Across the last several weeks, clinicians in Covid-19 hotspots have been operating in environments of significant resource scarcity, and some have had to make decisions that conflict with long-held ethics and care procedures.
These decisions, from preparing to ration ventilators to asking frontline staff to work without optimal PPE, have the potential to lead to moral injury—the trauma of perpetrating or bearing witness to acts that transgress deeply held moral beliefs and expectations.
One of the ways leaders can bolster resilience is to educate staff about difficult tradeoffs in care delivery before they encounter them. Here are three ways to help staff.
1. Identify situations that can lead to moral injury
The concept of moral injury was originally developed in the context of military settings, but as this table from a recent article published in the British Journal of Medicine illustrates, Covid-19 provides many direct parallels of moral injury for health care workers. Here are a few examples:
By identifying situations that can lead to moral injury, you can take steps to mitigate it, such as sending transparent communication to staff that explain the reasons behind evolving care delivery practices. Additionally, managers who identify situations that could lead to moral injury can be on heightened look-out for front-line staff exhibiting symptoms of distress or burnout during these situations.
2. Prepare staff for difficult patient conversations about care delivery trade-offs
Health care workers around the world are caring for frightened patients and their relatives and may need to explain why resource scarcity is impacting optimal care delivery. Information and hospital policies are evolving rapidly, but providing staff with guidelines or lightly scripted answers can give them needed in-the-moment support. VitalTalk, a Seattle nonprofit dedicated to helping clinicians talk with patients about serious illness, has developed a Covid Ready Communications Playbook to help front-line staff manage difficult questions in a variety of situations, such as when screening or admitting patients. (The playbook is available in several languages.)
3. Use simulation to help clinicians practice making difficult tradeoffs in care delivery
In preparation for a surge of Covid-19 cases in Boston, Brigham and Women's Hospital began simulation exercises for triage staff to help them determine who to ventilate if demand overwhelmed supply of ventilators. These exercises were linked to clinical best practices, but equally important, they forced clinicians to confront the possibility of having to ration care and make difficult, in-the-moment decisions over treatment choices. Similar situations in reality will still be wrenching, but the exercises can help staff be better prepared to manage them.
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