Also available as a video with subtitles here.
Welcome to Season 2 of the When Work Hurts podcast.
We start this second series of conversations with a look at moral injury.
It’s a term we’ve come to hear a lot recently, so to get a fuller understanding of what moral injury is I chat to health psychologist and expert in moral injury amongst healthcare workers, Dr Esther Murray.
Esther’s book is The Mental Health and Wellbeing of Healthcare Practitioners.
You can connect with Esther on Twitter @EM_HealthPsych
I’d love to connect with you so come and find me on LinkedIn, Twitter or Facebook.
Sign up to my weekly newsletter here to get updates about the podcast as well as psychology tips and insights direct to your inbox.
Follow and subscribe so you don’t miss an episode!
Transcript
[Music]
Dr. Paula Redmond: Hi, I’m Dr. Paula Redmond, a clinical psychologist and you’re listening to the When Work Hurts Podcast. On this show, I want to explore the stories behind the statistics of the mental health crisis facing healthcare professionals today and to provide hope for a way out through compassion, connection, and creativity. Join me as I talk to inspiring clinicians and thought leaders in healthcare about their unique insights and learn how we can support ourselves and each other when work hurts.
[music]
Moral injury is a term we’ve come to hear a lot recently. To understand more about this, I spoke to Dr. Esther Murray, the health psychologist and expert in moral injury amongst healthcare workers. I began by asking her what moral injury is.
Dr. Esther Murray: That’s a brilliant question because it depends who you ask. If I just situate a little bit historically, in the 1990s a psychiatrist called Jonathan Shay started writing about it. He worked in veterans hospitals in the US. If you think about the 1990s, just think about it historically. He was still treating veterans from Vietnam in the course of his career. He’d already been a psychiatrist for 20 years by that point.
They’re treating people largely for PTSD but these are people who are in hospital and then subsequently coming in for lots of outpatient treatments. These are people who are really struggling to function effectively in society because of their experiences in war. He said, amongst other things, one of the things he also said was about listening about the ways in which we need to listen to people, not to diagnose and categorize them but just to hear what they have to say.
He said, “When I listen to these people, even though they’ve had all the treatment for PTSD, we’ve done everything that we should have done, they are unable to see a world in which they can fit now because of the experiences that they’ve had and not only the things that they’ve done but the things that they’ve seen and the ways in which they’ve suffered injustice at the hands of their leaders.”
He’s written a lot about this in his books really, really worth reading. There’s a book called Achilles in Vietnam. What’s interesting about it is the ways in which he talks about failures of leadership, which is something we really need to talk about today. I think time has come to get that out. He said, “Listen, I think what this is is a moral injury.” I think what’s happened is that people’s sense of a right and moral world has been so badly disrupted by their experiences that they can’t come back.
It happens in two different ways. We all have a moral compass and we all come to an understanding of a right and moral world and we see this with children. Kids will say to you but it’s not fair and the next thing we go, oh, well, life’s not fair but their expectation is that the world will behave in a certain way. As we grow up, we learn that it doesn’t and it’s still true that we hold our own moral codes as individuals and we tend to share these with our group members, whatever our group might be. We know when someone’s done something wrong. In really blatant terms when someone’s done something wrong because they go to prison say, or they’re prosecuted or whatever.
What Shay was trying to say was, what if not for fear-based reason. When we talk about PTSD, we’re talking about fear-based usually threat to self stuff which has completely discombobulated people so far that they struggle to function. What if it’s not that, what if it’s more like guilt and shame and sorrow and grief for a world that should be but that isn’t, and it’s like seeing a world that other people don’t see because you see the wrongness of it and you can’t be in it.
There’s a lot to say about that and there’s so many parallels with people working in healthcare, especially in pre-hospital emergency medicine, which is where I started out. Quite some years later, another researcher Litz writes about moral injury as well and says, it’s really about not just seeing one’s self and one’s colleagues and brother’s arms thing betrayed by a person in legitimate authority, in a high stake situation. It’s not just that it’s doing things that are terrible but also failing to prevent things that are terrible.
For example, if you’re thinking about war, it’s like destruction of infrastructure, civilian casualties, collateral, that kind of thing, but even just bearing witness to it. Being present to it and learning about it in other people, it says it’s so transgressed your moral belief and expectations that something happens that affects maybe not function in the most extreme sense. Like in a clinical sense. People can continue to function but they will socially isolate. Largely it leads to social isolation because it’s about guilt and shame.
One of the things that’s been so interesting for me through the whole time is thinking about we have all these campaigns to encourage people to talk. What we don’t offer, I think is enough nuance in the way we talk about talking because with healthcare professions that I’ve worked with, especially in pre-hospital medicine and emergency medicine but also, so I’ve spoken to counter-terrorism specialist firearms officers. Quite a lot of police barriers, if you like. First responders, quite generally, they don’t want to tell the civilians, if you like, about what they’ve seen because it feels like a kind of contamination. It’s like, this is a horrible thing to know and I don’t want you to know the horrible thing.
This is especially, and you see it even in the medical students that I first did my research with. They’re young, young people and they would say to me, “I absolutely do not tell mom about this stuff because my mom doesn’t need to know it.” They’re very protective of the people around. What we know really is that people who work in certain types of jobs tend to talk to one another about the job rather than talking to people outside the job. Because when you already all know about it, you have a shorthand. That’s why peer support works so well and why we need to facilitate that. That’s a very lengthy definition for what moral injury is but it’s trying to explain how it expands out from the personal to the social, I think.
Paula: That really resonates in thinking about the doctors that I was working with, particularly in the middle, maybe of the pandemic, that sense of isolation, because not feeling able to talk to anybody about what they had experienced for those reasons, wanting to protect them. I think wanting to protect their loved ones from seeing a side of them that they were ashamed of having been part of, I think, particularly keeping families away from dying or very sick patients, I think has been a massive theme.
Esther: Yes, of course. It completely goes against what people have trained to do largely. I was speaking to a nurse who’d been in ICU and that was the thing that stuck with her the most and upset her the most because it was the opposite of what she’d been trained to do.
Paula: Can you tell us a bit about what impact, we’ve talked a little bit about functioning, but what impact does it have moral injury on individuals resting with it?
Esther: The biggest problem is that when we transgress, so we all have social rules all the time. That’s how societies function. It doesn’t really matter what kind of society it is. We have lots of social rules and we learn them as children. We know when we’ve transgressed them because people tell us we can read it in their face and we know it or perhaps we’ve got a set sanctions that we’ve all agreed in and somebody doesn’t speak to you or they put you away somewhere, or they take something away from you or they incarcerate you, whatever it might be. we know.
All these social agreements are present to us all the time. When we’ve done wrong, if you like, whether something we did deliberately or whether we were following rules that meant we did a wrongness. For example, keeping the families away, that was following the right rule for the right reasons but it was still a wrongness. What happens is that because we’ve transgressed, we internalized the shame of that. We want to repair it and make it better so that we can be forgiven.
Most societies have got a set of rules and systems. Especially in religion, you see, is really clear to see the rules by which that can happen, that forgiveness can happen. In these social settings, like working in healthcare, there isn’t a way to make it better. What the problem with shame as an emotion is incredibly sticky. It’s really hard to get rid of, especially on your own. It makes you isolate from other people because there’s a contamination idea about it or that you’ve become something horrible so you can’t inflict yourself on other people. You don’t want people to see that part of you. Even it’s nothing to do with the other people, is it really, really internal experience?
People are more likely to isolate themselves and we know that not being able to share experience means you are less likely to be able to process it and move on from it and all this sort of thing. We would like people to be talking or writing or doing something to share stuff so that they move on through it. With a moral injury, they don’t. I think the other thing that can happen at the same time and in parallel and what definitely what happened in the pandemic was, so we had individuals who were feeling very badly about the things that they’d to do because of resources or because of infection or what it might have been.
But then there’s also this failure, so our moral code, like was much more of a collective or much more of like people who work in the NHS or whatever that was transgressed by some of the leadership decisions. Some of the decisions made by the government, these figures in who, to a greater, less extent we’ve placed our trust in who form part of our moral architecture.
We’re making choices that were wrong. Then in the individual, you’d see all the anti-vax movement, the anti-masker movement, the anti lockdown thing. This is basic social psychology in groups and out-groups. These groups are transgressing each other’s rules all the time. Now what that does is to create a lot of anger. We get really angry and feel really resentful, which is also horrible to live with. All of these are moral transgressions of barriers.
Paula: You mentioned earlier about that failures in leadership. I guess I think what’s been so hard in a recent month about, people having made decisions that they knew were wrong, but as you said, following the rules, that have left them with a wound, that’s very painful. Then to hear that our leaders were not following the same set of rules and have rewritten the rules in retrospect, I think that is hugely harmful, isn’t it?
Esther: Yes. It’s breaking trust and it’s breaking the psychological contract. We’ve got lots of psychological contracts all the time. Haven’t we got the one we’ve got with work, we’ve got the one that we have with the government? There’ll be the ruling of this. Our part is to do this and your part is to do that. Then they just consistently haven’t done their part. Then the idea of trying to say, oh, I didn’t know what the rules were or whatever it might be when we’ve got no redress. We can’t just sit down with this man and say, “Hey, what the hell man? What happened there?” There isn’t a system– We’re trying to have a system, let me the idea of having prosecution on these kinds of things.
We are trying to make our systems work in the face of this violation and it keeps slipping out of our collective hands not happening, not happening or not happening. It’s really devastating and I’ll be interested to see what the outcome will be.
Paula: I guess for me, there’s a sense of rage that it emerges from that. I don’t know what we do with it.
Esther: It’s normal though. I mean, think part of it is saying, listen, if you look at all the social psychology and you look at any evolutionary psychology type stuff, of course, you are angry, you are designed to be angry about this. That is right and proper. In a way, I’d be easier with the angry people. It’s the people who are numbed out and disassociate from it. I think I’m more worried for, or burnt out in the cynical end of the spectrum.
Paula: I was thinking yesterday, I saw you talk at a conference in January 2020. It was the last real-life work event I went to. All these issues felt so live and so relevant than a really high level of burnout particularly working in mental health services, real struggle with people not being able to offer, good quality evidence-based care, and having to really let people down and then COVID came along and I’m wondering whether your understandings or reflections on moral injury have shifted or evolved, given the experience of the pandemic.
Esther: Right at the beginning, watching it start to like you could see the wave coming in from China and moving across. I remember thinking, oh, God, this is it. This is what this is. This is really happening. It was so awful. I’m an academic really. I do it applied stuff in. Really, I’m an academic, I have an intellectual interest in this stuff, then it’s nice to have an intellectual interest in something, in a manageable way, even though with the levels of burnout and everything. That was something that was manageable. I handle them. I knew what I was doing. I was quite useful.
Then this thing came in, it was like, oh, no, please don’t let it be this because we knew not only. There’s people like me sitting around saying, oh, God, we’re in trouble here, there all say there’s lots of research on what happens to people in pandemics. None of it was applied right at the beginning. The systems did not kick in fast enough in terms of staff support and that stuff. We knew and have known for some time what should be done.
That was awful, that was my- where I felt really hurt and upset and angry, and I didn’t know what to think or do. I don’t think my understanding of it has changed. I think if I go right back to what Shay said is a betrayal of what’s right by a person in legitimate authority, in a high stake situation. That’s exactly what’s happened. I suppose what is interesting now is what we’ve got to be careful about is
[crosstalk]
I’d be interested to know what you think about this as well. In psychology, we’ve got lots of words that we use terms and concepts, ways of understanding, frameworks in which we can explore things with people. What worries me sometimes in the workplace and in the NHS, for example, is that words get picked up and weaponized really fast and their meaning changes I’ve really been thinking about.
In moral injury specifically, there’s a lot of contention like. Well, but what does it mean? This, that, and I think, I just don’t care as long as I can have a conversation with someone about what’s going on with them. If they call it that happy days, as long as we can get some work done. What we don’t want is to reduce our understanding of people’s experience and go, oh, right? Well, I’ll slap that diagnosis on it and moving it, not a diagnosis, it’s not a disorder, it’s an observation. It’s a clinical formulation this guy made about from the years that he’d spent sitting in rooms with people, listening to them. Talk to one another. I think that’s the important thing.
Paula: You’ve mentioned, your work with pre-hospital staff paramedics. How were you drawn to that? I’m curious about how those experiences are different to other professionals.
Esther: Yes. When I first started to think about what was happening with regard to the experience of trauma in healthcare professionals, I thought it would all be in the pre-health to world because that’s where you see the worst, if you like inverted com stuff. Okay. I thought it’s going to be all the gory accidents, people under trains and RTCs and what have you, and I was wrong about that.
When I started to talk to people, the sorts of things that they would describe was morally injurious for them. You got to remember that there is no set type of event that would cause moral injury necessarily. It’s complicated, but it’s largely to do an interpretation things, it’s very much about how people experience it. What was really disturbing to them, the things you like, taking an elderly person out of their home knowing that person would never go back there. The patient didn’t necessarily know, or their family didn’t necessarily know. Seeing people living in extreme poverty, not having enough–
I had a student who talked to me about the experience of treating someone who was almost the same age as him, who was in sickle cell crisis. They didn’t have enough painkillers for this guy, they had to wait and watching this person in pain and not being able to do anything for him was really, really what stuck with him. Interesting sorts of things, the students said, which the more experienced staff didn’t say was that they felt like a shame and a social awkwardness about knowing the trajectory of things.
If they saw somebody with a head injury, they knew roughly what the trajectory might be, but they felt that the family members didn’t know. They could see a future that other people couldn’t see at that point and that really troubled them. I thought that was really interesting that kept coming up. Then with the more experienced paramedics and so in the pre-hospital world, you get teams that are working together very very experienced, highly qualified paramedics, sorts of doctors and needs.
Doctors are very kind it needs to their medical competence was such that they, that part tended not to bother them and didn’t really matter how spectacular the injury and all that kind of the things that they did or the things that might be shocking for live people to hear it was almost always the very human aspects of things like the point listener. In London, you see a lot of night knife crime, amongst really young people, and it was the pointless dreadful of that. Now, there was nothing different that they could have done. Once they get to the scene, there’s somebody who’s saving stabbed, they can just do the medicine. The social causes, all the reasons that get people to the place where they’re in gangs, and they might get stabbed, are absolutely nothing to do with the doctors at that time.
They’re carrying a burden of upset, that it’s nothing to do with their direct work to me, if you see what I mean. Then I got into ED, then I started spending time in emergency departments and talking to people. Actually, once again, it wasn’t that that was so damaging. Damaging because there’s lots of things in emergency departments that are great, and staff really get a lot of benefit out of it, learning, and they can do the teams. The teams are extraordinary. Their work tends to be quite fast-paced, there are as many nice stories as there are sad ones, if you see what I mean, pre-pandemic.
They’re overwhelmed during the pandemic, that’s changed everything I should think. The other thing was starting to spend time, so there was an anaesthetist who I know really well. Said, “Listen, would you come and do some of your stuff, wellbeing stuff for theatre staff?” Then this is everybody who works in an operating theatre. They’ve often got a psychologist adjacent, so there’s often a psychologist in ICU. There’ll be a psychologist in ICU who’s there for the families, but also for the staff.
The staff that work in theatres, obviously, is closely related to ICU, because people are often going from there to there in various different units. The other thing is, it was interesting. A lot of the stuff that we did with them was, often if you’ve operated on somebody, we then don’t know what’s happened to them. They come into your theatres and they’ve been brought in. There’s a lot of ruptures in healthcare. We brought in hems, we’ll bring you in or the paramedics, the ambulance bring you, drop you off, kind of thing.
Then the team takes you into ED, and then you go on to the next thing, the next thing, the next thing. There are movements now to try to get better continuity and understanding for clinical staff, because it’s important for their learning. This was part of the thing we were talking about. With the theatre staff, they’ll see terrible things, terrible injuries, ways in which people have been violent and harmed one another, we found children, all these kinds of things.
It comes in awful, is there stitch and fix and do all your magic as much as you do? Hand them off. That really caused quite a lot of drama also, it’s physically quite a hard job. I think it makes a lot of difference when there’s physical being whether it’s being up or standing up for hours and then not being able to go for a wee, these sorts of things or have a drink. That was another really interesting look-see. In ICU, my first understandings of ICU where it’s a very intense job, the nursing prior pre-pandemic was one-to-one, do 12-hour shifts, one-to-one.
When people are very, very sick, you don’t leave their side, is really intense. You have to really pay attention, it must be exhausting to do. Then, of course, when the pandemic came in, everything that ICU was, was turned on its head in non-great ways.
Paula: What’s your sense of what the greatest deeds are now for healthcare staff in terms of mental health?
Esther: I think if I could wave my magic wand, I’d give everybody probably a good rest, because how would you even know what’s happened to you if you haven’t got time to feel it? That’s the thing, isn’t it? You don’t just feel it. You can’t switch it on and off like a switch you know.
Paula: That feels hard because we know that that’s unlikely for lots of people given–
Esther: That’s right. Not only is it unlikely that people will get the rest that they need. I know, and there’s so much upset going on all these people who leave the profession, and I thought, “Oh, good for them,” because if they’ve reached a point where they need to leave in order to be okay, well, good on them. I think there could be a way in which we could have better dialogue or more open conversations about what it is like to be overwhelmed emotionally.
I think there’s a really big perception of like, if I even open the lid on my emotions, they will overwhelm me and I will be destroyed for months and months and months. Of course, that can happen to people, but it isn’t always what happens. In medical schools, we don’t train students well about feelings. Like crying, we don’t talk well about crying at medical school, I think, or enough.
Usually, when people cry in a social situation like a consultation or something happens at work, they don’t cry for hours and hours and hours. They just don’t. They’re likely to just do a bit of crying. Really, if you are the listening person like, “You all right?” We wouldn’t be bothered by it at all because this is what we are really used to. We need to get that knowledge out there that things fall apart, people get distressed and then they come back up to their equilibrium in order to carry on.
That’s how everybody’s getting through therapy. If you go into therapy, some of those therapy hours are going to be awful, but you still get through your day, and then maybe you go home and be sad in the evening, but whatever, but it comes and goes with waves. It’s like children. Children are brilliant with this and we should remember it more, that they can be devastated and then 10 minutes later fine and then devastated again.
That’s usual. It’s more real for us to let ourselves flow in and out of our emotions a bit more. You don’t have to be devastated the whole time. You can be okay some of the time and still have stuff to process.
Paula: Makes me think of I went to recently see this Spiderman movie and I wept so much and came out of it with a very intense kind of grief headache. There’s something, I guess, I don’t know, there’s loss and unfairness and a lot of sadness. I guess we are all holding on to a lot of that in different ways.
Esther: That’s what’s so interesting, so the idea of going to see a film. We know this is a known tactic that people use. I’ll listen to a sad song. I’ll see a sound. I will do the thing that gives me a way into crying, for example, or rather emotions or anger, whatever it might be, or dance it out. We have got some mechanisms. I think what’s so interesting about needing to have a mechanism to get us into it, or to get completely drunk, let’s face it. We have a massive drinking culture in this country, so we might go and get hammered instead, so we can feel something.
What we need to do with that bit of information I think is to say, “Wow, how did we get so far away from ourselves that we need to find a root in? Why can’t we just sit quietly, take a few deep breaths, and know?” Well, because we’ve been holding, holding, holding for all this time, for years.
Paula: I guess there’s that sense of particularly, doctors and nurses who are doing really intense work for really long periods of time, that it feels almost impossible, I imagine, to take moments to contact their feelings. It needs to be or people think it needs to be all hold-up or kept aside until appointed, which it can be dealt with, but if we were able to be more fluid.
Esther: That is because of the work stress. If you’ve come off a really crappy night shift and you’ve got to go back and do another one. That’s it. You’ve got a few hours, you’ve got to try and sleep, you’ve got to eat. Maybe you see kids or whatever, or your friends, and then you go back and do it again. I’m saying feel your feelings guys, but also really aware that there’s a huge risk in thinking, “Oh, but what if I cry for six hours and I haven’t got six hours? What if I need to stare into space?”
There’s been a lot of staring into space going on, is just staring into the middle distance. We talk about that for a reason. Sometimes we have no idea how we feel at all. We’re just so numbed out. We just don’t even know. That’s when we get side whacked, isn’t it? Like somebody will be kind, put their hand on your arm or do something and the tears come terrible.
We need, I think, to get much better at talking about that stuff, the real nitty-gritty detail of what’s happening with our emotions and the energy that it takes to keep them down. Our strategies are appalling usually in this country. This is really a British thing. Sorry for international listeners, apply this to your media. We abuse alcohol really routinely without comment, without sanction.
Numbing out with food, TV, alcohol, drugs, licit or elicits, whatever you’re numbing out with, we do it all the time and we have forgotten to know that it’s not our best ever coping strategy. I really mean that with just lots and lots of love and compassion, because I do it too. It’s not judgment on anyone but it’s just information. It’s just to take a little audit of ourselves, like, what am I doing, even.
Paula: I think there’s something about learning and giving ourselves opportunities that we can go through these emotions. I think you talked about kids. I think that’s what they do. They travel through their emotion to the other side of I’m still catching up and might reach for the glass of wine to get me over that hump. We need to get better at learning how to go through.
Esther: Also, remembering that we can do. I think that we keep forgetting. I don’t know why we forget this. We have to actively remember, like bad things have happened before I got through them again, looking at loneliness, and sense of isolation and the idea of because we know how important social support is for well-being. The pandemic artificially isolated, us all, all kinds of different ways, whether we are physically isolated, or intellectually isolated in our beliefs.
Within families, you’ve got one who’s a massive anti-Vaxxer, anti-masker, and then the other ones do follow that. If you think about the UK, it’s hugely divided. Wales did something different. Wow, so much division isolation. How do you feel the sense of community that you need to be okay, because that’s how humans are built under those circumstances. I think it’s really worth trying to really consciously think, like, when have I got through a bad thing before? Who is there for me? Write them down. Just do a list. If there’s no one, then that’s information that needs attending to.
Paula: Maybe just to expand on that a bit more, if people recognize that they are struggling with moral injury and that’s something having a big impact on them, one of the sorts of things that can help?
Esther: Trying to get it out of your head and into the world is a really useful thing to do now that we’ve all got different ways of doing it. Talking is great if talking is available to you but it’s not everyone’s way. If you can write, writing with a pen and paper is better. I don’t ever forget the science of why it’s better for you but it is. If you can write it down, it doesn’t have to be coherent. Nobody else needs to see it.
There’s lots of research that says that expressive writing, so just writing about difficult things, getting out of your head and onto the page is great for your working memory because you have to remember that if this stuff is in your head, it’s taking up space. It’s taking up your bandwidth – you worry about what’s on your mind, whether you know that or not. It affects your sleep and your relationships and your ability to be present.
When we talk about processing and moving on, it sounds like guff. Just what I mean, when I talk about that is, listen, if you’re very in your difficult experience, and it’s in your mind, and sometimes we have lots of intrusive memories that come unbidden. It means you’re not engaging with your life now, because you’re not here because you’re in the sad place with the sad. There’s nothing wrong with being sad but we want you to be able to move through it to a more peaceful place.
Maybe that could be the motivator for trying to look at the difficult stuff so talking to the right kinds of people. We know really if you take a minute to think you know who your safe people are that you can talk to, or writing it down. You could write it to someone. Write an angry letter to whoever you’re bloody angry with. Probably don’t send it. [laughs]
If you’re really angry with, the government, name that person. What you are feeling in the sense of moral outrage is a usual human emotion. It is there to make you in groups function well so that we know what’s right and wrong. We do things for each other, not against each other. If there’s nothing wrong with you, at all the grief part of it the shame part, the things that have happened, the sense that we’re so hard on ourselves, and we tell ourselves that we’re so unlovable.
Usually, that’s not really accurate. If you were to check in with somebody, if you think of someone in your life who loves you, and have a little experimental try with a little something, and see if they’re going to hate you and run away. They’re probably not going to hate and run away. Just like, if they were to tell you their stuff, you probably wouldn’t hate them and run away.
Paula: There’s something there, I guess, what you’re saying about expressing what is going on for you which sounds like part of what’s helpful about that is just being able to process the experience. Also, something about counteracting the isolation that comes with shame, the connection with that expression come foster. Then I like that idea of experimenting with reaching out and opening up and navigating the safety of that, and proving to yourself or gathering evidence about.
Esther: Well, and that there’s a world you can trust, there’s stuff you can trust. If you do know, I really think about our non-human counterparts in this. If you’ve got pets, like your pets love you, man. They just do. If that’s where you can safely feel the feelings of love now, do that one. Parts equally if you’ve got a garden, hallelujah, go outside, be outside, dig around, be still, listen, whatever, all these things.
Emotion can feel like this real tsunami. You can approach it sideways and gently and get around the corner or something by other means. Also, do something for someone, the acts of kindness for other people, they make us feel fantastic. We are wired for them. That’s part of us. That’s like a repair thing that we can be doing. I’m not saying if you’re feeling empty, empty, empty, and lost, you’ve got to go and give more when you haven’t got more to give. That’s not at all what I mean. It’s just to smile. Smile at someone’s baby or their dog or I don’t know, pass them 10 off the high shelf in a supermarket. That’s the kind of stuff I mean. Say hello to the coffee person who can make your coffee for you, smile.
Paula: It sounds like a lot of this is part of maybe cultivating compassion for ourselves.
Esther: That’s such a hard ask, though, isn’t it? I have so many thoughts about compassion. I think it’s really important to talk about compassion and it’s very, very important to cultivate it, but you do have to cultivate it. That means work all the time every day. The other thing I think we do with a lot of the mental health stuff is that we forget to know that it’s work too. I always liken it to brushing your teeth. When you brush your teeth, you’re probably not thinking about how toothpaste works and how cavities are formed or the architecture of your teeth.
You’re not thinking about that. You’re just brushing your teeth because you know that’s how you keep them. What we do for our mental health and our well-being needs to be the same. We don’t have to delve into the theory of it every time but we do need to do it every day. The problem with compassion is that and it can be a generational thing. It can be a cultural thing, all kinds of reasons. Not everybody grew up with compassion in their lives. They weren’t shown it so they don’t know how to have it for themselves or for others.
Lots of people working in healthcare are massively compassionate to other people all the time and you see extraordinary love for. It’s just love, you see just the most amazing love poured out but learning to show it to yourself is a whole other deal, a howl other ballgame. This is another thing where you need to pay attention to your life. Okay, are you being compassionate? Are you doing it for other people? Do you ever do it for so yourself? What are you saying? What thoughts do you have? We talk about how we talk to ourselves inside our heads. Do you beat yourself up all the time? Would you ever speak to anybody else that way? That’s a pretty good marker.
I had a friend once who said to me, I told him something I was upset. He said, ” I think your worst enemy would struggle to speak to you the way you speak to you,” I was like, “Oh jeez.”
[laughter]
Have a word with yourself in the nicest possible way, small small, so they don’t have to be big things. I think people would just be amazed by just one thing and it disturbs me that you if you see a lot of advertising, things on the television or wherever social media. They act as if the kindnesses we need to show to ourselves need to be material they need to be really specific things like bubble bars.
So when you need a wee, you don’t have to answer another email before you go. If you’re hungry, eat, if you’re thirsty, have a drink of water. If you’re, I don’t know, cold, put a jumper. This is showing yourself compassion so it’s not something very light box chocolates in a bubble bath. In fact, the box of chocolates may be counterproductive.
Paula: Yes, and it’s so interesting to hear you say that because I can’t imagine anyone saying to someone else who needed a wee, or was thirsty or hungry. No, you can’t, just hold on a bit more.
Esther: We do it to ourselves all the time and what does it even mean? I know so there’s loads of people listening to this a lot of people in healthcare so I can’t go for a week because there’s no one to cover me. Well, absolutely, absolutely, absolutely, absolutely so, if that’s true in your workplace, and I know it’s true in lots and lots of workplaces, let that not be true in other parts of your life. When it’s you making decisions about you, you do the kind thing for you.
Paula: Maybe we can think now about what we could do in our teams or in organizations to combat more moral injury. What do you think we need to do?
Esther: I think in terms of leadership there are ways to be a great leader in difficult times. She says like I’m not anybody’s leader so this is very much in the theoretical realm here but I’ve read about it and written about it quite a bit but they do not have to do with having solutions. This is not about having solutions. This is not about being the great fixer. This is about being a fantastic listener and a communicator. If you think about a team, you’ve got a team to run and decisions need to be made and some of them are really hard decisions and they’ve been made for really specific reasons that doesn’t make them comfortable at all.
Being able to communicate effectively about difficult decisions, why they’re difficult, what ethical scenarios might need to be thinking about talking through, how can we find a way through this together and we’re not looking at feeling good necessarily. We’re looking at being okay, somewhere in the middle. Listen, listen, listen, really listen, not to fix, just to hear because a lot of the time what people need is to be heard, and often, your team showing with these lots and lots of evidence about what makes people feel great at work and to be valued at work, to be seen as a competent person to have a sense of autonomy to feel belonging.
These are the things that really help people feel great at work and to mitigate the awful, to remind the group, that they are a group that their values are still shared, that they are still part of this by– For example, like with regard to looking for support to competitors or taking breaks, if there’s a republic rest space that’s for staff go and be in it so that staff sees that senior people using it so then other staff will use it.
That’s proven there’s lots of research to show that’s how that works. Say when you don’t know. Communicate clearly, communicate frequently, accept that some things are bad and difficult. The resources are short and it’s not about saying, “Hey, we haven’t got resources, so I need everybody else to do that bit more.” Just say we haven’t got the resources. That’s the end of that sentence. Then we’ll do whatever needs to be done. What we’re not doing is quick sharp, let’s fix it.
In teams, it’s hard to be kind when you’re sad and hurt, because we’re trying to defend ourselves from being sad at what and hurt, especially at work. We don’t want to walk around work, tears running down our face. In some workplaces, that’s definitely possible, but it’s tiring. It’s tiring to be around other people’s emotions just as it’s tiring to be around our own emotions. What we bring to our team is the work that we’ve done with ourselves, which is learning to be a bit kinder, go a bit slower, be a bit gentler.
These are not normal times. Maybe second-guessing the snap remark or the joke or the whatever flip thing tiny bit gentler. It doesn’t take any longer to do that. I don’t mean be humorous. I don’t mean that, but little bit of kindness. Kindness, it’s not really fair to just say, well, be kind, because that’s another of these phrases that get banded about what does it even mean?
Maybe it means changing the picture of your voice. When you get really stressed out and you maybe get louder and higher and whatever, when something happened. If you’ve dropped your shoulders before you talk to someone, then you’re going to speak to them from inside your chest, which sounds calmer. It sounds nicer. It’s really tiny things and what you do for others, you are doing for yourself. The more you notice your own stress and your own unpleasantness, whatever, however it manifests, the more you don’t do it to them and you don’t do it to you.
Paula: There’s links there, I guess, with that cognitive load you were talking about, that if you’re carrying and working really hard to not be thinking and feeling about difficult stuff, it is hard to have the bandwidth to notice and to respond.
Esther: Sometimes you won’t notice. Sometimes you will miss it and people will be really sad and you missed it. It’s not always your responsibility. It’s okay. We’re in a system together. Not just all these end points, we’re all connecting this big web thing.
Paula: I’m curious about, you said that at the start of the pandemic, I can imagine that frustration of having a body of research evidence there about what should be done, what could be done to mitigate the disaster and it not happening. I’m wondering where we are with that now, whether there’s a sense of post-pandemic understanding, and what needs to happen now for people.
Esther: People periodically have written, “Hey, let’s do this now stuff.” It hasn’t been able to stick for all kinds of complex reasons. I think what will really be true and what I hope is really true is that there’ll be more of a grassroots movement. I know some of the senior people in those hospital trusts have talked to me like, do we need to do a truth and reconciliation type thing?
Do we need to air? Everybody needs to air their stuff. It’s difficult because it’s dynamic. This is a wicked problem. We need to treat it as such and we need to see it as something that’s dynamic that you do one thing, it affects the rest of the system. My hope is that there will be more of a grassroots understanding of what needs to be different. This is once again, it sounds like it’s saying to the individual that you have to do the work. I don’t mean it like that, I mean that the work is shared, but I cannot see signs from the government that it is going to be anything coming there.
When we share the work through the system, by listening to one another, so that each part of the system can represent its own needs and concerns and so on and so forth. We see how we all impact one another. Just for instance Corridor Care completely disappeared early in the pandemic, but all those years in emergency departments with people going, oh yes, sorry, man, there’s nothing we can do about this.
I think there is! All of a sudden, bish, bash, bosh, it’s gone! People built whole new departments overnight, unbelievable, just amazing. They’re creating these extraordinary sets of resources out of nothing, amazing, and we know we can do that, except we know it’s not sustainable but there’s so much we can learn from all of that.
Paula: What do you think if there was one thing or if the governments were going to listen, what would be on your wish list in terms of supporting staff with the burden of moral injury that people are carrying?
Esther: I think they should say sorry. I think the first thing is the selection of people I’d like to invite to leave their jobs, I think they should say sorry, make themselves bloody useful, go and do some work, ask staff what they need. I suspect they need more stuff, maybe they need better infrastructure, so that there are nice places to go for wee and to change your clothes and offices with windows. Then, any therapeutic interventions, which are lovely, like wellbeing interventions, family fun, and it is lovely, but you’ve got to be in a place to receive them.
Paula: You’ve got to trust where they come from.
Esther: Yes. Two rights, and be paid, those need to happen in paid time. People don’t need, they don’t want to be coming in on their free time to do that stuff, that happens in their paid time. Thanks very much. Yes, it’s a revolution, I’d like a revolution.
Paula: I think that that thing is you’re saying particularly about moral injury, about people saying, sorry, for the people who have held the power and have hurt us by transgressing their side of the bargain.
Esther: Repeatedly. That is how you make repair, that’s a socially accepted way of repairing relationships, “I am sorry, I did wrong.” Then maybe there’s reparation in other ways. We get people to sit down from their jobs all the time when they’ve transgressed. That is a well-known mechanism, and it’s just not that hard, guys.
Paula: I think you’ve written a book, Esther, can you tell us about the book?
Esther: The book, I co-edited a book, I’ve written a chapter or two in there. It’s a bit about the mental health and wellbeing of healthcare practitioners. The title is a bit dry but the content is that- It’s written by people who work in healthcare, whether they’re past paramedics or nurses or doctors of various kinds, and psychologists. It’s about stuff that they’ve done in their organizations to try to improve psychological wellbeing. There are also a couple of personal stories in there about experiences of recovering from PTSD, which they’ve got as a result of their work. It’s very much a book written by healthcare professionals for healthcare professionals.
Paula: Sounds brilliant, definitely, put details of it in the show notes.
Esther: A labour of love, and it came out in the middle of pandemic, and these clinicians were writing their chapters during the pandemic, amazing, amazing work.
Paula: Thank you for listening. If you enjoyed this episode, and you’d like to help support the podcast, please do share it with others, post about it on social media, or leave a rating and review. I’d love to connect with you, so do come and find me on LinkedIn or Twitter. You can also sign up to my mailing list to keep up to date with future episodes and get useful psychology advice and tips straight to your inbox. All the links are in the show notes. Thanks again and until next time, take good care.
[music]
[00:54:26] [END OF AUDIO]
