Helping Our Healthcare Workers: A Primer to Moral Injury

Are you or is someone you know in a helping profession? If so, this post is for you.

I’ve been hiding a secret from you all. Yes, I am very interested in what allows all humans to thrive. However, I’ve had a specific side agenda for nearly a decade. This agenda has been to deeply understand—in order to affect change—how to keep those who care for others (e.g., formal and informal caregivers, health and behavioral health providers, social workers, teachers, etc.) spiritually and physically healthy, and thriving. Over the last year, my focus has shifted away from burnout to moral injury. My hope with this post is to elevate your awareness to a growing social issue, to give you starter points on how to help, and open a space of communication for those who are experiencing the distressing cluster of impacts from moral injury.

Imagine This Story

You are a healthcare worker who has been on the frontlines for the last 18 months. The amount of loss you have seen is incalculable. As the pandemic wears on, the communal landscape of support has waned. You see less and less “Support our Healthcare Heroes” signs decorating front lawns. Windows in the houses of your neighborhood no longer shimmer with the decorative hearts that implied solidarity, and the 8 p.m. community “howls” have faded to a nearly non-existent whisper.

You are about to start day five of your 12-hour shift in the ER. It’s August 2021 and COVID-19 is surging again, but it is different this time around. The patients are younger, sicker, and scared. Oftentimes, they are filled with regret for not making health behavior choices that could have prevented their current situation. You are exhausted, angry, and maybe even cynical. On this particular evening, you have patients who have been in the ER for over 15 hours. Your healthcare center no longer has open ICU beds.

You’ve been here before; and another surge means that unfathomable choices are going to have to be made. Your body remembers very keenly a circumstance you were in last winter. You recall the first time you had to decide who of your patients were going to live, and who were going to die. You had five patients in the ER, all of them needing and deserving a higher level of care; however, only one ICU bed was open. This decision has haunted you ever since. You had to play God in a way you were never taught to do. As the surge charges forward, you know you will be put in that position again. You start to wonder, “Are we really healthcare heroes when we are repeatedly being forced to go against our moral code?”

This is not an isolated story. If you have any personal connection to healthcare, you know this is generalizable. Our healthcare workers, along with so many others, are not okay. At some point, the spirit breaks.

What is Burnout?

Burnout is a cluster of symptoms characterized by exhaustion, cynicism (or a decreased capacity for empathy), and decreased productivity or engagement. Burnout is oftentimes treated like an isolated case, an individual defect, one person’s inability to “cope” with the stressors in front of them. Because of this view, institutions have been targeting individual level interventions as a means to mitigate. Its interventions include “resilience training” and other individual-based mindfulness activities. These interventions fail to acknowledge that burnout is a systemic issue, and only offer ephemeral benefits. These solutions put the onus on the individual.

The term burnout fails to capture the whole picture, and has not sit well with those in healthcare circles for some time. Despite the attention it has received, and the vast interventions developed to reduce or repair, it ultimately implies a lack of resourcefulness or a character weakness in the individual. Take the person out of the system they are embedded within that is contributing to symptoms of burnout, and they will likely improve. If you know anyone in healthcare, you’ll know that resilience is already a baked into their DNA.

What is Moral Injury?

A large majority of people enter healthcare because it is a calling. It is a deep passion to care for others. Moral injury occurs when a person knows what the right thing to do is (as evidenced by a great deal of education and training), but is unable to do the right thing (e.g., provide equitable and quality care for everyone). Two elements contribute to suffering moral injury:

1. A troubling event (or a continued series of events) that causes distress, and
2. Moral trespass (when the event or events transgress deeply a person’s held beliefs).

“Moral injury requires an element of insult that erodes one’s deepest sense of oneself as a moral being—a loss of calibration of one’s moral compass, so to speak.”¹ It means the system is set up in such a way that hinders a person’s ability to do what they have been trained to do. If burnout is present, there is a high probability that moral injury has already occurred. Having to choose who lives or dies, when everyone deserves the highest level of care; re-using the same PPE for a week due to a shortage driven by lack of preparedness; having people question or discredit your training due to pervasive mis-and-disinformation; being unable to provide basic levels of patient and human caregiving—are all potential drivers in moral injury.

How Can We Help?

1. Name It

There is power in naming something. As someone who has experienced moral injury, it was incredibly reassuring and validating to understand the difference between burnout and what I was facing. Knowing the difference didn’t fix it, but it sure did shift my perspective. The first step is sharing knowledge, naming the phenomenon, and opening the door for conversations. Moral injury is a collective assault on all of our human psyches—the ripple effect will be felt by all. Use this language to start a conversation with those closest to you, and you’ll see you’re not alone.

2. Listen Empathetically

If you suspect that a loved one is suffering from moral injury, ask them how they are really doing. When they are ready to share, compassionately and empathetically listen. God gave us two ears and one mouth for a reason.² Start the conversation with, “What would you like my role to be in this conversation? Do you need to vent, would you like advice, or would you like to work collaboratively on a resolution?” Don’t throw solutions at them. If meditation, clean eating, and quality sleep actually fixed a systemic problem, this emerging pandemic within a pandemic would not be occurring.

3. Ground Yourself with Spirituality

Re-orient yourself with the passion that called you to be a healer. Being a healer is innately spiritual. It is an orientation beyond yourself, it connects you the transcendent moments in yourself and in relationship with others. Suffering opens the door to spiritual transformation. It awakens something within us that is deeply innate. Be open to the possibility of growth through these crisis situations and remember we are all spiritual beings, so tend to those parts of yourself. To learn how you can start fostering spiritual growth in times of suffering, please read my previous post here.

4. Advocate

If you are a leader in a position of power or influence, now is your time to step in and step up. Our country is facing an impending mass exodus from health and human services, healthcare specifically. The change will come when we have compassionate leaders in positions of power. This is not an easy fix; nothing ever is when it’s systemic. Ask yourself: “Is it possible that anyone who works for me is suffering from moral injury;” “In what ways am I actively or unknowingly contributing;” and “In what ways can I advocate for their wellbeing?”

In order for all of us to thrive, don’t we especially need those who care for us to be thriving too?

References

1. Dean, W., Talbot, S.G. & Bedzow, I. (2021). HeaR-MI: How reframing distress can support your workforce and heal your organization. Moral Injury of Healthcare, LLC.

2. See Proverbs 25:11-12.