Support for clinicians with moral loss after the pandemic

Moral dimensions arising from the pandemic

When clinicians’ agency is constrained or undermined, as occurred in the pandemic, a sense of moral disorientation arises involving a loss of coherence between their sense of moral identity and imposed workplace requirements.1 As clinical ethicists working in large metropolitan hospitals in Australia we observed loss of moral identity and agency, moral distress, and moral injury among clinicians (box 1).

In the early phases of the pandemic, clinicians faced overwhelming numbers of patients, distressing triage decisions,12 and anxiety about their own and their family’s wellbeing.312 Across all areas of clinical practice, clinicians had to pivot from their ethical orientation of individual based patient centred care to accommodate public health ethical values of protecting population health and safety.13 Protecting their own safety at work became a pressing concern4 and an ethical imperative to preserve the health workforce.7 Governments and hospital leaders imposed constraints related to infection control, including personal protective equipment,35 visitor restrictions for inpatients,3 and disruptions to established and evidence based clinical care pathways.14 For example, delaying cancer surgeries and stopping cancer screening services because of government mandated restrictions was frustrating and distressing for staff who believed the long term consequences and burdens for these patients were greater than the benefits of preventing covid infections.15 Staff were redeployed, their responsibilities were changed, and in some situations they lost professional control over care decisions.135612

A UK mixed-methods survey study of 257 NHS staff in a single organisation and a US based qualitative study both found that staff burnout and moral distress were linked to loss of control of their work through imposed redeployment and new working patterns.15 A Chinese survey study similarly concluded that a substantial proportion of clinicians in the region were at risk of moral injury symptoms, and that clinicians caring for patients with covid-19 experienced a 28% greater risk than their colleagues caring for other patients.12 In Spain, a mixed methods study investigating the impact of the pandemic on intensive care staff found that participants perceived a “dehumanisation of care.”3

These studies highlight that being required to care for patients in ways that conflicted with fundamental health ethics values of patient centred care was distressing for clinicians, inducing feelings of shame and guilt and a loss of moral identity.1416 When clinicians are prevented from doing what they believe is right for their patient by a workplace authority (eg, health administrators or governments) their moral distress may lead to an erosion of trust in self and in leadership,17 feelings of professional powerlessness,5 and loss of professional integrity to be able to perform their role in accordance with their values.1 While many of the underlying factors causing distress among healthcare staff were present before the pandemic and are likely to continue as health systems face backlogs and workforce shortages, the intense and large scale disruption caused by covid-19 greatly worsened the situation, tipping clinicians into a state of moral loss.

Strategies to repair moral loss

Although the knowledge that structural efforts to improve healthcare staffing, the state of essential equipment, and working conditions (including fair rotas and vacation time approved well in advance, for example) are under way is essential for sustaining healthcare workers in the wake of the pandemic and to avoid future harm, these will not resolve the moral injury that individuals have experienced.

Similarly, systematic interventions that avoid clinicians having to ask for and seek out mental health support, such as peer programmes, reinforcement of social bonds between colleagues, and close monitoring and mentoring by supervisors or managers,813 are important but may not deal with moral injury. Such programmes are often grounded in a deficit perspective (an individual clinician is either lacking in psychological resources or resilience)18 and include approaches which promote cognitive reappraisal of a past event or response to a past event.19 However, moral injury and moral loss have been described not as a psychological injury or an erroneous appraisal of past experience but as an injury to a person’s moral integrity, professional identity, and sense of morality.18 Responding to moral injury requires strategies directed specifically at moral repair—for example, by acknowledging the norms that have been violated and listening to and validating emotions of guilt, shame, and resentment.20  

To ensure frontline clinicians are able to function optimally, recovery efforts should include individual level strategies designed to respond to moral loss as well as other psychological distress or poor mental health. Health leaders must acknowledge the moral dimensions of clinicians’ experiences during the pandemic and provide workplace support to counter reactive behaviours such as self-preservation responses, shutting down, disengaging, and avoiding patients.9 In healthcare, interventions that have been reported as mitigating moral distress include educational interventions, facilitated discussions of 30-60 minutes, specialist consultation services, multidisciplinary rounds, self-reflection, and narrative writing.21222324

Evidence is emerging linking workplace supports in the form of facilitated ethics discussions to increased moral agency and professional integrity for individual clinicians. This, in turn, empowers them to provide feedback and take on advocacy for change within their clinical community and at a systems and health policy level.16Facilitated clinical ethics discussion and debrief give clinicians an opportunity to name and process their reactions and experiences, to hear from others and therefore situate and make sense of their own experiences, and to make connections between their feelings of moral distress and possible causes. They enable clinicians to distinguish between moral distress arising from constraints on their practice that may or may not have been avoidable11 and situations where something of value was lost despite appropriate moral balancing informing the decision.25 Clinicians being able to name the ethical values they believe were being promoted, balanced, or traded-off and identify the constraints placed on them as decision makers, validates their experiences of moral loss and distress, normalises their responses and feelings, and creates a safe space for nurturing the understanding16 and fostering the resilience required for professional growth and repair to occur despite repeated adversity.926

Such discussions require a facilitator with specialised clinical ethics expertise who understands the scope and limits of their role, including the potential beneficial and adverse effects of the facilitation approach. Not all health institutions have this expertise readily available.2728 These discussions also take time, which is scarce in healthcare settings. However, the potential ongoing damage from failing to acknowledge feelings of resentment in staff who experienced a lack of support from health leaders is more burdensome than the repair work, especially as moral distress contributes to staff attrition.29 In the absence of a clinical ethicist, some of the benefits of facilitated ethics discussion can be achieved through other avenues such as clinician mentors or “buddies” who partner with colleagues and regularly check wellbeing,10 peer support groups, and professional supervision.28 These types of discussions nurture a supportive moral community of colleagues10 to assist clinicians to make sense of and re-orient their professional moral identity to care for patients.91028

The types of questions that can help clinicians to process and heal from experiences of moral loss, distress, and injury are underpinned by a disposition of empathic curiosity30 and of availability.10 The facilitator needs to convey genuine curiosity about the clinician’s experience and their capacity to understand and make sense of past moral challenges in their clinical practice (box 2). Importantly, the questions and focus of the facilitated ethics dialogue should be pitched at the level of the moral loss clinicians have experienced during the covid pandemic. They are designed to allow clinicians to identify ways of repairing their agency and sense of moral identity and to provide an avenue for clinicians to contribute to redesigning and restructuring processes necessary to repair systems of care after covid.

The process of attaining greater clarity and resolution about what was possible or not possible in the circumstances28 directly addresses experiences of moral loss. Giving clinicians the opportunity to discuss their experiences and interpretations and to listen to others’ perspectives and accounts provides an avenue for psychological repair26 and fosters the capacity to open up thinking rather than close down ways of responding and working with others.

The supportive and safe space of ethics discussions promotes the development of resilience to respond positively to distress and adversity caused by an ethically complex situation.26 In this way, facilitated ethics discussions offer the possibility of transformative learning and renewal both for individual clinicians and at the interface between the clinician and the health system in which they work.129 As such they should be considered as essential as structural change in policies to renew and repair our health services after covid-19.