Moral Injury IX

Take-Away II - Validation

Validate the provider experience of moral injury and talk about it openly.

One of the biggest lessons I learned working as a psychotherapist was the value of validation.

According to a 2012 article in Psychology Today , the key points to understand about validation are:

• Validation communicates that a relationship is important and solid even when two parties disagree.
• Using validation effectively begins with being present, both with one's own emotions as well as others'.
• Being uncomfortable with emotions may lead one to inadvertently invalidate another person's experience.
• Validation is never about lying or simply agreeing with someone else, but rather understanding their point of view.

Let’s take each of these points and examine how they can be used by leaders seeking to validate the experience of moral injury for physicians and other clinicians.

Imagine that you are a physician in a busy emergency room. Your supervisor tells you that you need to see everyone who comes in the door within 15 minutes of arrival. You greet one patient who is medically stable but his wife is sobbing hysterically. She told the nurse that she needs to tell the doctor about all of her concerns and she doesn’t want to talk to the nurse. You have 3 other patients who have arrived within the past 10 minutes. You tell the wife that you can’t talk to her right now because you have to see other patients, even though you think it would be the right thing to do to spend 15 minutes with her. You feel like your values have been transgressed and you might be missing important information about the patient.

In this scenario, the supervisor could talk with the physician and use active listening. When the physician says things like “it didn’t feel right,” you can validate that feeling. You can say “It sounds like you felt like you weren’t able to do your best work in that situation, is that what you mean?” Once you clarify and reflect back what you heard, you can validate. “Yes, I can see why you felt that way, that makes sense. I could imagine I might feel the same way in that situation.”

A second example - imagine now that you are a nurse in a community health center. There is a patient in the waiting area who has become agitated because they have been waiting for over an hour. The policy of the center says that you must call security and kick anyone who is agitated out of the building. When you go out to meet the patient, you find out that this young man has autism and he is having difficulty with the overstimulation in the waiting room. You think the right thing to do would be to let him jump the line and take him into a quiet room, but you know this will derail the rest of the patient workflows and you will get in trouble for not calling security as per the protocol. You call security and the young man and his mother start crying, saying he doesn’t mean any harm and he just wants to get help for his stomach problems. As security takes them out of the waiting area, you feel terrible.

In this scenario, you (as the leader of the center) are called into the break room. The nurse is sitting at the table, shaking and on the verge of tears. She looks at you with anger and says “That policy isn’t right. I shouldn’t have to kick someone out just because they have autism.” You immediately feel defensive, ashamed, and guilty. You were the one who put that policy in place six months ago after a nurse got hurt by an agitated patient. In this case, validation means that you have to check your emotions and the emotions of the nurse. You could say “This is an intense situation. I really want to talk with you in detail; do you want to talk now? I am OK if you want to take a break and come back and talk about it later. Or we could go and walk outside while we talk now. What works for you?” By acknowledging the intensity of the emotion and giving the nurse some options to bring down that intensity, like taking a break or walking, you are validating her experience. You have also identified your own emotions and can self-manage if you need a break to bring down your own emotional state.

Third scenario - imagine a physician assistant starts their first job at a cancer clinic. They are very anxious and nervous to do something wrong, especially with patients who have just been given a cancer diagnosis. The other physician assistant went on emergency medical leave and now the PA has to see twice as many patients for the next two months because there is no money to pay for a temp. You are the physician supervising the PA and you are trying to help pick up some of the slack. The PA comes to you every 45 minutes with anxious, repetitive questions. You are annoyed because you are trying to get extra work done too.

In this case, as the supervising physician, you are tempted to say “You worry too much. It is all fine, you don’t need to keep checking in with me. Just go out there and do the work.” However, by telling the PA that they worry too much, you are invalidating their emotional experience. You are invalidating their emotions because it is uncomfortable for you. If you had more time, you would sit down and say to yourself, “This PA is annoying the crap out of me, but I understand. They are really anxious and just want to do a good job. This situation is very stressful for them.” A better response to the discomfort you are experiencing is to be self-aware then find a quiet time and place (even if it is just for 5 minutes) to validate the PA’s feelings of anxiety: “Hey, I see that you are feeling really anxious and nervous. It is totally normal to feel that way, especially when you are new to this kind of work. I would love to spend more time with you discussing cases, but with the short staffing I’m not sure that is possible. What if you and I planned for a quick prep in the morning for 10 minutes, then another check-in at lunch? We could also spend the last 10 minutes of the day doing a debrief of what went well and what didn’t go well. Would that work for you?”

In a final scenario, imagine a nurse practitioner (NP) has moved to a new state. In her last job, she had a supervising physician who encouraged her to send patients to the ER when they had suicidal ideation. She was taught that it was irresponsible and inappropriate to manage suicidal patients in the outpatient setting. Now the NP is starting her new job in an outpatient mental health clinic and you are her supervisor. In the first week on the job, she sends 3 patients to the ER because they reported suicidal ideation during their appointment. You are shocked when you hear this because in two years of working at this clinic, you have only sent patients to the ER two times. During your supervision session, the NP tells you that it is wrong to manage patients who say they are thinking about death. You tell her, “No you are wrong, you have to do a further assessment before sending them to the ER.” The NP looks upset but says “fine” and stops making eye contact for the rest of your session. You notice over the next few weeks that she stops sending patients to the ER, but she appears upset with you and keeps making excuses as to why she cannot come to your scheduled supervision sessions.

You have inadvertently caused your NP to suffer moral injury. How could you have handled the first conversation in a way that was validating without agreeing with her position? You could have said something like, “I was surprised this week that you had three patients go to the ER. Could you tell me more about each patient and what happened during their assessment?” Then with a curious and nonjudgmental active listening approach, you could confirm that the patients actually did not need to go to the ER. You could then say, “It sounds like these patients had passive suicidal ideation. I am curious to understand how you made the decision to send them to the ER.” She would then tell you that this is what she was taught by her previous supervisor. You could then say “Ah - OK, I think I understand now. This was the algorithm that you learned from your last supervisor. Let’s take a look at the algorithm that we use here in the clinic to manage suicidal ideation. We can see where it might be similar or different to the one that you learned before.” Then, using the guidelines or procedures as a reference, you can have a conversation about the clinical pathway and help the NP to discover why you are going to recommend doing things a different way. You can also say, “I know this is different than what you were doing before. Do you have any concerns about trying it this new way? Why don’t we plan to have a quick chat after the next few patients who have suicidal ideation, so we can make sure this change is working OK for you?”

Each of these scenarios may sound minor in the scope of moral injury. But for each of the clinicians, the stakes felt high. Missing important information in the ER, denying care to an autistic man, creating distress for patients with a new cancer diagnosis, or managing safety for suicidal patients are all high-stakes for the clinicians involved.

Managing moral injury in these scenarios may seem unnecessary and time-consuming. However, these are the small, routine, repetitive events that cause even the best physicians and clinicians to break. Validation of small events can add up. Taking a few minutes to validate clinician experiences can heal the small cuts of moral injury before they become a gaping wound.