Crisis time for morally injured health care workers

HEALTH CARE workers who cannot put the needs of their patients first because their energy is being diverted to administrative and regulatory demands in an environment of resource and service reduction, may experience moral injury and burnout.

It is time for the executives in health care organisations, clinical leaders, consumers and political leaders to have respectful dialogue and establish and maintain systems and processes to support health care workers to deliver comprehensive care to patients. Any perception that the consultative process is token in nature will undermine trust and will put the high standards in the health care system at risk.

The COVID-19 pandemic has presented unique challenges to the individual, families and local, national and international communities. Addressing these challenges has highlighted two equally important but seemingly diametrically opposing priorities in health care that broadly shape policy making, namely the current health and safety of the people in the nation versus the drivers that have an impact on our economic future.

This played out at the national level in broad terms as a debate between decisions to prioritise “lockdown” or “opening the borders” and elimination or suppression strategies for COVID-19 in the community. Within this broader context, health care workers are now encountering unprecedented pressure.

The same opposing priorities may be played out at local health boards and health care organisations. Are local health boards scrutinising budgets and reducing or stopping clinical services that run at a loss but the health care workers believe are essential and core business?

The challenge for health care administrators, executives and health care workers is to balance economic accountability with the Australian Commission on Safety and Quality in Health Care (ACSQHC) standard on providing comprehensive care to patients.

Health care workers are paying the price for working in these conditions. The incessant pressure to cut services, to do “more with less” and to fight a system that seems at odds with the health care workers’ primary intent to provide the best health care for their patient creates a workplace that potentially promotes moral injury in these workers.

Moral injury and moral repair were first described as a construct in war veterans who by “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long-term, emotionally, psychologically, behaviorally, spiritually, and socially”. Moral injury threatens the person’s identity and inflicts damage to the moral belief system. In the United States Navy and Marine Corps, the term “inner conflict” is preferred to moral injury. It can manifest as social and behavioural problems, trust issues, spiritual and existential issues, psychological problems, and self-deprecation (here).

This construct was extrapolated to physicians who were “unable to provide high-quality care and healing in the context of health care”. Health care workers may encounter morally injurious events when they cannot “put the needs of the patients first” due to competing drivers of financial constraints, administrative burdens and overcomplicated system “rules and regulations”.

At times, external factors impose extreme time critical pressures on an already stressed health care system. During the height of the COVID-19 first wave, health care workers in many countries experienced and developed moral injury. How can they make a decision as to who can be given an intensive care unit bed when the system is overloaded? How can they come to terms with the reality that there are no beds in the hospital to treat the patient with cancer? Health care workers relied on the support of the organisation to carry out their work.

More commonly, though, chronic issues compounded by the ongoing pandemic threat can result in health care workers experiencing moral injury. Their experience is not helped by the perception that key decision makers in the health care organisation place greater priority on meeting the budget over the delivery of essential health care to patients (here, and here). Experienced health care workers have seen the discordance between recruitment to administrative services compared with patient facing health care workers over the past 20 years.

Decision makers rely on data collected by the burgeoning administrative services to plan the budget. What if the data used to inform budget estimations are inaccurate but still result in reduced services for our patients with increasingly complex medical and social problems? Accumulating challenges in the health care system may lead to health care workers developing moral injury.

The goodwill of health care workers in an overstretched health care system has also been identified as an area of risk. Goodwill is further undermined if health care workers suspect key decisions have already been made before a token consultative process is offered to them.

Administrative burden, overcomplicated rules and regulations and rule-driven health care practices are frustrations experienced by health care workers in a complex health care system. Complicated processes that distract from providing efficient patient-focused care can potentially result in health care workers developing moral injury by taking them away from attending to the patient’s needs. Ofri provides an opinion that complex electronic health records may contribute to the increased workload. In a complex adaptive system, minimum specifications should replace complicated plans.

For health care workers, manifestations of moral injury include anger at executives and managers, disengagement and presenteeism, and conflict between health care workers. They do not feel valued. They complain about the dysfunctional system that promotes a silo mentality where individual units and departments become more concerned about their own survival and existence than the patient. This conflict reduces the effectiveness of highly functioning collaborations between health care workers teams. The characteristics of exhaustion, cynicism, and reduced efficacy all point to burnout.

Conversely, a crisis can inspire positive responses, as was demonstrated in many different ways during the COVID-19 pandemic with reports of innovative solutions to “wicked problems”. Either way, the managers and administrators of health care organisations need to support the health care workers with workable systems. ACSQHC Standard 5 states:

“Leaders of a health service organisation establish and maintain systems and processes to support clinicians to deliver comprehensive care, and establish and maintain systems to prevent and manage specific risks of harm to patients during the delivery of health care. The workforce uses the systems to deliver comprehensive care and manage risk.”

The standard goes on to state that comprehensive care should be delivered if required or requested by a patient. Health care workers will often identify when comprehensive care is required during a consultation with the patient.

Clinical leaders, managers and administrators of health care organisations need to collaborate to strike a balance between fiscal accountability and maintaining safety and quality in health care services. The balance should be reached by respectful dialogue and not be seen to be unilaterally imposed without consultation. This approach is outlined in Standard 5.4 of the ACSQHC standard on comprehensive care. Such an approach should reduce the burden of inner conflict or moral injury on those who are at the public face of health care service.

A disruptive approach, outside the box, to meet this Standard may require clinical leaders, managers and administrators, consumers and political leaders openly consulting together or adopting new frameworks recognising the complex adaptive system in health care.

The health care system also needs care.

Professor Yee Leung is a clinical academic at the University of Western Australia (UWA), Head of Department at the Western Australian Gynaecologic Cancer Service at Women and Newborn Health Service, and a Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Board member. The opinions expressed in this article reflect the views of the author and do not represent the official policy of UWA, Health Department of WA or RANZCOG.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.