What Is Moral Injury?
March 28, 2023
Moral injury can be described as “psychological harms we may experience at work when poor decisions are made, either by ourselves or those in leadership positions in high stakes situations, that contravene [violate or contradict] our moral code.”1
The term moral injury was coined by clinical psychiatrist Jonathan Shay2 and primarily studied in combat veterans. I believe it is an overlooked and often misunderstood factor that can also affect those working in the dispatch environment.
My favorite definition of moral injury is “an injury to the soul that results from having to make a choice, or a failure to make that right choice, that you can’t tolerate at a moral level within the ethical framework that comprises your conscience and with that, your self-identity.”3
Many of us chose to work within emergency services for moral reasons, and our jobs comprise a large part of our self-identity. When I joined the ambulance service in the height of the pandemic, I did so to help others in a time of uncertainty, and it began to comprise a large part of my self-identity.
How does moral Injury occur?
Our moral code is a set of beliefs about how the world should be—what’s right and what’s wrong. When this is violated strongly enough, we can expect it to affect us.
Moral injury can occur in three ways: an act of commission, an act of omission, or an act of betrayal (usually by those in a leadership position). This can be self-induced where we are disturbed by having violated our own morals or other-induced where we are disturbed by what we perceive as immoral acts committed by others.
It is important to note that moral Injuries occur along a spectrum.4 We could experience the same event, and some people won’t be much affected at all, some could experience short-term distress with no lasting impact, and some could develop a moral injury, which could then lead into a formal mental health disorder.
The effects of moral injury
Experiencing a moral injury can bring feelings of guilt, remorse, shame, and anger. It can lead to thoughts of self-criticism, feelings of unworthiness, thoughts of being unforgiveable, and feeling like you are permanently damaged.5 When a poor decision has been made, by ourselves or others, we start to ask “What does this say about me? Did I do enough?”
This can manifest in changes to sleep patterns and habits, isolation, compulsive behavior, and difficulty feeling empathetic or compassionate. Those who suffer moral injury can have a change in their behavior and become disengaged with the world around them. Morally injured people are vulnerable to PTSD, anxiety, depression, and suicidality. In a 2021 study, nearly half of intensive care staff reported symptoms of PTSD, severe depression, or anxiety due to moral injury.6
In the dispatch environment
How could we see moral injury at play in the dispatch environment?
Day to day, we are making decisions that affect our patients and the public. James Jeffrey wrote in a 2021 article posted on The Critic that “Healthcare workers are finding themselves in positions similar to combat medics on a battlefield—conducting triage to prioritize who gets treated and who doesn’t, in essence deciding who might live and who dies.”7
It has been suggested that moral injury may become the most significant injury for healthcare staff dealing with the Covid-19 pandemic.8
When triaging and deciding who gets what resource in the dispatch environment, especially in periods of high demand and resource scarcity, it can often feel as though we are making the least-worst decision. Not good decisions, but whatever is the least-worst decision at the time. This is rarely what we joined the service for or came to work to do.
Particularly during the height of the Covid-19 pandemic, we may have felt as though we were unable to provide the level of care we wanted to and may have felt a sense of betrayal toward those in leadership positions due to inaccurate information and poor planning.
How can we help?
A Greenberg, et al. article9 explains that following exposure to a challenging situation, one of the following outcomes can emerge: psychological growth or psychological and moral injury. The authors outline how supervisors and managers can provide valuable support to the workforce before, during and after a crisis, thereby reducing or avoiding the traumatic effects of the events experienced.10
This includes use of open and honest dialogue to prepare staff for the challenge ahead, encouraging emotional off-loading and self-disclosure of moral challenges, and making staff aware of what moral injury is. Active monitoring for early intervention opportunities is extremely important as well as appropriate support and referrals if necessary.
The American Psychiatric Association recommends putting systems in place like an anonymous hotline that empowers and encourages healthcare workers to speak freely about the stressors they face and advocate for their own health as well as that of their patients.11
Self-talk is also a key tool in enabling staff to positively reframe challenges. Encouraging reflection and opportunities for learning can help us develop our psychological resilience as opposed to increasing the potential for moral injury.
When we experience a situation in which we go against our better judgment and our moral code, we are undoubtedly going to feel negative about it. The best thing we can do is accept what has happened, try not to judge ourselves, and think about how we could do things differently next time and what we’ve learned about our values.12
Being able to discuss your experiences openly is another important part of preventing/reducing the effects of moral injury. Find someone you can talk to: a family member, friend, co-worker, faith leader, chaplain, psychiatrist, or counselor. It is often only in conversations with others that we hear different perspectives, which can help you consider something you hadn’t before and perhaps interpret a situation from a different perspective. It can be helpful to get support about feelings that come up when dealing with these complex moral situations.
As Ray Dalio, Founder and CIO Mentor of Bridgewater Associates, says, “Pain plus reflection equals progress.”13 If we can take something positive from a painful situation, then the pain has the potential to turn into something positive. We can use our experience to teach others, help more people, and develop a deeper sense of understanding and compassion.
- “Esther Murray (Part 1): How to Take Care of Yourself After a Moral Injury.” Anchor by Spotify. Pre-Hospital Care Podcast. 2019; June 17. https://podcasters.spotify.com/pod/show/medics-academy/episodes/S02E04-Esther-Murray-Part-1-How-to-Take-Care-of-Yourself-After-a-Moral-Injury-e4c390
- Shay J. “Moral injury.” Psychoanalytic Psychology. 2014. https://psycnet.apa.org/doiLanding?doi=10.1037%2Fa0036090
- Jeffrey J. “The moral injuries in store for NHS workers.” The Critic. 2021; Jan. 25. https://thecritic.co.uk/the-moral-injuries-in-store-for-nhs-workers/ (accessed Oct. 10, 2022).
- King’s College London. “The History of Moral Injury.” YouTube. 2020; Oct. 8. https://www.youtube.com/watch?v=QX8_QkNUoy8
- Launder A. “What Is Moral Injury & How Do You Deal With It?” The Awareness Centre. https://theawarenesscentre.com/moral-injury/
- Greenberg N, Weston D, Hall C, Caulfield T, Williamson V, Fong K. “Mental health of staff working in intensive care during Covid-19.” Occupational Medicine. 2021; March. https://doi.org/10.1093/occmed/kqaa220
- See note 3.
- Shale S. “Moral injury and the COVID-19 pandemic: reframing what it is, who it affects and how care leaders can manage it.” BMJ Leader. 2020; July. https://bmjleader.bmj.com/content/4/4/224
- Greenberg N, Docherty, M, Gnanapragasam S, Wessely S. “Managing mental health challenges faced by healthcare workers during covid-19 pandemic.” British Medical Journal. 2020; March 26. https://wellbeinghub.scot/wp-content/uploads/2020/05/Greenberg-et-al-2020-Managing-the-mental-health-challenges-faced-by-health-care-workers-during-the-covid-19-pandemic-2.pdf
- “Technical Advisory Group: moral Injury in health care workers during the COVID-19 pandemic.” Welsh Government. 2021; Aug. 3. https://www.gov.wales/technical-advisory-group-moral-injury-health-care-workers-during-covid-19-pandemic-html (accessed March 9, 2023).
- Prepared by the APA Committee on the Psychiatric Dimensions of Disaster and COVID-19. “MORAL INJURY DURING THE COVID-19 PANDEMIC.” American Psychiatric Association. 2020. https://www.psychiatry.org/file%20library/psychiatrists/apa-guidance-covid-19-moral-injury.Pdf
- El-Moselhi S. “This Is Why You Are Tired: MORAL FATIGUE and 5 Ways to Handle It.” Healthy Business Builder. 2021; Sept. 1. https://healthybusinessbuilder.com.au/?s=moral+fatigue
- Dalio R. “Life Principle: Pain + Reflection = Progress.” Principles. https://www.principles.com/principles/4a903526-2db6-4a0a-9b71-889868f0f475/ (accessed March 9, 2023).