. ‘We want to build more of a culture of talking about things and trying to prevent these issues,’ says Redlin. ‘Could we start talking about these things in medical school; in nursing school?’

For some of those who are struggling, they know their approach won’t be enough. ‘But if we're looking at a system where everyone needs a one-on-one therapist appointment, speaking as an NHS GP, that's just not viable. And personally I don't think it's actually the best intervention for everybody,’ Redlin explains.

One thing all three worry about is that moral injury may become understood purely in terms of mental health, as just another ‘tick box’. But, they assert, suffering healthcare workers are not unwell, or inadequate. They are responding in a normal way to an untenable situation. People who work in healthcare want to be of service. But when this desire is in conflict with the priorities of the organisation they work for, they suffer.

The retreats give participants a safe space in which to let go of the weight they bear, and even become more resilient. ‘So often, we survive in the workplace by wearing a mask,’ says Edwards. But, he says, ‘Life is full of uncertainty. We're flawed, we make mistakes, we do the wrong thing. It's part of being a human being.’

Words by Lucy Peters.

If you’d like to know more or support the work of Moral Injury Partnership, please contact Simon Edwards on simon.edwards333@gmail.com