Читать книгу The Mental Health and Wellbeing of Healthcare Practitioners - Группа авторов - Страница 11

The initial research I undertook, alongside my colleagues Charlotte Krahe and Danë Goodsman explored the questions:

 Does the way in which medical students talk about their experiences in emergency medicine and pre‐hospital care resonate with the concept of moral injury?

 If social support can be protective, to what degree do students feel they have access to this support and want to use it?

The study was envisaged as an exploratory study, and simply the first of a series across professional groups, exploring the lived experience of providing emergency medicine pre‐hospital care, through the theoretical lens of moral injury. The focus group/interview schedule was adapted for healthcare populations from previous research on moral injury in military populations [18]. I conducted interviews and focus groups with students who were either on the intercalated degree in pre‐hospital care, or involved in the pre‐hospital care programme at the medical school, both of which would mean that they had exposure to traumatic incidents. The students knew me, as they had seen me attend symposia and so on in pre‐hospital care. The students were offered the opportunity to amend transcripts but declined, nor did they take up the opportunity to review the findings. Questions were designed to be minimally distressing for students while exploring moral injurious experiences and symptoms resulting from moral injury, potential protective factors were also explored.

The data was analysed with thematic analysis (Braun and Clarke), through the theoretical lens of moral injury and there were themes which did indeed resonate with the concept of moral injury. Participants spoke of the ways in which the mechanism of injury affected how they felt about the job:

‘it's always the ones with the violent connotations which are the hardest to process afterwards… when it's a violent attack there's an air about it of ‘God, someone else has done this and it's up to us to reverse it’.

Sometimes a lack of resources caused problems:

‘the paramedic had used up all his morphine… I felt so bad for this kid… he was in lots of pain and just basically lying on the floor and we couldn't do anything. I felt bad’.

In line with cognitive processing models, they found the clinical debrief to be useful, whether with a paramedic or physician who had also been on the scene:

‘They know exactly what happened and you can say, well why did we decide to do this…then suddenly there is some kind of scientific underpinning, understanding that helps you process what's happened’.

Equally, they also talked about the need for emotional processing, ‘Just sit down and understand and go, yeah, that's crap… talk me through it. Get everything out’. even when this was hard to do: ‘You've got to make the effort, I find I have to make the effort. If I'm going to talk about it, I need to talk about it properly’.

Interestingly, this population did not talk about failures of leadership, or poor decisions made by leaders, but had unstinting admiration for their seniors and their extensive experience:

‘he (the doctor) was like, okay, let's look for injury patterns because that's quite useful. I just remember thinking, oh my God … Obviously I was feeling a lot more than he was but that's just by virtue of him having – that's his job and that's his life’.

It was not until I started talking to other groups that I began to understand the issues that were arising with leadership, and also, that I had actually begun my exploration of moral injury in healthcare in the wrong place.

The research I undertook with students in pre‐hospital care was meant to be the first step in a series of studies about whether moral injury was a concept that resonated with healthcare professionals. Once it was complete, I presented it with my collaborator, Charlotte Krahe, at a symposium in June 2017, two weeks after the fire at Grenfell Tower. I was overwhelmed by the response. I had thought there would be some interest in the topic, but I had not anticipated the number of people who would want to talk to me about their experiences, and their concern for themselves and their colleagues. It was this event that meant that I began to understand the extent of distress in paramedics and other ambulance staff, and in specialties such as intensive care, critical care, and, of course, emergency department staff.

Those who had not spoken to me at the time often wrote to me later, many were educators who wanted to know how to protect the students in their care:

‘I actually think there is huge potential for use of the term “moral injury” to describe the feelings arising in clinicians and students from seeing patients in situ where there is severe deprivation, isolation, poverty, squalor, and sadness ‐ a large part of what paramedics do and probably more frequently encountered than significant trauma, disturbing violence and serious illness.

‘The themes it (the published paper) has highlighted are the exact same that resonate across the entire student cohort and it's such a positive thing to see it professionally worked up. It points me in the right direction as to the best and better ways to keep our boys and girls as safe as possible’.

Others sent me long emails about how moral injury resonated with their experiences, either because of the kinds of jobs they had seen, or the way they felt the system had treated them. At a conference, one physician told me: ‘I just feel like a piece of meat on a conveyer belt. One day I'll fall off and they'll just put another piece of meat on’. It is clear that staff are feeling unsupported at work and we know from recent surveys that the degree to which staff will identify themselves as burnt out and stressed beyond their capacity to deal with it is worryingly high [1]. Since that first presentation of the research in June 2017, I have been invited to speak about moral injury at conferences, symposia and study days both in the United Kingdom and abroad. Clearly there is an appetite for discussion about moral injury and the psychosocial effects of working in healthcare more broadly.