"Moral Injury": an Internal Alarm System for Helping Professionals

For teachers, doctors, nurses, clinicians, and other helping professionals - don't let others tell you this is just "burnout" and write you off.

Photo by K. Mitch Hodge on Unsplash

For the last 2+ years of this pandemic, particularly after the first few months of confusion and shock from the initial lockdowns in 2019 and early 2020 had just begun to wane (and it became clear that the “two weeks to slow the spread” stuff was - as it turns out - merely a ruse to extend things interminably to where we are now), I recall dealing with an ongoing problem at my work.

Initially, it was easy to write off as the accumulation of stress from dealing with ongoing crises. Staying on top of constant screening / temperature checks in my residents and the periodic need to rapid test everyone (staff and residents) every time yet another person tests positive for COVID, symptomatic or not. Dealing with irate family members - *don’t they understand that this is the rules*? I’m sympathetic, but I’m also aghast that they don’t realize that these guidelines are set by Medicare and the CDC - and we are required to follow them.

Despite all of this, and despite our generally very-adherent staff and strict COVID protocols - still having periodic (two significant ones at this point) outbreaks at our facility, which have resulted in a small handful of deaths from COVID amongst our population - and yes, in case you’re wondering, these deaths were concentrated amongst the extremely debilitated residents at our facility. All had severe dementia, average age was just under 90 years old.

We still have not issued a single day pass for our residents. Outside visitations from family or friends are strictly controlled with PPE & and social distance being mandatory. Congregate dining - the three-times-per-day ritual of getting all of our residents together so the ladies and men can socialize, eat together (which as we all know tends to encourage greater food intake - which is always good in older adults) - that’s been gone for almost three years now. Volunteers are essentially nonexistent. They haven’t seen the faces of staff for nearly three years now. Our nursing home is not really much of a home now to be honest.

It’s hard because despite all of these COVID precautions, we’ve had outbreaks anyways. Sure, I can go to work knowing me and my nurses won’t get sued for negligence or malpractice, given our strict adherence to COVID protocols. Great! But why do I continue to feel anxious, distressed, “burned out” - like work just doesn’t feel good to me anymore? Am I working too hard? I mean - I’ve been at this for almost two decades now. I have a lot of support at work and if anything, I’ve learned how to work smarter and not harder. Is it pay? No - I’m paid well for my job. Is it my colleagues? I *like* my colleagues.

Recently I was privvy to a discussion amongst some of my colleagues on a national listserv and I found them discussing COVID protocols and the effects it’s had on clinicians, themselves, in enforcing them. For the first time in a long time, I heard the term “moral injury” and something just clicked. That’s it. That’s what I’ve been feeling.

What is “Moral Injury”?

From the VA’s National Center for PTSD:

Moral injury can occur when someone engages in, fails to prevent, or witnesses acts that conflict with their values or beliefs. Examples of events that may lead to moral injury include:

• Having to make decisions that affect the survival of others or where all options will lead to a negative outcome

• Doing something that goes against your beliefs (referred to as an act of commission)

• Failing to do something in line with your beliefs (referred to as an act of omission)

• Witnessing or learning about such an act

• Experiencing betrayal by trusted others

This article in particular is a somewhat interesting read, although it suffers unfortunately from a lot of the issues that seem to plague most of the discussions about moral injury in healthcare workers during COVID: either it focuses on the element of “staying safe” (e.g., managing a healthcare workers personal concern about themselves or their family getting infected - honestly never a huge issue for me), the concerns about triaging or prioritizing care or resources, or simply just nonspecifically notes concern about vicarious trauma in healthcare workers in the context of COVID.

Similarly there’s this article from the Department of Health & Human Services, where it speaks of “Potentially Morally Injurious Events” in the context of the COVID pandemic:

Since moral injury results from participation in or observation of action(s) that challenge one’s core values, risk can be characterized in terms of such potentially morally injurious events (PMIEs). Events that place healthcare workers at risk may include the following:

• Loss of a vulnerable person (e.g., an elder or child)

• Situations where death may have been the result of insufficient resources or staffing, particularly when these issues are perceived to have been preventable

• Having to save one patient over another due to limited equipment or resources

• Following clinical instructions that the worker feels are immoral

• Issuing directions that result in the death of a patient

… interestingly, it’s almost as if “moral injury” as per healthcare workers and COVID is simply about guilt over losing a patient, or guilt over prioritizing care, or a product of worry about infecting your family or whatnot. This is possibly because a lot of these articles were generated 12-18 months ago (the HHS article was 2020).

But - I also suspect that there simply has been no room in the public conversation for “moral injury” as a result of feeling like you’re being, well, basically a warden or jailer - or that the things you’re doing are genuinely harming the well-being of your patients (like nonstop masking, or restricting family visits).

Moral Injury in other Fields due to ongoing COVID Restrictions

It’s not just geriatricians. I’m hearing lots of really pained reports from a variety of fields. Obviously my fellow nurses. But also:

Speech and language therapists. (AKA Speech Language Pathologists, or SLP for short), particularly those who work with children. Think about it - you’re working with children struggling with in some cases serious language problems. It’s extremely important that the SLP is able to see the mouth of the child move as they attempt to articulate words, and also for the child to see that of the therapist’s.

In many cases, as far as I am aware, SLPs and their patients are *still* required to mask in session due to COVID rules. How crazy is that?

Sure - it’s one thing if you, as an SLP, are requiring that of your patients mask because of your anxiety about infection (patients can, after all, seek services elsewhere). But it’s another entirely if, say, a healthy SLP and their client, possibly an entirely physically healthy child who needs intensive help with, say, a lisp, or a stutter, or some other issue - and both are required d/t masking rules to cover their faces. I can only imagine what that feels like for SLPs - it must feel horrible, at times fraudulent, and at best just wasting your and the child’s time.

Schoolteachers and school staff. If you’ve followed Twitter posts from Randi Weingarten over the pandemic, you’d get the picture that public schoolteachers, as a group, consider themselves a high-risk group by virtue of their profession - and the school shutdowns that extended for some school districts into even this year (2022) along with the mask mandates and other measures certainly reinforce that notion.¹

However, there’s any number of schoolteachers, particularly those that have become increasingly aware of the severe cost of extended school closures and imposition of “hybrid” school schemes that probably have the same sinking, horrible feeling that I’ve had over the last year or so… that the cost of these “mitigations,” mandated masking, etc. - has exceeded (and in the case of schoolkids, likely far exceeded) the benefits.

Police officers. I’m including this group because “I was only following orders” only goes so far. While some police have been likely unconflicted about the bizarre and autocratic orders they’ve had to enforce (e.g., mask mandates, business closures, etc.) - I’m sure that so-called moral injury, or just plain guilt - has plagued any number of them given the damage lockdowns have clearly done to society.

Listen to your internal alarm system. It’s not “burnout” - It’s your gut telling you something.

So, again, I’m really glad I now have a name for what has been plaguing me. It’s not “burnout.” It’s moral injury. I’ve been asked to provide care that goes against a lot of basic principles I have as a geriatrician, which have so often been about balancing people’s self-defined best interests, providing comfort and maintaining well-being against the interests in life extension and the promise of cure. Instead of that balance I’ve been asked to prioritize COVID avoidance over everything else. What normal person wouldn’t feel this way?

1. Obviously, I’m not even going to talk about the shrinking fringe group of people that think COVID is anything but a minor illness for the overwhelming majority of schoolchildren that catch it.