PTSD: National Center for PTSD

Moral Injury in Health Care Workers

Patricia Watson, PhD, Sonya B. Norman, PhD, Shira Maguen, PhD, Jessica Hamblen, PhD

Moral injury can occur when someone engages in, fails to prevent, or witnesses acts that conflict with their values or beliefs. Examples of events that may lead to moral injury include:

• Having to make decisions that affect the survival of others or where all options will lead to a negative outcome
• Doing something that goes against your beliefs (referred to as an act of commission)
• Failing to do something in line with your beliefs (referred to as an act of omission)
• Witnessing or learning about such an act
• Experiencing betrayal by trusted others

Such potentially morally injurious experiences may lead to feelings of moral distress such as guilt, shame, and anger. Moral injury is the lasting psychological, spiritual, behavioral or social impact that may result from these experiences.

Potential Sources of Moral Injury in Health Care Workers

Most health care workers typically do not experience significant distress from difficult situations at work because of their training and preparation, health care cultural norms, messages and behavior of peers and leaders and acceptance by families and the culture at large. However, health care workers are sometimes faced with unfamiliar and potentially highly distressing work experiences where they have to make difficult decisions that may contradict deeply held beliefs. They may have to prioritize one important set of values (such as caring for patients with contagious diseases) over another (such as keeping family members safe from infection). Moral injury may also happen when health care workers are called to work in extremely difficult circumstances, such as in the context of disasters, humanitarian crises, combat deployments or pandemics.

Moral injury in health care workers can result from a variety of sources. Although health care workers are prepared to see patients suffer or even die, witnessing a great deal more suffering and death than what is normally expected may create moral distress. On the battlefield, in large scale disasters and during pandemics, health care workers may be faced with situations where they need to decide who to treat first, which patients receive limited resources and how to best use limited time when multiple patients need help. Health care workers may find themselves in situations where they do not have the right tools or training to save the person in front them.

Moral injury may develop when a health care worker needs to care for someone while experiencing life threat themselves, such as in combat, a disaster or during a pandemic. During pandemics, some health care workers may feel like they must choose between caring for infectious patients and keeping their families safe, especially if they have elderly or at-risk family members or children in their lives. Moral injury can also develop in health care workers when they are present for end of life scenarios that are counter to their beliefs about how people should die, such as patients dying without loved ones present. Some workers may feel guilt and shame because they felt numb in the face of suffering and death. On rare occasions, health care workers may witness what they perceive to be unjustifiable or unfair acts or policies that they feel powerless to confront.

Potential Impacts of Moral Injury

Feelings resulting from morally injurious experiences can include guilt if the person feels remorse about these experiences (e.g., "I did something bad"); shame if the person blames themselves because of a perceived personal inadequacy and flaw (e.g., "I am bad."); and distress, withdrawal or self-blame. If time passes without reflection, intervention, or peer and leader feedback, a person may have an increasing sense of being unforgiveable and irreparably flawed. A person who experiences betrayal may also feel anger, resentment, and/or diminished confidence in leaders or the organization.

Morally injurious experiences, and the resulting guilt, shame or anger, may contribute to stress reactions such as changes in sleep, significant and persistent negative changes in behavior or habits, mistakes, isolation, compulsive behavior (e.g., overworking, overeating), and a weakened sense of empathy or compassion. Situations that cause moral injury are sometimes traumatic events that can also lead to symptoms of PTSD in addition to moral injury. These may include intrusive memories, avoidance of people or places, changes in mood or ways of seeing the world and trouble concentrating.

Long-term negative consequences of exposure to morally injurious events are not inevitable. Although exact data is not available, it is likely that most health care workers who experience morally injurious events will not have long term negative outcomes. In fact, after potentially morally injurious experiences, some even eventually develop a redefined meaning in life and, with time and support, begin to incorporate the experience into growth or helping others. People may have new insights about how to help the systems in which they work or that can help them grow in their own work or lives. Health care workers, their colleagues, and leaders can use strategies to take care of themselves and each other both during and after potential morally injurious situations, to support recovery and growth.

What Self-Care Strategies Can Reduce the Potential for Moral Injury?

Self-care for moral injury can be particularly challenging for people working in health care, given that those in this field typically strongly value caring for others and may prioritize the needs of others over their own. These characteristics are usually protective, but during highly stressful events they can mean that a person may not have time to take care of themselves, and that their personal standards put them at higher risk for moral injury. Therefore, self-care for moral injury should include seeking out others to assist in making difficult choices when possible, and for support about circumstances that cause moral distress.

It is often only in conversations with others that we can hear a different, more helpful way to think about or make meaning from morally distressing situations. It can be helpful to get support about feelings that come up when dealing with these complex moral situations. Health care workers may not feel that they have the time or energy to immediately engage in getting support, but it may be an important protection against the social withdrawal or negative coping that sometimes happen as a result of moral injury.

The COVID Coach mobile app may help workers cope with some of these complex feelings. It is designed to help you build resilience, manage stress and increase your well-being during the pandemic.

Anyone experiencing moral distress resulting from a highly stressful work context also may need to try to be more aware of their internal self-talk. Thoughts that cause increased distress and interfere with the ability to function, while seemingly realistic, may be unhelpful. For instance, a person may need to modify their expectations to meet their current reality, changing thoughts such as, "I should have done better," to, "I did the best I could, given the circumstances." Talking with others can help a person get a new perspective.

More information about how to identify and change unhelpful thoughts is included in:

• Skills for Psychological Recovery Manual
• Helpful Thinking During the Coronavirus (COVID-19) Outbreak

It can also help to find satisfaction in what can be accomplished, however small, and to be more patient or kind with oneself. For some people, a good strategy may be to draw more strongly on religious faith or spirituality, or on personal beliefs and values that support persevering and finding meaning or acceptance.

How Can Coworkers Support a Colleague Who Has Experienced Moral Injury?

Health care workers experiencing moral injury are likely to benefit from coworker support. Coworkers can be especially helpful in that they often have experienced similar feelings so have natural empathy.

Reach out to coworkers

Reach out to coworkers who are showing signs of distress. Shame, guilt, and the expectation of condemnation or rejection can make coworkers reluctant to talk about their experiences. If they say they're "fine," let them know that you have seen changes in their behavior and that you are care about them. If they choose not to share their experiences with you, realize that It may take time for a person to open up about their feelings. It may also be that they do not have the energy or time to discuss what is bothering them. If so, let them know that you care, and that you are willing to listen if they want to talk. Depending on the person, it may be helpful to suggest that they talk to a member of the clergy.

Be a good listener

If the person wants to talk about their feelings or experiences, be a good listener. What we do and say is often not as important as what the other person says. The person may just want is to know that someone cares enough to check on them and to listen. Even a short conversation can convey that the person is not alone and that someone cares. Be nonjudgmental and understanding.

• If you want more information, try saying something like: "It sounds like you've experienced some things that nobody should experience. Can you help me understand how that's impacting you now?"
• If the person speaks of guilt because of acts of omission, say something like: "It sounds like you're sad about something you didn't do," to facilitate further discussion. If they have guilt because of acts of commission, you can say something like: "It sounds like you're really burdened by things you did, or that you believe you did," to facilitate further discussion.
• If you don't know how to respond, say something like: "That must have been incredibly hard. I can't imagine how I would feel in that situation."
• If you can't tolerate having a conversation because of your own stress, be honest. Say something like: "I don't know if I can hear this story, but I know someone who can. I can connect you to them."
• If possible, try to help the person gain a different perspective on how they view themselves or others. They may be telling themselves they should have been able to prevent a bad outcome or that they were solely responsible for what happened. You may be able to help the person see a broader perspective on what happened, remind them what they could or could not control, help them find what meaning their experiences hold for them, or highlight their strengths and core values.

Additional resources on supportive conversations

• Psychological First Aid Manual: More on engaging in supportive conversations
• Skills for Psychological Recovery Manual: Resources on changing unhelpful thoughts

Information on engaging in supportive conversations or helpful thinking in the context of pandemics can be found in:

• Tips for Providing Support to Others During the Coronavirus (COVID-19) Outbreak
• Helpful Thinking During the Coronavirus (COVID-19) Outbreak

How Can Leaders Support Employees Who Have Experienced Moral Injury?

Leaders can be particularly helpful both in preventing moral injury and in mitigating its effects, particularly if their employees have respect for their experiences and opinions. Leaders have a strong role in setting ground rules and communicating organizational values and standards, and their prior experiences with mentoring and problem solving can serve them well in supporting their employees.

Leaders can help by increasing communication with employees, particularly around changing policies and the decisions that are being made. Send a clear message that during times of extreme stress, high volume of cases and changing circumstances, guilt, shame, anger and difficulty functioning may occur. As a result, it is important to be patient with oneself and others. Try to have check-ins—even brief ones—after particularly difficult days or cases. Leaders may not be able to predict what employees need during unusual times, so checking in is important. Increase expressions of praise and gratitude for the work employees are doing, particularly those in less senior but still supervisory positions, who often are less likely to seek support because they have fewer peers to reach out to. When appropriate, remind employees that they were doing their best and that a bad outcome may not have been preventable. Also let employees know that these are challenging times and remind them that it's okay to seek help and support.

Pay attention to the signs of moral injury, and either make time to check on employees showing these signs, or delegate that responsibility to other staff. Have support and referral sources ready for those who show signs that they may need professional help. The following may require professional care:

• PTSD symptoms that do not resolve on their own, such as intrusive memories, avoiding people or places, changes in mood or ways of seeing the world and trouble sleeping or concentrating
• Self-harming behaviors, such as poor self-care, alcohol and drug abuse, coping with excessive use of food, recklessness and parasuicidal behavior
• Self-handicapping behaviors, such as retreating in the face of success or good feelings and undermining efforts by others to help
• Demoralization, which may entail confusion, sense of futility, feelings of depression, hopelessness and self-loathing

Leaders can make it easier for an employee to seek more formal help by letting the person know that others have benefited from seeking help, and that getting help when needed will foster getting back on their feet sooner. If the employee chooses not to seek help at that time, honor that decision unless the person is a potential risk to themselves or others. But check in with them regularly to make sure help is given if and when it's needed. Find more tips at For Leaders: Supporting Your Staff During the Coronavirus (COVID-19) Pandemic.

Helpful Resources

• Moral Injury: Learn more about assessment and treatment for moral injury and related problems.
• COVID Coach mobile app: Supports self-care and overall mental health during the COVID-19 pandemic.
• SAMHSA's Disaster Distress Hotline offers 24/7 support to anyone experiencing emotional distress related to natural or human-caused disasters.
• Suicide and Crisis Lifeline is available 24/7 for free and offers confidential support for anyone in distress, including prevention and crisis resources and best practices for professionals.