Understanding Moral Injury in Healthcare Workers

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Written by Diana Campion, MSN, APRN, ANP-C Education Development Nurse, Content Writer, IntelyCare
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Reviewed by Ayana Dunn, BSN, RN Content Writer, IntelyCare
A man thinks about moral injury in healthcare.

Burnout is a widely discussed issue among healthcare workers, approximately 89% of whom are considering leaving the profession for that very reason. However, moral injury, which has a crucial connection to burnout, has only recently started to gain attention.

What is moral injury in healthcare? If you’re seeking clarity on this, you’re not alone. We aim to assist you in understanding this newer concept by discussing its definition, providing examples, explaining the distinctions between moral distress vs. moral injury vs. burnout, outlining the symptoms, and offering tips on prevention.

Definition of Moral Injury

The definition of moral injury is nuanced. It refers to the consequences that arise from an individual engaging, witnessing, or failing to prevent events or actions that violate their deeply ingrained ethical code. These consequences can be psychological, social, and even spiritual. Although moral injuries are often associated with military service members and PTSD, they also impact individuals in high-risk professions, such as healthcare workers.

Moral Distress vs. Moral Injury vs. Burnout

Moral injury falls on a continuum alongside moral distress and burnout. For example, ignoring persistent moral distress can lead to moral injury, which can eventually lead to the development of burnout.

Moral distress refers to the troubling conflict experienced when an individual can’t act in a manner they know is correct due to constraints or limitations outside their control. Early identification and action can halt the progression of moral distress to preventable injury and burnout.

Moral injury typically occurs after significant events or prolonged episodes of moral distress. It differs from moral distress in that it results in lasting harm or repercussions to the person violating their moral code, and it’s often mistaken for burnout.

Burnout, according to the World Health Organization (WHO), is a “syndrome resulting from workplace stress that has not been successfully managed and is characterized by exhaustion, increased mental distance from work or cynicism, and decreased professional efficacy.” The adverse effects of this medical diagnosis negatively impact the individual’s personal life, their ability to care for patients, and the healthcare organization where they work.

Examples of Moral Injury

Health professionals in nursing, medical, and allied health must navigate various challenges and ethical dilemmas. This makes examples of moral injury in healthcare all too common. If you work in healthcare, you have likely experienced such incidents — maybe even unknowingly. Here are several moral injury examples to help you recognize these instances and take action.

  • A nurse consistently fails to meet the necessary professional standards of care for their patients due to understaffing. As a result, the nurse develops negative perceptions of their management and themselves in addition to a profound sense of shame, self-condemnation, and guilt.
  • A nurse is expected to perform CPR on an elderly patient with Alzheimer’s Disease despite the patient’s poor prognosis. This goes against the nurse’s judgment, but the patient’s family insists on preserving life at all costs. The psychological distress from providing futile or harmful care is a common cause of moral injury in nursing and healthcare workers.
  • A rural autonomous nurse practitioner (NP) faces the difficult decision between allocating finite resources to save one patient’s life versus providing adequate care to multiple patients with less acute needs. This significant burden forces the NP to determine the ethically correct course of action within practical and financial constraints, leading them to question their purpose and become socially withdrawn.
  • A respiratory therapist (RT) accepts a job at a hospital because its values align with their own. After one month, the RT voices concerns over the discrepancies between the hospital’s principles and their department’s culture. In response, the RT receives the silent treatment and is assigned unfavorable shifts, resulting in feelings of betrayal and loss of trust towards their coworkers and management.
  • A physician sacrifices their personal well-being and personal life to meet the demands of their patients, employers, and insurance companies. They find they are unable to sleep, which leads to chronic fatigue. The physician struggles with angry outbursts and demoralization.

Moral Injury Symptoms

It is essential to be aware of the symptoms of moral injury so you can seek support for yourself or assist colleagues. Moral injury symptoms can vary in degree and presentation but generally include the following:

  • Loss of meaning and purpose from being forced to question one’s core values and beliefs. This can lead to a sense of aimlessness and a loss of faith and trust in people or spiritual practice.
  • Physical manifestations that don’t have a clear cause, such as:
    • sleep disturbances
    • fatigue
    • weight gain
    • pain
  • Psychological distress caused by moral injury in healthcare can include one or more of the following feelings:
    • Shame
    • Betrayal
    • Self-condemnation
    • Depression
    • Anxiety
    • Irritability
    • Anger
    • Guilt
  • Self-harm — such as substance abuse, nonsuicidal self-injury, or suicidal behaviors — may be used to cope.
  • Social difficulties can develop from feelings of isolation and the recognition that others have not experienced similar situations, which can lead to social withdrawal.

Ways to Prevent Moral Injury

Healthcare is an industry where ethical challenges and dilemmas are especially prevalent. You may personally identify with the definition of moral injury, relate to the examples and symptoms, or recognize your risk factors. Whatever the case, here are some tips that can help you safeguard your well-being.

1. Prioritize Your Care

While nurses focus on promoting patient health, prioritizing your wellness is also critical. There are a number of ways to do this: practicing practical self-care, using workplace health and wellness benefits, and leaving a job to seek a work culture that allows nurses to thrive.

2. Build Resilience

Resilience is the ability to adapt to adversity while maintaining well-being. Try incorporating the critical skill of mindfulness into your daily routine. This can help develop healthy mental habits, like letting go of things outside of your control, self-compassion, and gratitude.

3. Understand It’s Not Your Fault

Moral injury in the workplace arises from organizational failures, not individual nurses. It’s unnecessary to blame yourself for circumstances beyond your control that are caused by poorly designed systems. Understanding the root causes of this complex problem relieves many nurses of oppressive guilt.

4. Seek Help

If you’re feeling overwhelmed or experiencing symptoms of moral injury, reach out to a primary care practitioner or mental health provider. Ignoring moral distress and injury can escalate to burnout, significantly increasing the risk of suicide. Remember that it’s okay not to be okay, but it’s not okay to suffer in silence. Support is just one click, one text, or one call away.

Prioritize Your Well-Being Without Sacrificing Financial Security

Now that you have greater insight into moral injury in healthcare, you may be looking for a job with a better work environment. Find a job that meets all your goals on IntelyCare.