New research¹ by the BMA has revealed doctors are suffering ‘moral distress’ and even ‘moral injury’ because they cannot give their patients the care and support they want to when they feel they need it.

The Association has undertaken the first ever pan-profession survey of its kind and as part of the research, the BMA surveyed UK doctors during March and April of this year. Almost two thousand doctors took part and, whilst the majority said they were experiencing distress when they weren’t able to provide the care they knew was needed, many did not realise they were suffering what is identified as ‘moral distress.’

Moral distress can be understood as the feeling of unease stemming from being unable to undertake an ethically correct action due to institutional or resource constraints². Over three quarters (78.4%) of respondents stated that moral distress resonated with their experiences at work. An even greater proportion of critical care doctors and foundation year junior doctors stated that moral distress resonated with their experiences at work (88.9% and 88.5% respectively).

Over half of doctors who responded to a question about causes of moral distress cited ‘insufficient staffing to suitably treat all patients’ as one of the leading causes of their moral distress, with ‘individual mental fatigue’ as the second most significant contributing factor. A ‘lack of time to provide adequate emotional support to patients’ and an ‘inability to provide timely treatment’ were both cited as the third leading causes showing clearly how much the inability to provide the level of care for patients they would like to is having a serious impact on doctors. In addition, regarding the causes of moral distress, 41.9% of female respondents highlighted a ‘lack of time to give sufficient emotional support to patients’ compared to 30.9% of male respondents. 

Consultant psychiatrist, Dr Simon Mullins, told the BMA: "If somebody is in a crisis – the early stages of psychosis – there are a lot of risks: they aren’t coping, they hear voices, they have paranoia and their reality is driving them to self-harm or making them very vulnerable.

"You want to respond quickly but there wouldn’t be a bed to admit them to, you would be waiting an increasingly long time for a Mental Health Act assessment, there is nowhere to admit them, crisis teams are overwhelmed, other support wouldn’t be in place and social care was decimated.

"You were left with a huge concern for a fellow human being – someone who is very distressed and also quite risky. You fear something bad is going to happen and that you will be blamed somehow."

The research also examined the notion of moral injury³ as the BMA found some doctors are experiencing longer-term psychological harm – or moral injury. 51.1% of respondents reported that moral injury resonated with their experiences at work. 53.7% of consultants said that moral injury resonated with their experience at work, compared to 52.1% of junior doctors and 44.1% of GPs.

A GP told the BMA: “I’m very aware that under normal circumstances I could’ve done a lot better, I’m frustrated that the personalised care that I value so much has been wiped out in a sea of demand and different ways of working and I just want all this to end and go back to normal, but I do not see that coming, at least not in the working life that I have left.

“In January this year I had a particular low point and just wanted to leave to escape the unpleasantness, sheer exhaustion and the long winter.”

The doctor’s union also asked respondents if they intend to change their career plans for the next year with almost two thirds (62.4%) saying they would work fewer hours and over half (51.3%) saying they would consider taking early retirement. This is alarming, given the relationship between insufficient staffing levels and moral distress which could potentially lead to a ‘vicious circle’ further impacting patient care.

Covid-19 has had a stark impact on levels of moral distress, with 96.3% of those respondents experiencing it saying the risk of it had worsened because of the pandemic. Alarmingly, of those doctors who saw only COVID patients, 96.6% stated they had experienced moral distress (as opposed to 84.7% of those who saw non-COVID patients and 87.7% of those who saw both COVID and non-COVID patients) in relation to their own ability to provide care during the pandemic.

Dr Maria Vittoria Capanna, a psychiatry trainee and part of the North Thames BMA Junior Doctors Committee, said: “Over time I have seen motivated and energetic colleagues lose hope in change and settle in a state of learnt helplessness where the less than ideal status quo is accepted begrudgingly.

“I have seen the strain it can take on colleagues to know they cannot do what they know is best for patients because there simply aren’t enough resources or time. I myself have tried to grasp onto the small wins and improvements to continue to advocate for patients and colleagues; but as many will have experienced themselves, the difficulties in putting your head above the parapet can make it a difficult and draining experience.

“Many times, to allow ourselves to manage these feelings of moral distress, we push ourselves – we stay late, we work at home long after we have left work, and we carry that stress with us when we are with family and friends.”

Dr Helen Fidler, deputy chair of the BMA consultants committee, said: “The results of this research are, without doubt, incredibly worrying. However, what is important is being able to now name the struggles that many doctors are facing is the first step in helping to tackle these issues and pinpoint exactly what needs to be done to alleviate them. As doctors, we need to be the doctors we want to be, rather than the doctors we have to be.”

“As with many pre-existing pressures on staff in the NHS, the Covid-19 pandemic has only exacerbated moral distress and moral injury. Doctors have less autonomy, Government support has failed to keep up with patient demand, and we’re now at the point where these pressures are driving talented professionals to breaking point, with many staff even leaving the health service because of it.

“For those who stay, we know that fewer staff is a key driver of even more moral distress and moral injury, thereby creating a never-ending cycle of damaged staff wellbeing, psychological turmoil and poorer or unsafe patient care.

“Perhaps moral distress and moral injury can never be eliminated, but it certainly shouldn’t be a part of everyday life for our healthcare staff or their patients. All doctors want to do is to help others – it’s why we’re in this job – but when we’re unable to make decisions that we believe are ethically right, it’s not only distressing, but also goes against every fibre of who we are: it’s entrapping, stifling, and directly impacts the care we give to our patients.”

Notes to editors

The BMA is a professional association and trade union representing and negotiating on behalf of all doctors in the UK. A leading voice advocating for outstanding health care and a healthy population. An association providing members with excellent individual services and support throughout their lives.

1. BMA paper ‘Moral distress and moral injury: recognising and tackling it for UK doctors’.
   
   
2. Moral distress is defined as the psychological unease generated where professionals identify an ethically correct action to take but are constrained in their ability to take that action. Even without an understanding of the morally correct action, moral distress can arise from the sense of a moral transgression. More simply, it is the feeling of unease stemming from situations where institutionally required behaviour does not align with moral principles. This can be as a result of a lack of power or agency, or structural limitations, such as insufficient staff, resources, training or time. The individual suffering from moral distress need not be the one who has acted or failed to act; moral distress can be caused by witnessing moral transgressions by others.
   
   
3. Moral injury can arise where sustained moral distress leads to impaired function or longer-term psychological harm. Moral injury can produce profound guilt and shame, and in some cases also a sense of betrayal, anger and profound ‘moral disorientation’. It has also been linked to severe mental health issues. 
   
   
4. The BMA has developed two sets of key recommendations necessary to address the serious levels of  moral distress and moral injury among the medical workforce. The first and most essential are structural solutions that would help mitigate the risk of moral distress in UK healthcare staff which include:

• Adequate funding and resourcing Substantially increased levels of investment in our health system are essential to ensure doctors are satisfied with the level of care they are able to provide for their patients. No rationing of beds, etc.
• Increase staffing Our survey showed insufficient staff to suitably care for all patients was the most common cause of moral distress. More staff means better patient care which means reduced risk of moral distress.
• Empower doctors Clinical autonomy is essential and doctors should be allowed to make decisions for patients, not removed management.
• Develop an open and sharing workplace culture When medical professionals do not think something is right, they should be able to speak up.
• Provide support for employees Emotional strains like moral distress are regular occurrences in doctors. Medical professionals should be directed to suitable support services, like counselling, when suffering from these burdens and this should be done at an early stage.
• Streamline NHS bureaucracy Layers of NHS bureaucracy can frustrate doctors and create barriers to patient care. Streamlining this should allow doctors to help their patients more efficiently.
• The second are steps doctors can take themselves to alleviate the effects of moral distress, though the ability of doctors to enact these ideas is highly dependent on their work environment, including:
• Opening a dialogue about moral distress and moral injury. Research shows that just ‘naming the problem’ can be a relief for doctors – it encapsulates what the problem is for many and proves they aren’t the only one feeling this.
• Developing support networks for doctors who are suffering Peer support and facilitated groups can allow doctors to discuss these issues without fear of reprisals. Balint groups and Schwartz rounds are examples of this, as well as less formalised settings.
• Speak out (when possible) Though dependent on the culture in which they work, doctors can help alleviate the problem by voicing concerns about structural problems leading to moral distress and, in turn, encourage colleagues to do the same.
• Seek advice  Sometimes, when making a difficult ethical decision, checking your reasoning can help. A colleague, a local ethics committee, or the BMA are all good options when seeking advice.
• Develop a self-care plan Physical and mental health are intrinsically linked. Doctors should make the time to look after themselves, which is important for their own health as well as patient care.
  
  The survey also revealed there is a significant equalities aspect to moral distress as more doctors from ethnic minority backgrounds were likely to cite the following as contributing factors compared to white doctors.

• 88.4% of doctors from ethnic minority backgrounds reported that moral distress resonated with their experiences at work compared with 75.6% of white doctors.
• 64.6% of doctors from ethnic minority backgrounds felt that the term moral injury aligned with their experiences at work compared with 47.0% of white doctors.
• 58.9% of respondents who said they have a disability, or physical or mental health condition or illness (lasting or expected to last 12 months or more), said that moral injury resonated with their experiences, as opposed to 48.4% of those without a disability.

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