Moral Injury and ‘Is what I’ve done good enough?’

You might be relieved to see that this blog is 100% Harry and Meghan free, although TRIGGER WARNING, there will be a mention of bed pans. But for the moment I wanted to talk about the #caring4ourNHSpeople webinar I attended last week.  I think these are really great little webinars and you can find more information about them here. Last week, the webinar featured Professor Neil Greenberg. What an interesting person he is. His day job is a consultant occupational and forensic psychiatrist who is also a fabulous researcher. Before moving to King’s College London, he served in the armed forces for some 23 years. He is well qualified and experienced in treating psychological trauma, and since 1997 has been the ‘go to’ authority on the development of peer-led traumatic stress support packages. His work will resonate with many of us as we look to find ways to support colleagues through the pandemic. I love his title – Professor of Defence – perhaps revealing his psychoanalytical leanings - but what a great title for a doctor who has served in the military for so long.

His talk looked at many things, the notion of moral injury was one element I thought was particularly interesting. It’s not an illness in itself, but can leave you vulnerable to stress and other mental health difficulties. Moral injury occurs when something we might normally take in our stride becomes something that becomes so fixed in our thinking that it starts to interfere with our normal functioning. So, for example, we all have possibly been in the situation where we wonder if we did the right thing, could we have done more to save someone perhaps? At the heart of moral injury is the thought that I did my best, but it just wasn’t ‘good enough’. I imagine that there will be many health and social care colleagues who over the past 12 months will have experienced those feelings. Professor Greenberg’s suggestions for how we prevent moral injury and or deal with the impact of it were surprisingly (and refreshingly) non medicalised. This didn’t mean that if someone developed a mental illness that they shouldn’t seek skilled help and treatment, clearly if that is what is needed, then we should do all we can to make sure such help is available.

We know that many people who might benefit from such help and treatment often don’t access it. So, I liked his description of metaphorically putting your arm around someone who might have such needs and guiding them to those who could help them. However, there was much that he advocated that many of us, with very little training, could use to effectively support others. Supportive, but regular conversations with colleagues, end of shift reviews (not psychological debriefings), buddying up with colleagues for each shift, and watchful waiting. There was something else that I liked, an approach called PIES (nothing to do with cheese and onion or meat pies) which very much resonated with how I think psychological support can best be provided. You can find out more about these approaches here.

However, Professor Greenberg’s talk also made want to think about something else that was on my mind last week. I had been taxed with the question of what makes for an effective partnership and how would I approach creating these. It’s an interesting question, and again a question that challenges the zeitgeist landscape envisaged in the recent NHS White Paper. Almost  13 years ago now, I undertook a large-scale piece of research that looked at trying to explicate the role of partnerships (what they had to offer, what was important and how to make them effective) in changing the health and wellbeing of local communities. This work led to the development of a conceptual model, that also drew upon the Winnicott's psychotherapeutic notion of being ‘good enough’. The ‘good enough’ partnership model is made up of eight elements. 

Now then, back in 2009  (when I first started posting my blogs) I was in that school of thought that subscribed to the ‘why use 10 words to explain something, when 1,000 words might be better’ (J has now educated me otherwise).  As a consequence, it took 3 volumes to explain these elements in full. Don’t worry dear reader I’m not going to try and work my way through them here, but as I reflected upon this work, I thought how much of what I had written then is still germane today.

We should only develop partnerships for the ‘right reasons’. There should be a shared vision of what might be possible, what the long term focus of the partnership might be. In the context of the NHS White Paper, I hope it’s to reduce health and other inequalities. The proposed partnerships will be ‘formalised’ as the legalisation is taken through parliament. However, there are ‘high stakes’ involved in this process. Effective partnerships can’t be simply prescribed and legislated for. Partners must have a compelling reason to become part of a partnership. This will mean having the ‘right people’ involved. Identifying and facilitating the involvement of all the appropriate stakeholders needs careful handling in order to avoid having too little views around the table, or too many that might cause more conflict than collaboration.

Achieving this will necessitate having the ‘right leadership’ available. I’m sure this might be functional, personality-based in approach or simply a combination of all of these, to be used at different times and in different contexts. Great leadership will promote ‘strong well-balanced relationships’. Such relationships don’t just happen. They need to be nurtured, managed, and supported in order to create better interdependent working. This is not going to happen in the absence of ‘trust and respect’. Trust and respect are absolutely about demonstrating how the espoused (and hopefully shared) organisational values are enacted. I say hopefully shared because ‘good communication’ will be critical. Learning to listen to what’s being said, not just the words, but the message too. This is sometimes more difficult to do than say.

And Bed pans? Last week I was asked the question ‘did I know how they got to where they needed to be?’ by my youngest daughter. She has this knack of asking such metaphysical questions. She has just started her first placement on the NHS Graduate Management Scheme. Last Wednesday she spent the entire day pushing trolleys around a very large acute Trust delivering bed pans to the wards and departments. She ended the day with very sore feet (daft shoes) feeling very tired, but also very happy too. She understood the message of what she had been doing. Bed pans are essential if you need one. Getting them to the right place at the right time was all about effective partnership working between clinical and non-clinical colleagues. I think that on Wednesday, she definitely became the ‘good enough’ partner.