Healthcare professionals are being exposed to “avoidable moral conflicts” at work, leading to ill health and many of them quitting their profession, says a team of international experts.

Dr Deborah Morris, Director of the Centre for Developmental and Complex Trauma (CDCT), part of St Andrew's Healthcare, was asked to co-write an article about global healthcare and why there is a worldwide shortage in doctors and nurses.

Published in the highly prestigious New England Journal of Medicine, Dr Morris was joined by a number of international experts who are industry leaders in moral injury, a term used in healthcare to indicate a type of trauma that both patients and clinicians can experience.

Moral injury can happen when a person either engages in, witnesses or fails to prevent events, which go against their deeply held moral beliefs.

It has strong associations with shame, guilt and anger, and can have a profound impact on mental wellbeing, which can lead to suicidal feelings. The behaviour can also compromise the safe delivery of patient care.

Recently published research shows that large numbers of healthcare professionals in the UK, at all levels, including senior leaders, are experiencing moral injury, which is significantly affecting their wellbeing and functioning.

Dr Morris said: “Healthcare workforces around the world,  are struggling and shrinking at unsustainable rates. Recent figures suggest that one in five doctors and one in four nurses may leave the profession in the next three to five years, which is deeply worrying

“Whilst ‘burnout’ is typically highlighted as the cause of these problems, 30 years of burnout interventions have failed to make significant impacts into clinician wellbeing, in part because this framework fails to recognise the critical role and impact of moral and ethical violations in the workplace.

“Whilst some degree of ethical and moral conflicts come with working in healthcare, clinicians are increasingly exposed to avoidable moral conflicts by the organisations they represent. Many of these decisions, we believe, are driven by a focus on finances that compromise care in various ways and by the erosion of clinically led health systems and care.

“Healthcare professionals put their trust in the organisations they work for, but we’ve found they often feel betrayed when asked to make decisions which negatively affect patient care and may present for them an ethical dilemma.

 “Being forced to make clinical decisions against their best clinical judgement is distressing for medical professionals and many are leaving their jobs because of it. We need a significant re-think on the current emphasis on individually focused wellbeing interventions and instead prioritise developing healthy organisational ethics and culture.

 “We’re calling on healthcare leaders to acknowledge the impact of moral injury and commit to preventing it by restoring the historical moral grounding and values that healthcare professionals swear to uphold, which is prioritising patients’ needs. This is long overdue and needed to reduce misalignment between professionals’ obligations and their organisations’ management principles.”

Other recommendations made by the article authors include establishing ethical frameworks in Trusts and hospitals and to create a culture that accepts workers’ varied responses to difficult situations without admonishing them.

A focus on strong ethical management who advocate for clinician and patient welfare in decision making should also be enforced. It is thought this will enhance trust with front-line staff and help improve patient care.

Dr Morris added: "It is vital that changes are made, as failure to address these challenges may lead to further people leaving the healthcare profession, and discourage people from entering it. Ultimately, the failure to address moral injury will lead to further significant impacts to the quality and safety of patient care.”

At St Andrew’s is committed to ensuring that staff are well-supported, offering reflective practice, mentoring and ongoing training for colleagues. 

Additionally, the complex mental health charity has followed the lead of the NHS, and has a cohort of Freedom to Speak Up Guardians who can support staff to raise any concerns they have about the organisation or care provided.

To read the Perspectives piece, Moral Injury and the Global Health Workforce Crisis — Insights from an International Partnership in the New England Journal of Medicine, click here.