How to Repair Moral Injury Before You Burn Out

A common refrain heard among doctors today is that they would not encourage their children to become physicians. They note that burnout is at an all-time high, and the profession lacks the esteem it once held. Although medical school applications soared after the COVID-19 pandemic’s onset, one-fifth of exisiting health care workers left their jobs since then as well. We thus are confronted with tension—doctors, nurses, and others leaving medicine at a time when students are keener than ever to become doctors. What do we make of this?

In our latest paper, “Moral Injury in Health Care: Identification and Repair in the COVID-19 Era,” published this month in the Journal of General Internal Medicine, colleagues and I argue that what ails most medical practitioners is not “burnout” per se, but a more pernicious phenomenon known as “moral injury.” It is critical to distinguish moral injury from related concepts of “moral distress” and “burnout” if we are to disrupt health care professionals' mass resignation and repair moral injuries. An accurate diagnosis is critical to effective treatment.

Moral Injury v. Moral Distress v. Burnout

The term “moral injury” typically refers to the harm that results from being required to violate deeply held beliefs in a high-stakes situation, either because a superior requires it or because circumstances demand it. Moral injury as a concept has its origins in the military veteran literature. Soldiers might be required to shell an area where women and children are known to be present because they’re ordered to do so or because they feel they have no choice. Other times they may bear witness to acts they feel are morally repugnant but are powerless to intervene. In all scenarios, moral injury induces feelings of guilt, shame, and social withdrawal.

How is moral injury different from moral distress? The latter term is related and derives not from the military but from the nursing literature. Moral distress is perhaps best understood as a milder form of moral injury. A doctor writes orders for a nurse to give a patient a treatment that the nurse feels is not indicated. The nurse, however, feels constrained from acting on what she knows to be right and suffers psychological distress. Usually, the distress clears up after her shift, but sometimes it leaves a moral residue, which can accumulate and cause moral injury.

As we note in our paper, burnout classically refers to “a combination of emotional exhaustion, depersonalization or cynicism, and a sense of reduced personal accomplishment.” Its symptoms include numbness, carelessness, and disengagement. It is the final consequence of unmitigated moral injury and drives people to addiction, therapy, and/or career change.

Putting these three together, we might say that moral distress is the acute discomfort one feels when constrained from doing what is right. If sustained and chronic, moral distress becomes moral injury, which, if persistent, becomes burnout. We argue that:

Physicians who burn out are no longer distressed at violating deeply held moral beliefs because they are beyond feeling. The detachment and depersonalization associated with burnout can be viewed as the absence of distress or moral investment altogether.

It is thus critical to intervene at moments of moral distress—by removing inciting situations and cultivating moral resilience—and, more critically, by intervening at the level of moral injury.

Individual, Structural, Leadership, and Community-Based Interventions

To mitigate the progression of moral distress to moral injury and moral injury to burnout, we need interventions at the personal, structural, professional, and community levels. The failure to recognize the need for a multi-faceted approach accounts for continued health care workforce attrition.

First, although not a panacea, individuals can and should cultivate moral resilience to equip them to handle morally challenging situations. But exceptional resilience can’t solve the problem of inhumane systems.

I recall years ago sitting in a room of disgruntled physicians who had requested an audience with a high-ranking leader of a health care system. The physicians were morally injured: They felt constrained to squeeze complex care of patients into brief office visits. They worried that this amounted to bad practice and loathed feeling required to treat patients brusquely. After hearing their concerns, the health system VIP drily retorted, “You just need to build more resilience.”

In contrast to the VIP’s flippant suggestion, structural reforms are necessary to thwart moral injury. Clinicians need time and healing environments to care for sick and dying patients well. Accomplishing this might require more support staff, clinical space, facetime with patients, and lower revenues.

Moral Injury Essential Reads

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A New Writing Therapy is Helping to Heal Moral Injury

Third, health leadership can do its part to prevent moral injury by committing to clear communication with clinicians and staff. Communication is essential for building trust, and employees who trust leadership report lower job stress, greater wellness activity participation, and healthier behavior.

Fourth, communities themselves can address the circumstances that lead to moral injury. Physician groups developed during COVID-19 to cultivate support for frontline health care workers. Much as the U.S. Army assigns to combatants “Battle Buddies” who have suffered similar traumas, health systems have paired clinicians with members of their clinical unit to promote a sense of purpose and hope.

Conclusion

Medicine is an extraordinary profession, and society should continue to encourage its compassionate and excellent students to become physicians. Medical training itself is a test of endurance and cultivates resilience. But it does no good for anyone to send young physicians into broken organizations. Health care leaders must restructure systems, despite the costs, and communities must unite to support frontline workers to ensure moral repair—and flourishing—for all.