Rita Brock, director of the Shay Moral Injury Institute at Volunteers of America, recently spoke to Vision editor David Lewellen about moral injury in healthcare, particularly after two-plus years of the coronavirus pandemic. The following is a slightly condensed version of their conversation.
Q: Can we start with some definitions?
A: Sure. There are three levels of moral conflict. Moral discomfort is when you do something wrong and it bothers you and you do something to correct it. It doesn’t disrupt your entire life. Moral distress is a different level of severity, sometimes it can’t be fixed, and maybe you’re not sleeping well or avoiding certain things, suffering from low-grade depression. So it has to be addressed. Moral injury can occur for multiple reasons. It can be accumulated moral distress, happening over and over, and finally you break, go into an identity crisis. Or there’s one catastrophic experience, where you inflict harm or fail to prevent it. It especially afflicts people who have a life purpose that’s serving others. Those people can be especially susceptible to moral injury.
Q: And what about healthcare workers, particularly in the last two years?
A: There’s been almost a firestorm in the media of reports of moral injury in healthcare workers under the weight of the pandemic, when your job is to save people or help them die and there isn’t time to do that and everything feels out of control. I have a friend who was a battlefield surgeon in Vietnam, and when the pandemic hit, we had a conversation about how doctors would face battlefield conditions and they aren’t trained to triage. And even if you are trained, it’s not easy. You have to shut down any capacity for empathy and move on.
Q: How are chaplains coping with it?
A: In the course that we offer, chaplains report that their load of counseling staff has more than doubled. It puts an extra load on them to sustain staff in work they’re doing, but also the chaplain is often the person who has time to help somebody die, setting up the phone calls with family during isolation and those sorts of things. One chaplain told us she’d been doing that for nine months, almost without a break, and questioning if she could continue. The group validated her experience and affirmed the courage it took for her to go work every day. Moral injury is not an easy thing to talk about. You wind up talking about things you believe people are judging you for, or you’re already judging yourself for. Breaking down that barrier is the first step, because it’s not going to go away. Two years in, people may cope by drinking or drugs. Overwork may become a habit because it keeps them from having to look at what they’re going through
Q: It sounds like just identifying the problem is an important step
A: Naming moral injury can be quite a gift. The psychologist Wendy Dean and the surgeon Simon Talbot wrote an article in 2018 about “Stop calling it burnout, it’s moral injury.” And that was before the pandemic; they were talking about managed care and bureaucracy. But burnout makes it sound like it’s the individual’s problem. Then the pandemic hit, and everyone was talking about it.
Q: You’ve mentioned doctors, but I hear a lot more from chaplains about the struggles of nurses.
A: Yes, nurses are squeezed in middle management, between patients and doctors. Cynda Hylton Rushton has done a lot of work about it. Of course the pandemic made it worse, but even before that, half of nurses were considering leaving, and that has increased. Nurses are the frontline workers, and they’ve taken a huge hit. We do a training program for a healthcare system that would routinely lose half of their nurse trainees in the first year. After the Omicron surge, they decided to build our training into the work schedule as paid time. It’s always optional – you can’t require these things – but usage dramatically increased.
Q: How do you run a session about moral injury?
A: Because it’s so difficult to talk about, we give people a chance to calm down, to use mindful breathing and guided meditation to talk about the space they’re in and what they’re experiencing. Having a group of people who can relate and validate and believe them is a really important step. We have materials on self-care and journaling and ways they can sustain that processing. We use trained facilitators in small groups, and for our eight-hour class, that’s the first three hours. When people are more aware of what they themselves are carrying and what others are, they feel a lot less incompetent. Then we do the content delivery, and it makes more sense to people.
Q: Chaplains have to recognize and try to treat moral injury, but are they suffering it themselves?
A: A lot of chaplains have compassion fatigue. They’re emotionally worn out and feel like they’re not a good chaplain anymore because they haven’t replenished that. Or they may have mishandled something because a person was a different religion or culture and they didn’t know what to do in that particular case.
Q: What else have I forgotten to ask you?
A: Well, sometimes patients are suffering from moral injury. If someone is toxically angry or withdrawn, sometimes just mentioning moral injury will help people get a handle on what they’re feeling. Often if people are angry, they’re feeling betrayed by someone or by the system. A while ago I was at a table of Vietnam veterans for an Honor Flight banquet, and I mentioned moral injury and described it, and one of the men said, “I’m being treated for PTSD, but that’s what I have.” It gave him a sense of control to have a word for it.
