Editor’s Note: As part of the Center for Deployment Psychology’s ongoing mission to provide high-quality education on military- and deployment-related psychology, we are proud to present our latest “Guest Perspective.” Occasionally, we present blogs by esteemed guests and subject matter experts from outside the CDP. This allows us to offer more insight and opinions on a variety of topics of interest to behavioral health providers. As these blog entries are written by outside authors, one important disclaimer: all of the opinions and ideas expressed in them are strictly those of the author alone and should not be taken as those of the CDP, Uniformed University of the Health Sciences (USUHS), or the Department of Defense (DoD).
For all its power to terrify, Covid-19 can’t keep us from marveling at the courage of frontline human service workers all over the world. They are braving not only the physical dangers of repeated exposure to the deadly virus, but also the emotional dangers of empathically sharing so much suffering with so many, and the moral dangers of possibly being unable to save every savable life, such as when intensive care services become overwhelmed. Their courage seems all the more remarkable given that all three of these dangers are invisible, operating mostly outside of anyone’s immediate awareness.
Of course, none of these occupational hazards is new. Occupational fatalities are two to three times more common in emergency medical service workers than in the rest of the U.S. workforce (Maguire et al., 2002), and nurses and nursing assistants are perennially in the top five occupations for rates of workers’ compensation claims, with mental or emotional stress often identified in those claims as a precipitating factor (Insurance Information Institute, 2019). And occupational moral distress has been studied in numerous human service professions since 2002, when Corley and colleagues published their study of the Moral Distress Scale (MDS) for nursing (Corley et al., 2002). Since then, the MDS has been revised and validated in several populations of health care professionals (Epstein et al., 2019), including psychiatric nurses (Ohnishi et al., 2010).
Moral distress in health care is the emotional pain health care professionals feel when they are unable to provide the best possible care and achieve the best possible outcomes in high-stakes situations (Jameton, 1984), often but not always because of failures of systems of care to provide needed resources. Like physical pain, emotional pain exists for a reason; at lower intensities, it warns of impending harm, and at higher intensities, it may indicate emotional harm that has already occurred, just as an abrupt onset of intense physical pain signals injury to one’s body.
One serious harm known to be associated with moral distress in health care is burnout, a global problem for which moral distress is emerging as a major risk factor (National Academy of Medicine, 2019). Burnout is a syndrome with three components: (1) emotional exhaustion; (2) reduced ability to feel and express compassion (often called depersonalization, though not to be confused with depersonalization as a form of cognitive dissociation); and (3) reduced feelings of professional accomplishment (Maslach & Jackson, 1981). Studies using self-report questionnaires that measure the magnitude of these three components of burnout have found that burnout is way too common in health care, with consequences for the delivery of care and the well-being of workers that are way too dire.
Over the past decade, studies have found significant levels of burnout in up to 39% of practicing social workers (Siebert, 2005), 45% of nurses, 54% of physicians, and 60% of medical trainees (National Academy of Medicine, 2019). Burned-out health care workers deliver care less effectively and efficiently, and they make more medical errors, the greatest of all sources of moral distress in health care. They also tend to leave their professions sooner than they intended, contributing significantly to global shortages of certain front-line health service workers.
Besides its societal costs, burnout takes a staggering toll on the health and well-being of individual professionals and their families. Burnout has been found to significantly increase risk for stress-related physical disorders ranging from heart disease and diabetes to chronic pain, and stress-related mental and behavioral disorders from depression and substance abuse to suicide (National Academy of Medicine, 2019).
A possible key to understanding empirically observed connections between moral distress and burnout in health care was proposed by Dean and colleagues (2018), who drew the parallel with moral injury and posttraumatic stress disorder (PTSD) in military Service members and Veterans. The term moral injury was coined by Jonathan Shay in his 1994 book, Achilles in Vietnam, in which he compared the moral harm done to Achilles by the Greek king in Homer’s Iliad to the moral harm done by the United States to the Vietnam Veterans he treated as a psychiatrist at the Boston VA.
Shay’s (1994) definition of moral injury – as lasting harm resulting from a betrayal of what’s right by a legitimate authority in a high-stakes situation – easily translates to moral distress in health care, given that the vast majority of root causes for moral distress in health care involve betrayals of the public trust by health care systems that increasingly place profit and other motives ahead of the welfare of patients or providers (Dean et al., 2018). Like Service members engaging in combat, health care professionals suffer moral injury when they perpetrate, bear witness to, or fail to prevent a violation of what they know is right.
The moral injury concept has evolved since Shay’s first definition, which recognized only the culpability of external moral agents such as military leaders in the genesis of moral injury. Litz et al. (2009) drew attention to the flip side of the moral injury coin – the moral harm that can befall service members through their own failings to live up to deeply held moral expectations. In moral injury research, moral injury inflicted by another person or entity is sometimes referred to as moral injury by other (MI-O), whereas moral injury resulting from one’s own actions or failures to act is called moral injury by self (MI-S). MI-S can occur in health care any time a professional makes a wrong decision or takes a wrong action resulting in harm because of their own limitations – such as from fatigue, stress, inexperience, or simply inattention – rather than because of limitations in systems of care. Moral injury in health care is predominantly but not exclusively MI-O.
What are the implications of drawing a parallel between moral distress in health care and moral injury in military service? How does the moral injury idea help us tackle burnout in health and other human service professions?
Most significantly, drawing this parallel redefines professional burnout as a form of psychological trauma, suggesting that burnout may be a posttraumatic stress syndrome and a full cousin to posttraumatic stress disorder (PTSD) as defined in DSM-5. Several similarities exist. Both burnout and PTSD are chronic states of often-worsening distress and loss of functioning that can be triggered by one or more betrayals of moral expectations. Event-related moral betrayals are assessed in health care workers using self-report measures of moral distress that are analogous to empirical measures of moral distress in military service such as the Moral Injury Events Scale, which has been found to strongly predict subsequent military-related PTSD (Bryan et al., 2015; Nash et al., 2013). Both burnout and PTSD have broad and serious comorbidities, including the gamut of stress-related physical, mental, and behavioral problems, as well as persistent impairment in social and occupational functioning. For neither burnout nor combat-related PTSD do we yet have consistently effective treatments (Steenkamp et al., 2020).
Conceiving of burnout as a form of trauma is not new. The pioneering traumatologist, Charles Figley (1995, 2002), studied and raised awareness about compassion fatigue among health service professionals who treated traumatized persons on a regular basis. Early traumatologists made the crucial link between compassion fatigue and secondary traumatization or vicarious trauma, adverse stress states that are also common among family members of persons who have suffered serious psychological traumas, likely for many of the same reasons.
How is this possible? How can burnout, compassion fatigue, and vicarious traumatization in health care workers be forms of psychological trauma if the psychological injuries that evoked them involved only mechanisms of moral betrayal rather than fear for one’s life? How can a person be harmed by an experience that poses only moral dangers rather than physical dangers, and evokes predominantly moral posttraumatic emotions – especially guilt, shame, anger, and hatred – rather than posttraumatic fear, horror, or helplessness? Aren’t posttraumatic stress symptoms always and only the direct result of fear conditioning that failed to spontaneously extinguish?
The answers to these questions may be found in the early history of PTSD as a mental disorder. The first set of diagnostic criteria for the new disorder, published in DSM-III (APA, 1980), was created from lists of symptoms observed in two recently identified traumatic stress syndromes: Rape Trauma Syndrome in rape survivors and Post-Vietnam Syndrome in combat survivors. As a new mental disorder, PTSD was 12 years old when the first two serious attempts to understand its nature were published: Judith Herman’s (1992) Trauma and Recovery and Ronnie Janoff-Bulman’s (1992) Shattered Assumptions. Jonathan Shay’s (1994) Achilles in Vietnam followed two years later. All three conceived of psychological trauma not as fear conditioning but as an identity wound – as lasting harm to a person’s core sense of self and self-esteem and ability to live in the world and form sustaining relationships based on trust and love. All three described psychological trauma across a broad landscape, occurring from early childhood to late life and drew attention to serious posttraumatic stress symptoms not captured by DSM-III criteria, particularly problems with self-regulation, as one might expect to be associated with an injury to the organ of self-regulation, the core self. For all three, the ultimate meaning of traumatic events was far more important than what was experienced at the moment of trauma.
Theories about psychological trauma as fear conditioning were introduced to the public soon afterward by Resick & Schnicke (1993) and Foa & Rothbaum (1997). These cognitive-behavioral practitioners focused narrowly on fear-related posttraumatic stress symptoms, and they studied predominantly single incidents of rape or accidents. They did not attempt to reconcile their fear-conditioning models with the identity-wound models published by Herman (1992), Janoff-Bulman (1992), and Shay (1994).
Had mental health science done its job, we might now – 40 years after the PTSD diagnosis was first established in DSM-III and 28 years after the first wave of theoretical models for understanding PTSD were laid out – be in the thick of a really interesting conversation about the nature of psychological trauma in persons and communities, informed by well-conceived empirical studies testing the relative predictive value of each of these theories about the nature of trauma. We would have performed the studies to measure the relative effect sizes of fear conditioning and identity wounding as mechanisms for posttraumatic stress symptoms of various types. We might even be able to offer customized treatments for various types of psychological injury rather than fielding one-size-fits-all programs.
For whatever reason, that never happened. The global trauma-psychology field has been dominated by fear-conditioning models that have not only proven to be relatively ineffective for the treatment of combat-related PTSD (Steenkamp et al., 2020), but through their insistence that maladaptive coping choices are necessary for the etiology of PTSD, may also be fueling the mental health stigma that has long magnified the public health impacts of psychological trauma (Nash, 2019).
That maladaptive coping is not a significant contributor to burnout seems evident from research on risk and protective factors for moral distress and burnout in health care. Although moderators of risk for moral distress and burnout operate in all socioecological domains, including within health care professionals as individuals, the moderators with the greatest impact all appear to operate in the outside environment. This is why the National Academy of Medicine’s (2019) call to action to address clinician burnout urges a systems approach to prevention and care.
This brings us back to our initial concern: the health and well-being of heroic frontline human service workers during the Covid-19 pandemic. How can we help protect them against moral injury and burnout as they work to protect us from the virus and its aftermath?
Here are my thoughts. First, we should acknowledge out loud that the moral hazards our frontline workers face are every bit as serious as the physical dangers they face, maybe more serious. They already know this; they just deserve to hear us say it, thanking them as we do. For them, moral injury, with all its downstream effects, is every bit as immediate a threat as coronavirus infection, with all its potential consequences. We cannot wish this risk away without inflicting more moral injury on those at risk.
Second, we should work fast and hard to identify the greatest systemic enhancers of risk for moral injury in frontline human services and eliminate them. We already know what some of those are: shortages of personal protective equipment and ventilators, for example, and sufficient means to conduct testing and contact tracing to isolate the virus and limit its spread. But the majority of risks for moral injury in frontline workers are the same ones that existed before Covid-19 – risks arising from the chronically under-resourced and structurally unjust health care systems in the United States (Dean et al., 2018).
Third, we should work equally hard to identify and strengthen protective factors for moral distress and burnout for frontline workers. We can guess what some of those are. For example, like warriors on a battlefield, health care workers in the trenches of the pandemic are likely protected from moral distress and injury by the love they feel for each other and for us as the people they serve, and by the honor and pride they derive from their important work on our behalf. We should find more ways to express our own positive moral emotions of love, honor, and gratitude for the work they do, as we encourage the communication of these protective positive moral emotions within health care teams grappling with the pandemic. Love is moral injury’s natural enemy.
Fourth, we should develop and evaluate programs to promote professional well-being that harness the functioning of innate systems of moral emotional appraisal, rather than working against them, using the intensity and duration of persistent negative moral emotions like guilt, shame, anger, or sadness as markers of increasing risk for moral injury and burnout – so we can intervene early. The emotional pain that accompanies negative moral emotions could become as useful a target for assessing emotional well-being as physical pain scales are for assessing moment-to-moment physical well-being.
Finally, everyone who is responsible for the delivery of health care, especially managers of systems of care, should read and act on the National Academy of Science’s (2019) call to systems-focused action against clinician burnout. Many of the systemic weaknesses placing our workforce at risk can be fixed with a sustained investment of effort. We need action. Now.
At the end of the day, risk for moral distress and burnout will never be completely eliminated from human service professions because we will never give up the two aspects of human service work that place us at greatest risk: our willingness to care deeply about the people we serve, and to assume responsibility for their welfare. We are vulnerable because we care.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
William Nash, M.D., is a leading researcher, educator, and clinical consultant in military and veteran psychological health.
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