Empowering Caregivers to Recognize Moral Injury in Others

As healthcare workers struggle with demands that are contradictory to their training, stress levels can rise as they face morally challenging dilemmas. Recognition of the concept known as “moral injury” is increasing, and the need to address the problem is growing more urgent. Healthcare workers and leaders are wondering how to help their colleagues, and they all are seeking guidance.

Moral injury is a relatively new term in healthcare, which was first used to describe soldiers’ responses to their actions in war. In the context of healthcare, moral injury represents “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Use of the term has increased in recent years and especially now during the COVID-19 pandemic, because the concept accurately captures the dilemma caregivers face when being unable to provide high-quality care and healing.

Research into moral injury is now illuminating how such injuries can impact people across all walks of life, but especially first responders and healthcare workers facing the COVID-19 pandemic.

It’s worth noting that moral injury differs from employee burnout—a term commonly used in healthcare, characterized by feelings of sadness, irritability, and exhaustion. While clinician burnout has been linked to factors such as excessive workload, staffing ratios, and frustration over inefficient work processes, moral injury speaks to an emotional dilemma with a healthcare worker’s inability to perform their job in alignment with their values, despite how much they want to.

Moral Injury During the COVID-19 Pandemic

While moral injury is not a new concept, the COVID-19 pandemic has placed extreme pressure on the healthcare workforce and, in many settings, has meant that healthcare workers are confronted daily with morally challenging dilemmas. Recent articles in both the New England Journal of Medicine and JAMA describe sources of moral injury associated with the pandemic, such as fears of:

• Not being able to protect oneself.
• Not being able to protect patients.
• Causing potential harm to one’s family because of insufficient supplies of personal protective equipment.
• Not being able to provide quality care to every severely ill patient.
• Taking on roles for which one feels inadequately trained.

Supporting Those Experiencing Moral Injury

Today, with the country depending on the healthcare workforce like never before, it is vital for leaders to consider the burdens placed on front-line clinicians. Moral injury is an extremely complex concept, making it difficult for organizations to provide quick solutions, especially during the COVID-19 pandemic.

As a relatively new topic in healthcare, education and training specific to moral injury may not be readily available, leaving those affected by it feeling isolated and even more distressed. By first empowering healthcare workers to help recognize moral injury in others, organizations can more effectively address this growing problem.

Looking Out for One Another

While we’ve often heard that medicine is a team sport, it rings especially true in today’s healthcare industry. As caregivers work to improve cross-functional communication and performance, an inherent sense of teamwork and solidarity is also created—particularly helpful during times of crisis. For those experiencing moral injury, having support from those also on the front lines can make all the difference. Healthcare organizations can help encourage and empower caregivers to recognize moral injury in others through:

1. Education

As a first step, leaders should introduce or review the concept of moral injury with their teams. This conversation could start as part of a huddle, but might also warrant a larger forum for discussion as well. Leaders should stress the importance of being mindful of moral injury in others during the discussion.

2. Resources

Letting caregivers know that resources are not only available, but easily accessible, is key. Resources on tips for self-care (articles, tip sheets, webinars) or crisis hotlines (both national and organizational) provide help and support 24/7, both at home and in the workplace. If a healthcare worker notices that a team member is affected by moral injury but is unsure what to say or how to help, simply being able to remind a colleague about existing resources can be greatly beneficial.

3. Support

As unprecedented times call for unprecedented measures, leaders should support caregivers trying to help their team members in new (perhaps unconventional) ways. For example, a caregiver might help arrange transportation as an alternative to public transportation to ease fears of exposure and transmission. Having leadership’s support to help make these types of solutions possible can encourage caregivers to adopt a “no problem is too small” mentality and speak up for those that might be struggling, but unwilling to voice their distress.

4. Communication

Some healthcare systems have adopted the “battle buddy” system—a partnership between two caregivers committing to regular, ongoing communication. As a system popularized by the U.S. Army, this approach helps foster a connection and encouragement to support the safety and wellbeing of those on the front lines during times of crisis.

5. Appreciation

Practicing self-care is difficult enough to manage during a crisis and often leaves little energy for looking out for others’ well-being, as much as caregivers might want to. When someone takes the time to speak up for or act in the interest of someone else on their team, it shouldn’t go unnoticed. Managers and leaders should make a solid effort to show their appreciation, perhaps through meaningful recognition. Programs such as The DAISY Foundation empower organizations to recognize nurses, shown to fight nurse burnout and improve nurse morale.

A Support System Is Essential

As Johns Hopkins Medicine advises, it is absolutely essential that caregivers have and use a support system. Especially for those on the COVID-19 front lines, support from team members also experiencing distressing factors can reduce feelings of isolation and despair.

Care teams are trained to provide patient care, but they should also be cognizant of the team’s overall health—paying special mind to those affected by high-stress situations. By empowering caregivers to recognize moral injury in others, organizations can help shed light on a relatively new topic in today’s healthcare industry and make a strong effort to help those it affects.