The Human Cost of Caring: Navigating Moral Injury

In this powerful episode of The Symptom Media Podcast: Bridging the Divide in Mental Health, host Dr. Lindi van Niekerk is joined by Dr. Sophie Redlin and nurse Andrea Mackay for an intimate conversation about moral injury in healthcare. Originally a term from military psychology, moral injury has become a resonant framework for understanding the inner conflict and lasting harm many health professionals experience when systemic failures or ethical dilemmas violate their sense of what is right. Drawing from their personal stories during the COVID-19 pandemic and beyond, Sophie and Andrea unpack how these experiences shape caregivers—and how community, storytelling, and compassion can help repair the human cost.

For more information about the resources shared in this episode you can visit:

The Moral Injury Partnership: www.moralinjurypartnership.com

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Transcript

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Hello everyone and welcome back to the Symptomedia podcast, Bridging the Divide in Mental Health. I'm your host, Dr. Lindy Fanigat and I'm grateful you've joined us for this valuable conversation. To learn more about Symptomedia's mental health resources, visit symptomedia.com. Our mission here is simple but vital, to bridge the divide between the clinical and the experiential. Today we turn our attention to moral injury, a concept originally used to describe the psychological, emotional and physical distress experienced by military personnel. when actions in combat violate their moral and ethical values. In recent years, this term has entered the healthcare field as professionals navigate daily system pressures, witness extreme human suffering, and are either forced to act or prevented from doing so in ways that profoundly challenge their moral and ethical values as a caregiver. Moral injury is a universal human experience. In this episode, we share the stories of a doctor and a nurse in the United Kingdom who are faced it firsthand. We also explore the path to healing and the ways to prevent moral injury in the future. Sophie Redlin is a London-based medical doctor, researcher and filmmaker specializing in family medicine, mental health and expedition medicine. She's also the co-founder of the Moral Injury Partnership, a UK initiative offering retreat-based programs designed to provide restorative support for frontline workers experiencing moral injury. Andrea McKay is registered adult nurse with experience in surgery, accident and emergency, critical care, orthopedics and ophthalmology. She has lived and worked in Asia and Europe and currently lives with her family on the beautiful South coast of Scotland. Let's dive into the conversation. Sophia, Andrea, thank you so much for joining today. I see you both have come prepared with your cups of tea and I wonder if you want to tell us where you're joining from because I know tea is very important where you are. Hi, Lindy. I'm joining from London in the UK and yeah, it's six o'clock here, but I'm still drinking tea and it's light outside and it's been a beautiful day. Hi guys, I'm currently calling in from Scotland up on the West Coast there and it's also been a very beautiful day here. I also have my cup of tea, so I'm ready to go. Sophia, I'd like to start with you and I'm sure like me, trained in South Africa, you did your medical training in the UK and you started at 18 years old. What inspired you to pursue this path and make such a big decision at such a young age? I decided I wanted to be a doctor really early, which was interesting. So even at the age of sort of five or six, I would tell family members I wanted to be a doctor and a surgeon at that point. And I think I had always been interested in the human body and just anatomy generally. So it's funny, weird story, but when I was young, I used to actually ask my mother if I could remove the giblets or the innards of the turkey at Christmas, which is really strange when I think back. But I was just very curious and interested. And I was also interested in the human side, I think, the stories, people, and that's certainly what I'm still interested in in medicine. But I think being honest, as I reflected on it, there was also a sense of feeling that medicine was a very worthy thing to do. I think it was very approved of. And so I'm sure that did play a part in ending up as a doctor. Andrea, you started your journey a bit later. And I know you come from a family of nurses and you took a while before you decided to join the family profession to some extent. So as you say, my mum's a nurse, my dad's a hematologist, so I grew up hearing all the stories from work. My mum, she used to do lots of night shifts, so she'd come in and over breakfast my parents would discuss what she'd seen the night before and I was fascinated by what was going on. So I was all set at 17, had applied for nursing school and was ready to go and just had a last minute feeling that I was only going because my mum was a nurse, so I gave it away and spent 15 years. trying other jobs and doing other things and interestingly, always people-centered and then eventually, in fact my husband had spotted a job offer in the paper for a maternity healthcare assistant at our local hospital and I just thought, I'll try it and the day I started it was like, this is why I should have been all this time. I don't regret having done the other things but it felt absolutely right when I eventually got there. Well, I can resonate with not just wanting to do something because of your parents, seeing as I had two medical doctors as parents and I used to fight very hard as a kid and saying, I know what I won't do and that's what mommy and daddy did. And yet there I found myself as well. seeing how much they cared about people was inspirational. I also want to ask both of you, was there ever a moment where um everything you envisioned about this career that you were setting to do at some point was quite different from the reality of the experience. And if you remember that moment of maybe just, oh, this is not quite as I envisioned or imagined it to be. Absolutely. I think for me, it was really starting work. So I did six years at medical school from 18 to 24 in the UK and then started my sort of junior doctor years. And I really felt in some ways at medical school. didn't really prepare us for the realities of being a junior doctor. And yes, I do remember having a real wobble of was this what I thought it would be? And going back to why I had done medicine in the first place, I think I had had this vision of medicine as being quite glamorous and, you know, as I said, very worthy and a very sort of honorable thing to do. And I think it is in some respects, but really there's a very kind of gritty side to it as well. Andrea, how about for you? Yeah, so similarly, it's when I started my training as a nurse. So I'd spent five or six years working as a healthcare assistant in maternity and really loved it then went on to do my training. And when I first joined university, a lot of the people in my year were quite young and just coming straight from school into nursing. And I remember feeling a bit smug that I had all this life experience and I knew all about nursing because I'd worked in a hospital and my mum was a nurse and, you know, I was going in ready for anything. And on my very first day of my first student placement, I went, it was on one of the older people units here. One of the patients that I was looking after was dying. And it was coming from one end of the spectrum to other, having come from maternity. That was my first day. And I remember going home to my husband and saying, I think I've made a bad choice. I don't think this is for me. But then, like Sophie said, you remember why you're doing it. And I went back and... recognize that you can help people at this stage of their life and it's another part of the journey and quite an honor to be there at that stage of somebody's life and then you get through the tough times and glad that I stuck with it. I think my realization almost came in my second year. So guess when I was 20 and I was looking around what the messages that I was hearing about how we should care for people and then also being aware of what we being exposed to, everything from autopsies to dissections and never really feeling or seeing any care being shown to us or being modeled by any of the other lecturers that we had. And it was just the striking. scenes for me where I couldn't put it together knowing I really did enter into this profession because I deeply care about people and I wanted to care about them, but I'm not seeing a lot of care happening around me. And I think that just stayed to be the lingering question for so many years. And maybe with that to segue into our topic of conversation today, which is moral injury. And you both are really on the forefront of understanding this topic. And I think it's a new term that many people may not have heard about. And so maybe to start us off, I was reading some books on moral injury and I found one by David Woods who was actually a war journalist. And he explores kind of moral injury in the context of war. And he wrote, soldiers who have served in Iraq and Afghanistan are coming to understand this lingering pain as a moral injury. Trauma as real as a flesh wound. And it's most simple and profound sense. Moral injury is a jagged disconnect from our understanding of who we are, what we ought to do, and what others are doing. Experiences that are common in war, inflicting violence, witnessing sudden maiming of a loved buddy, or the suffering of civilians, challenge and often shatter our understandings of the world as a good place, where good things should happen to us. The foundational beliefs we learn as an infant, the broader loss of trust, loss of faith, loss of innocence can have enduring psychological, spiritual, social and behavioral impact. And I can't help like reading through this David's book and feeling like, wow, he's describing my experience. And I used to compare my medical school training to in the military. And so, Sophie, I want to ask you if you can maybe help make this connection for our listeners as to how has moral injury become applied in healthcare and still. How can there be such similarities between the experience of patrons and the experience of health workers? I think firstly, that's such a beautiful description, isn't it? And yes, I think for me that confusion, as he says, and that real questioning of the world around us is sort key to moral injury. So for me, the real crossover really, the several sort of reasons I think why we see it in medicine and healthcare as well is because People who are working in fields of service and care, I think are very prone to moral injury. And I think that's because when we work in a caring profession or performing sort of acts of service, what we do as a day job very quickly becomes very intertwined with our sense of self and our identity. And therefore, when a mistake is made, even if that's a personal mistake where I have agency or something higher up that I don't have control over, it very quickly becomes, I am wrong. rather than simply, I've done something wrong. A second point is that when we're thinking about sort of the military and sort of areas of conflict and we're thinking about healthcare, they're both areas of really high stakes. So they both involve life and death. They both involve human suffering and therefore people working in those fields are faced every day with morally challenging encounters potentially where people working in different fields perhaps are not. But if we think about those particular sectors, as I say again, you're facing things that many people will never sort of see or do. And I think finally, and this speaks to Lindy, what you saying about your medical training, they're both fields where they're usually as a sort of professional hierarchy where... you're often taking orders as it were from structures or people to hire up. And therefore there's a real potential for feeling failed or betrayed by higher systems or structures. But really what we saw in the pandemic were healthcare workers again receiving these orders to carry out acts or to witness acts that didn't feel morally right. And so I think when we begin to think of it in that way the comparison actually makes a lot of sense. And Sophia, I'd like to ask you maybe just before we move on. So we've done an episode on burnout as well. And there's so much written about and known about burnout amongst health workers or post-traumatic stress disorder even. But why is this different from burnout? Yeah. So moral injury for me is it's been described many times, as you say, it speaks to the wound of either carrying out an act or witnessing an act. or preventing an act from occurring that feels morally wrong to you as a human being. And therefore it is a very, what we call a human wound. So it can be on a spiritual level, on a psychological level, an emotional level. And unlike PTSD or PTSI, the post-traumatic stress injury, I think, as it's more often called, by people experiencing it, moral injury isn't technically a mental health condition per se, as of yet. It's not a sort of diagnosed medical condition. But I think it's really important to sort of value the difference because it speaks more to me of really the nature of the human condition, of what we are used to seeing as humans, what's familiar and what happens to us when that changes. And again, unlike something potentially like post-traumatic stress, it also speaks to systemic failings and how really people can be made sick by a sick work environment, if you like, which I think is important when we look at solutions and addressing it. Yeah, I have really learned from you that moral injury is, like you say, it's a human wound um and it's not a pathology per se. and we're so quick to put things in a pathology and then there can be shame and guilt around what's wrong with me again. But knowing that experiencing this is just what we will experience as human beings. Andrea, um you were a nurse on the wards during the COVID pandemic and that was extremely distressing for so many people. And I'm wondering if you can share that experience. What was it like working as a nurse, being aware of this threat coming along and what you had to do in that time? Yeah, so it was interesting to look back now. It's almost exactly five years this week since we went into our first lockdown in the UK. And for me, the pandemic was kind of in two parts. The beginning of it, I worked on one of the surgical wards and towards the end of the pandemic, in the second wave, I worked in ITU in critical care. So I had two very different experiences of the pandemic, but when it first kind of broke, and the first cases were announced in China. I had family living in Hong Kong at the time, which is where I grew up. So I was sort of hyper aware of it from a very early stage, but more worrying about my family than anything else. I remember particularly when it really hit my radar as a nurse was when the cases in Italy went crazy. And that was really terrifying because we knew it was coming and we knew it was going to be bad, but we couldn't really foresee exactly what it was going to look like for us. I remember describing it to somebody at the time as standing on a beach watching a tsunami coming and not being allowed to leave the beach. The hospital that I worked in at the time were quite proactive and they fitted out a brand new ITU unit in that time. didn't, I think they turned it around in about eight weeks. It was extraordinary. So the cases grew and grew and then finally they came to us. And I was at the time working on a surgical ward, which was elective surgery. All elective surgery was cancelled. So we initially kind of didn't have anything to do. We were very much ring-fenced to try and keep our theatres clean so that we could still conduct some kind of operations if necessary and so forth. So the first feelings were of guilt that we weren't doing anything because I had colleagues who were working on COVID wards in other hospitals. But then I remember in the months leading up to the pandemic, my ward manager had... got a matron's post, so she had left not knowing what was coming. She had taken another post and so there was myself and two other junior sisters were left to run the ward. One of my colleagues stepped up temporarily into the sister's post to manage. And I remember that the day the bed manager phoned us to say, that was it, we breached because our clean ward had the final side room in the hospital, so we had to take a COVID patient. And there was this sort of tangible fear because at this point we really didn't know what we were dealing with. Everything was very still, very new. So myself and my colleague went into the office with a list of our nursing staff and had to just go individually through the list. And so we were making decisions about who to send in to nurse this COVID patient, not really knowing how they were going to be affected. And that sort of weight of responsibility was... quite heavy. And then my colleague declared that she was pregnant, very early stages of her pregnancy. She was then off shielding. So it was myself and another junior sister running the ward. And we would go to meetings and we would get the latest advice from Public Health England. And almost within hours of coming out of the meetings, the information was redundant. because some new information had come to light. So we were in this constant state of flux of not knowing what we were doing. And there were issues with PPE, masks and so forth. And it was very slow to get everybody fit tested for those because we were essentially a clean surgical ward with limited COVID patients. So that was difficult. And then eventually I moved during the pandemic to ITU and that was obviously a completely different. scenario. It was just as the second wave was coming and that was very difficult from a sort of moral injury point of view, which I didn't understand what that was at the time. But looking after patients and not allowing family and any of their relatives to come in. We had patients that were dying and we weren't allowing anyone to come in. We used to have patients make recordings that we would take into our sedated ITU patients and play them. And I remember many, many shifts of doing night shifts, listening to these recordings of somebody's child, grandchild, talking to them, knowing they probably would never see them again. It was absolutely heartbreaking. It felt wrong not to allow people in to see them. That was a really difficult thing. And small things. There was, teenage daughter recently played me a song by Taylor Swift called Epiphany. I don't know if you know it. But there's a line in it and it talks about the military and about nursing and there's a line in it about touching through plastic because we were covered in plastic. We had aprons and we had our gloves on. as a nurse, obviously for doctors as well, but I think probably more so for nurses, we spend a lot of time holding people's hands and that sort of therapeutic touch. And to have it through a gloved hand felt awful. This was... possibly the last handhold somebody might have. so all of that felt very, I'd use the word uncomfortable, but it was obviously much worse than that. And I'd come home and be exhausted from trying to give as much as I could and knowing it probably wasn't enough because they deserved more. And so yeah, was dark times and yeah, it's all being evoked again now, as I said, because it's the anniversary. Thank you for sharing that, Andrea. Yeah, it is, you're right. It's important not to forget because we can go through tough things and then the world wants to move on really quickly. And in listening to your story, it does sound like you were this, almost this young soldier being sent onto the battlefield with very little protection or knowing what to expect and having to make all these really tough decisions, both about your colleagues, which I think is really a hard thing to ask anyone to do, who will be sent in for a death sentence almost. And then as well about caring for patients in a way where it feels like the care is almost removed from the equation. Sophie, you've worked with many health workers when it comes to moral injury in the UK. And I recently read a report that said about a third of health workers in the UK have experienced some level of moral injury. And I wonder if you can tell us bit more about that. how Andrea's experience, is that a common experience across the system? Andrea, you had an experience that you mentioned to us previously, and I wonder if you can share that, where you particularly felt your values were being compromised in terms of what it meant to care as a nurse. Yeah, of course. course, when I was still working on the surgical ward, as I've just mentioned, PPE was an issue. didn't have many of our staff hadn't been fit tested for the proper masks. And one day the lead nurse for the resuscitation team came to speak to me. We went into the office and she explained that we were going to stop working under a new protocol for resuscitation and that if a patient on the ward collapsed and needed chest compressions. Because that was an aerosol generating event, you can only do that once you have the correct PPA on, including the mask. So in the first instance, you would have to stand by and properly put all your PPA on before you could touch the patient. But more to the point, none of our nurses had been fitted for masks. So we weren't allowed to touch the patient at all. And we would have to just put out a crash call and stand by and wait for the recess team to arrive. I was absolutely horrified the whole idea of it, that as a nurse, a human being, let alone a nurse, would stand by while somebody's dying in front of you and you wouldn't help them. And as a trained nurse, that's literally what I'm supposed to be doing. It just felt so wrong and so uncomfortable. And I then had to call in the rest of the staff to feed this information down to them. It was awful. whole staff base just were horrified by the idea. People were crying, almost without exception. Everybody said that they would not be adhering to that policy and that if somebody collapsed and needed chest compressions, they would just step in and do it. And I don't think I've ever got over that feeling of that day and watching the reaction from the nurses that I worked with that somebody had asked that of them. Andrea, how did it affect you? I mean, I almost feel like I'm hearing you saying it made you feel like a failure, but I don't want to put words in your mouth. did like hearing this, what was happening inside for you emotionally, physically? Well, it's a struggle because you think, you know, I'm likely not to be in that situation because hopefully nobody is going to collapse on the ward and I'm not going to need to make that decision. But equally, I can categorically say that I would have still given chest compressions to a patient without the correct PPE. But it did feel like my hands were tied because I would be disobeying somebody by doing that. So there was a real sense of what was right for me. as to what I had been told to do, what was right for the organisation, not to put the nurses at risk, etc. So yeah, it was just a horrible feeling and it was one that I hadn't really experienced in that way before, that somebody had directly told me to do something that felt wrong, or to not do something, I should say, to just stand by and not do something when I could do something. Yeah, it's never really gone that one. It's very powerful, isn't it? think particularly Andrea, your line of, you know, as a human being, I wouldn't do that. You know, we go into caring professions because we care. All three of us, you know, that's part of our drive to do what we do. So when that is compromised, it is injurious. That's where moral injury comes from. And I think it's... putting people like Andrea in that situation of having to go against orders, to do what felt morally right, really speaks to the gravity of moral injury. So we would rather disobey, potentially lose our jobs, break the rules, because we cannot live with ourselves if we don't step up in that way. yeah, mean, it really, really speaks to me and it does remind me of things, again, outside of the pandemic as well that I've experienced myself. Sophie, you and some colleagues set up the Moral Injury Partnership, I think because of your passion to want to see a change in this area. And you've also helped health workers, like you've mentioned, Andrea came to one of your retreats, really helped them kind of process the experiences and heal. What have you found has been helpful in taking people through a process like that of acknowledging maybe the pain and coming out on the other side? So in... In I set up Moral Injury Partnership with two others, so Simon and Alison, and we connected through a research fellowship where they had both been studying moral injury in veterans and I was studying talking practices within indigenous communities. So very different, you know, topic at the time. And we came together to form a sort of response to moral injury in healthcare workers, but I have to confess. confess when Simon approached me, I wasn't aware of the term and I was a doctor working in the pandemic, morally uh injured myself. So I think that shows really the lack of awareness. But we got together, we decided that we wanted to form or build a residential retreat program, which would give people the opportunity to step away from their place of work and their role. and have three days together in community, processing what had happened. And the original impetus was the events of the pandemic. The retreat really works on three kind of core themes. The first day is all about sort of remembering and reconnecting with who you are and why you went into the field and the work that you do. And really that for me addresses this idea of loss of sense of self and moral injury. The second day is all about forgiveness. So it addresses these feelings of guilt and shame by allowing people the space to forgive themselves and potentially move towards forgiving others as well. And we actually include a sort of fairly ritualized activity where people can say out loud, you know, I want to be forgiven for, and we've found that very powerful. And then the third day is about post-traumatic growth. So as you say, enabling people to see ways in which they can move past what's happened and actually learn from it and take. what they've learnt and put it into something. It's allowing them to see that there is a future for them. I think in terms of what really at the heart of the retreat is the sense that it's really peer support. So although we facilitate, it's very much people on the retreat guiding each other, talking circles are at the heart of it, and they're very much sort of non-hierarchical, non-professional spaces. So people are there as people, as human beings, and we basically share stories and listen to each other's stories. and realize we're not alone because stories are very similar. And for me, that's never been a magical thing in terms of the methodology, but it's magical in terms of the effect it has on people. Andrea, you, like Sophie said, you were part of one of these retreats and how did that collective experience and even just becoming aware of the term moral injury, how did that help you in your own process? It really was the most extraordinary time for me. I had spent some time in some counselling through work after the pandemic, trying to deal with what had happened. I was really burnt out and I didn't really understand. I was really struggling. If people asked me about the pandemic, I wouldn't be able to talk about it without crying. It was really a really dark time for me. And when we got to the retreat straight away on the very first night, one of the other persons on the retreat, as we were going around sort of introducing ourselves, talking about where we were working, et cetera. She started to talk and she's just broke down and started crying and she couldn't hardly get her story out for crying. And I remember just watching her thinking, I understand that, that's how I feel. She feels how I feel. And there was this extraordinary realization that you realize you're not alone, that you're not the only person experiencing this. I had... really struggled with the word resilience that was often bandied about at the time, that you know, you need to be resilient and you need to... And it really felt to me like victim blaming that I wasn't coping with what was happening because I wasn't resilient enough. So it was my fault that this was happening. And when we came together at the retreat and everyone started sharing their stories and allowing that vulnerability. of really expressing yourself. It felt immediately like a very safe space. And you realize immediately that everybody felt the same. We'd all had very individual experiences, but there was so much common ground that you just felt really seen, genuinely life-changing and learning about moral injury to understand all those emotions that I had been feeling, all that guilt and shame and all of those things. for somebody to talk about moral injury and how it works and what it means and to be able to recognise that of how I was feeling. Just you felt validated and seen and I could start to unpick what had happened to me. It definitely does sound magical and just so special that there's healing that can come from just the collective of us coming together and sharing experiences, which sound like it was done without you driving an agenda, Sophie. You just created the space for people to be themselves. Sophie mentioned forgiveness also being so part of these treats. And I was just curious about how that process was like for you, whether you've been able to forgive yourself or forgive the system. So to say, you impose some of these things where, yeah, how did that affect you? Yeah, so again, that was a really emotional day when we were talking about forgiveness and forgiving other people and so forth. And there was a lot of conversations about your inner voice and how you speak to yourself. And it sounds like the most simple thing in the world, but it had kind of never occurred to me that you can choose your own inner voice because I've grown up all my life with this sort of self-doubt and... you know, that's not good enough and all of those things. And throughout the pandemic and all the struggles and challenges that we were up against, there was always that this isn't good enough, you're not doing enough, you failed, all of those things. So to learn that I could actually switch that to you've done your best, you've done more than others, somebody else may have done in this, you know, all of those things and just to be kind to yourself. And I remember when we were asking for forgiveness from people, I asked for forgiveness from myself for all of that sort of harsh inner voice that I had been carrying all of that time, because I'd been quite horrible to myself about it, and recognizing that it was okay and that I could look after myself. And that genuinely has carried through all the way. Yeah. very memorable experience of moral distress that probably did result in moral injury for me was being involved in the death of a patient when I was a junior doctor. Probably would have been in my second year and was working on a very busy night shift on the sort of orthopaedic team. It was a horrendous night. I felt completely out of my depth with every case that came in. At one point during the evening an elderly man came in. and one of the doctors in the emergency department, thinking they were being very helpful and kind, called me and said, we've got this gentleman, but he, if you want, I'll see him, I'll send him up to the ward, don't worry about it, you can just see him when you get a moment. And that was probably about four in the morning, I don't know, I blinked and it was then eight. And the next thing I knew, I was being called to the morning orthopedic meeting and was dragged to the front of the room in front of everybody and told that this man had died about half an hour earlier and... was sort chastised that there'd been something wrong with the blood test. I'd not been told that I hadn't checked at the same time. And clearly there'd been other things going on that I wasn't aware of. And I still remember that feeling. It was just the worst feeling. I remember sort of leaving the room and crying. And the hardest thing about it was sort of what happened next. You know, just terrified and nothing happened. No one spoke to me about it. One of the other juniors kind of came up and said, are you okay? And then sort of left. but the consultant, I think, just walked past me, looked at me and didn't say anything and kept walking. And it was almost that lack of reprimand that was almost worse than anything else. It was the silence. And I remember leaving and just feeling this crushing sense of shame the whole weekend that I'd done something absolutely catastrophic and I was... terrible person, a terrible doctor, had no way of making sense of it, had not really had any space to explore what had happened. And the reality is I think the whole team were like, well, this happens, let's move on. But for me, I was left completely stuck. And I think I probably carried that for a long time. I do. Interestingly, it's also about the death of a patient, unfortunately. When I was relatively newly qualified, I'd probably been qualified a year. I was working on a surgical ward, but we used to often have medical outliers, so medical patients that should have been on a medical ward, but they were on our ward. And it was always more challenging to get the appropriate doctor to come to review them. I was looking after an elderly gentleman who essentially was dying, but he wasn't We weren't expecting him to die imminently. He was going to go home. We were getting him ready. There was kind of nothing more that we were going to be able to do for him, but we were going to make him comfortable, send him home. And there was no do not resuscitate form, although all the medics had agreed that it was appropriate and they needed to speak to the son, et cetera. So this was handed over to me at the very beginning of the day and I spent most of my morning trying to get hold of a doctor to come to fill in the do not resuscitate and nobody came and I was so twitched about it, I kept being put off and being put off. So eventually the gentleman's son came to visit him and he was in fresh pajamas and he was lying in his bed with his son next to him holding his hand and he passed. But because we didn't have the paperwork in place... I had to try to resuscitate him. So we had the emergency bell, we had the crash trolley, we had everybody running, calling. I had to perform CPR on him. And even as I was doing it, I knew I shouldn't be doing it. It was the most awful thing. And I was just left with this horrible, horrible sense that not only had I failed to save this man's life, I'd failed to give him a dignified death, and that was worse. because it could have been perfect with his son next to him holding his hand quietly going. And yet it became this horrible, horrible, traumatic event that was absolutely unnecessary because paperwork hadn't been filled in. And again, like Sophie said, was a bit of a, well, you know, it's too bad that we didn't get that done in time, but there's nothing we can do about that now. It's like, well, that's this man's lasting image of his father. has been taken away into this horrible traumatic event when it could have been so dignified and perfect in a way. We don't do death very well, I don't think, because we're constantly trying to fix people, but that could have been done better. And that was really hard and that stayed with me. It's always stayed with me. I can still remember the patient's name and this was 10 years ago. So I can add a similar story. was also, I was 24, newly qualified on the wards having to care for a young gentleman of my age, 24, who came in, his name was Leslie Franca, so the name stays with you. And he was in acute respiratory distress and we found out that he had kidney failure. I remember I didn't have a senior registrar working with me for some reason and I was trying to care for this patient all by myself. And so I referred him to our main tertiary hospital in South Africa in the hope that he will qualify for dialysis. And it was, I think the 21st of December, we were at our hospital Christmas party and my phone rang and I was told by the referring hospital that he's denied for dialysis and they're sending him straight back to me. In the party dress, I ran off to go find our senior consultant and I said, I haven't had any help with this patient. I've tried my best. What must I tell him? What else can we do for him? And he turned around and he told me, go tell him this goose is fried. And I remember the next week I walked into the hospital and it was just the worst feeling sitting in front of this family. And them asking me saying, well, if we had health insurance, would he survive? And having to admit that yes, if he wasn't part of the government health system. if he had any health insurance, he would still be living. And so that was just, think, both feeling like I failed a patient, but also very much feeling failed by the seniors who's around. And even if we're not curing him, how do we care for him until the end of his life? And that, know, that he has stayed with me. And I think very much changed the trajectory of my career. I think we all, remember these quite extreme examples, but the sort of day to day. almost micro traumas of the number of blood tests that I've taken on people who were hours away from passing away and how that sits and just sort of slowly erodes your sense of right. I think that takes its toll. It can be very cumulative rather than simply being these big sort of traumatic events. Sophie, you've done such amazing research recently looking really at the training machine of healthcare. And one of the things you described, which was really enlightening to me, is this process of separation. Like you've just alluded to, there's so many big traumas, micro traumas we experience every day, but we get trained to separate first from the broader community as we enter a healthcare training program, and then later even from ourselves, and especially from our emotions. So I want to read something that you wrote in your dissertation, which I thought was just beautiful. Aspiring doctors are conditioned to believe that their abilities and the sciences are all that matter, when this is commonly not the reality. They aren't being primed for meaningful transformation, they are being primed for distress and potentially even moral injury. When it comes to breaking bad news to a patient or consoling a relative following a loved one's death, it's not just a doctor's ability in organic chemistry that enables them to offer care that feels morally right. These destabilizing encounters require far more human skill. and surely deserves just as much honing. In fostering a stage of separation that tones the technical muscle at all cost, the system risks disabling doctors as caregivers and removing them from the parts of medicine that offer genuine meaning and purpose. Could you tell us a little bit more about how you've kind of discovered our training really disables us as caregivers, both in caring about our patients as well as ourselves? Well, firstly, thank you for your kind words. Yes, I mean this idea of separation I find really interesting as well and it was something I had not really thought about before doing this research and looking at the concept of rites of passage which involve a stage of separation to begin with and as I began to interview other doctors and think of my own story I could really relate to this sense of even that application process to medicine requires a sort of honing of the skills that the medical system deems important and in doing so separating ourselves both from sort of wider society potentially but also from those other aspects of our character that actually might be quite protective going forwards. What I mean by that is certainly in the UK and it's still the case as far as I'm aware the only prerequisite really for entering medical school in terms of non-negotiable is achievement in the sciences, so academic ability. And of course you may need to demonstrate other qualities in interview, et cetera, but it's really that ability that sort of hallmarks as the important thing. And so for me, going through that process, I put everything into honing that, I stopped doing other activities, I carried on English literature actually to A level because I loved it, but that was quite unusual. People were a little bit like, why you're going to be a doctor, you know? And so... very early on I sort of believed in what I was being told and then as I referenced earlier when I became a doctor I very quickly realised that While of course academic ability is important, there were so many other things about care that were so different to that. mean all the stories that we've just shared demonstrate that need for human contact, for good communication. All the studies show you know that often actually what really matters to patients is that connection with their doctor and yet I felt in that application process and then throughout training that wasn't what was acknowledged or prioritised. In terms of separation there was also an element of of as a healthcare worker, we do see very challenging things. And therefore I think that automatically does separate us from our peers and colleagues in other areas. I referenced, I think in my dissertation, a number of doctors who spoke to me about their families of commenting, gosh, you you've seen more in your two months than I've seen in a lifetime. And so that is a natural thing that happens. But unfortunately, what doesn't happen is a lot of guidance and framework to help people navigate that. I mean, you spoke, Lindy, of that real struggle, that real moral challenge of someone having insurance or not. So I don't think that separation is necessarily a bad thing for healthcare workers. I think that is a fact of life. But the ways in which we help people cope with that are, in my opinion, really lacking, unfortunately. I mentioned to you, I think, previously as well, how at medical school, I actually went to ask our by Steen why the training is so brutal on us. And I was told that the whole purpose was to blunt us for the first few years and then to try resensitize us. And of course that never quite worked out, I think the way they wanted, but blunting, they really try work very hard at. And Safi, what do you think is the cost at which that kind of philosophy comes to when it is training? And again, I understand we need to be able to handle things that the general population can't, but it does come at a greater cost to ourselves. The cost is that when we numb to emotions, we create an internal dissonance, an internal divide between how we actually feel about something and how we think we have to speak and behave as professionals. And that's very, very unhealthy. We've got research to back that up, but we also just know that as humans, we know that in our personal lives, if we feel a certain way and act a different way, it feels... terrible and that really lies at the heart of moral injury. And I think unfortunately, I mean, your story is such an overt example of this. In the UK, it's perhaps a little more subtle, but I would say is still present. There's a real silence around quite destabilizing, disturbing encounters in medicine, know, take death and dying for an example. And therefore, while I don't think I was never told you need to like numb yourself off from this, the very silence around it. create stigma around expressing struggle. um So many of my colleagues have said, you know, this was really difficult, but I just learned I had to get on with it, otherwise I'd be like the wimp in the department, you know. And so I think the emotional cost is heavy. I think it causes real internal conflict and distress. And also if you're numbing yourself off from one emotion, you're numbing yourself off from every emotion. So on a kind of slightly lighter note, it takes away the joy of what we do. And for me, I went into medicine for those human encounters to experience the privilege, as Andrea said, of watching someone have a good death. or holding someone's hand to do something difficult. And when we desensitize, we're no longer able to have that connection. And that is detrimental for both doctor and patient, in my opinion. Andrea, you've just come off a long shift just an hour ago. And I was wondering, do you find it, these countless moments in a shift where you just have to numb how you are feeling, put it aside, move on? You do, you absolutely have to. Certainly working on a busy surgical ward and you'd have some patients like Sophie said who are going to receive bad news. We often hear the news that they're going to receive before they do, obviously. I've had moments where I know a young patient is about to receive life-changing news. but we're waiting for the consultant to come out of theatre to tell them. So I've carried it for like an hour, having to talk to this patient about his plans and what he's doing next week and next month and, you know, he's planning up for a wedding and all this sort of thing. You really have to compartmentalise what you're dealing with because as soon as you walk away from that patient, you're then going to another patient who needs a different kind of comfort or what have you. And then you're constantly switching from... different forms of comforting people and helping people. And if you're carrying the sadness for what's happening to patient A, as you go into the next patient, you can't give them your full focus. So you need to be able to shut that little bit away temporarily whilst you deal with this and so forth. It's a skill, I guess, but it's, yeah. And I don't think you can survive in this field without being able to do that. As Sophie says, it does. strip everything else away, get home at the end of a 12 and a half hour day and I'm spent and I walk into my teenage children and I've got nothing left for them and they've had some trauma at school that they want to talk to me about and I can feel the dread of I actually don't have anything to give you. Left it all at work and then the guilt of then not being able to look after your own family and so yeah I think it is it does chip away at you over time. Hi, I do remember that feeling of being so spent that please don't talk to me, don't look at me, just leave me be after a long day. Sophie, you're right in your research, again, this is so much part of trying to normalise things that's not normal. And I wonder if you could read another extract from your work for us. Research suggests that while doctors have a higher rate of suicide as compared to the rest of the population, there is not enough evidence to suggest that this is due to a higher percentage of pre-existing diagnosable mental illness. Therefore, I can only conclude that these figures illustrate that doctors are being made sick by a sick system. The danger in framing and labeling doctor distress as mental illness is that it places the owners wholly on them and takes the focus away from the root causes, much like we are seeing within wider societal conversations around mental health generally. In having a service that not only promotes this labeling, but requires it of sufferers needing support, do doctors have any choice but to yet again, dissociate and distance themselves? from the realities of what they're experiencing in order to survive. Sophie, I love the link that you drew between this normalizing what's not normal by dissociating and distancing ourselves. But I wonder what is the role that plays in actually causing the moral injury or proning us to experiencing moral injury because of doing that? It's a really thorny topic, this idea of dissociation, because... As we all know, the brain uses association as a coping mechanism to cope with traumatic events. You know, we see that a lot when people are in conflict zones, et cetera, we're able to somehow physically function despite taking in extreme things around us. And so Andrea's right in that there is often a need, you know, I for one have had to perform CPR at five in the morning and somehow hold it together to do that. And of course there's a need to do that. and I certainly don't dispute that in my dissertation. But I think what we need to be really careful of is accepting that when we do dissociate from emotions, those emotions don't go anywhere. They're still there. And therefore how we then process those emotions is really important. And at the moment, there's a lot of people sort of numbing themselves and carrying on, but is there a lot of aftercare for that? And I think this plays into this idea of normalizing. So we are again taught through this, I think I call it as a hidden curriculum in my dissertation, this sort of silence around quite weird experiences in training, take dissection for example, because there's a lack of sort of conversation about how that is quite a weird experience, it becomes uh a sort of pressure to to make it normal. And it becomes part of life and you you sit alongside this sort of funny kind of dissonant feeling and there's a pressure I think to not talk about the sort of weirdness of that. What I would say in contrast to that is that I think we shouldn't be normalising abnormal experiences, but we should be normalising conversation around those experiences. It's not about scaring medical students or nursing students. and sort of saying, you're going to see lots of terrible things and leave now if you're worried about it. But it's about giving people the space, a bit like we do on the retreats, to sit and talk about how that felt. So again, it's tricky and half the problem with this is that when people don't have enough time to have lunch or go to the toilet, when do they have enough time to sit and talk about their feelings? But we could challenge and change that. And for me, like the retreats, it's not about... It's needing necessarily to be professional support, although that is needed for some people. It's about just giving you the space to chat to another nurse who gets it. If we can make healthcare organizations see the value in giving sometimes those space to step out into a different setting and just being with each other, how much could get taken care of in helping us process our experiences and being better caregivers. So as we close, Andrea, I wonder if you have any practical advice you could offer to anyone else listening. from your awareness of this idea of moral injury and how maybe people could take forward some small practices or even just thinking about this into their own work setting or into their own lives. Yeah, so think pretty much the stuff that we've mentioned already, I think it's about allowing your vulnerability and making sure you're communicating with people and communicating with people who understand what you're talking about. Coming home and trying to explain to my husband what my day at work was like, although he's very empathetic and, you know, says all the right things and makes me a cup of tea, he has no idea and I can't express. The feelings that you carry throughout a 12-hour shift, hope and despair and exhaustion and all of those things, you can talk about it, but he doesn't get it. So to be able to communicate in a safe space, like when we were on the retreat with other people who understand what you're talking about, it's so helpful because you know that they know how you feel. So it really makes you feel seen that they're not just saying, that sounds awful because they actually know that it is awful because they've lived it. And I think that really makes a difference. Talking, yes, but talking to the right people is important. And just to be kind to yourself. I think by the very nature of the jobs that we've chosen to help other people, we always come to ourselves last. So I think to be kind to yourself and to recognise that you can't pour from an empty jug, you have to look after yourself if you want to be able to have anything to give to somebody. If you can find the people or the space to just step out and reassess and have a moment and talk to somebody. It's all, it's going to be okay. ah to that, it's possible. Sophie, what suggestions would you have for training the next generation? You've really kind of unpacked how medical training happens and I wonder how do we better equip people mentally and emotionally to face these challenges? Yeah, I think for me I'll go back to the anthropology actually of if we do accept that having these encounters with human beings as part of healthcare changes us, which of course it does, both for the good and the bad. That sort of transformation could be structured in a way that allows people to cope with it and to be able to make sense of it. When we talked about what is the damage of normalizing things that are abnormal. As I say, it creates a sense of inner confusion that leaves people stuck. In anthropological speak, know, this sense of sort of liminality of I'm stuck here, I can't get out of it, I can't make sense or move through it. So I think for me, the first step is acknowledging the nature of what we do. And as I say, not in a way that scares people, but actually in a way that encourages people. You as a doctor or nurse will experience things that will change you, that you will see the human condition in a way that your family and friends won't. That's an amazing privilege that people need to have the tools to be able to make sense of it and you know do the job. And then this idea of rituals you know allowing people to for example very very briefly I read a paper on a nurse in the US who started a program called the five minute pause where after the death of a patient on a ward the team would stand together in silence for five minutes. Now many teams will do that organically anyway, but it was a way of bringing in a very tangible ritual into their practice that allowed people just a moment of peace and space to process. before they then had to sort of move on. So I wonder whether the use of ritual, of those kind of regular practices, both in medical training, you know, perhaps around these really confusing things like dissection, and then later in practice could help people kind of make sense and cope with it. And then finally, to echo Andrea, of course, the use of sort of peer-led spaces. So I think introducing that early on in training and normalising that. So normalizing, you do dissection and then you just have it, you have a chat about how it felt. It doesn't have to be you're struggling, therefore you need mental health support. It just helps you to explore how that feels as a human being, make that normal so that people want to carry that on into training. And I think that personally, I think that would make a huge difference despite the systemic struggles that are happening at the moment. Thank you. Those are usually encouraging because again, it feels like there's something we could do. The system's not bigger. with the nurse, there's a way to change the system for the better. And I want to thank both of you for helping me make sense of my own journey. And I think whether it's experiences from South Africa, England, Scotland, all the way to the U.S., it is wonderful to just step outside of being the doctor or the nurse maybe for a while and just sharing a very human experience. And I think that is the takeaway from this. This is just human for us to feel this way and through some care and support, there is a way out of this as well. So thank you so much, Sophie. Thank you, Andrea. Thank you. Yes, we lovely talking. Thank you for taking the time to join us for this discussion. To learn more about our guests and access the resources mentioned, please visit the Sim2media podcast page at Sim2media.com. We look forward to having you with us again for our next important conversation.