How to Repair Moral Injury Before You Burn Out
A common refrain among doctors today is that they would not encourage their children to become doctors. They find that burnout is at an all-time high and the profession lacks the appreciation it once had. Although applications to medical schools surged after the outbreak of the COVID-19 pandemic, a fifth of healthcare workers have since left their jobs. We therefore face tensions – doctors, nurses and others are leaving medicine at a time when students are striving more than ever to become doctors. What do we make of it?
In our recent article, “Moral Injury in Health Care: Identification and Repair in the COVID-19 Era,” published this month in Journal of General Internal Medicine, colleagues, and I argue that most physicians do not suffer from “burnout” per se, but from a more damaging phenomenon known as “moral injury.” Distinguishing moral wounds from related concepts such as “moral distress” and “burnout” is important in order to disrupt the mass resignation of health professionals and repair moral wounds. Accurate diagnosis is critical to effective treatment.
Diagnosis: Moral injury v. moral distress v. burnout
The term “moral injury” typically refers to the harm of having to violate deeply held beliefs in a high-stakes situation, either because a supervisor demands it or because circumstances warrant it. Moral injury as a concept has its origins in military veteran literature. Soldiers may have to shell an area where women and children are known to be, because they are asked to do so or because they feel they have no other choice. In other cases, they may witness acts that they find morally repugnant but are powerless to intervene. In all scenarios, moral injury leads to guilt, shame, and social withdrawal.
How is moral injury different from moral distress? The latter term is related and does not come from military literature, but from nursing literature. Moral distress is perhaps best understood as a milder form of moral injury. A doctor writes to a nurse to give a patient treatment that the nurse feels is not indicated. However, the nurse feels compelled to do what she thinks is right and suffers from psychological stress. Usually, distress clears up after their shift, but sometimes it leaves a moral residue that can accumulate and cause moral injury.
As we note in our article, burnout classically refers to “a combination of emotional exhaustion, depersonalization, or cynicism and a sense of diminished personal accomplishment.” Symptoms include numbness, neglect, and withdrawal. It is the ultimate consequence of unrelenting moral injury, driving people into addiction, therapy, and/or career change.
So, if we put these three together, we could say that moral distress is the acute discomfort felt when compelled to do the right thing. If prolonged and chronic, moral suffering becomes a moral injury which, if prolonged, becomes burnout. We argue that
Physicians who are burned out are no longer concerned about offending deeply held moral beliefs because they are beyond emotion. The detachment and depersonalization associated with burnout can be viewed as the total lack of stress or moral investment.
It is therefore crucial to intervene in moments of moral distress – by removing irritating situations and promoting moral resilience – and, more importantly, to intervene at the level of moral injury.
What to do? Individual, structural, leadership and community-based interventions
To mitigate the progression from moral distress to moral injury and moral injury to burnout, we need interventions at the personal, structural, professional, and community levels. Failure to recognize the need for a multi-faceted approach leads to persistent attrition in the healthcare workforce.
First, while this is not a panacea, individuals can and should cultivate moral resilience to equip them to deal with morally challenging situations. But extraordinary resilience cannot solve the problem of inhuman systems. I remember years ago sitting in a room of disgruntled doctors who had requested an audience with a senior health care system leader.
The doctors were morally offended: They felt compelled to squeeze the complex care of the patients into short visits to the doctor. They feared it would amount to bad practice and hated the feeling of having to treat patients harshly. After hearing their concerns, the healthcare system VIP dryly replied, “You just need to build more resilience.”
Contrary to the VIP’s flippant remark, structural reforms are also necessary to prevent moral injuries. Clinicians need time and healing environments to provide good care to sick and dying patients. Achieving this may require more support staff, clinical space, face-to-face interactions with patients, and reduced revenue.
Third, health leadership can do its part to prevent moral violations by committing to clear communication with physicians and staff. Communication is essential to building trust, and employees who trust leadership report reduced work stress, greater participation in wellness activities, and healthier behaviors.
Fourth, communities can deal themselves with the circumstances that lead to moral violations. Physician groups have evolved during COVID-19 to encourage support for frontline healthcare workers. Much like the US Army assigns “battle buddies” to combatants who have suffered similar trauma, healthcare systems have brought clinicians together with members of their clinical unit to foster a sense of purpose and hope.
Conclusion
Medicine is an extraordinary profession and society should encourage its compassionate and brilliant students to become doctors. Medical training itself is a stress test and trains resilience. But it does no one any good to send young doctors into broken organizations. Healthcare leaders must restructure systems despite the cost, and communities must come together to support frontline workers to ensure moral recovery — and thriving — for all.