I’ve always thought that if shame were an animal it would be a box jellyfish, at times delivering its effect slowly through repeated contact with its tentacles and at other times swiftly, with a sudden and devastating sting.
As a medical student, doctor in training and now GP I’ve come to know shame well over the years. I’ve embodied the ‘brush of tentacles’ as a feeling of heat radiating from my stomach to my jaw, perhaps on discovering a missed blood test result or patient misdiagnosis. I’ve also felt the devastating ‘sting’, though thankfully on far fewer occasions. I’m not alone in having a medical career punctuated by episodes of shame – ask any of my colleagues – and in recent years, as an anthropologist, I’ve been drawn to exploring the questions of ‘why?’ and ‘what might the repercussions be?’
It would be fair to say that humiliation, and as a result shame, still plays a part in the medical educational journey. I’ll never forget standing at a patient’s bedside and failing to reproduce all 12 cranial nerves in order in front of my peers. The embarrassment was acute. However, while this type of educational conditioning may put medics at higher risk of experiencing shame later on in their careers, it’s not the full story.
Where guilt might prompt negative reflection on our actions, shame manifests as a sense of inadequacy or failure in ourselves. As healthcare workers, as carers, our work inevitably becomes intertwined with who we are as people, to the point of forming the basis of our identity (Cahill, J. M. et al., 2023). Within this context, therefore, mistakes or unsatisfactory outcomes have the potential to symbolise for medics not only a flaw in our actions, but also in our character. Healthcare workers, therefore, are highly prone to feelings of shame.
Healthcare workers are also susceptible to moral injury (MI); a condition characterised by, and closely linked to, feelings of guilt and shame. MI was originally observed in military conflict zones (Dean, W. et al., 2019) and is defined as “the cognitive and emotional response that can occur following events that violate a person’s moral or ethical code” (Williamson, V. et al., 2021). It is now increasingly recognised in healthcare workers, occurring in part as a result of the moral dilemmas presented by the COVID-19 pandemic (Greenberg, N., 2020). While not a mental health diagnosis in and of itself, MI can lead to symptoms such as depression, burnout and suicidal thoughts and likely accounts for a large proportion of the mental health problems facing NHS staff today.
In 2020, I joined forces with Simon Edwards, an ex-military veteran and Alison O’Connor, a therapist, to formulate a response to this issue. We connected through the Churchill Fellowship network and, using our collective research findings, developed Moral Injury Partnership (MIP); an initiative working to both prevent and heal moral injury across multiple sectors.
At the heart of MIP is our retreat programme for frontline workers and military personnel. Understanding that moral injury is a human condition characterised by feelings of shame, and that shame is exacerbated by silence, the retreat offers a non-judgemental space where healing is achieved through the sharing of experiences. Drawing respectfully on my own research into transcultural talking practices, over a residential three days we co-facilitate a series of talking circles that explore the themes of personal and professional identity, self-forgiveness and post-traumatic growth. Key to the retreat is group equality and safe story-telling, all ‘professional hats’ and hierarchies are left at the door. In this space, we build a community that supports each other in the moment and after the retreat has ended.
Our pilot took place in 2021, kindly funded by the Churchill Fellowship and the Cameron Grant Memorial Trust, making it free of charge for our health and social care participants. I’ve had the privilege of sitting in a number of talking circles and feeling the benefits over the years, but I don’t think even I was prepared for how impactful and how moving those three days would turn out to be. Following the retreat, as journeys have evolved, two in the group have been able to return to work, having been on the brink of leaving, and we all continue to stay in touch and support each other two years down the line.
Moral injury doesn’t always manifest as a sudden and sharp ‘sting’ following a devastating event. Like shame, it can creep up on us slowly. Though MI came to attention during the COVID-19 pandemic, a time of extremes, it existed both before and since; in the GP who missed a blood test result, in the nurse working the fifth under-staffed shift that week, or in the junior doctor facing the decision of whether to strike.
It would be fair to say that across the globe, populations are living through morally desperate times. Hence, MI is certainly not limited to healthcare. However, as medics, we have the opportunity to be an example of how acknowledging and addressing this problem can be transformative both professionally and personally. Much of the change that is needed is systemic, yet there are things that we can do as a profession to raise awareness of the issue, campaign our leaders to take note and to look after ourselves and our colleagues.
As this is published, I am delighted to report that we have received £20,000 from the National Lottery to continue our work and, most importantly, keep it accessible to those who need it the most. With this generous grant we will be facilitating two further retreats as well as delivering Moral Injury prevention workshops for NHS staff of all grades. We are also excited to be working in partnership with Durham University and the International Centre for Moral Injury in evaluating the retreat programme. We hope that our contribution to the emerging evidence base around moral injury will further enhance the support avenues available to those suffering.
Dean, W., Talbot, S., Dean, A. “Reframing Clinician Distress: Moral Injury not Burnout” Federal Practitioner (2019) 36: 400–402.
Greenberg, N. “Moral injury in healthcare workers“. MDU Journal. (2020)
Williamson, V., Murphy, D., Phelps, A., Forbes, D., Greenberg, N. “Moral Injury: the effect on mental health and implications for treatment”. The Lancet (2021).
Dr Sophie E M Redlin, BSc(Hons)MBCHB MRCGP FRSA FRGS CF, GP and Expedition Doctor – Medical Anthropologist – Filmmaker
8th January 2024