When two worlds collide: values and morality

Since the COVID-19 pandemic hit, staff have increasingly reached out to me for support. For most healthcare workers, their working lives have become unpredictable, potentially increasing their risk for psychological distress (Lai et al., 2020). I have spent time listening to their anxieties, normalising work-related emotions, some of which they have not felt so far in their career, and 'containing' their internal conflicts. As a practitioner of Acceptance and Commitment Therapy ('ACT') for over 10 years, no other approach felt more apt in supporting staff move to a place of acceptance. That is, while staff and the system are doing their best, at times the outcome is not what anyone wants, or can sometimes prevent.  

A key outcome of ACT is psychological and behavioural flexibility, defined as fully contacting the present moment, experiencing what is there to be experienced, and working to change behaviour such that it is in the service of chosen values (Hayes et al., 1999). However, staff need to feel safe at work to be in the present moment, which requires teams creating psychological safety. Accordingly, the panoply of emotions and thoughts can be 'held', freeing individuals to make choices that are based on individual and team values, rather than current emotional states, or past events. The desired change therefore is measured not necessarily by feeling better, but by engaging in values and responding flexibly to the current context in a healthy way.  

Most healthcare workers enter their profession to provide the best possible care, irrespective of a patient's gender, age, and condition.  This is their moral code and often their professional values. However, many are currently practicing in a system where they are unable to provide the standard of care that they have been trained to deliver. Their work-related values are therefore compromised and their moral code shattered. Since the epidemic has spread throughout the UK, I have seen many healthcare staff experiencing moral injury, heightened distress, and emotional pain. Some have reported working for many years in a health system which has pulled them in too many directions. However, the moral injury they now suffer is the consequence of having to make decisions which are in conflict with their professional values. The depths of their moral pain, which also signifies their humanity, is indicative of the degree to which their values have been violated.   

I have spent a significant part of my career supporting families and staff impacted by psychological trauma sustained through the healthcare system, so feel reasonably comfortable with having difficult conversations. Yet, I felt ill prepared when asked by a staff member, "tell me how I can be okay with not providing the care that I want to?" Discussing the role of acceptance at that time would have felt insensitive. It seemed more useful to support them to try not to control the feelings of guilt and shame, which accompanied these thoughts (and attempt to avoid/distract from them), and be willing and accepting of their internal experience.

Guilt and shame are common features of moral injury, and some might conceptualise these as attempts to control the past (Nieuwsma et al., 2015). Supporting staff to acknowledge this and be present, whilst fostering self-compassion for their thoughts and feelings relating to their experiences, has been found to be effective. Many healthcare professionals I have seen have found it difficult to connect with their self-compassionate selves. We have role played how they might respond to a colleague experiencing similar thoughts and feelings, which has engendered more self-compassion and also enabled them to be less fused with these thoughts. Helping staff clarify values relating to their own wellbeing, and behaviours which would reflect they are acting in accordance with these, has helped some individuals make wellbeing plans.

Some staff have reported that the psychoeducation elements about moral injury, ACT and values, have helped them understand why they are feeling morally wounded and pained. Also, I have spent time encouraging some to create team values, where moral decision-making is shared and staff cohesion fostered. As of yet, I have not received feedback on whether these suggestions have been implemented and their efficacy.     

There is a dearth of information on the role ACT can have in supporting healthcare professionals impacted by moral injury. Now is not the time for staff to begin psychological therapy, and indeed to open this up could be more detrimental to the mental health of staff. Therefore, focus should be placed on optimising staff wellbeing, psychological safety within teams, sharing moral decision-making, and preventing the work force from becoming traumatised. ACT could make a positive contribution in achieving this.

- Dr Janice Smith is a Chartered Psychologist and Clinical Lead at Make Birth Better 

References 

Hayes, S.C., Strosahl, K.D., Wilson, K.G. (1999).  Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. New York: Guilford Press.

Herman, J. (1992).  Trauma and Recovery: The Aftermath of Violence—from Domestic Abuse to Political Terror. New York: Basic Books.

Janoff-Bulman, R. (1992).  Shattered Assumptions (Toward a New Psychology of Trauma). New York: The Free Press.

Lai, J., Ma, S., Wang, Y. et al. (2020).  Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.  JAMA Network Open, 3(3):e203976. 

Montgomery, A., Georganta, K., Doulougeri, K., Panagopoulou, E. (2015).  Burnout: Why Interventions Fail and What Can we Do Differently.  In Karanika-Murray, M. & Biron, C. (eds).  Derailed Organisational Interventions for Stress and Wellbeing.  DOI 10.1007/978-94-017-9867-9_4.

Nieuwsma, J.A., Walser, R.D., Farnsworth, J.K., Drescher, K.D., Meador, K.G., Nash, W.P. (2015).  Possibilities within Acceptance and Commitment Therapy for Approaching Moral Injury. Current Psychiatry Reviews, 11, 193-206.

Shay, J. (1994). Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York: Scribner. 

Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2): 182-91.