ADDRESSING AND PREVENTING MORAL DISTRESS AND MORAL INJURY IN THE HEALTHCARE WORKFORCE

To acknowledge the acute and chronic exposure of the healthcare workforce to potentially morally injurious events across the continuum of care; further,

To recognize the risk of moral distress and moral injury when a healthcare worker is unable to provide ethical, safe, and effective care; further,

To advocate for consistent support for equitable and transparent allocation of resources across care teams and health systems to ensure that healthcare workers can provide safe and comprehensive patient care services; further,

To advocate organizations prevent and address moral distress and moral injury among healthcare workers.

Rationale

Moral injury is defined as the “perceived betrayal by a legitimate authority in a high stakes situation, which leads one, through action or inaction, to deeply transgress held moral beliefs and expectations.”  It is considered to be a syndrome associated with clinical symptoms such as psychological distress, increased thoughts of self-harm and various mental illnesses. Moral injury occurs when workers begin to question the moral framework of the system and their own moral framework for continuing to work within that system. It is increasingly being included in discussions with occupational burnout, as a differentiating factor for healthcare workers from other professional fields struggling with occupational burnout in their workforces and due to exposures to potentially morally injurious events that occur in healthcare environments. It provides an important insight for healthcare workers who believe that occupational burnout, a syndrome of emotional exhaustion, depersonalization, and a low sense of accomplishment, is a symptom of a larger problem, beyond individual well-being and resilience.

Moral injury has been described as a process, or continuum, in which an individual progresses through a range of experiences from moral dilemma, to moral distress, and then to moral injury. The Workforce Change Collaborative advanced a National Framework for Addressing Burnout and Moral Injury in the Health and Public Safety Workforce which overlays the continuum of moral injury and burnout and depicts environmental, relational, and operational drivers and outcomes impacting workers and learners, patients and community, organizations, and society.  Left unresolved, moral injury has not only consequences for the individuals experiencing it, but also for patients who are impacted by increased risk of errors, threats to safety, and diminished quality of service. Organizations may experience significant employee turnover and declines in quality and patient satisfaction ratings.

Moral injury was originally a military term used to describe a soldier’s response to serving during times of conflict depicted as a “deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.” In the context of healthcare, moral injury is not comparable to a soldier’s actions taken during a war; however, it occurs when a healthcare worker feels unable to provide high-quality care due to ethical dilemmas experienced in their workplace. Calls for action include commitments from leadership and organizations to be proactive and corrective in addressing patterns that lead to moral distress and moral injury and ensuring equitable allocation of resources for healthcare workers to perform their jobs in an ethical, safe, and effective manner.