In the mid-2010s, I noticed subtle erosions of medical team cohesion and physician satisfaction in my work managing research funding for the U.S. Army.
At informal dinners during medical conferences, I began asking colleagues from prestigious organizations around the country about their experiences practicing medicine. Were they the doctor they imagined they would be when they embarked on the profession?
Each responded with some version of “I love my patients. I still love the medicine I practice. But everything else — billing, documenting, attesting, defending — which takes up so much more time and energy than it did even 10 years ago, is grinding me down. I don’t know how much longer I can take it.”
They struggled to characterize their experience correctly. Burnout wasn’t quite right, they said, because they had known they were signing up for long hours and seeing impossibly hard things. They chafed against being unable to care for patients according to their education and training because of constraints outside their control: business decisions, policies, or regulatory and legislative requirements that prescribed their care.(1)
Some went so far as to wonder at the calibration of their moral compass if they stayed with their organizations, as participants in delivering suboptimal care because of those restrictions. Increasingly, their promise to patients, which they’d sworn as an oath on entering the profession, was implicitly or explicitly at risk.
Defining Moral Injury
After hearing this same lament dozens of times, my colleague, Simon Talbot, and I began searching for better language for this sense of compromised oaths. It wasn’t the commutable experience of burnout, which a longer vacation, being more efficient, eating better, sleeping more, exercising enough, using an electronic medical record with an intuitive user interface, would improve, if only temporarily. It was a deep-seated relational unease of breaking a promise and betraying the people on the other side of it — their patients, their colleagues, their successors.
Then we came across the term “moral injury.” Unlike moral dilemma or moral distress, moral injury signifies a profound, durable disruption in one’s sense of oneself — a “soul wound that pierces a person’s identity, sense of morality and relationship to society,” as journalist Diane Silver put it.(2)
Jonathan Shay, a psychiatrist who worked for years with Vietnam veterans, first defined moral injury as deriving from an experience with three requisite components: 1) a betrayal 2) by a legitimate authority 3) in a high-stakes situation.(3) The sense of betrayal was what we’d heard at those conference dinners, from physicians asked to put an organization’s needs — for revenue, profit, market share, reputation, or something else — ahead of the needs of their patients. That betrayal fractured the physicians’ relationship with and trust in healthcare organizations, whether their own hospitals, insurers, pharmacy benefit managers, or others.
Litz and his colleagues expanded the definition of moral injury after their experience caring for veterans who fought in Iraq and Afghanistan. They defined it as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”(4)
While seemingly disparate — Shay’s definition describes moral injury as imposed from without and Litz’s as emerging from within — the two definitions can be viewed as a stimulus-response pair. Faced with a betrayal (the stimulus), clinicians have a choice (the response) either to acquiesce to the betrayal and transgress their deeply held moral beliefs (the oaths we took to put patients first) or to resist the betrayal and refuse to transgress.
Betrayal, the root of moral injury, is a “violation of a person’s trust or confidence.”(5) At its heart, it is a profound relational rupture by those whom we should seek for protection and support.
Reframing distress this way has resonated deeply with clinicians across the healthcare spectrum (and with public defenders, educators, veterinarians, journalists, and others). It captured what clinicians faced when practices of paring staff, supplies, and space to the bone to maximize margins — everyday annoyances they had long warned were dangerous — suddenly became catastrophic in the context of COVID-19.
Researchers are identifying potentially morally injurious events in the experience of medical students,(6) residents,(7) nurses, and other front-line health workers(8) that are distinct from their experience of burnout. Some researchers have found healthcare administrators suffer moral injury, too.(9) And those health workers encounter potentially morally injurious events at rates comparable to post–9/11 combat veterans.(10)
Interestingly, the experience of moral injury is impacted by race and gender. However, moral injury scales currently in use, developed for and used primarily in white, male, military populations, may not reliably reflect this.(11)
Finally, moral injury may make unique contributions to health worker functioning, separate from other psychological diagnoses or burnout.(9) It poses a risk to health worker well-being and potentially to patient outcomes. It is imperative to begin exploring solutions.
Considering Interventions
Moral injury is rooted in the relational breakdown of betrayal, so solutions must necessarily attend to repairing relationships and restoring trust. Burnout interventions legitimately focus on efforts to reduce workload, improve workflow, or streamline processes to reduce worker demands. But failing to acknowledge the morally challenging and relational consequences of the business structure of healthcare has led to incomplete resolution of distress, as evidenced by burnout programs that perform below expectations.
Most of the interventions developed to address moral injury to date were designed for military contexts. While exploring those interventions for adaptation to healthcare will be useful, we must remain vigilant to the fundamental differences in the fields before such adoption.
First, moral injury in healthcare rarely occurs from a single, egregious event, as is more often the case in military contexts; in healthcare, it is more often an accumulation of smaller incidents that amass into an unresolvable wound. Secondly, the conditions that create moral injury are ubiquitous in healthcare’s current business framework; consistently avoiding those situations without leaving the field is difficult and complicates moral injury repair.
Finally, moral injury in military contexts stems primarily from the unsanctioned or undisciplined deployment of specialized skills, often lethal force. That situation is usually a modest and momentary creep of the military’s contract with society to provide protection, not a wholesale departure from its mission.
Moral injury in healthcare stems from the imposition of values that should not reside in healthcare — revenue-focused business constructs — as eloquently described by Chokshi and Beckman.(12) Moral injury, it could be argued, should be a never event in healthcare — a warning to systems straying from their values and the best interests of their patients.
Repairing Moral Injury
Repair of moral injury focuses on re-establishing, or establishing for the first time, a trusting and trustworthy relationship between the workforce and the institution, which is the foundation of a resilient organization. Workers must believe they are led by those who are skilled and suited for their positions and who care about and support the front-line staff.
Managers and leaders must believe in the competence and commitment of the workforce. Such mutual trust speeds change, reduces stress, increases accountability, and improves communication, and it develops through repeated small actions replete with transparency, integrity, consistency, and selflessness.
Basic steps to a better culture are outlined below, though the process must be tailored to the unique needs — and betrayals — of each organization, revealed in the damage assessment. It is important to recognize that completing the process may take months to years, depending on how entrenched the distrust is, and it will require buy-in from everyone for the fullest effect.
Moreover, it will challenge the organization’s resolve as leadership is asked to bear witness to the suffering of the workforce and absorb at least some of its pain, and for the workforce to acknowledge contributions it may have made to the situation.
However, once trust is rebuilt and potential betrayals reframed as a warning signal that continued repairs or restructuring are necessary, the organization will be significantly stronger.
1. Renew the organization’s commitment to mutual respect and shared goals. An unwavering commitment by a transformational leader is at the heart of recovery.
2. Get support and/or guidance from experts to facilitate the repair. This is hard work that most will not have undertaken previously. Calling in experts can help the organization through the most difficult periods of the initiative.
3. Assess the damage. It’s important for the person who betrayed to witness the extent of damage inflicted on others. The level of remorse they express, in words and deeds, correlates with how the relationship moves forward.
Whether the betrayals are intentional or not, those who committed the acts must see and hear firsthand the repercussions of those decisions. Validating the experiences of those who suffered is critical, as is providing comfort.
4. Take Responsibility. Potentially morally injurious events do not happen in a vacuum. Repair asks all stakeholders to critically analyze and acknowledge what they brought to the situation — their expectations, motivations, and their willingness or reluctance to communicate discomfort or objections.
5. Reinforce just culture, which holds that individuals should not be accountable for mistakes made in a system they cannot control.(13) Instead, all stakeholders share accountability for errors. Transparency and learning from mistakes are favored over assigning blame to ensure the safest clinical systems and processes.
6. Invest time, attention, and support in the process. Help clinicians know when to speak up by teaching and reinforcing the skills of introspection and giving them time to practice it. Provide advocacy and assertiveness training so they know how to speak up most effectively and codify protections for them when they do. Redesign, restructure, or replace activities clinicians deem low utility (get rid of “stupid stuff”).
7. Think beyond the organization. Especially working in collaboration with peer systems, organizations have more clout than any individual to reform or to end regulations or legislation that unduly constrain clinicians’ autonomy and latitude to practice: prior authorizations, patient satisfaction scores, meaningful use criteria that drive communications through the electronic medical record rather than through synchronous channels, and others.
Organizations must also reestablish trust with communities. Hospitals were once bastions of generosity and respected health information, but business pressures have shifted health systems and communities into transactional relationships.
Patients like Barbara Kolpin, pursued by debt collectors after an illness, feel “betrayed” by her health systems and understandably mistrustful of subsequent interactions.(14) Consistently transparent, high-integrity interactions with patients reestablishes the hospital as an authority in the community and best positions the institution to engender support for its workforce.
Building Solutions Together
The framework of moral injury adds a relational and moral dimension to the discussion of distress in healthcare, the absence of which may explain why results from interventions addressing burnout have been less robust than hoped. Interventions for moral injury require a collaborative approach among clinicians, administrators, hospital systems, payors, regulators and legislators to interrupt conflicting incentives and allegiances, which erode trust between stakeholders.
Patients deserve care aligned with their values and free of corporate interests, and clinicians deserve to deliver such care in keeping with their professional contract with society. Realizing the vision requires a commitment to rebuilding trust, recommitting to the integrity of healthcare’s mission, and focusing on what’s in the best interests of patients and the workforce that cares for them.
That work can begin tomorrow with leaders who engage in being present — lingering in a clinic, the emergency room, or an inpatient unit on the way to work every morning or making extended visits to different areas each week — and curious. How does the workforce experience the environment, and what can you promise each other as you begin building solutions together?
References
Dean W, Talbot S, Dean A. Reframing Clinician Distress: Moral Injury Not Burnout. Fed Pract. 2019;36(9):400-402. Erratum in: Fed Pract. 2019;36(10):447. PMID: 31571807; PMCID: PMC6752815.
Silver, D. Beyond PTSD: Soldiers Have Injured Souls on Truthout, Miller-McCune.com, September 3, 2011. https://truthout.org/articles/beyond-ptsd-soldiers-have-injured-souls/
Shay, J. Moral Injury. Psychoanalytic Psychology. 2014. 31(2):182–191. https://doi.org/10.1037/a0036090
Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, Maguen S. Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy. Clin Psychol Rev. 2009;29(8):695–706. doi: 10.1016/j.cpr.2009.07.003.
Merriam-Webster Dictionary. Betrayal. https://www.merriam-webster.com/dictionary/betrayal
Murray, E, Krahé, C, Goodsman D. Are Medical Students In Prehospital Care at Risk of Moral Injury? Emerg Med J. 2018;5(10):590–594.
Ngo SB, Clark PJ, Parr SE, Thomas AR, et al. Moral Injury During the COVID-19 Pandemic: A Delphi Model Survey of Family Medicine Residents. Int J Psychiatry Med. 2022;57(4):293–308. https://doi.org/10.1177/00912174211054385
Mantri S, Song YK, Lawson JM, Berger EJ, Koenig HG. Moral Injury and Burnout in Health Care Professionals During the COVID-19 Pandemic. J Nerv Ment Dis. 2021;209(10):720-726. doi: 10.1097/NMD.0000000000001367
Morris D. Moral Injury in Healthcare: The Evidence. Presented at the Erickson Institute Fall Conference. October 15, 2022.
Nieuwsma JA, O’Brien EC, Xu H. et al. Patterns of Potential Moral Injury in Post-9/11 Combat Veterans and COVID-19 Healthcare Workers. J Gen Intern Med. 2022;37:2033–2040. https://doi.org/10.1007/s11606-022-07487-4
Morris DJ, Webb EL, Trundle G, Caetano G. Moral Injury in Secure Mental Healthcare: Part I: Exploratory and Confirmatory Factor Analysis of the Moral Injury Events Scale. J Forensic Psychiatry & Psychology. 2022;33(5):708-725. DOI: 10.1080/14789949.2022.2111318
Chokshi DA, Beckman AL. A New Category of “Never Events”—Ending Harmful Hospital Policies. JAMA Health Forum. 2022;3(10):e224703. doi:10.1001/jamahealthforum.2022.4703
Boysen PG. Just Culture: A Foundation for Balanced Accountability and Patient Safety. Ochsner J. 2013 Fall;13(3):400-406. PMID: 24052772; PMCID: PMC3776518.
Silver-Greenberg J, Thomas K. They Were Entitled to Free Care. Hospitals Hounded Them to Pay. New York Times. September 24, 2022. https://www.nytimes.com/2022/09/24/business/nonprofit-hospitals-poor-patients.html