You may have heard the term moral injury more frequently these days than ever before. Between the TEDx talks, the YouTube rants, and the LinkedIn articles, moral injury is being compared to post-traumatic stress disorder (PTSD) symptoms and is heading to replace one of our favorite words in the nursing world: burnout. However, there is a growing movement that believes that moral injury is the root-cause of burnout and PTSD. In other words, if burnout or emotional exhaustion is organ failure, moral injury is sepsis.
In the August 2018 issue of STAT News, Dr. Simon Talbot and Dr. Wendy Dean associated the term moral injury as the true cause of burnout; the cynicism, emotional or physical exhaustion, and diminished productivity that can be prevalent in many health care organizations. However, burnout implies that the clinician is not resilient enough to manage the components of the job, or perhaps is not participating in enough hot-yoga-self-care practice, whereas the actual root cause of the emotional discord is moral injury.
Historically, moral injury is associated with military personnel who have witnessed, participated in, or failed to prevent transgressions against humanity or acted contrary to “deeply held moral beliefs and expectations” according to a study published in 2009 in Clinical Psychology Review. While civilian clinicians in the U.S. are not necessarily bearing witness to the horrors of war, they are attempting to provide care, compassion, and healing in health systems that are broken and, oftentimes, focused on compensation rather than the patient or clinicians.
The slope of document-for-maximum-reimbursement vs. document-the-excellent-care-provided is slippery. The fact is, health care is a business. To take it one step further, given the publicly reported information on patient satisfaction scores, readmission rates, infection rates – not to mention social media – health care is a commodity and patients can trade their provider with the click of a mouse. Organizations simply must maximize revenues from the ever-changing world of insurance coverages to keep the doors open, let alone to fund strategic initiatives to make improvements or plan for growth.
Clinicians find themselves in the middle of the battle between care and compensation. For example, when a patient presents with a wound and, after they are seen and treated, the nurse knows the patient cannot afford the appropriate dressings, but the organization does not allow staff to offer long-term supplies (brown-bagging). Or a patient who needs an expensive biologic medicine that the clinician knows is the best on the market for the diagnosis yet is required to order the cheaper medication that is on formulary. These betrayals to the calling of medicine to provide excellent care in and of themselves are not impactful. But numerous and repeated injuries to the morality of health care takes a toll.
Cases of moral injury occur at all levels of the health care organization. While working as a Certified Nursing Assistant (CNA), Doug McGann experienced emotional exhaustion. “I felt very undervalued in my role as a nursing assistant. I knew that I worked hard and provided compassionate care, but the organization really didn’t do anything to recognize the role. In fact, when they removed tasks from the assistants, like measuring and recording vital signs, it felt insulting. We were providing less support to the team when most of us wanted to contribute more. Eventually, I left the role as it became too mundane and repetitive and went to nursing school.”
How do clinicians guard themselves against moral injury? What can organizations do to combat the insult? The answers are still being hypothesized and churned by many articles in the health care space. One answer could be to encourage clinicians to embrace nurturing practices such as meditation and other stress-relieving activities while acknowledging that self-care means something different to each person. But a “Code Lavender” approach to increasing stress is not always that simple, and once again puts the onus on the clinician to improve their coping mechanisms.
What needs to improve are the institutional patterns that perpetrate the moral injuries. Organizations need to reduce the competing demands on health care workers and strive to treat each discipline with the respect it deserves so that providers can practice at the top of their scope. Institutions should provide, advertise, and encourage employees to utilize employee health services that include a behavioral medicine practitioner for debriefing and centering. Also, there is strong data emerging related to the effects of supportive, competent, and empathetic leadership on reducing the effects of moral injury.
By changing the language and mindset of how we approach burnout to address the root of the issue, the business of health care can move away from moral injury and into a place of mutual respect, acknowledgement, and empowerment towards all levels of the medical team.