Moral injury is understood to be the strong cognitive and emotional response that can occur following events that violate a person’s moral or ethical code.1 Potentially morally injurious events include a person’s own or other people’s acts of omission or commission, or betrayal by a trusted person in a high-stakes situation. For example, health care staff working during the COVID-19 pandemic might experience moral injury because they perceive that they received inadequate protective equipment, or when their workload is such that they deliver care of a standard that falls well below what they would usually consider to be good enough.”  – The Lancet March 2021.

The health care world is experiencing great trauma right now.  The increased personal risk from the pandemic, surging volumes of critically ill patients, staffing shortages, and the denial of medical and scientific expertise all add to the burden of moral injury carried by our doctors, APPs, and nurses.  It’s been going on for so long now.  Long enough to lose and mourn loved ones.  Long enough for a first-year high school student to become a junior or a kindergartener who has never had a full year of school to be starting second grade.  Long enough to be exhausting, even with enduring resilience. 

I’ve been reading the articles defining the trauma, listening to the accounts of hundreds of leaders and frontline clinicians. There is no doubt that this is real and different from chronic burnout. The question is…what to do?  What do we do with this moral injury?  Are we helpless in the face of societal and pandemic events?  Are we doomed to watch this play out, a slow-moving train wreck, without any recourse except to lament? If there is something to do, what is it?  How do we react to help ourselves and our teams survive and thrive in this environment?

While the COVID-19 pandemic has increased the discussion around clinician professional well-being, moral injury and burnout in medical practice was a pressing issue before the pandemic.  We know that the approach to clinician burnout needs to be systemic, and the approach during the current pandemic does too.  Organizations and employers need to keep human wellbeing a priority during system design and operational improvements.  Every system change should include the question, “How does this impact our clinicians and care teams? Are we making their work easier or harder?” Help our dedicated, talented, caring clinician workforce care for patients by smoothing the systems and improving the effectiveness of their support.   Also, consider the support and recognition given.  Consider a personal message of increased support to clinicians, recognize teams and individuals for the difficult work of caring for patients.  Our health care heroes are also health care humans, and need food, breaks, sleep, and time away.  

While organizations, employers, political and cultural leaders work to support our clinicians and care teams through system improvements, individuals must also do everything possible to protect themselves.  For frontline care team members, first and foremost, understand the remarkable stressors you are experiencing and that you may need to use different coping strategies (by magnitude and kind) to thrive through this time.  Each of us has developed ways to deal with the stressors in our careers so we can deal with the strain of caring for humans at their most vulnerable. Recognize that this is a unique time, and the coping strategies we use now may be different.   

What framework are you using to put these events and the extraordinary things you are being asked to accomplish into perspective?  Are you deliberately employing strategies to consider how your current work fits into your personal life’s mission?  Are you able to accept what you cannot control in the situation and work to be true to your ideals in the actions you can control?  Feeling our feelings can be painful and often kept for a “later time,”…but when a pandemic goes on for 18 months and more, “later” may not be reasonable.   Where do you go to feel?  Who do you think things through with?  Whose shoulder do you lean on? Do you get help when you feel despair?    

Now, more than ever, developing deliberate strategies for dealing with moral injury and work-related stress becomes essential.  

In the meantime, please do what you can to care for yourself..

And remember, the trauma IS real.  The moral injury IS pervasive. You are NOT alone. It is OK to not be OK right now. AND there are also many opportunities to impact patients, our clinical teammates and the communities we are part of as we care for ourselves and each other during these profoundly challenging times..  The work you do, caring for the ill, explaining and sharing your expertise, makes a difference…makes THE difference for so many.  There are many who want and seek to support you and who appreciate the work you do. There are others thinking about ways to manage the stress and heal from the injuries.  Not everything that changes us forever leaves us broken.  This, too, shall pass. 

STEFANIE SIMMONS, MD

Dr. Stef Simmons is a board-certified emergency medicine physician and lead faculty for the Clinician Experience Project’s well-being program.  She serves clinicians as vice president of clinician engagement for Envision Physician Services and on the board of directors of the Dr. Lorna Breen Heroes’ Foundation. She is a mother of three, an avid kayaker, and enjoys blowing off steam at the gym.