Moral Injury: What is it?

Moral Injury has been studied in soldiers and military personnel, but it’s only since COVID-19 that research had started to include healthcare professionals. Because of its recent emergence in healthcare, moral injury remains ill-defined in healthcare context. 

Despite the differences of definition, moral injury is often characterized by guilt, existential crisis, and loss of the trust that develops from either witnessing or participating in a perceived moral violation, whether it be by themselves other others.  

The risk of moral injury is increased when there is a loss of life to a vulnerable person such as children, women, or elderly. The risk also increases when staff feel unaware or unprepared for consequences of decisions made by either themselves or another, when the morally injurious event happens at the same as they’re exposed to other traumatic events, or there’s a lack of social support following the morally injurious event.  

Differences in Moral Injury and Moral Distress

Moral injury and moral distress may sound alike, but there are key differences that separate them.  

Moral distress happens when an organization or powerful individual prevents another individual from acting according to their morals. Whereas moral injury is internal moral conflict being raised by both traumatic events and the immorality of a situation. 

Both result in psychological consequences such as guilt, blaming others, self-blaming, anguish and powerlessness, leading to functional impairment. Moral distress can turn into moral injury when left untreated. 

Differences in Moral Injury and PTSD

Post Traumatic Stress Disorder (PTSD) is a mental disorder and moral injury is not, however the two overlap. While morally injurious events may contribute to PTSD, the events themselves do not cause PTSD. The combination of PTSD and moral injury increase the risk of suicidal thoughts and behaviors. 

PTSD symptoms include exaggerated startle response, trauma-related memory impairment, flashbacks, nightmares, and insomnia. Conversely, moral injury symptoms include guilt, shame, anger, anhedonia, and social withdrawal. Moral injury may also contribute to PTSD symptoms. 

The Effect of Covid-19 and Moral Injury

Prior to the COVID-19 pandemic, moral injury was primarily studied in military personnel and veterans. The pandemic shed light on the challenging working conditions and the long-lasting impacts on healthcare workers. Since then, moral injury has become an emerging topic in healthcare. 

One study that focused primarily on moral injury in healthcare workers during the pandemic ran between September and December of 2020 found that around half of the study’s participants felt perceived transgression by others and betrayal. More than 60% of those surveyed reported symptoms of anxiety, depression, and/or PTSD which aligned with moral injury and exposure to COVID-19. This study concluded that the lingering effect of COVID-19 resembles that of a traumatic event.  

How Moral Injury Affects Healthcare Professionals

Core symptoms of moral injury are identified as guilt, shame, spiritual/existential conflict, and loss of trust. The core symptoms come from their own perceived transgressions against others, which may also perpetuate a belief that they’re unlovable, and aid in developing difficulty with forgiveness towards themselves and others.  

Secondary symptoms include depression, anxiety, self-harm, and social problems. 

Other behaviors that have commonly been associated with moral injury such as withdrawal, rumination, substance abuse and self-harm, all prevent the reappraisal of negative cognitions and processing of the trauma memory. 

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Moral injury can also stir up deep emotional wounds, blaming others and self, as well as feelings of powerlessness.  

An Overview of Moral Injurious Effects: 

  • PTSD  
  • Self-Harm  
  • Substance Abuse  
  • Feelings of Powerlessness  
  • Depression  
  • Anxiety  
  • Suicidal Ideation  
  • Guilt  
  • Shame  
  • Social problems  

Burnout 

There was found to be a significant association between higher levels of burnout and stronger moral injury. Although burnout and moral injury often occur concurrently more research needs to be done to say whether moral injury leads to burnout. 

Moral Injury Solutions

Finding solutions that work for medical professionals so that they can both be unburdened by morally injurious events, and able to do their job without the effects that come with that event is important. Although the study of moral injury in medical professionals has begun relatively recently, a few different strategies have been studied on military personnel that may work on healthcare works.  

Self-compassion 

Self-compassion plays a preventative role in morally injurious events. It was found that people high in self-compassion experienced fewer negative mental health symptoms, such as PTSD, depression, and self-harm, than those with lower self-compassion.  

Cognitive Therapy 

Cognitive therapy currently used for PTSD may be able treat Moral Injury by identifying and changing the individual’s perspective. Moving forward and healing from moral injury involves making amends, reparation, commemoration, or forgiveness. 

Forgiveness 

Forgiveness includes accepting responsibility for their actions, cultivating self-compassion, making amends where they’re able to, and reconstructing their moral identity. This path of forgiveness enables people to re-engage with their life, have fulfilling relationships. 

Self-forgiveness helps combat the effects of moral injury mentioned in the previous section such as lower levels of anxiety, suicidality, and problematic substance use.  

Boost Awareness 

Providing education on moral injury as well as opportunities for screenings could contribute to increased awareness of this term, allowing workers to feel less alone and encourage them to access resources available to them.  

Peer-led interventions 

Current research shows the importance of workplace team connection. Co-workers, especially in healthcare, share similar experiences. There’s a desire to be understood. 

Moral injury, characterized by guilt and loss of trust from witnessing or participating in perceived moral violations, continues to be a growing concern in healthcare. COVID-19 has only exacerbated moral injury, and we are still feeling its lingering effects. Continued research is needed to shed light on this emerging topic in healthcare.