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Addressing Moral Injury in EMS: A Global Mission
It is widely acknowledged that health care workers, including paramedics, around the world have experienced prolonged stressful workplace environments over the last several years. Common to the experience of all paramedics and health care workers globally has been the impact of the COVID-19 pandemic. Meanwhile, the “business as usual” work in different locations has included mass casualty events, natural disasters, and powerful social upheavals that at times included violence.
Now more than ever, these events have caused health organizations to consider how they guard and promote the well-being of their staff. Two ambulance chaplains from opposite sides of the world recently compared notes on well-being programs in their organizations and the challenges facing those organizations, leaders and frontline staff now and into the future.
I recently visited Allina Health EMS, based in Minneapolis-St. Paul, Minnesota. As a PhD researcher at Charles Sturt University and a chaplain with New South Wales Ambulance in Australia, I share a passion with Chaplain Russ Myers, chaplain with Allina, for supporting the well-being of frontline EMS providers.
In his 2021 book Because We Care, Myers notes the important role chaplains have in “bearing witness” with staff as they reflect on their experiences. Myers serves the Minneapolis-St. Paul area, which became the epicenter of the Black Lives Matter movement after George Floyd was killed in Minneapolis. Paramedics attended not only the scene of Floyd’s death but had to attend to the outpouring of emotion and violence that swept the city and the world. These scenes placed enormous pressure on staff through both the physically and morally challenging nature of the situation.
The Australian experience in which I have served has seen historically large wildfires and floods bookending the pandemic. Operating in places of danger, coupled with stretched resources, have caused staff high levels of distress. A recent Australian study revealed that those levels of distress were not primarily caused by exposure to trauma, but often by underlying organizational factors that included communication and connection with management, overwork, uncertainty and perceived lack of support.1
![Layson [left] with Dave Matteson during an Allina Health EMS active shooter drill.](https://d148x66490prkv.cloudfront.net/hmp_ln/inline-images/Mark%20and%20Dave%20Matteson%20at%20active%20shooter%20drill.jpg)
Moral Injury and the Role of the Chaplain
My research involves applying the model of moral injury in a first responder context. Arising in the military, the term moral injury describes how distress can arise when a person crosses their own moral boundaries through acts or omissions (e.g., not being able to give treatments they should, or giving treatments that have no real benefit), or from a sense of betrayal by leaders, the organization they work for, or even their treatment by the public.
Health workers may recognize the prevalence of betrayal incidents during the events of the last few years, from violence expressed to clinicians, to a lack of resources, to the absence of leadership at the front line of operations.
While still actively serving as a chaplain, I have been presenting research on moral injury across Australia and internationally, such as the Nordic College of Caring Sciences conference in Sweden, followed by a visit to Minnesota. Another research trip to England to collaborate with pastoral carers and attend the UK Psychological Trauma Society Annual conference confirmed the need to investigate, treat and prevent moral injury in health care workers.
Chaplains play an important part in responding to morally injurious environments. While chaplains come from a variety of religious backgrounds, they do not promote their religion. Instead, they provide expert spiritual and pastoral care to those from any faith background—or none at all. Pastoral care involves caring for the whole person; so you might see a chaplain cooking barbecue, sharing a cup of coffee, helping with relatives of dead or dying patients, providing for the physical needs of staff with food or shelter, helping someone find forgiveness, or helping a manager think through the moral and ethical situations they must manage. Chaplains are often seen by staff as a highly confidential sounding board and a trusted friend who listens without judgement and may then help staff seek other help as it’s needed.
Organizations can also help prevent moral injury in several ways, including the creation of a “just culture” in which errors or oversights are responded to with reconciliation and learning as a greater priority than retribution and punishment. Leaders too can be supported to understand and respond to the physical, social, psychological and spiritual nature of the staff under their care through a model of servant leadership. Another important finding is that engaging multidisciplinary well-being teams will greatly help when they act with interdisciplinary trust and collegiality.
Moral injury has been said to leave lasting psychological, biological, spiritual, behavioral and social impacts on staff.2 The process of moral repair, then, requires a well-integrated, holistic and collaborative model of care that attends to all these impacts.
One barrier to effective care can be interdisciplinary rivalries in well-being teams, caused by traditional disciplinary hierarchies or distrust between different professions. Recommendations from the research include the creation of a collegial environment, plus practical team-building activities and inclusion in training simulations to allow their care to be practiced.
Intentional, Integrated Support
In recent years both Allina and NSW Ambulance have been developing their well-being programs in an intentional, integrated model of employee support. Chaplains, EAP mental health providers, peer support, therapy dogs and post-incident care are elements of both programs. Chaplains discussed with other team members how to build trust, communication and commitment to provide best care to paramedics under their care.
While in Minnesota, I met Allina’s therapy dogs Evie and the newest recruit Westin. Dogs are also a part of the NSW Ambulance continuum of care—I work alongside my Labrador Wallace. The visit included hearing about the needs of different elements of operations from front-line staff at the Allina Communications Center, riding along with a field supervisor, and observing an interdepartmental active shooter drill. Allina leaders learned about NSW Ambulance, a part of the state health service, which serves the entire state of New South Wales with over 6,000 paramedics and support staff.
While recognizing the organizational differences in paramedicine between the U.S. and Australia, many common themes exist surrounding the moral and traumatic stresses of working on the front lines of emergency medical services. Care for the caregivers is vital, and merits a well-designed, well-equipped employee support program in which the whole person is provided a seamless continuum of care.
References
- Roberts, R., Dwivedi, A., Bamberry, L., (2021). The mental health, well-being and work impacts of COVID-19 on first responders and frontline workers in Australia.
- Litz, B.T., Stein, N., Delaney, E., et al. (2009). Moral Injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695-706. https://doi.org/10.1016/j.cpr.2009.07.003
Mark Layson is a former first responder and university researcher who has worked in police and firefighter roles as well as serving as an ambulance chaplain in Sydney, Australia.
The author acknowledges the support of the New South Wales Center for Work Health and Safety as funding his research into moral injury.
Comments
Great research and article. I am a 45 year EMS veteran (EMT, Paramedic, EMS Director and developer) who also answered the call to ordained ministry 33 years ago. Today I serve as a chaplain for the State Police and local EMS agencies. I also have done considerable research in "Emotional preparation" and contend that we can effective decrease CIS by the proper emotional preparation and strength. I would love to continue this conversation with you if you'd be interested. Thanks for what you do and Stay Safe!
—Howard Woodruff