Moral injury drains medical community, further imperils post-COVID-19 recovery
The pandemic shone a light on the limits of the health care system. But it also illuminated the distress that has long beleaguered doctors and nurses. Neither burnout nor post-traumatic stress disorder, this moral injury could undermine medicine’s efforts to bounce back after COVID-19.
“The public need to both understand and appreciate that our health system was not in a great place before COVID,” said Dr. Simon Talbot, a reconstructive plastic surgeon at Brigham and Women's Hospital in Boston.
Talbot described how health care’s profit motive inflicts a spiritual death-by-a-thousand-paper-cuts on its workers.
“We're tracked on how many operations get done a year or how many relative value units somebody generates in the clinic,” he said, referring to a measurement based on the cost of services that includes mental and physical effort, business expenses and professional liability.
Everyone’s had a bean-counting boss breathe down their neck. But for people whose work is rooted in their moral identity, cutting corners can feel like sectioning their soul.
“The treadmill has just started going faster. When that happens, we don't have time to connect with our patients; we don't have time to connect with each other,” said psychologist Wendy Dean. “We came into COVID in a crisis of distress, and COVID just made it impossible to look away.”
The distress experienced by people who felt they’d betrayed their oaths — in ways big and small, over and again — motivated Talbot and Dean to found Moral Injury of Healthcare, an advocacy, education and research group.
As their slogan says, “It’s not burnout.”
The term “burnout’ describes a mismatch between demands and resources, a state of chronic stress that leads to exhaustion, depersonalization and lack of accomplishment. Though some symptoms overlap, the causes of moral injury are different.
“Moral injury is a sense that, because of circumstances that are out of your control, you can't do what you know is right. So clinicians know what their patients need, but they can't get it for them,” said Dean.
Experts say burnout is often too widely applied and that people too often equate it with personal frailty.
“This is a situation where the demands have exceeded any human capacity to meet them. It's not a failure of the individual,” said Cynda Rushton, a professor of clinical ethics in the Berman Institute of Bioethics and the School of Nursing at Johns Hopkins University.
"This is a situation where the demands have exceeded any human capacity to meet them. It's not a failure of the individual."
— Cynda Rushton, Johns Hopkins University professor
Prior to the pandemic, paperwork, insurance or the need to keep the line moving left doctors and nurses feeling they’d somewhat shortchanged their patients.
Dean recalled how COVID-19 turned those skirmishes over scruples into a struggle for survival.
“Not enough beds; not enough PPE, at least early on; not enough staff to take care of patients to the standard by which we usually judge ourselves,” she said.
Rushton says the razor-thin margins that typify nurse staffing barely cut it before the pandemic.
“It barely works under less intense circumstances; but it is absolutely not sustainable, which is why the healthcare workforce is so exhausted,” she said.
As the pandemic hit, nurses had even less time to spend with patients, who were suffering and dying alone.
“Nurses will talk about the sort of residue from having to feel as if they weren't able to provide good care for any of their patients, because there were so many of them, and many of them were so sick,” said Rushton.
“The really worrisome consequence of that is moral injury begins to dismantle a person's sense of moral identity. ‘I don't know who I am anymore,’” she added.
Theater of operations
The concept of moral injury first gained traction among veterans. Things they’d seen and turned away from — done and not done — left spiritual wounds PTSD treatments could not heal.
But the same feelings of anger, disgust, guilt and shame can touch doctors and nurses who feel they can’t fulfil their oaths, though the details differ.
“You’re not exposed to it for a brief period of time, and rarely is it one single huge event that happens to you,” said Talbot. “It's coming to work and having to talk to patients about a diagnosis of cancer, but knowing you really don't have time to spend with them and process that with them because our system is designed around throughput.”
Dean described similar experiences.
“They can move from seeing a trauma patient in the ER and, as soon as they've seen that patient — and they have them stabilized or not — they move to the next room, which may have a child with an earache,” she said. “And you have to pull yourself together and leave all of the trauma behind to take care of that child the best day that you can.”
Those feelings deepen when doctors and nurses feel that doing their jobs means battling their own leaders and patients.
“The physical and often verbal abuse that many clinicians have experienced during this pandemic, I think, is just another layer of feeling as if our commitments and our goals have been corrupted in some way,” said Rushton.
Moral injury can feel like a betrayal of the self, of valued beliefs and of others’ trust.
“They’re constantly making these decisions and choices that are balancing the best thing for the patient with what's doable within the system. And that gets incredibly wearing after a while,” said Talbot.
Those affected can pin their perceived failures on circumstances, leaders or even an unjust world, but such reasons offer at best limited relief during an identity crisis.
“If I'm working in the system that constantly constrains my ability to get care for patients, can I still be the good person, the good doctor, the good clinician, that I think of myself as?” said Dean.
Training and therapy — and time to recuperate, if it ever comes — can provide space to process individual moral injury.
“We actually have an initiative here in Maryland, the Resilient Nurses Initiative, which is focusing on building capacity within nursing school faculty to cultivate these skills of what we would call self-stewardship and ethical practice from the first day of nursing school into practice,” said Rushton.
Dean says there’s never enough resources to go around, so such training is essential.
“The more we can help them imagine the scenarios that there'll be part of, the more we can help them rehearse their responses to it and help them understand the situations under which they may need to make difficult decisions, and who they can get to help them make those decisions,” she said.
But truly addressing the problem means digging out its deep systemic roots.
“In order to stop moral injury, we need to look at the systems that we've put in place: Who they serve, and how we can change them to better align the needs of the organization and the needs of the clinician and their patients,” said Dean.
For starters, it means no longer exploiting medicine’s culture of resilience.
“They keep telling me to be tougher. And I feel like what they're trying to say to me is, ‘Just get a better of flak jacket,’ when what they really should be doing is figuring out how not to have the bullets flying at me,” said Talbot, quoting a colleague.
Industrial complexes do not excel at the broad and rapid changes needed to address moral injury, but they may soon have to learn.
“I worry that once, the pandemic has really drawn down and people aren't feeling badly about leaving their colleagues in the lurch, more of them will start to separate earlier than they planned to originally,” said Dean. “I worry very much about what it means for the future of medicine.”
Whether a massive post-COVID-19 exodus collapses the increasingly skeletal medical workforce or the implosion is already underway, refilling the ranks will cost a pretty penny.
“There’s a study out of Stanford that showed that their excess staff costs over two years, due to what they referred to as burnout — and I think accurately did — were between $15 and $55 million,” said Talbot. “Well, if you extrapolate that across our entire healthcare workforce, you get a number which is in the tens of billions of dollars in excess staff turnover due to this kind of problem.”
As concerning as the workforce losses might be, Talbot also worries about those who remain.
“You've still got an awful lot of disengaged people, and I think that’s the potential tragedy that we've got coming down the track,” he said.
"You've still got an awful lot of disengaged people, and I think that’s the potential tragedy that we've got coming down the track."
— Dr. Simon Talbot, Brigham and Women's Hospital surgeon
Systemic remedies might include better communication and transparency; more doctors and nurses as leaders; and hours and staffing that encourage more patient- and self-care.
“It’s a financial driver, and that financial driver needs to be very seriously examined to see how it is actually contributing to the degraded workforce and the moral injury that clinicians are experiencing,” said Rushton.
Whatever happens, Rushton says the industry must begin by rebuilding empathy and trust.
“But to do it in a way that acknowledges the uncertainty and also acknowledges the consequences of those decisions on the people who have to implement them,” she said.
The pandemic reminded people of the need to care for those who care for them. It also revealed that even behemoths like healthcare can pivot swiftly when the need is dire. In those two simple facts lies hope for limiting moral injury — if leaders carry those lessons into the post-crisis world.
“We can no longer deny that we have got to think differently about our human resources as a scarce resource, and as a resource that is essential for the sustainability of our healthcare system,” said Rushton.