What Is Moral Injury In Healthcare Workers?

Moral injury is common among healthcare workers. It is what happens when your conscience registers a violation. Something happened that is anathema to your core. Perhaps something you did; or didn’t do; or saw but didn’t stop; that goes against your personal values and morals. Moral injury lands in the nervous system differently than the physiological stress response following your body identifying a potential threat to your safety and survival.  

Where does the term come from? 

In short, moral injury was originally coined by Shay in 1994; the term was related to the experience of combat veterans. He related it to the injury to veterans’ psyches when they returned home from war holding onto the experiences of things they saw or did in action. In 2009 Litz and colleagues proposed a psychological model and treatment approach. In 2018 Talbot and Dean extended the frame to medicine and brought into the mainstream moral injury in healthcare and the systemic issues that perpetuate its frequency. A 2022 Journal of General Internal Medicine study reported that 46.1% of post-9/11 combat veterans and 50.7% of healthcare workers endorsed potential moral injury. 

How does it commonly show up among healthcare workers? 

Have you ever had to ration care because you are short staffed; giving patients enough time to assess their risk of imminent mortality but not to address the five other questions they would ask their PCP if they had one, or could get an appointment in the next six months? Or having to choose who gets seen first and who gets access to limited resources. The literature suggests that the symptoms of moral injury often include guilt, shame, loss of trust, withdrawal, or loss of meaning. These may result from an incident you witnessed but did not intervene in because of policy, or a call you had no standing to question.  

How does moral injury differ from burnout and PTSD? 

• Burnout occurs when demand outpaces limited resources. It can respond to rest, and the World Health Organization classifies it as an occupational phenomenon.  

• PTSD as described in the DSM-5 and ICD-11 follows an identifiable traumatic event and confluence of symptoms including intrusive symptoms, avoidance symptoms, mood symptoms, and changes in arousal, that have been occurring for at least a month and impairing functioning.  

• Moral injury does not have a diagnosis code and is a response to a conscience-based injury.  

Is there treatment for moral injury? 

As of the time of this writing, there is no validated protocol specific to moral injury. In practice, what is currently utilized are trauma-focused approaches and cognitive approaches to work on moral repair and reducing isolation.  

Therapy for Moral Injury 

I am a licensed independent clinical social worker who has spent 14 years in the field and over ten years in emergency rooms and hospital settings. I utilize evidence-based trauma protocols including EMDR, ART, and somatic techniques. Nothing has to be disclosed to book a free consult or get in touch  

References

Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, Maguen S. “Moral injury and moral repair in war veterans: A preliminary model and intervention strategy.” Clinical Psychology Review. 2009;29(8):695–706. 

Nieuwsma JA, O’Brien EC, Xu H, Smigelsky MA, VISN 6 MIRECC Workgroup, HERO Research Program, Meador KG. “Patterns of Potential Moral Injury in Post-9/11 Combat Veterans and COVID-19 Healthcare Workers.” Journal of General Internal Medicine. 2022;37(8):2033–2040. 

Shay J. “Moral Injury.” Psychoanalytic Psychology. 2014;31(2):182–191. 

Talbot SG, Dean W. “Physicians aren’t ‘burning out.’ They’re suffering from moral injury.” STAT, July 26, 2018.