Moral Injury Research Articles

Moral Suffering in Frontline Social Care Workers: A Study of Moral Injury and Moral Distress

Introduction: Moral suffering (MS) is psycho-emotional harm derived from a conflict between one’s circumstances and one’s deeply held moral values. It includes the constructs of moral distress (MD) and moral injury (MI) and is characterized by constraints or mandates preventing the perceived morally correct event. Evidence has demonstrated the application of MS in helping professions, and research has linked MS to a deterioration of mental health, self-identity, worldview, and job-performance. Aims: In this study, we examined the relationship between MD, MI, burnout, and external/internal constraints in Frontline Social Care Workers (FSCWs) in the UK. Methods: We employed a quantitative, cross-sectional correlational design, recruiting 119 FSCWs (female = 91.6%, tenure 1–2 years = 27.4%) using convenience sampling. Participants completed an online survey including the Moral Injury Events Scale and the Copenhagen Burnout Inventory. Measures for MD, external constraints (stress, time, and resources), and internal constraints (psychological safety and preparedness) were informed by previous research. Results: Participants reported a significant prevalence of moderate-to-high MD (25.4%), MI (33.3%), and burnout (64.9%), and we found significant relationships between the constructs and dimensions. Constraints were significant predictors of MS (explaining 35.3% of MD variance and 30.1% of MI variance), with stress, time, and psychological safety making the strongest contributions. Conclusions: FSCWs can be examined as a unitary population experiencing morally challenging circumstances that may result in MS and burnout. Improved MS measures, increased awareness, and policy shifts are necessary to redefine the paradigm of work-related distress, taking systemic constraints and the potential for moral harm into account.

Burnout and Moral Injury Among Black Psychiatrists and Other Black Mental Health Professionals.

This column discusses burnout and moral injury among Black psychiatrists and other Black mental health professionals and highlights the contribution of racism to these outcomes. In the United States, the COVID-19 pandemic and racial turmoil have revealed stark inequities in health care and social justice, and demand for mental health services has increased. To meet the mental health needs of communities, racism must be recognized as a factor in burnout and moral injury. The authors offer preventive strategies to support the mental health, well-being, and longevity of Black mental health professionals.

Long-term impact of COVID-19 pandemic: Moral tensions, distress, and injuries of healthcare workers.

Given the longevity of the COVID-19 pandemic, it is important to address the perceptions and experiences associated with the progression of the pandemic. This narrative can inform future strategies aimed at mitigating moral distress, injury, and chronic stress that restores resilience and well-being of HCWs. In this context, a longitudinal survey design was undertaken to explore how health care workers are experiencing the COVID-19 pandemic over time. A qualitative design was employed to analyze the open ended survey responses using a thematic analysis approach. All physicians and staff at an academic health science centre in Toronto, Ontario, Canada were invited to participate in the survey. The majority of survey respondents were nurses and physicians, followed by researchers/scientists, administrative assistants, laboratory technicians, managers, social workers, occupational therapists, administrators, clerks and medical imaging technologists. The inductive analysis revealed three themes that contributed to moral tensions and injury: 1) experiencing stress and distress with staffing shortages, increased patient care needs, and visitor restrictions; 2) feeling devalued and invisible due to lack of support and inequities; and 3) polarizing anti- and pro-public health measures and incivility. Study findings highlight the spectrum, magnitude, and severity of the emotional, psychological, and physical stress leading to moral injury experienced by the healthcare workforce. Our findings also point to continued, renewed, and new efforts in enhancing both individual and collective moral resilience to mitigate current and prevent future moral tensions and injury.

Beyond Burnout: Nurses’ Perspectives on Chronic Suffering During and After the COVID-19 Pandemic

Nurses around the globe have been impacted psychologically and emotionally during and after the COVID-19 pandemic. The purpose of this study was to describe nurses’ perspectives on the concepts of compassion fatigue, second victimhood, burnout, and moral injury. Eight nurses were interviewed either individually or in groups of two. Data were analyzed using conventional content analysis. The following themes were identified: waves of compassion fatigue, traumatization within second victimhood, never the same after chronic burnout, moral injury: nurses couldn’t do their best, and connections across concepts. Results showed nurses were most familiar with burnout and compassion fatigue, which remain chronic struggles. Second victimhood and moral injury were more distinct experiences related to traumatic or morally distressing events and likely contributed to experiencing burnout or compassion fatigue. Nurses’ suffering heightened during the COVID-19 pandemic and remains prominent three years later. Future research and interventions are urgently needed globally to reduce workplace stressors and promote nurse well-being.

Getting Ours? "Girlbossing" and the Ethics of Nurse Reimbursement Models.

This article politicizes a reimbursement model proposed by some professional nursing associations that aim to better align the price of nursing labor (nurses' pay) to the value of nursing and make nurses' contributions more visible. Using the concept of "missing care," the critique reveals how professionalization directs attention to individual-level interactions between care seekers and practitioners while obscuring from view the harm inflicted by social institutions and structures constitutive of a capitalist political economy and the related carceral state. Direct reimbursement models render practitioners complicit in the harms perpetrated and perpetuated by the health care industrial complex while professionalization processes are deployed to reduce cognitive dissonance (and moral injury) produced by combining harm with nursing's normative principles. We describe and trace the complementary capitalist imperatives of extraction-based profit maximization and efficiency through the health care industrial complex to demonstrate how formative those imperatives are of the health care system, care-seekers' outcomes, nurses' experiences, nonconsensual modes of data collection, and surveillance. The naturalization of racial capitalism and the precarity and violence it entails foreclose the creation of ethical alternatives that prioritize well-being instead of the pursuit of profit that could bring the provision of and payment for care closer to the normative principles held by practitioners.

Statelessness as Moral Injury

Statelessness as Moral Injury

Physician Burnout: Evidence-Based Roadmaps to Prioritizing and Supporting Personal Wellbeing.

Current literature validates the magnitude of physician burnout as a complex challenge affecting physicians, patients, and healthcare delivery that mandates science-informed intervention. Physician burnout affects both individual practitioners and patient care delivery. Interventions, defined as roadmaps, to prioritizing and supporting personal wellbeing encompass organizational, individual, and moral injury, with virtually no consensus on optimal approaches. The purpose of this conceptual review is to present evidence-based innovative insights on contributing factors, mitigation, and designing adaptive systems to combat and prevent burnout. Science-informed policy initiatives that support long-term organizational changes endorsed by both leadership and institutional stakeholders are keys to sustaining personal wellbeing and ending burnout.

Amoral Actions and Relational Knowledge

Amoral actions are actions outside of the moral domain. To establish a way of understanding amoral actions, I will draw upon Dale Dorsey’s agency view which, in sum, maintains that an agent must have a reason to perform an action and be able to perform the action in question based upon that reason. Dorsey focuses upon both cognitive and circumstantial limitations to establish the fact that moral agents can (and do) perform amoral actions. In this paper, however, I will focus upon a kind of deficiency of knowledge that is imparted socially. Some actions of persons suffering from autism seem to fall into the category of amoral actions that I have in mind but, so too, would some actions of persons who suffer from a moral injury. In sum, I aim to expand upon the category of amoral actions among moral agents.

Bioethics and Burnout: Unpacking the Relationship

Canadian healthcare systems are facing unprecedented challenges in recruiting and retaining workers. Literature on healthcare burnout and professional exit suggest multiple intersecting causes. Understaffing, residual trauma, compassion fatigue, demanding hours, rigid hierarchies, and moral distress, interlock and compound to create and sustain the current burnout crisis. In the face of this frightening reality, healthcare institutions and governments are investing billions in wellness programs, aimed at attracting new workers and incentivizing staff retention. Amid this rapidly evolving landscape, our workshop asked: Does clinical ethics have a role in addressing the ongoing burnout crisis? If, as the research suggests, moral distress and moral injury are key drivers of the burnout problem, should bioethics be part of the “wellness” solution?

Advocacy in a Collapsing Public Healthcare Sector

Abstract The last 15 years have seen a decline in public health services with poor performance and outcomes while the disease burden has increased. Many South African healthcare workers, whilst working in the public sector, are increasingly exposed to deteriorating conditions in which they work and are often witnesses to poor practices and suboptimal treatment. A feeling of futility adds to the burden of moral injury caused by these circumstances. South Africa has a tradition of muzzling healthcare workers who speak up and expose any malpractice, but this should not deter us from performing due diligence on our patients’ care. We need to find innovative ways of documenting and reporting health delivery deficiencies, holding people to account, and if the issues are not addressed, following them up with protected disclosure to an appropriate authority.

How do professional connections and relationships impact midwives' well-being and career sustainability? A Grounded Theory study protocol.

Significant attrition and projected workforce shortages within the midwifery profession are global issues. Extensive research has identified that high levels of workplace adversity, chronic stress, and increasing rates of vicarious trauma and moral injury experienced by midwives, underpin this situation. Researchers have explored midwives' intention to stay in the midwifery workforce and identified ways to support students' transition to professional practice. Supportive collegial relationships have been reported to be protective for new and early career midwives' well-being and resilience. However, there is a gap in knowledge and understanding of the impact and significance of professional connections and relationships for midwives across their careers. This article describes a protocol for a study designed to explore and understand how professional connections and relationships impact midwives' well-being and career sustainability. Glaserian Grounded Theory (GT) methodology will be used to conduct the study. Constant comparison will be used to analyze data collected from in-depth interviews with midwives at various stages in their professional careers, with the aim of understanding the significance of professional connections and relationships on their well-being and career sustainability, and in understanding the potential protections and benefits. It is anticipated that the findings and theory generated from this study will have national and international implications and provide evidence about the impacts, including benefits and any potential disadvantages, of professional relationships in sustaining midwifery careers. This will be of significant value to, as well as inform, the development of midwife retention strategies.

A Case of Moral Injury in Global Context: Francisco Cantú’s Memoir, The Line Becomes a River: Dispatches from the Border

A Case of Moral Injury in Global Context: Francisco Cantú’s Memoir, The Line Becomes a River: Dispatches from the Border

The Moderating Role of Moral Injury on the Neurocircuitry of Trauma-Related Dysfunction

The Moderating Role of Moral Injury on the Neurocircuitry of Trauma-Related Dysfunction

Moral Injury Among Transplant Providers: Evaluating the Effects of Training in End-of-Life Counseling.

Ethical issues are pervasive in healthcare, but few specialties rival the moral complexity of transplant medicine. Transplant providers must regularly inform patients that they are no longer eligible to receive a potentially life-saving operation and the stress of these conversations poses a high risk of moral injury. Training in end-of-life counseling (EOLC) has proven to significantly reduce provider stress and burnout. The purpose of this study was to determine whether training in EOLC reduces levels of moral injury among transplant providers. This was a mixed methods study. We interviewed 10 patient participants and administered a survey to staff in the solid organ transplant department at the University of Kansas Health System. Respondents indicated whether they had received training in EOLC and completed the standardized Moral Injury Symptom Scale-Healthcare Professionals version (MISS-HP). A two-sample, one-sided t-test compared levels of moral injury between trained and untrained staff. Subsequently, we conducted semi-structured interviews with transplant providers, then performed inductive coding followed by thematic network analysis. Thirty-seven percent (14/38) of respondents reported a moral injury score at or above the threshold for psychosocial dysfunction associated with moral injury. Analysis revealed no difference in moral injury scores between the trained and untrained groups (p = 0.362, power (1-β) = 0.842). Thematic network analysis demonstrated high-level themes of "challenges", "training", and "stress relief". Our study demonstrated a concerning prevalence of moral injury among transplant staff and suggested that EOLC training did not significantly mitigate the threat of moral injury.

Viewing Moral Injury Through a Lens of Attachment Theory & Relational-Cultural Theory

ABSTRACT This article argues for viewing moral injury as an attachment injury. We show how Relational-Cultural Theory may be applied to treat and research moral injury. We broaden the construct of moral injury, make moral injury more culturally responsive, and outline how treatment for moral injury may be improved. The paper includes a case study to illustrate how Relational-Cultural Theory may be utilized to treat moral injury.

Moral injury and the four pillars of bioethics.

Healthcare providers experience moral injury when their internal ethics are violated. The routine and direct exposure to ethical violations makes clinicians vulnerable to harm. The fundamental ethics in health care typically fall into the four broad categories of patient autonomy, beneficence, nonmaleficence, and social justice. Patients have a moral right to determine their own goals of medical care, that is, they have autonomy. When this principle is violated, moral injury occurs. Beneficence is the desire to help people, so when the delivery of proper medical care is obstructed for any reason, moral injury is the result. Nonmaleficence, meaning do no harm, has been a primary principle of medical ethics throughout recorded history. Yet today, even the most advanced and safest medical treatments are associated with unavoidable, harmful side effects. When an inevitable side effect occurs, the patient is harmed, and the clinician is also at risk of moral injury. Social injustice results when patients experience suboptimal treatment due to their race, gender, religion, or other demographic variables. While minor ethical dilemmas and violations routinely occur in medical care and cannot be eliminated, clinicians can decrease the prevalence of a significant moral injury by advocating for the ethical treatment of patients, not only at the bedside but also by addressing the ethics of political influence, governmental mandates, and administrative burdens on the delivery of optimal medical care. Although clinicians can strengthen their resistance to moral injury by deepening their own spiritual foundation, that is not enough. Improvements in the ethics of the entire healthcare system are necessary to improve medical care and decrease moral injury.

The Serious World of Cis

Drawing on Simone de Beauvoir’s account of “the serious world” and her considerations of childhood in The Ethics of Ambiguity and The Second Sex, this paper considers how the formal and social legislation of cis gender by adults forecloses the moral freedom of children. More specifically, Beauvoir’s account of becoming is read as a claim about how the serious world works. It is argued that her description of becoming in Volume II of The Second Sex shows us how gender is fastened to and enforced in lived experience by adults in order to produce and maintain an unethical social order, namely the serious world of cis. Through this reading of Beauvoir, this article accounts for the moral injury of contemporary anti-trans legislation that targets children and advances preliminary remarks on gender freedom as necessary to moral freedom.

Reintegration and Anamnesis: Theological Tools for Wartime Harms

War is a complex phenomenon, which both results from and produces intersecting forces of power, trauma and reaction. This paper uses the story of Cain and Abel, found in Genesis 4, to open up the exploration of two particular harms which war causes: the silencing of victims and the moral injury of combatants and civilians. Scripture provides tools for helping to heal these harms. In place of silence, the Old Testament offers the outcry, the inarticulate cry of the afflicted which rises to heaven and causes God to come down to investigate and respond. For the soul-wound of moral injury, Scripture offers rituals of confession and lament, and preeminently, re-integration, which is not only the healing of communities but of fractured souls. Both of these are found at the Lord’s Table, where the outcry of the groaning world is held in the wounded heart of the Saviour, and where communities and souls find their healing through the Cross.

Inside the ‘imperfect mosaic’: Minority ethnic women’s qualitative experiences of race and ethnicity during pregnancy, childbirth, and maternity care in the United Kingdom

BackgroundPersistent, high rates of maternal mortality amongst ethnic minorities is one of the UK’s starkest examples of racial disparity. With greater risks of adverse outcomes during maternity care, ethnic minority women are subjected to embedded, structural and systemic discrimination throughout the healthcare service.MethodsFourteen semi-structured interviews were undertaken with minority ethnic women who had recent experience of UK maternity care. Data pertaining to ethnicity and race were subject to iterative, inductive coding, and constant comparison through Grounded Theory Analysis to test a previously established theory: The ‘Imperfect Mosaic’.Analysis & findingsA related theory emerged, comprising four themes: ‘Stopping Short of Agentic Birth’; ‘Silenced and Stigmatised through Tick-Box Care’; ‘Anticipating Discrimination and the Need for Advocacy’; and ‘Navigating Cultural Differences’. The new theory: Inside the ‘Imperfect Mosaic’, demonstrates experiences of those who received maternity care which directly mirrors experiences of those who provide care, as seen in the previous theory we set-out to test. However, the current theory is based on more traditional and familiar notions of racial discrimination, rather than the nuanced, subtleties of socio-demographic-based micro-aggressions experienced by healthcare professionals.ConclusionsOur findings suggest the need for the following actions: Prioritisation of bodily autonomy and agency in perinatal physical and mental healthcare; expand awareness of social and cultural issues (i.e., moral injury; cultural safety) within the NHS; and undertake diversity training and support, and follow-up of translation of the training into practice, across (maternal) health services.

Remote Warfare with Intimate Consequences: Psychological Stress in Service Member and Veteran Remotely-Piloted Aircraft (RPA) Personnel

The use of remote piloted aircraft (RPAs) has been a part of military operations for decades and this type of service can present its own unique constellation of combat experiences and psychological consequences. The RPA crewmember experience has typically involved surveillance, targeting, striking, and after-battle assessments of individuals of interest to a host country or agency from a distance that can span several thousand miles. These operators are engaged in physically remote activities that carry a significant degree of intimacy due to the live, high-resolution, high-fidelity images and sounds that are available to the combatants in real-time. The potential psychological consequences of this type of military occupational specialty can include the symptoms of depression, anxiety, and posttraumatic stress disorder (PTSD) as well as moral injury, mental exhaustion or burnout, and disturbed sleep. The following narrative review examines the current state of RPA warfare from a psychological trauma perspective with an emphasis on the evolution of the inherent technology, the operator force, the psychological experiences and consequences of this type of service, and potential preventative interventions for servicemembers. A key objective of this narrative review is to integrate the available peer-reviewed empirical data, experiential military perspectives and analyses, clinician observations from this unique population, and exemplar reports from those with lived experience on an RPA crew regarding psychological consequences of this military occupational specialty.