Morals in the Emergency Department: Experiences of Doctors
Research type
Research Study
Full title
An interpretative phenomenological analysis of Doctors' experiences of moral injury in emergency medicine
IRAS ID
324188
Contact name
Maxine Blackburn
Contact email
Sponsor organisation
University of Bath
Duration of Study in the UK
1 years, 2 months, 28 days
Research summary
Summary of Research
This research aims to explore experiences of moral injury (MI) in Doctors working within emergency medicine. MI may occur when stressors transgress one’s moral beliefs and values. Although well recognised in the veteran population, it is only in more recent times, accelerated by the COVID-19 pandemic, that MI in health professionals has become a focus of research. Risk factors for MI that increased during the pandemic include exposure to loss of life, inadequate resources, high levels of uncertainty and high stakes decision making. The pressure on the NHS has continued despite reductions in case numbers of COVID, with long waiting lists, disputes around pay and working conditions, and high levels of staff sickness and absences.
The importance of learning more about how Doctors experience MI lies in the corrosive impact it can have for those individuals affected, their relationships and occupational functioning. MI is associated with suicidal thoughts and behaviours, diagnosable mental health problems such as PTSD and major depressive disorder, substance misuse and changes to religious and spiritual beliefs. Empirical research has highlighted the link between MI and burnout and mental health difficulties. Research suggests MI could lead to an increase in medical errors and staff leaving the NHS and reduced patient care.
This is a qualitative study which seeks to explore the experience of working in EM from a moral perspective. Initially doctors working in the ED at one NHS trust will be invited to participate. If required (due to problems with recruitment), the study will be advertised using Twitter to EM doctors in England. Semi-structured interviews will be carried out with up to 10 EM doctors to capture descriptive accounts of morally challenging experiences. Interviews will be analysed using interpretative phenomenological analysis (IPA) focusing on how each individual makes sense and ascribes meaning to their experience.Summary of Results
Thank you to all Emergency Medicine Doctors who took part in this research.
The research was carried out at the University of Bath, as part of the lead researcher’s Doctorate in Clinical Psychology, supervised by Dr Jo Daniels and Dr Mike Osborn. The University of Bath sponsored the research.
Our study was designed in response to growing research indicating that health professionals are being impacted by moral challenges through their work within the NHS. One group of front-line health professionals working in particularly challenging conditions, due to a range of factors including resource constraints, staff shortages and in the wake of the COVID-19 pandemic, are doctors working in Emergency Care. Little research has been carried out with Emergency Medicine (EM) doctors to understand their experiences of working in these conditions or to look in depth at the nature of their distress. The study aimed to explore the way that doctors experience and make sense of situations in the emergency department which challenge or go against their moral code or what they know to be “right”. It was hoped that the study would build on other studies exploring the nature of moral challenges and distress, increasingly conceptualised as ‘moral injury’, in a health professional population. An original contribution of our study is that it involves a sample of EM doctors only, in contrast to existing studies which include a diverse range of health professionals. The aim was to capture rich and situation-specific experiences from EM doctors to help us better understand more about how individuals make sense of moral challenges, in addition to how the context doctors work in, influences their sense making.
In line with the purposes of the study, a qualitative methodology (interpretative phenomenological analysis or IPA) underpins the study with semi-structured interviews being used to collect the data. During the design of the study, two Consultants in EM with experience of working in Emergency Care in the NHS, reviewed the interview schedule and recruitment poster and shared their views about ways this could be improved to make it relevant to EM doctors. We invited doctors who identified with having their moral code or values challenges at work, to participate.
A small sample (n = 10) of EM Doctors were recruited to the study through targeting the Emergency Department of one NHS hospital and all EM doctors working in the NHS in England through advertising the study on X (formerly Twitter). All EM doctors recruited were currently practising in the NHS and had worked in EM for at least 2 years. Of the final sample, 80% of the EM doctors were Consultants. Interviews were carried out in person or via Microsoft Teams depending on the preference of the participant.
Three main themes can be used to summarise the way that EM doctors experience their work in Emergency Care (1) the impossibility of the job (2) feeling disconnected – from leaders and management, colleagues, and their own needs, and (3) the unbearable weight of responsibility. In line with other research in the field, participants mainly expressed a sense of betrayal and anger, rather than, shame or guilt although all of these emotions were evident across participant accounts and some Doctors indicated they felt complicit in failing to meet the needs of, and provide humane care to patients in the ED. There was a sense from most participants that those in power (managers and the government) were aware of the crisis in Emergency Care but did not understand how it felt to be working in such conditions and, importantly, were not responding to this crisis. For many EM doctors in this study, the risk they feel they are being forced to take in a fractured, overburdened system is alienating them from a job they are clearly committed to. Our findings point to the high personal cost to doctors who may feel trapped and helpless working in a system which they perceive no longer cares.
Our data suggests that moral challenges (events that feel wrong or unfair) occur regularly in emergency care and there was an expectation from participants that they would continue to happen. There seems to be a lack of intervention or even acknowledgment about these events despite the significant emotional cost they have for those involved. This contrasts with events that are collectively agreed as being traumatic where there is more likely to be acknowledgement and an intervention (e.g Trauma Risk Management (TRIM)). Further research is needed into how EM doctors can be supported when being exposed to frequent and potentially cumulative events that feel wrong or unfair and which evoke betrayal, anger and powerlessness.
To date, the research has been written up as part of the lead researchers Doctorate in Clinical Psychology thesis, presented at the University of Bath’s Clinical Psychology third year research conference and the abstract was submitted to the British Association for Behavioural and Cognitive Psychotherapies (BABCP) research conference. Participants have received a summary of the findings via a brief report. The lead researcher is currently in the process of writing the study up as a journal article and this will be submitted to a peer-reviewed, high impact journal.
REC name
North of Scotland Research Ethics Committee 2
REC reference
23/NS/0083
Date of REC Opinion
11 Aug 2023
REC opinion
Favourable Opinion