Presented by: Dr Joanna Taylor
The language of moral distress and moral injury has been introduced to this context to articulate something more specific than the idea of burnout. Terminology emerging from nursing literature and adapted from military trauma research includes the useful concepts of moral dilemmas, moral distress, and moral injury.
Moral Dilemmas:
Expected, difficult part of clinical practice
Training must include best-practice approaches (incl. e.g. ethics consults, team discussions, supervision).
Moral Distress:
Occurs when an individual knows the right thing to do, but institutional or other constraints make it difficult to do what is right.
Each episode of moral distress is either resolved with sufficient processing, or leaves moral residue.
Moral residue is the unresolved emotional and psychological conflicts that make subsequent incidents less tolerable.
Moral injury is defined by Litz et al as “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations”.
In health care, the beliefs and expectations include the oaths individual HCWs took to provide the best care possible for patients and to make a patient’s needs the first priority.
While stretched and increasingly “managed” health care systems globally are a breeding ground for moral distress and injury, the COVID 19 pandemic magnifies the pressures in a number of ways.
Rationing is something that can be in the category of a moral dilemma and if well-managed does not have to result in undue residue and injury, although there may well be some distress. South African HCWs are very familiar with rationing and know that it can contribute to sound clinical decision-making. But if protocols aren’t clear, support is not in place, and systems are overwhelmed, the pressures on individuals to make and convey rationing decisions will lead to moral injury.
Moral injury is not a mental illness, but experiences of potentially morally injurious events (PMIEs) can lead to negative thoughts about oneself or others and deep feelings of shame, guilt, or disgust, which in turn can contribute to the development of mental health problems including depression, PTSD, and anxiety.
Factors that increase the risk of moral injury include the loss of life of a vulnerable person, if leaders are perceived not to take responsibility for the event/s and are unsupportive of staff, if staff feel unaware or unprepared for emotional/psychological consequences of decisions, if PMIE occurs concurrently with other traumatic events, e.g. death of a loved one, and if there is a lack of social support following the PMIE.
The following factors are relevant to supportive and preventative measures:
• Preparation: preparing psychologically for the impact of PMIEs is helpful
• Seeking informal/peer support early on is protective
• Confidential professional support must be available, and help-seeking encouraged
• Clinicians should be made aware that individuals who develop moral injury-related mental health disorders are often reticent to speak about guilt or shame and may instead choose to focus on more classically traumatic elements of their presentation. Therefore sensitive enquiries about PMIEs are advisable
• If the shame/guilt is missed, Greenberg says, and the “if people knew what I was really like, I’m a monster” thought gets planted and not addressed, it dooms future treatment. Bear in mind the prevailing hero discourse.
The last thing that I think we should really emphasize is the idea of each unit or smallish hospital having responsive and available ethics committees. I am really seeing this in practice now – when the ethics support systems work it takes a huge burden off individuals. The system needs to adapt to these circumstances so that decision-making assistance is readily available. Using retired experienced clinicians or clinicians in isolation for this purpose should still be strongly encouraged.
References
Dean, W., Talbot, S. G., & Caplan, A. (2020). Clarifying the Language of Clinician Distress. JAMA, 10.1001/jama.2019.21576. Advance online publication. https://doi.org/10.1001/jama.2019.21576
Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009; 29(8):695-706. doi:10.1016/j.cpr.2009.07.003
Williamson, V., Murphy, D., & Greenberg, N. (2020). COVID-19 and experiences of moral injury in front-line key workers. Occupational Medicine, 70(5), 317-319. doi: 10.1093/occmed/
Yeterian, J.D., et al., Defining and Measuring Moral Injury: Rationale, Design, and Preliminary Findings From the moral Injury Outcome Scale Consortium. Journal of Traumatic Stress, 2019. 32(3): p. 363-372.
Williamson, V., Murphy, D., & Greenberg, N. (2020). COVID-19 and experiences of moral injury in front-line key workers. Occupational Medicine, 70(5), 317-319. doi: 10.1093/occmed
Greenberg, N., (2020 April 21). Managing Traumatic Stress: Evidence-Based Guidance for Organizational Leaders [Webinar]. The Schwartz Center for Compassionate Healthcare
Shay, J. (2014) Moral Injury. Psychoanalytic Psychology, 31(2), 182-191.
Phoenix Australia – Centre for Posttraumatic Mental Health and the Canadian Centre of Excellence – PTSD (2020) Moral Stress Amongst Healthcare Workers During COVID-19: A Guide to Moral Injury. Phoenix Australia – Centre for Posttraumatic Mental Health and the Canadian Centre of Excellence – PTSD. ISBN online: 978-0-646-82024-8.
Sun, N., et al., A Qualitative Study on the Psychological Experience of Caregivers of COVID-19 Patients. American Journal of Infection Control, 2020.