Moral Injury: What It Is and What We Can Do About It

By Stephanie Balint, Vytas Karalius, MD, Amanda Ritchie, MD, Cindy Bitter, MD, MA, MPH, Amy Kontrick, MD, Al’ai Alvarez, MD, and Amanda J. Deutsch, MD, MPH on behalf of the SAEM Wellness Committe

Moral injury as a term used to describe the psychological, emotional, and spiritual harm resulting from participating in or witnessing acts that violate one’s deeply held moral and ethical values.

For many of us, moral injury happens not infrequently while working in the emergency department (ED); however, moral injury is not synonymous with burnout. On February 7, 2023, the SAEM Wellness Committee sponsored a national webinar, Moral Injury: What It Is, What It's Not, and What We Can Do About It. The webinar explored how moral injury manifests at work, how it impacts us, and how we may act as individuals and institutions and start healing from it. Healing requires that we name and recognize moral injury.

Participant engagement during the webinar allowed us to learn more about the extent of impact moral injury has in our practice. It was empowering and disheartening to hear and see reverberations of experiences shared throughout the hour. We also learned collective strategies to combat moral injury.

Strategies to Combat Moral Injury

While searching the PubMed database for “moral injury” yields 578 results, adding “mitigation” narrows the results to five. Despite limited data, our webinar showed that everyone understood and had experienced a moral injury. Here are some ways webinar participants described moral injury:

“When we don’t intervene in a situation when we know we should, we feel guilty.”

“When we struggle with the duty to maintain standard of care when it may not be in line with our beliefs.”

“When what we are asked to do conflicts our personal ideology or values or ethics.”

“Not delivering care as we know we could.”

“Doing what feels wrong.”

“Accumulation of moral distress, betraying myself to do something else for others.”

Beyond sharing our collective experiences of moral injury, we also learned about barriers to addressing it.

Barriers to Addressing Moral Injury

First, everyone has unique needs; therefore, no strategy works for everyone. Risk factors, protective factors, and the context and environment within which a person experiences moral injury add to the variability. It does not help that the emergency department is considered a VUCA environment, with a constant flux of volatility, uncertainty, complexity, and ambiguity.

In a field where we bolster decisions with evidence and science, it is challenging when no robust scientific data addresses a relatively ubiquitous experience of moral injury among physicians. (see figure 2)

Individual Strategies

Drs. Wendy Dean and Simon Talbot, founders of the Moral Injury of Healthcare organization, describe moral injury as “the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control.”

In their paper, they shared strategies they have observed in their careers. One suggestion is for physicians to form relationships with administrators to facilitate shadowing opportunities and workplace empathy.

“An administrator shadows a physician to get a unique perspective on their ED staff. This signals a commitment from leadership to offer support to its employees. I was drawn to this idea as it was a method I saw in practice. Seeing one of the administrators in the trenches with us was inspiring.”

The paper also suggests that physicians take part in political organizations. While it can be frustrating to witness the slow wheels of the political system without physician representatives at the table, the decisions are made without the voice of the day-to-day challenges emergency department physicians experience.

The webinar also highlighted the need for creating spaces to acknowledge and address moral injury, even on shift. For example, think back to when you were a trainee and felt you had no voice or power to make actionable changes. Do you remember that attendee who stood up for something with you and how that made you feel empowered and supported? As individuals, we can leverage our roles in health care and start modeling this behavior of advocacy and allyship. We can do so on every shift.

One colleague shared that it is not merely “delivering care as we know we could”; it is also navigating “the conflicts between the stated organizational mission and values and what actually happens in our day-to-day practice.”

This requires a level of vulnerability from attending physicians who are willing to share their challenges and acknowledge the compromises in their decision-making. For example, instead of simply continuing to chart on the patient while addressing your moral distress internally and alone, share with your nurses, residents, and medical students how that ethically “gray” case made you feel.

Chances are, that if you felt you somehow transgressed your own values, so did other team members. Sharing this experience may not only create a sense of community, but it may also spark continued on Page 56

Wellness

continued from Page 55 some creative solutions that lessen or even avoid the sense of betrayal that was experienced. Perhaps then everyone can go home feeling less guilty about decisions being made at work while managing an overcrowded waiting room, addressing the impacts of social determinants of health and other health care inequities, or simply compromising our own well-being at the expense of caring for our patients.

Organizational Strategies

In an overcrowded, resource-limited environment, the burden of addressing moral injury cannot rest on the backs of emergency physicians tasked with caring for patients who are presenting at their worst. Health care leaders have a critical role to play in protecting their teams. Ensuring that the organization's mission and values are aligned with the realities of the job is vital to reducing moral injury. As another participant shared, moral injury is “doing the ‘best we could,’ instead of doing the best.

Policies should support clinicians who do the right thing for patients, and resources, including technology, should be provided to help staff do their jobs. Transparency in decision-making and clear, consistent messaging may reduce moral injury.

Everyone wants to feel appreciated by their organizations. Beyond recognition for the work, this means having equitable policies on staffing ratios, scheduling flexibility, and staff redeployment. In other words, support means arming clinicians with necessary and appropriate resources and respecting them for their training and potential without expecting more than is reasonable.

Given the importance of community in reducing the impact of moral injury, leaders must continue to foster mutual respect and collaboration among teams. Initiatives like interdisciplinary ethics rounds and reflective debriefings are emerging as strategies for reducing moral distress, but more research is needed to determine the optimal use of these tools.

Where do we go from here?

To begin to heal as a specialty and as individuals, we must acknowledge and understand the impact of moral injury. Moral injury is not the same as burnout, but moral injury can lead to burnout. Moral injury is “what happens when you can’t do what you know is right.” Repeated instances of moral distress leads to moral injury, leaving a residue on us that accumulates over time.

Each of us has a role to play in addressing moral injury. It can start with knowing what is within and beyond our control. We can name the problem and work on creating solutions at the system level instead of simply applying ad hoc patches. As emergency physicians, we’ve learned to navigate uncertainty, making us more susceptible to just taking the emotional hit, compartmentalizing it, and seeing the next patient or showing up to our next shift. This is not sustainable. Together, we can learn better ways of tackling moral injury.

Join us in Austin at SAEM23 on Thursday, May 18, 2023, from 1:00 PM – 1:50 PM local time to explore more about the topic. In the meantime, check out our next Wellness Committee webinar, Beyond Burnout: Achieving Personal and Professional Fulfillment, April 11, at 1 p.m. CT.

About The Authors

Stephanie Balint is a secondyear, EM-bound medical student at Quinnipiac University, Hamden, Conn., Class of 2025. @stephfosterski1

Dr. Karalius is a clinical instructor in emergency medicine and a medical education scholarship fellow at Stanford Emergency Medicine. @vytaskaralius

Dr. Ritchie is a second-year internal medicine/emergency medicine resident at Louisiana State University, New Orleans.

Dr. Alvarez is director of wellbeing at Stanford Emergency Medicine and chair of the SAEM Wellness Committee. @alvarezzzy

Dr. Bitter is associate professor in the department of surgery, division of emergency medicine, at St. Louis University, Missouri.

Dr. Kontrick is associate professor of emergency medicine and medical education at Northwestern University Feinberg School of Medicine, Chicago.

Dr. Deutsch is a clinical instructor in emergency medicine and an emergency medicine wellness fellow at Stanford Emergency Medicine. @amandajdeutsch