A few weeks ago I wrote something about moral injury. This was in the context of reduced alcohol and drug services during the covid pandemic, but I hesitated to post it, as I was concerned that it might seem critical of the organisation where I work, which was not my intent. I have continued to think about it, and acknowledge to myself that my feelings are mixed; however not being able to speak about something that matters very much to me is wrong, and is, in a sense moral injury to self, in the same way that one can self-stigmatise.
The greater part of my time at work is spent on an assessment and detoxification ward. Most of our patients are damaged by years of dependent drinking; some do well, some do badly, and some come back to us, again and again. We don’t just detox them, we try to patch up their physical and mental health, and to do the little we can for their often dire social situations. The short time they spend with us is supported by our community teams, who see them before and afterwards for much longer.
I believe more than anything that our work is important. These patients are often the forgotten ones, with seemingly self-inflicted pain, who can be seen as a drain and an embarrassment to our society. I strongly believe that some people are more susceptible to addictions, both by genes and by experience. And if, like us, you listen to their stories, you soon wonder what you would have become, had you lived their lives.
Our ward was shut to detox during the peak of the covid crisis, probably because it was the easiest one to empty, given that we have more rapid turnover than most. We became the covid ward in our hospital. My colleagues rose to the occasion, and this was good – we had dreaded it before it happened, but we were well supported, we had extra staff, and I have nothing but admiration for everyone involved.
It is now that the ward has emptied of covid patients, and we have returned to our natural detox territory that things have started to become difficult. We have less beds, to ensure social distancing, and we have a long waiting list, of people who were referred before all this started, who are still drinking day and night, unable to stop in case they have a seizure. All those waiting have complex problems, and all have waited too long. I’d like to prioritise each and every one, but I can’t. The referrals continue to come, and I don’t know how we’ll ever get back to the old normal, when waits were shorter.
And this might be easier had the old normal had any leeway, but even then we were only just managing our waits. Bed numbers had been reduced following funding pressures a few years ago, making things hard. The wait for an alcohol detox could feel like a punishment – why weren’t we offering this more quickly, before peoples’ health reached a place of no return?
I make no criticisms of the adaptations made across the health service to cope with covid. This has been unprecedented, and we have all had to do what was needed, to care for patients and support others. But now that we are past the immediate crisis, what will happen to all the services like mine that were put on hold, and are working on less? I should have said – what will happen to the patients who need these services? How will we catch up?
We are all trying very hard, but I fear that it won’t be good enough. There will be so many priorities that we may even waste more time while we decide what to do. There will be skirmishes over resources and funding.
I am spending more time talking and writing about how to improve things than I am just delivering care to patients. I am very sad about my service, and I am trying to think of ways to improve things for patients, but it is so difficult to make things happen.
I feel guilt that I am not able to do my job as I should and could, for my patients – is this moral injury? And, selfishly, I fear for the effect on my own mental health. I could just stand back and distance myself – possibly better for me – but I don’t think I can do this either.
So, what would I like? I’d like to be included and heard when decisions are made. I’d like to know how to do my best for my patients, while understanding what other services are doing and struggling with. I know that resources are finite, and that I can’t have everything I want – also that criticising others is unhelpful. But I need to be sure that my patients aren’t side-lined, and that they get the best that we can offer them. I need to know that I can speak out for them.