My partner recently injured his hand on a faulty ladder. This took off an area of skin over a proximal finger joint resulting in a dramatic amount of bleeding and an inability to use the finger. Over the days and weeks since we have watched the healing process with fascination, noticing the stages of recovery of both form and function. Normal wound healing has four recognised stages: haemostasis, inflammation, proliferation, and remodelling. For a wound to heal successfully, the four phases must occur in the right sequence and time frame. Many factors can interfere with this process, risking impaired wound healing.
As we watched the re-epitheliation and remodelling of his physical wound it made me think about the unseen wounds many of us have suffered since the start of the pandemic, and the impaired wound healing we have been experiencing. So many people have been harmed not only by the virus itself but also by the lockdowns and the lack of a social safety net, eroded for decades by austerity. I see wounded people often in my work. They are incredibly adaptive and resilient but the body keeps the score, and many chronic diseases and distressing physical symptoms have their roots in emotional and social distress. I cannot speak for these people but I see them. I see their suffering and their strength.
Neither can I speak for all NHS staff, but is is well recognised that the pandemic traumatised healthcare workers. We experienced moral injury long before COVID-19, when we did not have the resources to provide the quality of care we wished to, were let down by a decimated social care system, or were forced to turn people in need away due to factors such as their immigration status. The pandemic brought us challenges that were all too familiar, but, more than that, it highlighted the pervasiveness, severity and proximity of this harm. Moral distress is the immediate result of participating in or witnessing a morally troubling situation. It may linger a few hours after the event, but if an individual’s ‘sense of the good’ remains intact, it often resolves. Severe or repeated injustices may leave a ‘moral residue’, which can accumulate and lead to moral injury. Without intervention this can lead to burnout, where distress is replaced by symptoms similar to those experienced by trauma victims, including numbing, depersonalisation and detachment. During the pandemic, moments of distress were frequent: staff shortages; inadequate personal protective equipment; colleague sickness; shortages of critical care beds, caring for critically ill people on general wards; cancellation of outpatient and elective activity, letting down countless people in need; and the need to allocate limited resources, deciding which patients would receive which treatments. This was within an environment of: social fragmentation; family sickness and financial worries; loss of access to protective activities and hobbies; inadequate childcare; lack of trust in governmental instututions; undermining and attack from the press; anger from the public; and the general fear of what might come next both inside and outside the hospital.
I can now see that last year I teetered on the edge of burnout. Repeated moral distress left me injured but I, like so many of my NHS colleagues, trudged on through the pain of those injuries. Despite recognising the signs of depression and anxiety, and using techniques I had learned during previous periods of poor mental health, I did not adequately understand the cause of my distress and the process and importance of healing. Having come through the other side I am holding tight my restored self-identity. Knowing that by continuing to work in the NHS under the current government I will suffer moral distress again and again, I have committed to deepening my understanding of the process of injury, healing and moral repair.
For a small wound it bled a surpring amount, but having applied pressure and dressings to my partner’s finger, haemostatic processes began immediately and successfully produced a clot. In a fresh wound microvascular injury leads to extravasation of blood into the wound and initiates the coagulation cascade. There is constriction of vessel walls; and the resulting clot formation and platelet aggregation limits further blood loss. The platelets trapped in the clot are essential, not only for haemostasis but also for a normal inflammatory response, as they release pro-inflammatory cytokines and growth factors. These proteins attract and activate fibroblasts, endothelial cells and macrophages and amplify the response by activating the complement and kinin cascades.
In healthcare a moral injury may provoke a flow of emotions but there is a need to ‘hold it together’, to hide any injury from those for whom we care, and to continue the work. In a fresh wound the flow of emotions must be stemmed and therefore there is a constriction and suppression of the systems which allow feeling, reflection and insight. With the ‘bleeding’ controlled, we can continue to work, but the injury provokes an unseen emotional inflammatory cascade. This cycle of injury and suppression may happen many times a day in a system stretched far beyond breaking point: being forced to leave an elderly person on a trolley in A&E for 19 hours as there are no ward beds available; interrupting a patient expressing their distress as we have so many others to attend to, being forced to swallow the guilt of failing to show the empathy we feel; telling someone that their operation has been cancelled again due to lack of capacity; hearing the horror of a family’s fight to exist on the poverty line with nothing but words to offer; looking into the eyes of a woman trying to access much needed healthcare but whose immigration status leaves her with no recourse to public funds; apologising again that someone’s dignity has not been maintained as there are simply not enough nurses to provide ther personal care they need. Being a physical embodiment of an inadequate welfare state takes it’s toll. There is only so much that we can suppress.
After the bleeding stopped, we watched the finger swell as inflammatory cells migrated into the wound, The inflammatory phase is characterised by the infiltration of neutrophils, macrophages, and lymphocytes. Neutrophils clear invading microbes and cellular debris in the wound area, but also produce substances such as proteases and reactive oxygen species, which cause some collateral damage. Macrophages play multiple roles in wound healing. They release cytokines that recruit and activate additional leucocytes. They also induce and clear apoptotic cells, paving the way for the resolution of inflammation. As macrophages clear cells, they transition to a reparative state that stimulates keratinocytes, fibroblasts, and angiogenesis to promote tissue regeneration. T-lymphocytes migrate into wounds following the inflammatory cells. and skin gamma-delta T-cells regulate wound healing by maintaining tissue integrity, defending against pathogens, and regulating inflammation.
An emotional inflammatory state is a chaotic, raw mixture of psychological and physical sensations. There is no coherent narrative of the events causing the moral distress, but rather a fragmented series of visual and visceral memories, juxtaposed with previous related experiences. Rest and reflection are needed to order these fragments into a comprehensible story, and to clear the debris of the wound. Rather than recruitment of immune cells to stimulate a reparative state, neural pathways of repair are engaged to regulate and reduce the inflammation, and organise the experience so that it can begin to resemble memory and lose it’s intensity and power to overwhelm.
If there is no time and space to organise the inflammation then moral distress can lead to moral injury. The event and it’s contextual factors cannot be seen as separate from the self, leading to feelings of guilt, shame, and worthlessness. After a long series of moral injuries I could not see beyond myself to the complexities and inadequacies of the wider system. I felt guilty that I wasn’t a better doctor. I felt shame that I could not do more to alleviate the distress I saw everywhere. I felt embarrassed that I was not as resilient as my colleagues, who seemed able to glide serenely above the chaos, unharmed. My work felt pointless and I felt empty and detached.
Small injuries can be shrugged off but damage accumulates and leaves us vulnerable. For me, the deepest cut came at the end of a long day when I had stayed late to speak to the family of a patient who was dying. The family had already been abusive to nursing staff and junior doctors on my team. We had excused this as part of their distress at their relative’s illness but I had insisted that I provide the update that day to save others from further harm. On returning to the ward after a long and overbooked clinic, I explained as sensitively and clearly as possible that the elderly patient had multiple organ failure and that sadly no medical intervention could stop the dying process. Our focus was to treat symptoms and relieve suffering. I was met with anger, was accused of murder and was threatened with legal action and referral to the GMC. I left that day feeling empty, slept badly and returned the next day for more.
As days passed my partner and I watched the raw surface of the wound start to dull as epithelial proliferation established a new protective layer of nascent skin. At first fragile, it gradually gained strength as fibroblasts laid down collagen. In the proliferative phase of wound healing a provisional matrix is established over which re-epithelialisation can progress. In the dermis at this time, fibroblasts and endothelial cells are the most prominent cell types and support capillary growth, collagen formation, and the generation of granulation tissue. Within the wound bed, fibroblasts produce collagen as well as glycosaminoglycans and proteoglycans, which are major components of the extracellular matrix.
In the process of healing from moral injury, a matrix of self knowledge is formed, over which we can rebuild our agency. During this process there is pain and discomfort. It is an active, not a passive process and requires an honest examination of the circumstances of injury and clarity on what is and is not possible in the circumstances in which we work. It is essential to avoid a deficit perspective which suggests individual clinicians are lacking in psychological resources or resilience. Safe spaces for this type of discussion and reflection are lacking in healthcare. In addition, those who most need these spaces may not seek them out. Certainly a consequence of my own psychological distress was a detachment and self imposed isolation from those who might offer support. I am aware that a retreat from the world is a warning sign that I am not well, and yet this insight does not help me to reach out. I am eternally grateful for friends and family who reach in, continuing to extend love, support, invitations to social events and a listening ear, even when I repeatedly fail to respond. An unexpected thoughtful gift from colleagues shattered my illusion that I am nothing more than a name on a rota. In moments of darkness I do not feel deserving of such love, but the fact that it exists creates a safety net, preventing me from falling ever deeper.
Weeks later, my partner now has a thin pink scar over his finger. No longer a functional impairment the wound is a visual reminder of injury, and a warning to take care operating the ladder and other machinery. Following proliferation and extracellular matrix synthesis, wound healing enters the final remodelling phase, which can last for years. Many of the newly formed capillaries regress, and the extracellular matrix undergoes remodelling so that the wound structure approaches that of the normal tissue. The wound also undergoes contraction mediated by contractile fibroblasts that appear in the wound. Small wounds heal fully and leave no trace; larger injuries leave a permanent scar.
So it is with moral injury. The healing process involves a remodelling of our beliefs about the limits of our personal responsibility for a system which does not support our moral values. Shame is reorganised into self-compassion, worthlessness is remodelled into courage, our self-image undergoes repair such that it approaches that of our pre-injured self. But deep wounds leave a scar – we are forever changed.
Factors affecting wound healing
Multiple factors can lead to impaired wound healing; these may be local or systemic. Local factors are those that directly influence the characteristics of the wound itself, such as foreign bodies, oxygenation and vascular supply. Systemic factors are the overall health or disease state of the individual that affect their ability to heal. These include age, stress, diabetes, smoking, alcohol, and nutritional state. Many of these factors are inter-related but many are also modifiable.
Moral distress can be mitigated and moral injury prevented if the triggering event is removed, but this is not always possible. Addressing moral injury to prevent burnout is even more challenging. It ‘requires attending both to the organisational climates and structures that lead to ethical violations and to the clinician’s ruptured moral identity.‘ It has been found that healthcare workers commonly feel that healthcare leaders prioritise finances over patient and clinician health. These leaders may be department or care group leads, hospital executives or politicians. When employees trust that leadership is committed to their wellbeing, they report less job stress, higher participation in activities that support wellness, and greater levels of health promoting behaviour. They also perform better in their role. Such trust is hard won and easily lost.
My healing only began when I accepted that I was injured and took steps to create the space I needed to heal. I had taken on too many commitments, was suffering severe sleep deprivation, and had taken very little annual leave in the years since the start of the pandemic. These local factors interacted with systemic factors at work including: poor staff retention; the constant ask from government and management to do more with less; a feeling of being let down by a system only interested in treating sickness not on creating health; the daily frustrations of the inadequacies of the digital and physical healthcare environment; and being forced to witness the deep harms of longterm austerity on a daily basis. This toxic combination impaired my ability to shed the moral distress I experienced, which led to moral injury and the warning signs of impending burnout.
Healing was supported by restarting sertraline, which was essential to improve my sleep qulaity. I was routinely awake at 4am, experiencing intense anxiety; a racing heart and constant nausea. The lack of restorative sleep prevented any meaningful engagement with my feelings, or analysis of the causes of my distress. With sleep came perspective, the ability to articulate what I was experiencing, and the start of recovery. I was able to break out of my self imposed isolation cell and fall into the safety net of a supportive group of friends and family. I also cannot understate the value of a supportive partner. Love is not cinematic grand statements and gestures, it is the daily act of caring: making dinner, doing laundry, a word of encouragement, a hand on your hand, patience, sharing, making plans, investing in a future together. The other essential ingredient was a holiday. I took three weeks off work, my longest break since starting registrar training, and I left the continent. It usually takes a week to decompress and feel any separation of myself from my professional identify. The knowledge that I would be away for an extended period meant that I planned ahead and managed the expectations of others far more effectively than usual. The minute I switched on my out of office message I felt a weight lifted. People say that a change is as good as a rest but it’s not always true. Rest is essential.
Wound healing is a complex process. Multiple factors can affect the process and final outcome. Conceptualising the experiences of healthcare workers as moral injury reminds us of the profound moral questions central to the daily practice of medicine, and prompts us to examine local and systemic factors which influence the severity of injury and process of healing. ‘Clinicians are not simply tired after working long hours or physically strenuous shifts; they are taking great personal risk to care for their fellow human beings.‘
Feelings of detachment and worthlessness now feel distant, and I have returned to the enthusiastic, sociable, somewhat idealistic, person I recognise. But I know that if I am not alert to the risk of moral injury such feelings are not so far away. We owe it to ourselves to pay more than lip service to self care. We owe it to each other to reject the discourse of personal responsibility and resilience and to demand change in the circumstances in which we work. If we don’t, the wounds of healthcare workers will result in irreversible societal loss.