Moral Injury in Healthcare

A few years ago, I was asked to speak at the annual trauma conference held in Oklahoma City, OK, a conference that was started in the aftermath of the Oklahoma City bombing. The focus was on medical professionals, and the impact of not just mass traumatic incidents, but the day-to-day toll of what working in a hospital can do to someone. It really opened my eyes. I had no idea just how heavy the burden was that so many in that field carry.

When one thinks of public service and mental health struggles, the focus immediately goes to veterans and first responders. No amount of attention to them could ever be enough. But there are others who can suffer and don't receive the same attention. Trauma nurses and doctors, as well as all those medical professionals who work incredibly hard to save and extend life, knowing that ultimately, the end is always the same for each of us: death. It can make for a soul-defining struggle for those who try to help us extend life as long as possible.

What is moral injury in healthcare?

One key component to watch for in healthcare is that of moral injury. In particular, the feeling of, did I do enough? Was I at my best? If you and I are tired at work and we make a mistake, what are the stakes? Do that in the ER, or overlook something on a scan or during an examination of a patient, and the price could be death. What if you are haunted by what you see as your failure, or even just the feeling that you weren't at your best? You may be reminded of it because you will see something similar again.

I have always found with medical professionals and trauma that one incident could stand out among all the others: a child who was ejected, a beautiful young woman who looked angelic being carted in, only for all hope to fade when brain fluid leaked from her nose, the mass trauma that was the result of the Oklahoma City bombing, etc. But moral injury can come from more than a single horrific event, or the kind of horror one might expect to leave scars. It can be the nurse who knows a patient needs more attention but is too busy to provide it; the doctor who continues aggressive treatment on a dying patient even though he believes it is only prolonging suffering; or the respiratory therapist who repeatedly performs painful procedures on someone with little realistic chance of recovery. It might be watching a preventable mistake occur and feeling powerless to stop it, or realizing afterward that you missed something important. It could be choosing which patient receives limited time, equipment, medication, or a bed, or discharging someone into circumstances you know are unsafe because insurance will no longer pay. It can be a policy, one you believe puts finances, liability, or efficiency ahead of the patient. It may even be seeing a colleague treated unfairly and remaining silent, or losing a patient and wondering if you could have done more. Often, it is not what you did at all, but the feeling that an institution, supervisor, or system placed you in a situation where doing what you believed was right became impossible.

As rewarding and well-paying as a medical career can be, it can also be all-consuming. I remember visiting a high school friend finishing his residency and being shocked at the cloistered life he led with his fellow residents. They worked literally insane hours, only making enough money to pay the bills, much less pay off their student loans, until they could finish this trial of almost slave labor and begin their careers, some of them in their early 30s after years in school. And then what? The grind continues.

Moral injury can also be institutional. Many have felt betrayed by administrators, faced a lack of resources, and been asked to care for more patients than one should be caring for safely. Feeling part of the machine can lead one to feel like nothing more than a cog, and this machine doesn't always put "patients first," the very reason the system exists.

Because of this, even when financially successful, their lives can become unbalanced if they aren't careful. Burnout is rampant, but what are the options?

A large study published in 2023 involving 1,945 healthcare workers found that 40.9% screened positive for moral injury. The survey was conducted during the COVID-19 pandemic. Another review of studies involving emergency room nurses found that as many as 51% in individual studies had left or considered leaving because of moral distress.

Moral injury can develop after a betrayal, or after experiencing our own helplessness. Just like veterans and first responders, healthcare professionals are expected to suck it up and deal with it. It's the job, you get paid great, it's what you went to school for, suck it up, buttercup! And there you are in a maelstrom of overwhelming action, frustrating inaction, witnessing incredible amounts of trauma while making sometimes impossible choices, and then, at its worst, institutional betrayal.

It's also easy for medical professionals to leave work, take off the uniform, drive home, and act like everything is fine. But obviously, for many of them, it's not fine.

What are some recommendations?

1) Medical care should mirror the best of first responders and the military by offering regular, proactive mental health check-ins and peer support to their staff. These should be routine, not just something offered after a critical incident. The employee should always drive the conversation, with no requirement to disclose anything.

2) Sabbaticals and mental health screening should be a regular part of the career.

3) Opportunities should be created for the families of healthcare workers to learn about what they go through and how best to respond.

Mentally healthy workers will serve longer and better if we can meet their needs, quit neglecting their mental health, and help them learn to recharge so they are at their best as often as possible. It should be a goal for all of us, as all of us will want them at their best someday. And more importantly, we should always be ready and willing to take care of those who take care of us.