Moral Injury, Pt. 2: Term Usage Increases, Plus Practical Ways to Support Clinicians

[Editor's Note: The monthly blog post from Dr. Weingarten is here! Kaethe Weingarten, PhD, founder and advisor of MCN’s Witness to Witness, shares stories, resources, and helpful tips to support health care workers and others through the many stressors of their daily lives. This is the second installment of a mini-series on moral injury. Read the first installment here.] 

The term “moral injury” appears to be experiencing a surge in usage. As I wrote in the June blog, the term was introduced in 1994 by Jonathan Shay, MD, PhD, taken up and elaborated in 2009 by Brett Litz, PhD, and widely cited by many people in health care following a 2018 article by Wendy Dean, MD and Simon G. Talbot in STAT. Since January, like many people, I am hearing the phrase moral injury more than I ever have before. Its use may not be precise, but it captures an experience people are having at work and in the public sphere.  When people in positions of trust behave in ways that violate our understanding of right and wrong, of moral and immoral, when lies and deception are used to justify actions that are intended to create new norms, witnesses near and far can feel betrayed and offended to their moral core.

Witnessing a troubling event is one way that people can experience moral injury.  Acting or failing to act in ways that violate one’s moral beliefs in response to a situation with which one is involved are two other ways that moral injury occurs – this may also be called moral distress.  Andrew Jameton coined “moral distress” in 1984 after his observations of nurses.  He defined moral distress as “the experience of knowing the right thing to do while being in a situation in which it is impossible to do it.” That is, nurses might disagree with an order given to them by a physician but due to the hierarchical structure of health care, they would feel unable to question or challenge the directive.  Thus, they would do something or not do something against their better judgement. Some researchers suggest that moral distress is a less intense form of moral injury or even a precursor to it. Others see the terms as related but distinct.

In an important, comprehensive paper published earlier this year, Brett Litz and his associates try to make sense of the experience of moral injury.  Sometimes in response to moral injury, people engage in self-condemning behavior, resulting in internalizing shame, accompanied by anxiety, depression, withdrawal, and then isolation. Others turn the condemnation outward, leading to distrust and blame of others.  In either case, people often experience what the authors call “social pain” as a result of moral injury, in which they lose relationships that are important to them. They may also experience crises of faith, even a loss of faith in humanity.  

It is remarkable and concerning that at this current moment there are many public service positions, not just in health care, in which dedicated public servants are exposed to conditions that give rise to experiences of moral injury.  In a heartfelt statement, scientists at NIH, speaking about The Bethesda Declaration, voice both the conditions under which they work that violate their moral and ethical standards and the difficult choice to speak up.  They do so because, as they say in this short statement, what they are being asked to do is “soul crushing…[and] you cannot get another soul.”  Speaking up takes moral courage, which I will address in my August post.

At Witness to Witness (W2W), all of our programming and materials emphasize that, in most instances, it is the conditions and contexts within which we do our work that produce challenging emotional states. Even if causes of suffering are systemic and institutional, we will nonetheless experience them as individuals.  When we discuss strategies that individuals can use to protect themselves from and cope with negative experiences such as moral injury, we do so as a first step—not to imply that moral injury could have been prevented if only the individual had been more resilient, tougher, or taken better care of themselves. While W2W is clear that the solutions are systemic, we still sincerely believe that individuals need support.

Individual

Even when we provide ideas about how individuals might manage moral injury, we do so with the understanding that individuals fare better when they are supported within a community—whether among trusted colleagues in the workplace or within other caring relationships.  Sometimes, one person may feel stunned by an interaction that is disturbing but not be able to discern the elements that have made it upsetting.  Working in a setting in which trust has been established so that colleagues can help decode what felt “off,” is often a prerequisite to awareness that a potentially morally injurious event (PMIE) has taken place.  It often requires distance, which an uninvolved friend or colleague may have, to find language for the distress.  Words like “betrayed,” “violated,” “distrust,” “ashamed,” “slimed” and “enraged” are not typical words to describe one’s experience at work and so when one finds oneself using those words, it can be disorienting.  Yet, awareness that an event or series of events have occurred that have violated a person’s sense of what is right is a necessary first step for a person to make sense of and deal with a moral injury.  

A next step is often only done in conversation with a less involved person: creating a narrative about the event that one can live with.  This doesn’t mean absolving the people involved, including the self, but it does mean coming to understand the wider context within which situations arise that do harm.  A version of a narrative such as this may be useful: “No one asked to be placed in this situation, and no one had the answer as to what was the right action to take. We all did the best that we could under circumstances that were not in our control.”  If you are the colleague, friend, or family member who is assisting the person who has experienced a moral injury, it may be tempting to challenge the person’s negative judgment of self or other.  However, clinical experience suggests that a better approach is to acknowledge that the person’s evaluation may be correct, appreciate the complexity of the situation they were in, and help them forgive themselves so they can focus on living the best moral life they can going forward.  Sometimes this means acceptance and self-forgiveness and sometimes this means turning to activism to spare others from suffering moral injury.

Team/Institutional Level Concerns and Supports

During the pandemic, many people saw that health care providers were working under difficult conditions and could empathize with the distress they were routinely experiencing, whether they labeled it burnout or moral injury.  While on the surface, the situation now may not look as dire as it did then, many providers express the view that circumstances are just as strained, only in different ways.  Health care providers remain burdened by an increase in administrative tasks, like maintaining medical records and filling out insurance forms, which require time spent after hours so that they can meet the demands for increased patient productivity during scheduled work hours.  Many providers, especially but not only providers in safety net hospitals, work in systems where inequities in reimbursement mechanisms force them to deprive some patients of the tests and procedures they need.  Providers say these are the conditions that produce moral injury for them: knowing what a patient needs and not being able to provide it. The misalignment between health care leadership and frontline staff has become increasingly pronounced, with an emphasis on productivity metrics at the expense of patient care creating conditions that are ripe for moral injury.

W2W recommends a few strategies for teams to consider. Some frontline staff have managers who address these issues directly, while others avoid such conversations, creating less psychologically safe environments. When it is safe to raise ethical concerns, this psychological safety helps prevent moral injury.  Some health care systems use rounds to discuss moral issues.  One format is Schwartz Rounds, a program that provides “a regular open forum for a multidisciplinary discussion of the psychosocial and emotional aspects of working in healthcare. Each session is organized around a compelling theme or patient story, and includes both clinical and nonclinical panelists and participants.” These rounds make it clear that morally distressing circumstances arise for all providers and feeling distressed or injured is not about individual weakness, the solution to which would be to toughen up. 

At the team level, buddy systems that encourage debriefing after difficult situations, along with daily huddles that include both naming challenges and offering appreciations, are valuable tools. While many issues in health care require national-level solutions, staff feel more able to provide compassionate, appropriate care when their feedback to managers leads to meaningful change.

Understanding moral injury is essential, both for recognizing when others are suffering and for responding to it within ourselves. Moral injury carries lasting consequences—not only for those who experience it directly but also for the people around them: those they know, care for, and love. Yet, the term must be used with care. Overuse risks diluting its meaning and undermining its emotional and ethical impact. That would be tragic—especially at a time in history when clarity about moral injury, and the courage to prevent it, are more urgently needed than ever.

In my next post, I will describe how national politics are creating the circumstances for entire swaths of people to experience moral injury as they witness the degradation of the health care system.  These are times in which concepts such as moral silence, moral disengagement, moral activism, moral resilience, moral courage, and moral witness take on new urgency.  I look forward to sharing my ideas about these important concepts with you.