- Moral injury occurs when institutionally required behavior fails to align with one’s moral principles.
- Since the pandemic, many clinicians have felt worsening moral distress.
- Moral injury can lead to impairment of function, feelings of guilt, shame, disgust, anger, suicidality, and longer-term psychological harm.
- NHS workers' decision to strike—an agonizing choice for most health professionals—underscores the severity of their distress.
I spend a lot of time at the moment reflecting on NHS clinicians' state of mind. It’s not just those seeking my help as a therapist. Not a day goes by without news reports on the low morale of doctors, nurses, and ambulance staff and the various degrees of distress and anger prompting their reluctant decision to strike.
These clinicians seem exhausted. Many are tearful, and some are so overwhelmed by the circumstances in which they are working that they can’t find the words to convey the experience. On BBC Radio 4’s Women’s Hour recently, two nurses became so distressed when they described a recent work shift that the interview had to be stopped.
I was reassured to see my preoccupation reflected on the front page of Monday’s The Guardian newspaper: "Top Scientist Issues Stark Warning on 'Shattered' Healthcare Workers."
Professor Jeremy Farrar, director of Wellcome and soon-to-be chief scientist of the World Health Organisation, warned, "If you stretch people beyond their resilience, they won’t be there when you need them." He is concerned about the lack of spare capacity globally but said it’s particularly true in the UK. "As you can see from the strikes, morale and resilience [are] very thin."
Since I started working to support clinicians at the beginning of the pandemic, I have been particularly worried by the level of moral distress that I've heard. This seems to be getting worse rather than better. Almost every clinician I see describes some level of what is now called "moral injury," with significant symptoms of depression: helplessness, hopelessness, despair, and in some cases, suicidality.
Moral injury occurs when an individual encounters circumstances that force them to act or tolerate circumstances that go against their ethical and professional values. It is a major contributor to stress. It can lead to impaired function and feelings of shame, guilt, disgust, and anger, sometimes leading to suicidal thoughts and longer-term psychological harm, particularly if the circumstances are prolonged. The levels of anguish and the sense of alienation people experience distinguish it from other mental health diagnoses such as PTSD.
Before the pandemic, severe work stress tended to be subsumed under "burnout"—a concept that hints at a lack of resilience, individual weakness, or at best, overwork. I find the concept of moral injury more useful because it places the problem at the intersection of the individual and the organisation within which they work. It lays bare the price that is paid by individuals when institutionally required behaviour fails to align with one’s moral principles and professional standards. Increasingly, this is about a lack of resources.
For example, many clinicians are attracted to work in the ICU because of the one-to-one care they can give patients. These patients might be the most severely ill in the hospital, but the satisfaction for the staff comes from knowing they are doing everything possible to help them.
All of this changed in the first weeks of the pandemic. Nurses who used to focus on one very ill patient are now expected to split their attention over about six very ill patients, often supervising inexperienced staff who had volunteered from other hospital areas. It was more like working in a Red Cross station in a war zone than anything they had previously experienced.
Now accident and emergency departments in the UK are likened to war zones. Almost every day, we hear of queues of ambulances waiting for hours to unload the critically ill, patients in trolleys lined up in corridors, and emergency operations taking place in store cupboards. Outside my local hospital in Leicester, the work of A&E has extended into a permanently parked bus and a tent.
“The system has crashed,” one young doctor told me earlier this week through juddering sobs, “and you can’t carry on week after week doing resuscitation.”
Like most of his colleagues, this doctor is a fierce supporter of the concept of the NHS. The huge gap between how he was trained to expect a modern health service to work and his lived experience is frightening. He knows he cannot give the patients around him the timely, respectful care they need and have every right to expect in a rich country in the 21st century.
Striking raises moral issues for professionals trained to put patients’ well-being above everything. The level of support for these strikes within the professions is growing. In the junior doctors’ ballot announced this week, 77 percent voted, with 98 percent voting to strike. Presumably, the moral distress they feel at the deteriorating conditions they are working in outweighs the moral distress they feel anticipating the impact of striking.
Listening to them—indeed just reading the banners displayed during the strikes of recent weeks—it is clear that pay is one concern among many, and pay itself is linked to their despair at the implication of increasing vacancies and the fact that the NHS is failing to recruit or retain clinicians in numbers that will prevent sub-standard, sometimes inhumane, care. Union leaders, too, describe the conditions at work and the growing number of resignations and vacancies as one of the main reasons for the strike.
People leave because they don’t feel they can do their job properly or sustain their physical and mental health in the present circumstances. Put bluntly, parts of the NHS have become dangerous places for staff and patients. Of course, some areas still offer exceptional service, but with beds blocked because of the lack of social care and patients waiting for hours to get into A&E, there will need to be a concerted effort by all responsible to reverse what has become a vicious circle.
Meanwhile, healthcare workers will continue to struggle with moral injury. Their fury, grief, and sheer exhaustion run deep.
If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 in the U.S., dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. Outside of the U.S., visit the International Resources page for suicide hotlines in your country. To find a therapist, visit the Psychology Today Therapy Directory.
British Medical Association, (2021)‘Moral Distress and Moral Injury: Recognising and Tackling it for UK Doctors’; https://www.bma.org.uk/media/4209/bma-moral-distress-injury-survey-repo….
The Guardian (20th February2023) https://www.theguardian.com/society/2023/feb/20/health-workers-shattere…