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“After he died, the little plastic ID band that was around his tiny wrist should have been slipped onto mine. There was nothing more that could have been done for him, but there was plenty that needed to be done for me. I needed an infusion of truth and compassion. And the nurses and doctors who took care of him, they needed it too." Leilani Schweitzer[1] When someone is hurt, it is reasonable to expect the healthcare system to provide care to alleviate symptoms or to cure. It is also reasonable to expect those providing the care to be adequately trained and supported to do so. Yet, when harm is caused by healthcare, the spectrum of harm suffered is not well understood, care needs are not fully recognised and, therefore, the care needed to facilitate optimum recovery is not being provided.[2] In fact, with outrageous frequency, at a time when exceptional care is so desperately needed, those hurting describe how they are further harmed from ‘uncaring’ careless and injurious responses. Healthcare harm is a ‘double whammy’ for patients Healthcare harm is a ‘double whammy’. There’s the primary harm itself – to the patient and/or to those left bereaved – but there is also the separate emotional harm caused specifically by being let down by the healthcare professionals/system in which trust had to be placed.[3] This additional emotional harm has been described as being the damage caused to the trust, confidence and hope of the patient and/or their family.[4] Trust – you rely on professionals to take responsibility for what you cannot do yourself. Confidence - you believe that the system will protect you from harm. Hope – you have the conviction that things will turn out well. Anderson-Wallace and Shale[4] For the patient and family to be able to heal from healthcare harm, appropriate care must be provided not only for the primary injury and any fall out from this, but also this additional emotional injury (being let down by healthcare) and any fall out from that. For example, a parent who loses a child as a result of failures in care will need help to cope with the loss of their child and all of the processes that occur as a result. But they will also need support to cope with having had to hand over responsibility for their child’s safety to healthcare professionals, only to be let down, and all the feelings and processes associated with that. Much needs to happen to restore that parent’s trust, confidence and hope in our healthcare system and the staff within it. This is different to the parent of a child who has passed away from an incurable illness despite exemplary healthcare. A parent let down by healthcare has specific additional care and support needs that need to be met to help them cope and work towards recovery. Healthcare harm also causes emotional harm to the staff involved In 2000, Albert Wu introduced the phrase ‘second victim’ in an attempt to highlight the emotional effects for staff involved in a medical error and the need for emotional support to help their recovery.[5] The term has recently been criticised, since families should be considered the second victim,[6] and the word victim is believed “incompatible with the safety of patients and the accountability that patients and families expect from healthcare providers.”[7] While the term itself may be antagonistic, or misrepresentative, the sentiment – that staff involved in incidents need support to cope with what has happened, and to give them the confidence to do what is needed to help the patient/family heal – certainly stands. When staff are involved in an incident of patient harm, they may lose trust in their own ability and the systems they work in to keep patients safe, and they may worry about their future.[5],[8] They need care and support in order to recover themselves and, crucially, so that they feel psychologically safe and are fully supported to be open and honest about what has happened. They need to feel able to do this without fearing personal detrimental consequences for being honest, such as unfair blame or a risk to their career. This is essential to the injured patient/family receiving the full and truthful explanations and apologies they need in order to regain trust, confidence and hope, and, ultimately, to heal as best they can. So, in addition to patients and families there should be a ‘care pathway’ for staff involved in incidents of harm. A google search on ‘second victim’ reveals a wealth of research on the emotional effects of medical error for staff involved and the best ways to provide support for this, and this is resulting in the emergence of staff support provision to aid recovery.[9] In contrast, very little research has been done into the emotional effects and support needs of families and patients. How is ‘care’ for emotional harm given? The ‘treatment’ of the emotional harm has been described as ‘making amends’ – by restoring trust, confidence and hope.[4] Once a patient has been harmed by healthcare, every interaction (physical, verbal or written) they have with healthcare after that will either serve to help them heal or to compound the emotional harm already suffered. Trew et al.[10] describe harm from healthcare as a “significant loss” and conclude that “coping after harm in healthcare is a form of grieving and coping with loss”. In their model, harmed patients and families proceed through a ‘trajectory of grief’ before reaching a state of normalisation. Some can move further into a deeper stage of grief and seemingly become stuck in what is referred to as complicated grief. They can display signs of psychiatric conditions "if there are substantial unresolved issues, or where there is unsupportive action on the part of individuals associated with the healthcare system and the harm experience”. At the point of the harmful event, the patient/family experiences losses, including a drop in psychological wellbeing. From this point on, healthcare staff and organisations have opportunities to respond. If the response is supportive it may be helpful for the patient/family in coping with the losses. If the response is not supportive, this may cause ‘second harm’ complicating the healing process, leaving the patient/family with unresolved questions, emotions, anger and trust issues. The patient’s psychological wellbeing and ability to return to normal functioning are severely affected. “Most healthcare organizations have proved, in the past at least, extraordinarily bad at dealing with injured patients, resorting at times, particularly during litigation, to deeply unpleasant tactics of delay and manipulation which seriously compounded the initial problems. My phrase ‘second trauma’ is not just a linguistic device, but an accurate description of what some patients experience.” Charles Vincent[11] There is no shortage of individuals who have suffered extensive ‘second harm’ sharing their experiences in the hope this will lead to better experiences for others and some help for themselves to recover. Many are, wrongly, being ‘written off’ as historical cases that can no longer be looked at. This cannot be right – when these people are suffering and need appropriate responses to heal their wounds. The extent of suffering that exists now, in people who have been affected by both primary trauma and then second harm from uncaring defensive responses, or responses that have not taken into account the information patients and families themselves have, or relevant questions they ask, is no doubt nothing short of scandalous. There is a pressing urgency for the NHS to stop causing secondary trauma to affected patients and families. ‘Patient safety’ has to start applying to the harmed patient and their family members’ safety after an adverse event, and not just focus on preventing a repeat of the event in the future. Yes, future occurrences must be prevented, learning is crucial, but so is holistically ‘looking after’ all those affected by this incident. If they are not looked after, their safety is at risk as their ability to heal is severely compromised; in fact they are in danger of further psychological trauma. These same principles apply to affected staff. Avoiding second harm: what happens now and what is needed? This series of blogs will highlight that every interaction a harmed patient or family member has with staff in healthcare organisations (not just clinical staff) after a safety incident should be considered as ‘delivery of care’. With this view, the ‘care interaction’ should be carried out by someone trained and skilled and supported to do so, with the genuine intention of meeting the patient/families’ needs and aiding the patient/family to recover and heal (restore trust, hope and confidence). The interaction / response must not cause further harm. Stress or suffering, and the content of the interaction, for example a letter, should not have been compromised, as often occurs, by competing priorities of the organisation to the detriment of the patient/family. Thus, these blogs will look at: The processes that occur after an incident of harm (Duty of Candour, incident investigation, complaint, inquest) with the aforementioned focus. The care the patient and family need and the obligation (that ought to exist) to meet that need. Processes that are core to the package of ‘care’ to be provided to the harmed or bereaved and to be delivered by skilled and supported ‘care providers’. The blog series will seek to show that meaningful patient engagement in all of these processes is crucial for restoring trust, confidence and hope; therefore, aiding healing of all groups in the aftermath of harm. “It is important to respect and support the active involvement of patients and their families in seeking explanations and deciding how best they can be helped. Indeed at a time which is often characterised by a breakdown of trust between clinician and patient, the principle of actively involving patients and families becomes even more important.” Vincent and Coulter, 2002[3] It will also consider the additional care and support needs that might need to be met alongside these processes in a holistic package of care, such as peer support, specialist medical harm psychological support and good quality specialist advice and advocacy. It will describe what is currently available and what more is needed if healthcare is to provide adequate care for those affected by medical error in order to give them the best chance of recovery. Alongside this, the needs of the staff involved will also be considered. We welcome opinion and comments from patients, relatives, staff, researchers and patient safety experts on what should be considered when designing three harmed patient care pathways: for patients, families and staff. What is the right approach? What actions should be taken? How can these actions be implemented? What more needs to be done? Join in the discussion and give us your feedback so we can inform the work to design a harmed patient care pathway that, when implemented, will reduce the extra suffering currently (and avoidably) experienced by so many. Comment on this blog below, email us your feedback or start a conversation in the Community. References 1. Leilani Schweitzer. Transparency, compassion, and truth in medical errors. TEDxUniversityofNevada. 12 Feb 2013. 2. Bell SK, Etchegaray JM, Gaufberg E, et al. A multi-stakeholder consensus-driven research agenda for better understanding and supporting the emotional impact of harmful events on patients and families. J Comm J Qual Patient Saf 2018;44(7):424-435. 3. Vincent CA, Coulter A. Patient safety: what about the patient? BMJ Qual Saf 2002;11(1):76-80. 4. Anderson-Wallace M, Shale S. Restoring trust: What is ‘quality’ in the aftermath of healthcare harm? Clin Risk 2014;20(1-2):16-18. 5. Wu AW. Medical error: the second victim: The doctor who makes the mistake needs help too. BMJ 2000;320(7237):726-727. 6. Shorrock S. The real second victims. Humanistic Systems website. 7. Clarkson M, Haskell H, Hemmelgarn C, Skolnik PJ. Editorial: Abandon the term “second victim”. BMJ 2019; 364:l1233. 8. Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care 2009;18(5):325-330. 9. Second victim support for managers website. Yorkshire Quality and Safety Research Group and the Improvement Academy. 10. Trew M, Nettleton S, Flemons W. Harm to Healing – Partnering with Patients Who Have Been Harmed. Canadian Patient Safety Institute 2012. 11. Vincent C. Patient Safety. Second Edition. BMJ Books 2010.

Prerana Issar is the Chief People Officer of NHS England and NHS Improvement. She was appointed in February 2019 to this post, which was created after senior leaders in the NHS and Department of Health and Social Care realised that a new approach was needed to a number of serious workforce issues which had become apparent. Among these is the complex, and hugely important, issue of speaking up (sometimes referred to as whistleblowing or raising concerns). Prerana recently retweeted a message from NHS England and NHS Improvement that "It's so important (for NHS staff) to feel able to speak up about anything which gets in the way of patient care and their own wellbeing".[1],[2] She is absolutely right... in principle. She is right to point out that NHS staff have both the right and the duty to speak up about problems like this, as is spelt out in the NHS Constitution[3] and professional codes of conduct for healthcare professionals.[4],[5],[6] The problem is that in practice, as an unknown but substantial number of NHS staff have discovered to their cost, their careers may be at risk if they do speak up as is evident from almost all the replies to both tweets.[1],[2] There is a sad pattern of disciplinary action being taken against staff who have, in good faith, raised concerns in the public interest. Even though their motivation in speaking up in the first place is to improve patient care, they discover to their astonishment that they are considered to be troublemakers for having done so. A depressing cycle of suspension, isolation, unfair dismissal, denigration and blacklisting of the person who has spoken up is often played out, whilst the original concerns and their validity are covered up. What a waste of valuable resources. The existence of such hostility to staff who have spoken up is evidenced in the 2015 report of the Freedom To Speak Up (FTSU) Review: "an independent review into creating an honest and open reporting culture in the NHS".[7] The press release which accompanied its publication announced that the review "identifies an ongoing problem in the NHS, where staff are deterred from speaking up when they have concerns and can face shocking consequences when they do. The review heard stories of staff that have faced isolation, bullying and counter-allegations when they’ve raised concerns. In some extreme cases when staff have been brave enough to speak up, their lives have been ruined".[8] The FTSU report calls for "an overhaul of NHS policies so that they don’t stand in the way of people raising concerns with those who can take action about them" and sets out "20 Principles and Actions which aim to create the right conditions for NHS staff to speak up". The principles are divided into five categories: the need for culture change; improved handling of cases; measures to support good practice; particular measures for vulnerable groups; and extending the legal protection.[7] In theory the law protects whistleblowers, but in practice, as a procession of disillusioned NHS staff who have experienced reprisals from their employers after speaking up have discovered the hard way, it does not. Employment tribunals are an alien environment for most healthcare staff. Case after case has shown that they are woefully ill-equipped to deal with precipitating patient care issues, in which tribunals appear to have little interest. Even when NHS staff are, against massive odds, found to have been unfairly dismissed after raising concerns in the public interest, the so-called remedy they receive almost invariably amounts merely to paltry financial 'compensation'. These are monetary awards that generally come nowhere near compensating for the full financial consequences. The adverse impact of this lack of protection for whistleblowers is not only on the individual but also includes the chilling effect of deterring other staff from raising concerns and the consequences of cover ups. True overall costs to the NHS, patients, whistleblowers and taxpayers of retaliation against staff who speak up are very much greater than financial costs alone. Staff surveys show that nearly 30% of NHS staff would not feel secure raising concerns about unsafe clinical practice.[9] Over 40% would not be confident that their organisation would address their concern if they do speak up.[10] There is still a lot to do in this area, as has been brought to the fore by recent reports of hostile responses by some NHS organisations to staff who have raised serious personal protective equipment (PPE) concerns affecting patient safety and health of themselves and their families. To be fair, serial staff surveys show a marginal improvement in the percentage of NHS staff who agreed they would feel secure raising concerns about unsafe clinical practice, up from a disturbingly low 68.3% in 2015 to 71.6% in 2019.[9] And a further tiny improvement in the percentage confident that their organisation would address their concern, up from an even lower 56.2% in 2015 to 59.8% in 2019. Viewed from the perspective of NHS whistleblowers whose careers have been wrecked after speaking up these are painfully slow rates of improvement. Bearing in mind widespread reports of PPE shortages, and warnings to NHS staff not to make a fuss about this, it will be interesting to see whether this glacial pace of change in speaking up culture is maintained when the results of the 2020 survey are available. Based on experience in the last two years, we can expect another prolonged FTSU publicity campaign in the month preceding the annual autumn NHS staff survey. The NHS Interim People Plan, published in June 2019, refers to development of a focus on whistleblowing and speaking up. It highlights the need for inclusive and compassionate leadership so that all staff are listened to, understood and supported, and the need to do more to nurture leadership and management skills of middle managers.[11] The original aim was to publish a full, costed NHS People Plan by Christmas 2019,[12] building on the interim plan, but this was delayed by unforeseen events, including a change of government, general election, Brexit ramifications and now the coronavirus pandemic. The interim plan makes clear the need to embed culture changes and leadership capability in order to achieve the aim of making the NHS "the best place to work". There is much to do, and I wish well to those who want to make it safe for staff to speak up, but they must be under no illusion – there is a long way to go – and this will take more than an overhaul of NHS policies. I hope to develop these themes in future postings to the hub. Comments welcome. References NHS England and NHS Improvement tweet, @NHSEngland, 15 May 2020, 6:35pm. Prerana Issar tweet, @Prerana_Issar, 15 May 2020, 6:47pm. The NHS Constitution for England. Updated 14 October 2015. Nursing and Midwifery Council (NMC). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates, 2015, updated 2018. General Medical Council (GMC). Good medical practice: The duties of a doctor registered with the GMC. 2013, last update 2019. Health and Care Professions (HCPC). Standards of conduct, performance and ethics: The ethical framework within which our registrants must work, 2016. Freedom to speak up: An independent review into creating an open and honest reporting culture in the NHS. Report by Sir Robert Francis QC, 11 February 2015. Press release: Sir Robert Francis publishes his report on whistleblowing in the NHS, 11 February 2015. NHS Staff Survey 2019. q18b: % of staff agreeing or strongly agreeing with the statement that: 'I would feel secure raising concerns about unsafe clinical practice'. NHS Staff Survey 2019 q18c: % of staff agreeing or strongly agreeing with the statement that: 'I am confident that my organisation would address my concern'. Interim NHS People Plan, June 2019. https://www.longtermplan.nhs.uk/publication/interim-nhs-people-plan/ NHS People Plan overview, 2019.

My original plan for this blog was to explore why change is a bit Marmite – some of us love change (the ‘bring it on’ group), and others less so. Then the COVID-19 jar was opened and everything changed. We are all impacted in different ways, both staff and patients. Whether it’s even more time at work, less time with those we love, wanting to be at work but having to self isolate, loss of our identity as the one who always does x or y, how as patients we interact with our NHS, or the loss of those we love. Transitions are challenging William Bridges says it isn’t the changes that do you in, it’s the transitions. Change is something that happens to people, even if they don't agree with it. Transition, on the other hand, is internal. It's what happens in people's minds as they go through change. Change can happen very quickly, while transition usually occurs more slowly as we internalise and come to terms with the details of the new situation that the change brings about. Stages of transitioning include: Ending - letting go of the old ways and the old identity. The neutral zone - going through an in-between time when the old is gone but the new isn’t fully operational, when the critical psychological re-alignments and re-patterning take place. New beginnings – when we come out of the transition and develop a new identity, experience a new energy and discover a new sense of purpose. 3 tips for dealing with transition So what can we do to ease the transition? Here’s my three As for the day: Acceptance Accept that we will each make our transition at different paces. For some shock and denial through to acceptance and hope is rapid, for others it may take longer. So more than ever looking after each other is key. Steve Covey’s talks about making a deposit in the emotional bank account: understanding your friend, your colleague, a small act of kindness. What will be a deposit for you, may be a valuable withdrawal for them. Appreciation There’s already a zillion examples of people moving hell and high water to do what needs to be done to best respond to COVID-19, positive energy is thriving. Appreciating this is just as important. We can show our appreciation locally in our teams, on an individual basis or by joining the nation in clapping those who are helping to keep our world turning,. Awareness Be aware of high levels of anxiety and exhaustion in yourself and those around you. We are all stressed by different things. For some it’s spending too much time alone. Others ambiguity and uncertainty. Some will struggle most with decisions they think are illogical, last minute or require super human endeavours. Knowing our own limits and triggers and those of people around us is key. When you spot them, pause just for a vital moment, take a brief step back before anyone keels over and think through next steps. Explore information and ideas and talk them through with others. And where you can see that someone isn’t in a good place, give them permission to re-charge their batteries so their brilliance can continue to shine. “Not in his goals but in his transitions man is great.” —Ralph Waldo Emerson References William Bridges, Bridges Transition Model, 1988. Stephen R. Covey. The seven habits of highly effective people. Franklin Covey, 1990. Previous blogs by Sally Leading for improvement Immunity to change How a single piece of paper could help solve complex patient safety issues The art of wobbling: Part 1 The art of wobbling: Part 2

Key take-away messages The healthcare organisation you work in is a system of interacting human elements, roles, responsibilities and relationships. Quality and patient safety are performed by your human-designed organisational structures, processes, leadership styles, people's professional and cultural backgrounds, and organizational policies and practices. The level of interconnection of all these aspects will impact the distribution of perception, cognition, emotion and consciousness with the organisation you work for. What goes on between people defines what your health system is and what it can become.

Resources LfE Quality Improvement Toolkit (based on PRAISe project) Quick start up guide LfE (July 2016) LfE top 10 tips (Jan 2017) How to get started – a few tips from our experience Framework for “reverse SIRI” (now named IRIS) – adapted from Appreciative Inquiry methodology Template (in MS word) for IRIS meetings Example LfE FAQs – for you to adapt for your organisation Mini-AI template – Mini-AI template, as used in PRAISe project 10 uses for LfE & AI LfE how to set up checklist LfE Appreciation card template – front LfE Appreciation card template – back

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

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).