One of my first clients as an outpatient therapist 12 years ago involved a woman who was living in a hotel with her daughter and grandchildren, limited food, no reliable transportation unless she had money for public transit, unable to work due to multiple health conditions, and uninsured—all while experiencing significant mood disturbances. I was able to see her in her hotel room at most once a week for 53 minutes for a therapy session (travel expenses paid for by me, mind you) for up to 8 sessions, and she currently qualified for minimal social services, of which I would also need to seek out on my own time as care coordination was not reimbursed.
I came back from that session and cried in my supervisor’s office, I cried to my mom, I cried in my car. 1) I had no idea where to begin, 2) She had SO many challenges and each influenced the other, making providing her with support seem impossible, and 3) In Maslow’s Hierarchy of Needs, we know that unless your basic physiological needs are met, you can’t even begin to truly meet your additional needs of safety, needs for love and belong, or self-esteem—all of which were my area of expertise, as opposed to helping with physiological needs. I became a licensed Marriage and Family Therapist to help people feel better who were struggling with mental health conditions, and my role seemed inconsequential to what my client was experiencing and needing. But there were no other options for her.
I would have many more of these experiences after this that can only be described as moral injury—witnessing how our health care system and the business of health care can do a disservice to us as providers and the quality of care available to our clients or patients.
What is Moral Injury?
Moral Injury was often used to conceptualize the experience of soldier in war, “battling the mental, emotional, and spiritual distress people feel after ‘perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations,” (Litz et al., 2009). This concept for soldiers was then increasingly compared to being a health care worker in the United States which “…occurs when clinicians are repeatedly expected, in the course of providing care, to make choices that transgress their longstanding, deeply held commitment to healing” (Dean & Talbot, 2019).
Those who serve as health care providers, while often trained to expect and manage instances of distress, can be faced with consistent and difficult work experiences that make them battle what needs to be done and their values or beliefs. For example, health care workers during COVID were battling caring for their patients while faced with an under-resourced system and the knowledge that caring for their patients was putting their own family members at risk of infection.
The experience of placing competing priorities such as administrative burdens and financial concern over patient care can be increasingly taxing. Health care workers may feel burned out, including feelings of guilt, shame, or anger can persist as a result of the moral injury not being addressed. Symptoms of PTSD can be present including avoidance of certain people or places, withdrawal, self-blame, intrusive thoughts or memories, mood disturbances, or differences in how one sees the world. On a larger systems level without proper support, a person may feel betrayal, anger, resentment, and a lack of confidence in their leaders, organization or systems in which they work.
“All of us who work in health care share, at least in the abstract, a single mission: to promote health and take care of the ill and injured…But the business of health care—the gigantic system of administrative machinery in which health care is delivered, documented, and reimbursed—keeps us from pursuing that mission without anguish or conflict. We do our best to put patients first but constantly,” (Dean & Talbot, 2019).
An interesting parallel came in 2023 from Wendy Dean, co-founder of the non-profit Moral Injury of Healthcare, to work on clinician distress. Comparing physicians to high-performance automobiles, Dean shared that “the fault lies much less in them than in the bumpy road they are asked to navigate. We need to get about fixing those potholes.”
How to Tackle Moral Injury
On an individual level, self-care is critically important in addressing moral injury, particularly via connection. This can look like reaching out to others to get feedback and support in navigating difficult choices or in situations that lead to moral distress. This can allow for helpful alternatives to managing these experiences along with validation and emotional support.
Leadership can be helpful in both prevention of moral injury or in managing the impact of these types of experiences. Increased communication, extended patience with one another, and checking-in with staff are all important. Reminding employees that they are doing the best they can despite the challenges they are unable to change, or that what they did was not preventable, or that it is okay to seek professional support if needed. Praise and gratitude can have an impact. Larger organizational approaches and changes can be critical as well in prevention and mitigation of moral injuries. On a smaller scale, treating these incidents as occupational hazards and allowing health care workers to process with their peers (Rabin et. al, 2023). Additionally, and on a much larger scale, improving the health care and insurance infrastructure as well as organizations’ infrastructure will have lasting improvements on the well-being of healthcare worker’s mental health (Rabin et. al, 2023). Improved pay, appropriate working conditions, paid time off, increased access to equitable health care services and insurance coverage for all, and addressing moral injury within systems are all critical for the lasting careers and overall well-being of those working in health care. This allows us to fulfill the mission we had when joining the field: to help care for others.
Resources
- Cynda Rushton, Ph.D., M.S.N., R.N.Professor of clinical ethics and nursing, Johns Hopkins Berman Institute of Bioethics and the School of Nursing
- https://www.aamc.org/news/moral-injury-harms-providers-and-patients; Weiner 2023
- Rabin S, Kika N, Lamb D, Murphy D, Am Stevelink S, Williamson V, Wessely S, Greenberg N. Moral Injuries in Healthcare Workers: What Causes Them and What to Do About Them? J Healthc Leadersh. 2023 Aug 16;15:153-160. doi: 10.2147/JHL.S396659. PMID: 37605753; PMCID: PMC10440078.
- https://pmc.ncbi.nlm.nih.gov/articles/PMC10440078/