What is moral injury?

Aug 22

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Nurse Empowerment Coach Christen talks about moral injury in nursing, moral injury in healthcare, and what being morally injured means

During COVID, we had one ICU bed left in the hospital. A hospice patient comes through the ED and the ED doc wants to admit them. The bedside nurse comes to me because the patient is crumping.

I offer to coordinate a phone call between the ED doc and the family, but he declines letting me know “the doctor upstairs will handle it.”

Honestly, I didn’t know if the patient was going to make it upstairs.

I call the admitting doctor who now refuses to accept the patient since they need to be in ICU. The ER doctor now has to call the family.

Does he tell them the patient is actively dying? Is he honest about the situation?

Here’s what I overhear:

“She’s doing okay, we want her to stay the night in ICU. She’ll turn around with some antibiotics and a bag of fluid.”

If I could’ve screamed, I would’ve. There are no hospital beds. We’re in the middle of a global pandemic.

You’re taking away this family’s chance at seeing their loved one before they pass. What if a critical patient comes in and needs that bed?

There was nothing I could do.

The patient was admitted and the ICU was pissed. The intensivist had to break the news to the family and coordinate with hospice, which is what I was trying to do from the ED.

It was in that moment that I knew my time in this ED was limited. I had no respect for the laziness and lying that came from this doctor time and time again with no accountability.

It went against my own personal morals and ethics.

What is Moral Injury?

If you’ve ever served in the military or know someone who has, you’ve likely heard this term before. However, moral injury in the workplace for civilians, especially in healthcare, has grown in popularity.

The truth is, moral injury can happen anytime, whether you’re in the military, at work, or at home.

Moral injury is simply defined as the impact on an individual after watching or doing something that goes against their morals or beliefs.

Becoming morally injured can also happen after witnessing a traumatic event or feeling like you should’ve done something but didn’t.

Syracuse University defines moral injury as:

“the damage done to one’s conscience or moral compass when that individual perpetrates, witnesses, or fails to prevent acts that transgress one’s own moral beliefs, values, or ethical codes of conduct.”

Nurses are usually in a position of following orders, whether they agree with them or not. It makes sense moral injury in nursing is becoming more and more well known.

The Veteran’s Administration (VA) does a lot of work around moral injury as well since military personnel are also expected to follow orders…without question.

The VA defines moral injury as traumatic or unusually stressful circumstances where people commit, fail to prevent, or witness events that contract deeply held moral beliefs and expectations.

Dr. Norman and Dr. Maguen even give examples of when moral injury can occur:

If someone does something that goes against their beliefs
When someone fails to do something aligning with their beliefs
In a distressing event that can trigger psychological, behavioral, social, and spiritual aftermath
As a response to acting or witnessing behaviors that go against someone’s morals and values.

Although moral injury isn’t a mental health diagnosis, it can contribute to things like PTSD and/or burnout.

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Moral Injury: Healthcare

Moral Injury: Healthcare

What is moral injury in health care?

Moral injury in healthcare became well-known a couple years ago, ever since Z-Dogg started talking about it in his videos.

In fact, it’s gotten so popular that people have become offended to the word burnout and assume people still using the term “burnout” are ignorant.

The truth is, they’re both real problems that have the potential to influence one another.

Moral injury can actually contribute to an individual’s burnout.

You can even be morally injured and burned out at the same time.

However, they’re 2 separate issues so I put them in 2 separate blogs.

Fixmoralinjury.org is geared toward moral injury in the workplace. Their focus is on healthcare specifically and defines moral injury as a distinct form of distress in which the solution is improving the healthcare system.

The biggest difference between moral injury and burnout is:

Moral Injury lays blame on the healthcare system where some people feel the word burnout is shaming to an individual.

While I think we can all agree healthcare can use some improvements for sure, but just because you may be morally injured or burned out doesn’t mean it’s shameful.

In my opinion, both are occupational job hazards.

We need to improve the healthcare system to decrease moral injury while caring for ourselves and addressing burnout.

Making positive changes to healthcare won’t fully get rid of either but I imagine it’ll help.

Now you know what moral injury is, how would you know if you or someone you know is morally injured?

What would this look like?

Moral Injury Symptoms

Symptoms of moral injury are kind of tough because they aren’t always physical. You have to look at things like shame, guilt, and betrayal.

According to the VA, there are a couple questionnaires like the Moral Injury Questionnaire or the 9-item Moral Injury Events Scale for military personnel and the Trauma-Related Guilt Inventory and the Trauma Related Shame Inventory for civilians.

In my experience dealing with morally injurious events and even being morally injured at times, a common sign of moral injury is a feeling of betrayal.

Have you felt betrayed working in healthcare?

Have you been morally injured and/or burned out?

If you want to share your story or learn how coaching and breathwork can help you move forward, contact me here!

Moral Injury examples

As a doctor:

-Moral injury could be knowing your patient needs a lifesaving treatment, but you can’t help them because their insurance continues to deny it.

-Or as a doctor, maybe you know a colleague of yours should’ve done something however you keep the blinders on to protect the white coat society and it’s starting to eat you up inside.

As a nurse:

-You know someone wants to be a DNR because they’ve expressed it to you directly. Suddenly, the patient becomes unresponsive and their family wants everything done. The doctor makes the patient a full code and now you’re doing chest compressions. You feel a twinge of guilt every time you push down and feel their ribs cracking.

-You see a physician taking shortcuts or making questionable decisions on patient care. Maybe you speak up and you start getting the 3rd degree from management and HR. The doctor’s recollection of events aren’t quite what happened, but no one’s listening because you’re not the money maker. Now you’re dealing with unjust treatment on top of witnessing poor care. Unfortunately, you’re asked to leave.

Maybe you said nothing about the doctor’s questionable practice because you see what’s been done to others. Then, slowly but surely, it starts eating away at you.

Believe it or not, the 2nd nurse example I gave above about the doctor accused of poor care is a true story. I was on shift the day it happened.

That event set the tone for a grueling couple of months, people were unjustly let go, and a deep sense of betrayal was felt by many staff members.

It was incredibly morally injuring to me who witnessed it and to other nurses and clinicians if more directly impacted.

It was a very, very tough situation. Personally, this was the final straw at this job. It went against my own personal morals and values. I was able to take action, even if it was small, to say I can’t be part of this and applied for another job I eventually took.

So, how did I deal with being morally injured?

How do you help someone who’s morally injured?

Moral Injury Treatment

Moral Injury Treatment

Now that we know what moral injury is, how moral injury in healthcare is defined, and seen some examples of moral injury in nursing you’re likely asking: what can be done about it?

According to fixmoralinjury.org the first step is gathering information and bringing light to a very real problem. They’ve been working hard at this and I’m looking forward to seeing what solutions arise for the future.

The VA states approaches are still being tested but feel some treatments for PTSD may be helpful because it targets some components of moral injury.

There are new treatments being investigated which involve:

mindfulness
meditation
self-compassion
and even self-forgiveness in a group setting

Christen’s Bedside Nurse Survival System already contains many of these components in a small group setting in addition to a very powerful forgiveness process.

Some people dealing with moral injury may not be ready for coaching and need counseling.

Individuals that struggle with: survivor’s guilt, have suicidal thoughts/tendencies, extreme self-sabotaging behaviors, self-harm or addiction are just some examples that need a licensed therapist.

Coaching and counseling should not be competing entities, ideally they should complement one another.

Some of my clients have started out with counseling and when they were ready to move forward, started coaching with me. I myself have used both coaching and counseling services in the past and can attest to the positive, powerful experience of both.

For myself, healing my moral injury became easier when I was able to remove myself from a toxic situation. I felt that I had no power where I was, but I did have the power to not support the behavior.

I took another job with a hospital that better aligned with my values and ethics, which gave me some freedom to deal with what happened in a better environment.

Not everyone had that same luxury, some people were stayed at that same job for different reasons. If you’ve ever felt stuck somewhere, that doesn’t mean it’s hopeless and there’s nothing you can do!

You get to decide how much power over you a person or a situation has!

By combining breathwork and empowerment coaching, people in this situation are better able to heal and move forward even if they’re stuck where they are for the moment.

The worst thing you can do is either give up or to push it down, try to forget it, and hope it doesn’t happen again. It takes a brave person to navigate a tough situation and you don’t have to go through it alone.

I’ve been there, I know what it’s like and the best way to move forward.

If you’re struggling with moral injury or burnout, I’ve been there. I get it and I’ve got your back! Contact me here to learn if working with me is the right fit for you!