Doctors may not put a name to the unease they feel when they ‘cannot do the job properly’ – but they are acutely aware of the toll that moral burden is taking.
Increasingly, these feelings are finding expression in the term ‘moral distress’, the focus of the BMA’s recent, pan-profession survey of UK doctors. More than three quarters of respondents (78 per cent) said the term struck a chord.
And more than half (51 per cent) said the term ‘moral injury’ – implying more serious, lasting harm – resonated with their experiences at work.
Moral distress can be understood as occurring when ‘institutional and resource constraints create a sense of unease among doctors from being conflicted about the (quality of) care they can give’.
Doctors always want to do the right thing and find solutions to problems
When this leads to ‘impaired function or longer-term psychological harm’, moral injury can result.
Or as one doctor put it, ‘by their nature, doctors always want to do the right thing and find solutions to problems. When you cannot [do] that, due to circumstances beyond your control, it is extremely distressing’.
Among doctors who had experienced moral distress, 96 per cent of those who had worked before and during the pandemic said these feelings had worsened in the past 15 months, exacerbated by factors such as a sense of isolation in decision-making and ever-growing waiting lists.
For doctors working with COVID only patients during the pandemic, the number of those reporting moral distress in relation to their own ability to provide care reached a staggering 97 per cent.
However, the survey makes clear these feelings pre-date COVID. Sixty per cent of those who had worked before the pandemic said they had experienced moral distress in the 12 months leading up to it.
‘In emergency medicine we’re used to the moral injury year on year of lack of beds, undignified conditions of having no adequate space to see patients, and the feeling of providing an inadequate service,’ one doctor said.
‘It wears us all down and will contribute to burnout and people leaving the profession…’
The most commonly stated cause of moral distress was insufficient staff – an issue which the BMA has raised repeatedly, calling for stronger recruitment and retention strategies.
Alarmingly, 62 per cent of respondents said they were planning to work fewer hours in the next year; 51 per cent said they were more likely to take early retirement.
Other significant factors included: mental fatigue, lack of time to give sufficient emotional support to patients, and the inability to provide timely treatment.
It wears us all down and will contribute to burnout
Different branches of practice reported different experiences.
Critical care doctors were significantly more likely than other doctors to identify ‘insufficient staff to suitably treat all patients’ as a primary cause of moral distress.
GPs, meanwhile, were much more likely than consultants to cite the ‘de-prioritisation of certain patients’.
The findings also reveal a strong inequalities dimension to moral injury: for example, more doctors from ethnic minority backgrounds (65 per cent) say they experience it than white doctors (47 per cent).
Likewise, more doctors with disabilities or physical or mental health issues (59 per cent) experience moral injury than doctors without such conditions (48 per cent).
Interestingly, 44 per cent of respondents had not heard the term ‘moral distress’ before, while ‘moral injury’ as a concept was new to 48 per cent of them. Yet, the affinity people felt with the terms is beyond dispute.
Importantly, doctors recognised – and appreciated – the way the terms shift the cause of people’s unease away from the individual and onto the system.
As one doctor put it, ‘I hadn’t heard of the [terms] before but they really explain how I’ve been feeling since I started work as a doctor. We are taught such high ideals to work towards as medical students and told we have the power to make changes. However, the reality of working in the NHS is very different and I did become depressed when I struggled to live up to these ideals…’
A BMA report, Recognising and tackling moral distress and moral injury in UK doctors, based on the survey findings, makes a series of recommendations for government and senior management.
These include: adequate funding and resourcing for the health system; increased staffing; empowering doctors to make decisions about patient care; and a streamlining of NHS bureaucracy.