How Moral Injury Affects Our Healthcare Workers

Our healthcare workforce is grappling with an invisible wound rarely discussed but deeply felt: moral injury. The term is defined as the strong cognitive and emotional response that can occur following events that violate a person's moral or ethical code or when they feel betrayed by authority figures. It should be distinguished from the term "burnout," which is often used to describe the effects of ongoing stress in the workplace, but the two conditions can overlap. While moral injury is not officially classified as a mental illness, it is associated with post-traumatic stress disorder, depression, social isolation, and suicidality and should be treated seriously.

In the healthcare context, moral injury can arise from a variety of sources, such as witnessing excessive patient suffering, enduring staffing shortages or health insurance barriers that lead to a poorer quality of patient care, feeling compelled to prioritize patient care over personal safety or rationing care and personal protective equipment during crisis situations.

The impact of moral injury on our healthcare workers is alarming. Physicians, for instance, have one of the highest suicide rates of any profession, with an estimated 119 physicians dying by suicide every year in the U.S. The stigma associated with disclosing mental health issues among healthcare professionals, coupled with fears about potential repercussions on their licensure or career, often deters them from seeking help.

In one survey, around 1 in 15 surgeons cited recent suicidal thoughts, but more than 60 percent were deterred from seeking out mental health care because of concerns that it might affect their license. Physicians face intense levels of scrutiny when disclosing any form of mental health treatment to state licensing boards. Many physicians have also cited concerns about potential discrimination during hospital credentialing and repercussions related to personal and liability insurance if they disclose a mental health diagnosis.

A recent article in the Journal of Pediatric Rehabilitation Medicine called for systematic action to address the stressors in the U.S. healthcare system that are beyond the control of physicians. These include revenue generation, administrative issues surrounding the electronic medical record (EMR), patient satisfaction metrics, and health insurance barriers.

We need to implement systemic changes that reduce burdens on our healthcare workers. This could involve adjusting healthcare system expectations, reducing the administrative burden associated with electronic medical records, and ensuring that health insurance policies do not interfere with physician decision-making.

In addition to these systematic changes, we must also provide healthcare workers with the resources they need to cope with moral injury. This could involve establishing anonymous hotlines that empower healthcare workers to speak freely about their stressors or providing training on suicide prevention and behavioral health. The Lorna Breen Act, which provides funding for such training, is a step in the right direction.

We also need to advocate for legislative changes that protect the mental health of our healthcare workers. This could involve amending licensure applications to focus on a clinician’s ability to function rather than their mental health history, or implementing policies that protect healthcare workers who seek mental health care from discrimination.

By fostering a culture of openness, implementing systemic changes, providing resources, and advocating for legislative changes, we can help our healthcare workers continue to provide the care that our society so desperately needs.