CMDFA NSW Conference on Moral Injury

13 MINUTE READ

from Luke’s Journal 2021 | Fire in the Belly 2021 | Vol.26 No.1

As a career, nursing has allowed me into the most privileged of places humanity can offer:

• I have been present with the rich undergoing overwhelming medical procedures, 
• stayed with the poor in their time of fear, 
• been a buffer when health news dealt a harsh blow,
• sat with distraught parents, 
• lingered as a teen realised a whole new vocabulary involving scarves, hair loss and sore gums, 
• and helped gather the chaos of a split second car crash into some form of repair turning terror and fear back towards life, love and hope. 
• I have sat with those after a weather disaster attempting to make some kind of sense of the national devastation enveloping them while recognising quietly that there is no sense to be made. 
• I have delighted in hearing the first breath of a newborn, 
• and gently stroked the hand of someone else while listening to their last. 

I am comfortable in acute trauma, ICU and emergency departments, which are highly reliant on complex monitors, complicated machines and abundant resources. 

I am also comfortable in primary health care settings in remote regions where there is no currency, electricity or politics. 

I have also been a first responder, landing on an island that had only hours earlier been literally flattened by a hurricane¹ (category 5), which hovered for three days and nights to completely destroy the buildings, infrastructure and killed over 1500 people. I delivered medical assistance to those affected in the immediate aftermath. 

Am I burnt out? Fatigued? Or edging into Post Traumatic Stress Disorder? Nope. 

Clinically, I am doing well, but I do have memories and thoughts that wander back and challenge me – well, at a deep moral level.

‘Moral Injury’ has been defined as profound psychological distress that results from action or lack thereof, which violates a person’s moral or ethical code. Essentially, one’s core morals or core values have been injured or even violated leaving a residual feeling of being powerless, frustrated or sad. Unlike PTSD, Moral Injury is not classified as a mental illness. This in itself is a relief for healthcare workers today.

“Unlike PTSD, Moral Injury is not classified as a mental illness. This in itself is a relief for healthcare workers today.”

The term moral injury and its related expressions; complexity, ambiguity, distress, residue, courage and resilience², came from a military background where people had been given instructions to follow, yet had little or no say in the matter or its consequences. 

Although soldiers have an extraordinary capacity to follow orders regardless of the outcomes, at times nurses are sometimes caught having to follow orders they are very uncomfortable with, and yet are expected to resurface with clear conscience and voiceless memories on the next shift.

A range of factors can contribute to moral injury in nursing, which include:

• poor communication, 
• lack of input into clinical decisions, 
• disagreements with physicians about patient care, unsafe staffing levels
• inappropriate use of resources. 

When nurses find themselves in situations where they feel they cannot live up to their own values, or where their teams are not meeting high standards of care they may experience negative feelings such as guilt, shame, being voiceless and devalued.³ 

Moral injury from a first responder’s perspective takes on further layers of complexities. Some of these include:

• initial jetlag, 
• unknown international medical team, 
• instant frontline speed, 
• continuous 12-hour shifts, 
• unknown cultural etiquette, 
• language barriers, new routines, 
• overwhelming trauma, 
• the possibility of no initial electricity or clean sanitation, 
• and an exhausted population swimming in crisis. 

Let me take you to an island – not too far away and not too long ago 

I was present as a primary health care worker and educator. During a visit to a remote village I was asked to see a mother with a 3-day old baby for a check-up. Working in this capacity brings its own series of barriers: walking ten times further than you were initially led to believe, being aware of security and feeling responsible for venturing with another team member, carrying a heavy backpack of equipment, heat and humidity, and difficult-to-traverse terrain. Nevertheless, we were led to a dirty run-down hut, off the ground with a broken ladder to the open entry. It was barely waterproof and clad with bedsheets carelessly strung around. Inside I saw a young woman who appeared shy and vulnerable. 

Her friend who had guided us to the hut walked past the mother and showed us the newborn baby lying supine, flaccid and quiet. I noticed the mother did not move toward either the babe or us. 

With the use of broken language skills and my poor acting, we established that the babe was three moons (three days old) and last su-su (breastfeed) was when the shadow was on that far scrub path (let’s assume 5 hours ago).

With the mother’s permission, I examined the babe with the little equipment I had – my hands, head and heart. He was small for gestational age, had soft yet deep fontanelles, a reasonable heart rate, low blood sugar level, and shallow respirations – irregular and at times laboured. 

He did not respond to my picking him up or follow movements with his dear little eyes. I smiled and asked the mother if she had consumed marijuana during her pregnancy and she proudly claimed she had had a lot of it. My heart sank, but my face smiled toward her as I snuggled him into my neck flicking away the memories of my own son at this age and my heightened protective nature during this time. 

The babe was quiet, yet I was captured by his eyes which seemed to be looking but not seeing. Mother had not named the baby (which can be common due to high death rates) and my clinical red flags were wilting my heart as I tried to decide what my part was here. 

“Mother had not named the baby (which can be common due to high death rates) and my clinical red flags were wilting my heart as I tried to decide what my part was here.”

With absolutely no health resources in or near this remote village, a mother who seemed to be waiting for the inevitable to happen to her boy, and my clinical expectation that the baby had a poor prognosis, I asked if I could watch her feed. Both mother and baby were quite disinterested in each other, and the mechanical act took only a few moments to leave a devastating impression on me. 

Playing this scenario out in my home city would have this bundle of innocence, prodded with needles for blood gases, placed in a warm and soft humidicrib, examined by leading experts, monitored day and night then fearfully and wonderfully brought back to the hope and expectation of a full and long life filled with laughter, friends and mudfights. 

I had moments to decide my role and responsibility. I was also acutely aware that I had a younger health professional with me who I would need to debrief and help come to some level of resolution in this unexpected situation. 

I also had limited time as we were expected to return to the team shortly and knew of the long hike and tidal barriers to get there. 

Given the presenting facts, so many questions crowd in:

• Should I give the newborn standard injections, or will this be seen as precipitating his probable dire outcome? 
• How will the mother see this intervention? What right do I have to inflict pain on this flaccid babe? 
• Is it worth it anyway? 
• What resources that this baby should have access to are even remotely available? 
• Why are we so voiceless? 
• Am I enough? 

So, after a silent internal explosion of emotion and helplessness I decide to forego the injection and spend my remaining time alongside the mother teaching her to latch properly, watch for effective swallowing, stroking his dear little feet, encouraging eye contact and bonding with him.

We mimed out the importance of healthy foods and better hydration for her and in what seemed the blink of an eye, I knew my time was at an end. 

Walking back to the village, I talked at length to my younger team member, knowing that her spirit would take a few sessions to unpack the injustices of our world. 

I lay awake that night – and many thereafter – wondering about my actions, or lack of them; 

• The impact on the mother and baby and if I had given them the best opportunity possible. 
• Could someone else have done better and was my decision best practice in this circumstance? 
• Did my voice count for anything? 
• Was I enough?

Fast forward a few months and to another island far far away! 

I arrived 33 hours later somewhat jetlagged as a first responder to a new field hospital a few days after a hurricane has destroyed this and many other surrounding islands. 

Working straight away in the ED brought new faces, new routines, long hours and although grateful, also a stressed and endless line of casualties.

One of note was a young 6-year-old boy who arrived with his mother and presented with a cough, fever and obvious signs of severe pneumonia. Again, his dark innocent eyes of trust and faith in us captured my heart. The little man deteriorated very suddenly into an arrest situation with us working on him for well over an hour. The early stage of an emergency field hospital is not set up for intubation of a child and we watched this little chap slip from our hands into eternity. As a team we are well versed with death and dying. However, the inability to have had everything that may have made the ultimate difference was devastating, especially as we listened to the howling of his mother alongside us as she realised what was happening. 

That night – and many others thereafter – I lay in bed and saw his gorgeous little dark eyes and heard his mother’s primal recourse at God. 

• We were not enough.

• We did not have more. 

• Circumstance drowned us. I am not enough. 

• I failed. 

• It is all broken.

BUT GOD…

So how are we as Christian nurses able to turn up to the next shift? Somewhere in my heart I need to evolve a capacity to exist, survive and lead a way through this. I expect myself to be present for patients, colleagues and myself. 

My value, contribution and identity has been doubted, challenged and nearly discarded by moral injury. Yet my spirit is fiercer, more bountiful and strangely strong. 

In the Scriptures I have been able to reclaim my value, contribution and identity and realise that, bold as it might seem, maybe I was born for a time such as this (Esther 4:14).

Although stringing along Scriptures of convenience to fit my apparent spiritual need may not be the best theological practice at times it sure as heck works for me in these situations. My emotional headspace seems to perhaps outshine the need for true historical context:

“Gabi,

Psalm 139:14 – You were fearfully and wonderfully made,

Psalm 139:16 – Every day of my life was recorded in your book. Every moment was laid out before a single one of them had passed. 

Jeremiah 29:11 – For I know the plans I have for you, declares the Lord. Plans to prosper you and not to harm you. Plans to give you a hope and a future.

Ephesians 2:10 – For you are God’s handiwork created in Christ Jesus to do the good works which He has prepared in advance for you to do.

1 Peter 5:7 – Cast all your cares on Him for He cares for you.

Matthew 28:20 – And surely, I am with you always until the end of the age.”

So, all in all, I do know that the fruits of the Spirit do not include the fear, inadequacies, anguish, guilt or shame I carry back from these events. I cannot unsee some things and I cannot unsmell others.

Christ’s resurrection however allows me to bring the BUT GOD back into my internal dialogue. I tell many younger mentees that they are strategically positioned, well equipped, armed and ready for the interactions God has for them. I have remarkable confidence in them. No detail of life has taken God by surprise. It is my turn to take my own medicine. 

It takes, frankly, a mountain of effort to believe that I was wonderfully made to do each recorded day, to walk out His plans and purposes to do good works, with prayer as an active tool and am not alone in the journey. However that looks. 

“I do know that the fruits of the Spirit do not include the fear, inadequacies, anguish, guilt or shame.”

BUT GOD positioned me there and it was better than me not being there. 

BUT GOD provided me with a scope of practice that helped. 

BUT GOD brought voice to the situation by bringing my presence. 

BUT GOD knew that my hug and connection was more important than my shortfall of full medical knowledge. 

BUT GOD used my voice to still the waters. 

BUT GOD calmed my thoughts before I slept. 

Perhaps my perspective is not the ultimate answer. God’s perspective is greater than mine and my part was small, but enough. It is sometimes easier to listen to the voice that criticises my capacity than the voice that created my capacity. 

The topic of moral injury is certainly breaking new ground in academic circles and rightly so. Healthcare has a high fallout rate, high burnout, and tragically, high suicide record. It is imperative we identify moral injury and teach a broader understanding to our colleagues.

Ways to move forward

1. Create conversation 

As multi-disciplinary health care teams we can lead the way in education on Moral Injury. Many healthcare workers have not heard of the term and are often relieved once they have. On an informal level asking “How is your moral compass holding up?” or “What’s keeping you strong?” is a start. Using a pre/post huddle shift where nursing leaders can explain the term and introduce the value of mental well-being may create a fuller work environment.

In-service training, speakers, conferences and a safe platform to be heard are more formal approaches. Hot (immediate) and cold (delayed) debriefs, together with conferences and speakers can also address the topic. 

Placing value on healthcare worker’s morals should become normal conversation. 

2. Resources

Let the people you lead be aware of your intentional interest for their well-being and the resources available to them. Allocated times of debriefing in a confidential environment as a regular occurrence may diffuse lingering doubts and normalise the process.

A noticeboard with webinars, articles, information, chaplains and help lines may be helpful.

“Small acts of kindness remain a remarkable way to show compassion.”

3. Leadership

By expressing a genuine care and concern for your team members, others will follow the cultural shift in the work atmosphere. Small acts of kindness remain a remarkable way to show compassion. We must value each other and realise the impact this has on others.

4. Appreciation

Open appreciation and public thanks continue to keep morale up in stressful times and can quieten the voices that cause doubt and conflict. 

So what keeps me awake at night on deployment?

• The sounds of my favourite worship songs, 
• The reading of my friends’ encouraging emails, 
• Reading my kid’s silly texts, 
• My husband’s kind and faithful proud words 
• My reading of The Psalms and Scriptures, believing that…
• Maybe, just Maybe, I was born for such a time as this…

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1. Williamson V, Murphy D and Greenberg N, 2020, “COVID-19 and experiences of Moral Injury in Frontline Key workers’ Occupational Medicine”, viewed 18 April 2020 https://academic.oup.com/occmed/article/doi/10.1093/occmed/kqaa052/5814939
2. Lachman,V.D 2016. “Moral Resilience: Managing and Preventing Moral Distress and Moral Residue.” MEDSURG Nursing march-April 2016 Vol 25/No2 p121-4.
3. Duhig,S. 2020. Are your Nurses experiencing Moral Injury? www.relias.com/blog/are-your-nurses-experiencing-moral-injury