Moral injury and the Cwtch

07 Jul 2022

By Hiro Tanaka

Published 07 July 2022

Recently, I did something that I hadn’t done since I was an SHO nearly 30 years ago.  I was hiding in a corner of an empty patient room with my head in my hands, wanting to walk away.  I was there because of an overwhelming feeling of frustration, injustice and deep moral conflict which had built up over a difficult 24 hours.  And before you ask, this happened during an operating list.  As I tell you the story of what happened, I hope that it’ll resonate with you.  I think that by sharing our stories from the front-line we might not feel so alone in those dark moments.

Our trust has only recently resumed what could loosely be described as a normal elective service.  In reality, I know it’s far from normal.  We’re severely short-staffed, kit is missing and the equipment hasn’t been serviced in years so we never know what’s working or not.  I can’t quite understand what’s happened.  It’s as if someone came in to the theatre complex during the shutdown and walked away with random pieces of kit.

My first full elective list was rather optimistic even by pre-pandemic standards and to be fair, I’d contributed to that by agreeing to operate on a colleague’s urgent patient as an extra.  All the others were Priority 3 patients, many of whom had been waiting for over 18 months.

I sensed how the day was going to go during the team brief.  The Mini-C-arm had stopped working and the radiographer was sick, there was kit for less than half the cases on the list and the theatre staff were running on minimum numbers so we’d have to stop for lunch.  Actually, I normally  encourage the team to take a break during a long operating list.  A short rest over a drink and a chat builds trust and relationships within the team, something that’s been lost to the winds of efficiency.  But on this day, I could have done without it.

The team managed to get the kit ready from HSDU and blue-lighted them from other units but the list didn’t start until late morning.  All throughout the operating list I had an unfamiliar sense of unease that I had no backup kit.  I take for granted that if I ever dropped a drill guide or needed to change the plan intra-operatively then alternative options would be available.  But not on that day.

None of the conditions were optimal or perfectly safe but doesn’t pragmatism trump dogma when our patients are in need of our help?  That’s what I told myself.  The truth is, there are systemic problems everywhere.  I think one of the great characteristics of clinicians working in the NHS is the ability to adapt and find the safest solution for our patients within a finite resource.

I feel that there’s been a seismic shift in how I’m able to deliver care to my patients.  I’d like to think that it’s simply down to the effects of the pandemic but the truth is that it’s simply unmasked the problems.  Previously, I felt that I could advocate for each of my patients and deliver the best care within the constraints of the service.  But how do I advocate for a patient with a fracture dislocation of the shoulder who’s sat in a chair outside A+E for over 24 hours or an elderly lady with crippling OA who needs her ankle fused who’s operation is cancelled for the third time due to a lack of beds?  This happens every day and I fear that the longer this lasts, the more we’ll believe it to be normal.

I always believed that the day’s work is complete only when I’ve done everything I can for patients under my care.  Increasingly I feel guilt going home when I leave those patients in their chairs or when I know that the quality of care isn’t what it should be.  This is the moral injury which haunts me.  Whilst I may score high on the Maslach Burn-out Scale, I’m certain that I’m not Burnt-out.  I don’t need wellbeing training, I don’t need more resilience nor do I want recognition.  It’s moral injury and it’s systemic.

Anyway, back to my operating list.  As you can imagine, the list over-ran and guess who falls off the end?  You guessed it… the extra patient I added.  Within half an hour, I’m on the phone to a relative who’s shouting at me saying “you’re totally incompetent and refusing to pick up the patient until they got their operation.  There was nothing I could do, it was evening and the list was finished.

As I said before, adaptability is an NHS skill so I implored my colleague who had a list in another unit to allow me to operate the next day at the end of their list.  It was agreed that the patient was to be transferred first thing in the morning and the patient was happy.

The following day, I did the team brief via facetime as I finished my morning clinic.  It’s the first time I’d even thought about using facetime for a team brief so I was feeling quite pleased with myself driving to the unit.

That all changed whilst I was putting on my scrubs.

The ODP rushed in saying “You’ve got to come NOW”.

As I ran to the theatre, I could hear wailing coming from the anaesthetic room and as I approached, the poor anaesthetist ran out saying “I can’t do this!”… it was a wtf moment.

Understandably, from all the stress of being cancelled the day before, the patient had an emotional meltdown.  On top of that, the patient had been transferred at 4am in the morning.  I mean who does that!?!

After apologising and calming both the patient and the anaesthetist we were eventually able to carry on.  Back on the ward however, I was just about to receive a complaint from the physiotherapy manager who felt that transferring such a patient at 4am was inappropriate and that I should communicate more effectively.

That’s the moment I had to find an empty room to hide.  Everything I had said and done was to deliver care to my patient.  The sense of injustice was profound.  Worse still, the final injustice would have been caused to the patient if I screwed up the surgery by operating in such a frustrated and angry state.  I’m all for leaders taking accountability for things that go wrong and protect the team from the consequences but we all have our human limits.

In that moment, the door opened and one of the theatre staff walked in.  She said “Looks like you need a Cwtch”.  It was like a weight was lifted from my shoulders.  For those of you who aren’t Welsh, it’s a difficult concept to understand since there’s no literal English translation.  Loosely, Cwtch is Welsh for hug but it means a lot more than that.  It means “It’s OK, you’re safe”.  Something that our grandmother might say.  Without that I don’t think I would have been able to operate safely, not in that state of mind.

What I’ve come to realise is that it’s the people around me that help me to perform at my best.  It’s the empathy, trust and culture of the teams in which we work which matters as much, if not more than the systems.  It’s easy to ignore because it can’t be quantified but aren’t the greatest things in life often immeasurable?

I believe that the philosophy of Cwtch; developing a culture of telling each other “It’s OK, you’re safe” is a small but essential antidote to the moral injury facing our profession.

Orthopaedics Online