Earn CME For Learning About Moral Injury

Earn CME

for learning about moral injury

By ROBERT P. LENNON, MD, JD, FAAFP; BRENDA M. WILSON, MS, CHCP; and PHILIP G. DAY, PHD

Moral injury happens when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs.1,2 Recognized in combatants for thousands of years,2 in 2018 Drs. Wendy Dean and Simon Talbot were the first to suggest that physicians may experience moral injury as a function of practicing medicine.1,3 Moral injury is a particular risk to uniformed healthcare workers as a function of their military medical service and the professional obligation to maintain “usual level of medical care” in the absence of adequate supplies in a military setting.4,5

After a year of mostly academic debate, moral injury as a source of clinician distress received formal recognition from the National Academy of Medicine and the National Academies of Sciences, Engineering, and Medicine. In their landmark 2019 consensus report on clinician burnout,6 they identify clinician burnout as a major problem impacting clinicians and their patients, calling for immediate action, including research into factors that contribute to burnout.6 The report identifies “moral distress” as one contributing factor, and mentions “moral injury” in this context.6 While moral distress has been studied, especially in nurses,7 since the 1980s, relatively little research had been done to describe, define, and understand moral injury in healthcare workers. A year later, Dr. Sneha Mantri and colleagues published the first validated moral injury inventory for medical professionals.8 They found that moral injury had a lower prevalence than burnout, but had a greater negative impact.9 Now that moral injury has moved from a theoretical construct to a documented hazard of the medical profession, it is important for physicians to understand the practical outcome differences between moral injury and burnout. (For a detailed comparison of moral injury, burnout, and moral distress, see Day et al.’s, “Physician moral injury in the context of moral, ethical and legal codes.”)10

Burnout is a syndrome with three components: exhaustion, inefficacy, and cynicism/ depersonalization.11 It describes the physical, emotional, and intellectual exhaustion that occurs in the face of unrelenting stressors and a pathological response to the stressors in one’s work environment, and is linked to alcohol and other substance abuse, broken relationships, suicidal ideation, increased medical errors, and diminished quality of patient care.11 Most institutional remedies for burnout focus on increasing resiliency.11

Moral injury is the harm one suffers upon violation (as a result of their own or others’ actions) of one’s moral boundaries.12 Moral injury is associated with substance abuse, suicidal ideations and attempts, dysphoria, anhedonia, sociopathy, guilt and shame.12 In clinical practice, “Moral injury describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control.”3 We experience a moral injury when we are unable to adhere to our oaths to provide care (a core moral value) because of external contraints (e.g., unwieldly electronic medical records or insurance restrictions).

Comparing moral injury and burnout during the COVID-19 pandemic highlights the differences between these contructs. Mantri et al. found that during the first six months of COVID-19, physicians experienced no change in burnout, but an increase in moral injury.13 This is expected from the definitions above – the pandemic came with marked external constraints on care (e.g., lack of personal protective equipment)14, increasing moral injury, but over a short time (not long enough for burnout).

These differences have a practical impact on practicing physicians experiencing distress. While those suffering distress from burnout may benefit from burnout treatments like resiliency or work-hours reduction,11 those

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suffering from moral injury will not. In fact, resiliency training may increase harm among those suffering from moral injury.15 In combat veterans, healing moral injury has been described through reconnecting the injured with the moral network. Since much of veteran moral injury occurs in combat, this treatment occurs where there is not ongoing injury.16 Hence, this treatment may be less effective among healthcare workers. Dr. Brett Litz and colleagues have developed “Adaptive Disclosure” therapy to treat moral injury, but to date this has been studied only in those with Post Traumatic Stress Disorder.17

A better understanding of moral injury empowers physicians to recognize it in themselves and colleagues, and avoid improper labels and treatments. To facilitate this, we worked with the Division of Academic Innovation at the University of North Texas Health Science Center at Fort Worth to create an online education module, “Differentiating Moral Injury, Moral Distress and Burnout.” The module is built around a compelling narrative by Dr. Tyson Garfield describing events in his professional life that led to significant distress. These events are reviewed through the lenses of burnout and moral injury, giving learners a clear understanding of similarities and differences in these constructs. Successful completion of the module earns continuing education credit for physicians, nurses, pharmacists (and others!). To earn credit, users must register and take brief pre- and post-assessments.

References

1. Dean W, Talbot S, Dean A. Reframing Clinician Distress: Moral Injury Not Burnout. Fed Pract. 2019;36(9):400-02. 2. Litz BT, Kerig PK. Introduction to the Special Issue on Moral Injury: Conceptual Challenges, Methodological Issues, and Clinical Applications. J Trauma Stress. 2019;32(3):341-49. doi: 10.1002/jts.22405 [published Online First: 2019/06/05] 3. Talbot S, Dean W. Physicians aren't 'burning out.' They're suffering from moral injury. Statnewscom, 2018. 4. Baker MS, Armfield F. Preventing post-traumatic stress disorders in military medical personnel. Mil Med. 1996;161(5):262-4. [published Online First: 1996/05/01] 5. Hooft FB. Legal framework versus moral framework: military physicians and nurses coping with practical and ethical dilemmas. J R Army Med Corps. 2019;165(4):279-81. doi: 10.1136/jramc-2018-001137 [published Online First: 2019/03/25] 6. Committee on Systems Approaches to Improve Patient Care by Supporting Clinician W-B, National Academies of Sciences E, Medicine, et al. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being: National Academies Press 2019. 7. Jameton A. Nursing practice : the ethical issues. Englewood Cliffs, N.J: Prentice-Hall 1984. 8. Mantri S, Lawson JM, Wang Z, Koenig HG. Identifying Moral Injury in Healthcare Professionals: The Moral Injury Symptom Scale-HP. Journal of religion and health. 2020;59(5):2323-40. doi: 10.1007/ s10943-020-01065-w 9. Mantri S, Lawson JM, Wang Z, Koenig HG. Prevalence and Predictors of Moral Injury Symptoms in Health Care Professionals. The journal of nervous and mental disease. 2020;209(3):174-80. doi: 10.1097/ NMD.0000000000001277 10. Day P, Lawson J, Mantri S, Jain A, Rabaga D, Lennon R. Physician moral injury in the context of moral, ethical and legal codes. Journal of Medical Ethics. 2021:medethics-2021-107225. doi: 10.1136/ medethics-2021-107225 11. Maslach C, Leiter MP. New insights into burnout and health care: Strategies for improving civility and alleviating burnout. Medical teacher. 2017;39(2):160-63. doi: 10.1080/0142159X.2016.1248918 12. Callaway KL, Spates CR. Moral Injury in Military Members and Veterans: Oxford University Press, 2016. 13. Mantri S, Song YK, Lawson JM, Berger EJ, Koenig HG. Moral Injury and Burnout in Health Care Professionals During the COVID-19 Pandemic. The journal of nervous and mental disease. 2021;Publish Ahead of Print doi: 10.1097/NMD.0000000000001367 14. Williamson V, Murphy D, Phelps A, Forbes D, Greenberg N. Moral injury: the effect on mental health and implications for treatment. Lancet Psychiatry. 2021;8(6):453-55. doi: 10.1016/s2215-0366(21)00113-9 [published Online First: 2021/03/21] 15. Card AJ. Physician Burnout: Resilience Training is Only Part of the Solution. Ann Fam Med. 2018;16(3):267-70. doi: 10.1370/afm.2223 [published Online First: 2018/05/16] 16. Meador KG, Nieuwsma JA. Moral Injury: Contextualized Care. J Med Humanit. 2018;39(1):93-99. doi: 10.1007/s10912-017-9480-2 [published Online First: 2017/10/14] 17. Litz BT, Rusowicz-Orazem L, Doros G, et al. Adaptive disclosure, a combat-specific PTSD treatment, versus cognitive-processing therapy, in deployed marines and sailors: A randomized controlled non-inferiority trial. Psychiatry Research 2021;297:113761. doi: https://doi.org/10.1016/j. psychres.2021.113761

There is no cost to register, use the module,,or receive credit.,The module can be accessed here:

https://unthsc.rievent.com/a/OVIAMY