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Six months ago, I left my band 7 managerial role to work as a band 5 agency nurse on the wards. Despite the band drop, this move has financial advantages which will help me to achieve some personal goals. Signing up After successfully completing the recruitment process, I am asked to attend mandatory training. This includes basic life support, manual handling and infection control. The usual, run of the mill stuff. I can book shifts a week or a day in advance, but these shifts can change to any speciality or department in the hospital, depending on staffing levels. I book my first shift after six years of having not worked within a ward setting. An unsafe start I turn up to the shift and introduce myself to be met with a mutter. The team and I receive handover and I am allocated my bay of patients. I notice I have twelve patients, three more than the other nurses. I reiterate this is my first time here and that I haven’t worked in ward work for some years. I ask if it would it be possible for someone to show me around – resuscitations trolley, toilets, codes to the drug cupboards. General housekeeping. I receive a grunt and a point, followed by some numbers hurled at me, along with keys. Ok, perhaps they’re just not morning people. I will give them the benefit of the doubt. Off I go to introduce myself to my patients and to immediately make use of my prioritisation skills, escalating any concerns I have to the seemingly disengaged shift leader and (more helpful) doctors. I find that my patients are acutely unwell and in need of a lot of care. I have to remind myself of my 13 years’ experience and how good I am at communicating, reassuring myself I will be ok. Hours later and still no toilet break Seven hours later, hungry and in need of a wee, I ask my shift leader if she could cover me so I can take a break. I am met with, ”your patients are too unwell for you to leave them for 15 minutes, and I don’t have the staff to cover you”. Followed by the ultimate toxic saying within the NHS, ”that’s just how we do it here, always have”. I start to feel neglectful that I would even have thought to have a drink and pass urine. Ten hours pass and still I haven’t had any water or a wee. Three emergencies have taken place without me even having had a proper induction. I take solace in my bond with my patients and lovely doctors who understand how it feels to be isolated and new to an area. Speaking up Perhaps out of dehydration and kidney shut down, I find the voice to politely approach the other nurses and shift leader. I explain that my patients are now stable and highlight my own personal fluid needs. I mention that I still haven’t received an induction. No one has asked me my skills or background nor if I know how to use the different IT systems (drug charts are now on computers). Again, I am met with, “well you choose to be agency, we just all get on with it here”. These are words that frighten me. It isn’t safe to get on with it. I felt out of my depth, overwhelmed, deprived of basic human rights and unwell. Losing confidence Then, a patient’s relative approaches me to say, ”I didn’t want to trouble you as you were running around looking so busy, but dad has chest pain”. At that point my heart breaks. How have I given the impression that I am the unapproachable one on this ward? Have I neglected this poor man? The same man who had cried with laughter at a joke I had made about some TV show we both watched the night before while I was catheterising him. Protocol follows and I investigate his chest pain. No acute cause. Phew. I still leave his side feeling that I am terrible at this. The end of my shift approaches, still no break, still no water or food. Handover time… I introduce myself to the night team. Finally, someone kind welcomes me to the ward. They tell me they all feel like they are doing a bad job and not giving satisfactory care. I think they are trying to reassure me. I cycle home in tears; shattered and broken. The next day I have serious doubts about my own ability. I call my agency and have a long chat with my recruitment consultant (who has never set foot inside a hospital and works on commission). His response? ”Well, you don’t have to go back”. I start to have serious doubts about my choice to work in this way and feel even more perplexed that our wards and teams have become like this. What a difference a day makes My next shift is in an emergency department. Dreading it, I don’t sleep the night before and I turn up riddled with anxiety about what is to fall upon me. I meet the team and prep myself to ‘kill them with kindness’. Everyone is pleasant and welcoming. The senior nurse asks me about my skills and mandatory training and shows me around. She informs me of their expectations and what I could, in return, expect of her team. It seems so simple, a five-minute job, huddling with your team for the sake of patient safety. But what a huge impact it has on my shift. My patients are more acute, I am busier and still don’t urinate. But I am supported and able to escalate concerns without being gas-lighted. Final thoughts I have now booked all of my shifts on that busy emergency department, simply because of the manager. I respect her management style and her approach to the safety of her unit. She doesn’t use those unhelpful and unsafe words, ”we just get on with it” or ”that’s how we do it here”. Since becoming a bit more settled in this world of agency nursing, I have spoken with matrons and lead directorate nurses within this trust about my experience. Often met with, ”what can I do about that?”. But sometimes met with, ”I will look into how that particular ward manages staff safety”. The latter leads on to better patient safety. Key learning points Inductions to new staff in new areas, should be mandatory. It should be the nurse in charge's duty to support junior staff. Doing safety rounds and checking in on all staff would help to manage workload, support flow and build confidence and reassurance among staff on duty. Safety huddles at the beginning, middle and sometimes end of each shift are a simple way of combating so many of the patient safety issues raised in this account. Early warning scores should be displayed and visible for all professionals on duty. They should be checked regularly and actioned accordingly.

Recently Dr Peter Brennan tweeted a video of a plane landing at Heathrow airport during Storm Dennis. I looked at this with emotion, and with hundreds of in-flight safety information, human factors, communication and interpersonal skills running through my head. I thought of the pilot and his crew, the cabin crew attendants and the passengers, and how scared and worried they would have felt. On a flight, the attendants will take us through the safety procedures before take off. We are all guilty, I am sure, of partly listening because it is routine and we have heard it all before. Then suddenly we are in the midst of a violent storm and we need to utilise that information! We ardently listen to the attendants instructions and pray for the captain to land the plane safely, which he does with great skill! I now want to link this scenario to the care of our patients in the operating theatre. They are also on a journey to a destination of a safe recovery and they depend on the consultants and the team to get them there safely. Despite being routine, we need to do all the safety checks for each patient and follow the WHO Surgical Safety Checklist as it is written: ask all the questions, involve all members of the surgical team, even do the fire risk assessment score if it is implemented in your theatre. The pilot of that flight during Storm Dennis certainly did not think he was on a routine flight. He had a huge responsibility for the lives of his crew and many passengers! We can only operate on one patient at a time. Always remember, even though the operation may be routine for us, it may be the first time for the patient – so let's make it a safe journey for each patient. Do it right all the time!

Key findings 59.7% think their organisation treats staff who are involved in an error, near miss or incident fairly. This is a 1 percentage point improvement since 2018 (58.3%) and continues a positive trend since 2015 (52.2%). 71.1% think their organisation takes action to ensure that reported errors, near misses or incidents do not happen again. 73.8 think their organisation acts on concerns raised by patients / service users (2018: 73.4%). 61.1% gives them feedback about changes made in response to reported errors, near misses and incidents (q17d) This is a 1 percentage point improvement since 2018 (60.0%) and continues an upward trend since 2015 (54.1%). 71.7% would feel secure raising concerns about unsafe clinical practice. This is a 1 percentage point increase since 2018 (70.7%). 59.8% were confident that their organisation would address their concern .This has continued an upward trend since 2017 (57.6%).

So, what does it feel like working in chronically depleted staffing levels? "We are down three nurses today" – this is what I usually hear when I turn up for a shift. It has become the norm. We work below our template, usually daily, so much so that when we are fully staffed, we are expected to work on other wards that are ‘three nurses down’. Not an uncommon occurrence to hear at handover on a busy 50-bedded medical ward. No one seems to bat an eyelid; you may see people sink into their seat, roll their eyes or sigh, but this is work as usual. ‘Three nurses down’ has been the norm for months here, staff here have adapted to taking up the slack. Instead of taking a bay of six patients, the side rooms are added on making the ratio 1:9 or sometimes 1:10, especially at night. This splitting up the workload has become common practice on many wards. "That was a good shift" – no one died when they were not supposed to, I gave the medications, I documented care that we gave, I filled out all the paperwork that I am supposed to, I completed the safety checklists. Sounds a good shift? Thinking of Erik Hollnagel’s ‘work as done, work as imagined’ (Wears, Hollnagel & Braithwaite, 2015) – this shift on paper looks as if it was a ‘good shift’ but in fact: Medications were given late; some were not given at all as the pharmacy order went out late because we had a patient that fell. Care that was given was documented – most of the personal care is undertaken by the healthcare assistants (HCA) now and verbally handed over during the day – bowel movements, mobility, hygiene, mouth care, nutrition and hydration. As a nurse, I should be involved in these important aspects of my patients’ care, but I am on the phone sorting out Bed 3’s discharge home, calling the bank office to cover sickness, attending to a complaint by a relative. It’s being attended to by the HCA – so it's sorted? I have documented, probably over documented which has made me late home. I’m fearful of being reprimanded for the fall my patient had earlier on. This will be investigated and they will find out using my documentation what happened. The safety checklists have been completed for all my patients; comfort rounds, mouth care, falls proforma, bed rails assessment, nutritional score, cannular care plan, catheter care plan, delirium score, swallow test, capacity test, pre op assessments, pre op checklists, safe ward round checklist, NEWS charting, fluid balance charting and stool charting… the list is endless. Management have made things easier with the checklist ‘if it’s not written down it didn’t happen’ so now we can ‘tick’ against the check list rather than writing copious notes. However, I cut corners to enable me to complete all my tasks, some ticks are just ‘ticks’ when no work has been completed. No one would know this shift would they? What looks as if it has been a ‘good shift’ for the nurse, has often been the opposite for the patients and their family. There is a large body of research showing that low nurse staffing levels are associated with a range of adverse outcomes, notably mortality (Griffiths et al, 2018; Recio-Saucedo et al, 2018). What is the safest level of staff to care for patients? Safe staffing levels have been a long-standing mission of the Nursing and Midwifery Council (NMC)/Royal College of Nursing (RCN) in recent years. In the UK at present, nurse staffing levels are set locally by individual health providers. The Department of Health and professional organisations such as the RCN have recommended staffing levels for some care settings but there is currently no compliance regime or compulsion for providers to follow these when planning services (Royal College of Nursing 2019). I was surprised to find that there are no current guidelines on safe staffing within our healthcare system. It left me wondering… is patient safety a priority within our healthcare system? It seems not. While the debate and fight continues for safe staffing levels, healthcare staff continue to nurse patients without knowing what is and isn’t safe. Not only are the patients at risk and the quality of care given, but the registration of that nurse is also at risk. What impact does low staffing have on patients and families? ‘What matters to them’ does not get addressed. I shall never forget the time a relative asked me to get a fresh sheet for their elderly mother as there was a small spillage of soup on it. I said yes, but soon forgot. In the throes of medication and ward rounds, being called to the phone for various reasons, answering call buzzers, writing my documentation, making sure Doris doesn't climb out of bed again, escorting patients to and from the CT scanner, transferring patients to other wards – I forgot. My elderly patients’ daughter was annoyed, I remember she kept asking and I kept saying "in a minute", this made matters worse. She got annoyed, so that I ended up avoiding her altogether. How long does it take to give her the sheet? Five minutes tops, so why not get the sheet? MY priority was the tasks for the whole ward, tasks that are measured and audited on how well the ward performs by the Trust; filling out the observations correctly, adhering to the escalation policy, completing the 20 page safety booklet, completing the admission paperwork, ensuring everyone had their medication on time, making sure no one fell – changing a sheet with a small spot of soup on it was not on my priority list. It was a priority for my patients’ family. My patient was elderly, frail and probably wouldn’t get out of hospital alive this time. Her daughter was the only family she had left. It’s no wonder families feel that they are not listened to, are invisible, are getting in the way and not valued. These feelings do not encourage a healthy relationship between patients/families and healthcare workers. Studies have shown that involving patients and families in care is vital to ensure patient safety. Patients and their relatives have the greatest knowledge of patients and can often pick up subtle signs physiological deterioration before this is identified by staff or monitoring systems (O’dell et al, 2011). If our relationship is strained, how can we, as nurses, advocate for the safety of our patients? So, what impact does low staffing have on the staff member? "Fully staffed today!" The mood lifts at handover. People are sat up, smiling, quiet excitable chatter is heard. This uplifting sentence is quickly followed by either: "Let’s keep this quiet" or "someone will be moved" or "someone will have to move to XX ward as they are down three nurses". Morale is higher when wards are fully staffed. The mood is different. There are people to help with patient care, staff can take their breaks at reasonable times, staff may be able to get home on time and there is emotional support given by staff to other staff – a camaraderie. The feeling does not last long. Another department is ‘three nurses down’. Someone must move to cover the shortfall. No one wants to go When you get moved, you often get given the ‘heavy’ or ‘confused’ patients. Not only that, you are working with a different team with different dynamics – you are an outsider. This makes speaking up difficult, asking for help difficult, everything is difficult: the ward layout, where equipment is stored, where to find documentation, drugs are laid out differently in the cupboard, the clinical room layout is not the same. The risk of you getting something wrong has increased; this is a human factors nightmare, the perfect storm. I am in fear of losing my PIN (NMC registration) at times. At some point I am going to make a mistake. I can’t do the job I have been trained to do safely. The processes that have been designed to keep me and my patients safe are not robust. If anything, it is to protect the safety and reputation of the Trust, that’s what it feels like. Being fully staffed is a rarity. Being moved to a different department happens, on some wards more than others. Staff dread coming to work for threat of being moved into a different specialty. Just because you trained to work on a respiratory, doesn’t mean you can now work on a gynae ward. We are not robots you can move from one place to another. I can see that moving staff is the best option to ensure efficiency; but at what cost? Another problem in being chronically short staffed is that it becomes the norm. We have been ‘coping’ with three nurses down for so long, that ‘management’ look at our template. Is the template correct, we could save money here? If we had written guidance on safe staffing levels, we still have the problem of recruitment and retention of staff; there are not enough of us to go around. Thoughts please... Does this resonate with you? Has anyone felt that they feel ‘unsafe’ giving care? What power do we have as a group to address this issue of safe staffing levels? References 1. Wears RL, Hollnagel E, Braithwaite J, eds. The Resilience of Everyday Clinical Work. 2015. Farnham, UK: Ashgate. 2. Griffiths P et al. The association between nurse staffing and omissions in nursing care: a systematic review. Journal of Advanced Nursing 2018: 74 (7): 1474-1487. 3. Recio-Saucedo A et al. What impact does nursing care left undone have on patient outcomes? Review of the literature. Journal of Clinical Nursing 2018; 27(11-12): 2248-2259. 4. O’dell M et al. Call 4 Concern: patient and relative activated critical care outreach. British Journal of Nursing 2001; 19 (22): 1390-1395.

This powerpoint presentation from the Birmingham Women and Children's Hospital NHS Foundation Trust explains the data backing up this fantastic initiative.

On January 2020, Patient Safety will be on the G20 agenda (amongst other five health key priorities). One would ask: What is Patient Safety doing on an economic forum like the G20? Another cynic might even add: What is Healthcare doing on the G20? The G20 was established in the late 1990s with the objective of its members working together to achieve economic and financial stability. It is comprised of 19 countries and the European Union (EU). The G20 collectively represent more than 85 % of the world’s Gross Domestic Product (GDP), and more than two- thirds of the world’s population. Healthcare was only introduced in 2017 during the German presidency. WHY PUT PATIENT SAFETY ON THE G20 AGENDA? Patient harm is estimated to be the 14th leading cause of the global disease burden. This is comparable to medical conditions such as tuberculosis and malaria. In both U.S. and Canada, Patient Safety Adverse Events represent the 3rd leading cause of death, preceded only by cancer and heart disease. In the U.S. alone: 440 thousand patients die annually from healthcare associated infections (HAIS). In Canada: there are more than 28 thousand deaths a year due to Patient Safety Adverse Events. In Low – Middle Income Countries (LMIC), every year 134 million adverse events take place resulting in 2.6 million deaths annually. Having said all that, up to 70 % of harm is . (OECD, 2017) In addition to lives lost and harm inflicted, unsafe medical practice results in money loss. Nearly, 15 % of the health expenditure across Organization of Economic Cooperative Development (OECD) countries is attributed to patient safety failures each year (OECD 2017) But if we add the indirect and opportunity cost Economic & Social), the cost of harm could amount to trillions of dollars globally (OECD 2017). According to a report by Frost & Sullivan in 2018, Patient Safety Adverse Events cost the US alone 146.1 billion dollars annually. When you compare the cost of prevention to the cost of harm, the return on investment (ROI) becomes a “no brainer”. In a study that looked at patient safety ROI for Pressure Injuries, the cost of prevention was € 291.33 million compared to the cost of harm of € 2.59 billion (almost 1,000 times higher). (Demmarre et al 2015) Over the past 20 years, numerous efforts were made to improve patient safety in individual G20 countries as well as globally under the World Health Organization leadership. Despite all those efforts, the level of harm to patients persists and 20-40% of health resources are being wasted (WHO). Many healthcare structural causes are responsible for the ongoing harm: Healthcare Workforce Factors: In addition to the quality and quantity, the wellbeing and safety of health workforce are foundational to patient safety. A substantial body of research now points to link nurse staffing with patient outcomes. A business case by Needleman (2006) demonstrated cost saving from reduced complications and shorter length of stay associated with higher nurse staffing levels. This relationship is articulated clearly in the Jeddah Declaration on Patient Safety in 2019. Dall (2009) estimated the impact of increased nurse staffing on medical cost, lives saved and national productivity. Their research suggests that adding 133,000 nurses to U.S. hospitals would save 5900 lives per year, increase productivity by $1.3 billion, or about $9900 per year per additional nurse. Decrease in length of stay resulting from this additional nurse staffing would translate into medical savings of $6.1 billion and increased in productivity attributed to decreased length of stay was estimated at $231 million per year. Addressing and ensuring guidelines that are consistent with research findings for nursing staffing in acute settings is a viable key solution to prevent medical errors, improve patient safety and decrease cost of healthcare delivery. Healthcare Education Causes: Even though healthcare is provided by multi-disciplinary teams, healthcare education (undergraduate – postgraduate) continues to be conducted in separate settings. This siloed approach results in many of the communication failures / safety failures that are experienced on a regular basis. According to Joint Commission communication failures were the leading root cause of the sentinel events reported to the Joint Commission from 1995 to 2004. Healthcare education requires a serious reevaluation of its current curricula and practices. Furthermore, the lack of patient safety components to the medical and allied health sciences curriculum does a disservice to have safe medical practices imbedded within the day-to-day implementation of the healthcare workforce. Patient – Provider Information Asymmetry: The information and communication gap between the healthcare providers and their patients has caused ongoing harm. With the information abundance, patients turned to the internet as a source of guidance, regardless of its accuracy, which is minimally provided by Healthcare teams. Healthcare providers need to be the trusted guidance for information and the empowering force for patients to make informed decisions. Unempowered patients may result in lack of transparence and noncompliance to the care plans that contribute patient harm. Major movement for patient empowerment and community engagement is warranted. In addition, engaging patients can reduce the burden of harm by about 15%, saving billions of dollars each year. (WHO) Poor Safety Culture: The Hospital Survey on patient safety culture has been implemented in many countries to gain insight on the employees’ perception of the hospital patient safety culture. It has been consistently found that employees perceive hospital cultures lack transparency and results in punitive consequences when adverse events are reported. ‘Shame and Blame’ culture is one of the major barriers to improving safety. It is imperative that healthcare systems adopt strategies enabling Just Culture. Lack of consideration of Human Factors: In the healthcare sector, and since the Institute of Medicine (IOM) report “To Err is Human”, have come a long way in improving our services with elimination of potential harm in mind. However, healthcare can learn much more from other industries that have improved safety through use of HFE in redesigning work process and flow to ensure they are error-proof. HFE is an important discipline that can embed resilience to healthcare systems and could, potentially, transform patient safety. Lack of sufficient sharing and learning: The different sectors within the healthcare industry have created silos based on profession, departments, type of organization and many more subcultures and entities within a facility and at the national levels. This results in fragmented systems working in isolation, creating piece meal solutions and multi-levels of communication gaps, let alone the opportunity to share and learn in a manner that prevents harm from being repeated. Learning (from within healthcare), through Reporting & Learning Systems, and (from other industries), e.g. aviation, nuclear, oil & gas, is essential to healthcare safety innovation and transformation. Furthermore, population ageing has significant implications for patient safety as older adults are at higher risk for medical errors and the rate of adverse events due to increases in frailty, comorbidities, and incidences of chronic conditions, falls, and dementia makes providing health care more complex and increases costs. Individuals 65 years and older are at a two-fold risk for developing adverse events when compared with individuals between the ages of 16 and 44 years. (Brennan TA, Leape LL, Laird N, et al.) Nations across the G20 will face this challenge, which necessities innovate safety interventions and new approaches in health care to design a safer health care system. When it comes to patient safety, doing more of the same will result in: More lives will be lost More preventable harm will take place like Healthcare Associated Infections, medication errors, Anti-microbial Resistance (AMR) …etc. More money will be wasted (not to mention indirect cost and opportunity cost). When a patient is harmed, the COUNTRY LOSES TWICE: The individual will be lost as a revenue generating source for society+ the individual will become a burden on the healthcare system because he or she will require more treatment. Unless we do something different about patient safety, we would risk the sustainability of healthcare systems and the overall economies. OUR G20 PROPOSAL FOR PATIENT SAFETY Establishing a G20 Patient Safety Network (Group) that will combine two types of expertise: Safety experts from healthcare and other leading industries (like Aviation, Nuclear, Oil & Gas, other) Economy and Financial Experts This will function as a platform to prioritize and come up with innovative patient safety solutions to solve Global Challenges while highlighting the return on investment (ROI) aspects. This multidisciplinary group of experts can work with each state that adopts the addressed Global Challenge to ensure correct implementation of proposed solution. BENEFIT: Investment in Patient Safety – – > sustainability of healthcare systems – – > and overall economies In conclusion, patient safety is a global priority that goes beyond healthcare. It is a challenge that requires the collective wisdom of the G20 and the overall global community. It is not just an issue for health ministers, but it is an important issue that requires the attention of finance ministers and heads of states. The economic cost of failing patient safety could be risking the sustainability of healthcare systems and the overall global economies. WE NEED TO ACT NOW!

I don’t ‘do’ mental health. Growing up, my family always had a stiff upper lip, told me to "take a breath and get on with it". It was seen very much as a weakness. If I was ever feeling upset about something that had happened at work, they would always retort back with a story far more gruesome and awful than mine. My family are all healthcare professionals. Dinner table talk usually turned to horror stories of car crashes, attempted murders, limbs falling off, wounds and cardiac arrests. Very interesting and often led to great discussions, but didn’t explore how we felt about being involved in the worst days of other peoples' lives. My family spoke of these incidents as if they were viewing through glass, an invisible wall. They distanced themselves. This is how they dealt with the horror of healthcare. From their behaviour and how they dealt with ‘work’, I followed suit. It seemed to work. Something bad would happen – a traumatic cardiac arrest at the roadside, a stabbing of a young man, a four car pile up with three dead at the scene, a murdered child – I would then go back to my family home on days off, have dinner and we would swap stories. We would all try and out do each other, a bit like a game of gruesome top trumps. But I could not brush off what I had seen. I saw the trauma that was inflicted on survivors, the pain people had been through, the raw emotions from other during the worst day of their lives, the conditions people lived in. I was seeing this daily, not once a month or once a year, daily. It was bound to take its toll. All was going well, or so I thought. Until my life got in the way. I have two boys: 13 and 11 years old. Starting out in the world. I have been able to keep them safe; I keep them away from these horrors I see. I have protected them from the society we live in. The knife crime, the drugs, the violence, but as they grow up they have become more independent. They want to go out alone, they mix with other groups of kids I don’t know. No longer can I call the parents of a child I deem ‘suitable’ for a play date. I am relying on my children to make the right choices. I felt out of control. Whereas at work, I am in control. I may not have control about which job I go to, but I have control on how I manage the patient, I have drugs to ease pain and can give immediate treatment. I feel as if I am in a ‘bubble of professionalism’. What happens at work, stays at work (or my parent's dinner table). But here in the real world, there is no bubble. I tried bringing my feelings about the loss of control and fear around bringing up boys in 2020 at the dinner table. "That’s life," announced my dad. "We got through it and you're OK," said mum. And that was that. My feelings were deemed as mundane, not good enough to discuss. Before I knew it, the conversation had moved on to a patient who needed helicoptering off a rugby field with a broken leg. I wasn’t sleeping. I couldn’t concentrate. I had this weird pain in my chest. All I could think of was the safety of my boys. I replayed scenarios of them getting run over, getting into a fight and getting stabbed, being involved in a car crash. I wouldn’t go on unnecessary journeys in case we crashed and they died. I was just about coping with work. I did not have the capacity to take stress from any other angle. So, when I needed to step up to the plate at home, bringing up kids, it was all too much. Getting help I made an appointment with a GP. I’m never ill, so don’t see a regular one. Any GP would do. I wanted some help, but wasn’t sure what help was available. I felt embarrassed about going. I didn’t tell anyone. Once I was in there, I just burst into tears. I’ve seen GPs behind closed doors, people do it all the time. I bet they get sick of it. I was now one ‘of those’ people. She heard my symptoms; she heard the causes. With that she wrote a prescription for Sertraline (a drug for anxiety) and an offer to sign me off sick for 2 weeks and I was out the door with a follow up in 3 weeks. Looks like I am labelled now, and it took less than 10 minutes. Were pills the answer? Surely there are other therapies I could try? I don’t want time off. It won't make it better. After opening up to a colleague at work, it seems myself and my family are suffering with moral injury. The term ‘moral injury’ has been used to describe the psychological effects of ‘bearing witness to the aftermath of violence and human carnage’ (Litz et al., 2009[1]). Carnage sounds like a normal shift to me. The symptoms of moral injury are strongly linked to feelings of guilt and shame and can manifest as social isolation and emotional numbing. This was my mechanism for coping with the stress at work. Numbing the emotions, not allowing my emotions to show themselves in fear that I would not be able to do my job. I’m no good to anyone being a blubbering wreck am I, everyone else is OK, so I must hold it together. Binned the pills I was told about ‘talking therapies’ that my employer can refer me to – for free. I went to my line manager. We spoke at length about how I felt, and she referred me to the talking therapy provided by my Trust. While I waited for the appointment date, I opened up to friends. Found out I am not alone. Seems we are all struggling in different ways. Being able to speak freely with a trained counsellor has really helped. I have strategies to help me with anxiety and stress, I have started the NHS couch to 5K and have started to feel so much better. I have not taken the pills offered by the GP. I’m sure some people need them; I feel I don’t need them at the moment. We know that we need to have more and better conversations about our mental wellbeing, and it is worth thinking about what kinds of conversations might be useful; certainly a game of top trauma trumps isn’t a good idea while eating sausage and mash. It is true what the literature suggests, that paramedics are suffering from increasing rates of post-traumatic stress disorder (PTSD) (Regehr et al., 2002[2]), but it is also true that not all those who are psychologically affected by their work, even in lasting ways, will reach the threshold for a diagnosis of PTSD. Some people will become ill as a result of their work, and some will become distressed; moral injury offers a different way of thinking about the psychological harms that may result from the practice of prehospital and emergency medicine (Murray, 2019[3]). This may give paramedics and other ambulance staff the opportunity to think about the impacts of their work in ways which do not threaten their ability to do it. Ensuring there are opportunities to sit down and talk through their jobs in the course of a working day, or night, could be the best place to start (Murray, 2019[3]). References 1. Litz BT, Stain N, Delaney E et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev 2009;29(8):695–706. 2. Regehr C, Goldberg G, Hughes J. Exposure to human tragedy, empathy and trauma in ambulance paramedics. Am J Orthopsychiatr 2002;72(4):505–13 3. Murray E . Moral injury and paramedic practice. Journal of Paramedic Practice 2019;1(10).