Beyond Moral Injury
I was recently at an International Emergency Medicine (EM) conference with an incredible cohort of collegial learners. Mornings and early evenings were well mixed with timely clinical content. As the week progressed, not only did the engagement increase but also the glow from engaged melanocytes creating an alpine glow on everyone’s faces from afternoons spent exploring the National Park and the numerous ski resorts nearby.
Each morning and afternoon, conference attendees would share of their experiences regarding the best snow, an opportunity not to be missed, and any gustatory experience that delighted their salivary glands. Each day, there was a palpable increase in the level of discussions around incredible daily activities as well as shared learning regarding the conference content. And while discussing current evidence-based and other trending Emergency Medicine approaches to care, it was evident that despite the differences in approach, there was a greater commonality than difference within the greater global community present.
That became even more apparent on the final day of the conference. That morning, I took a slight divergence from the dedicated clinical content to engage in discussion regarding moral injury and its impact on those practicing EM (and life in general over the past few years) amidst the maelstrom of EM complexities. Medical boarding. System failures. Increasing length of stay of highly complex patients. Staffing shortages. Patient aggression. Leadership failures. Psychiatric boarding. Administrative pressure.
Moral injury has been defined as the strong cognitive, emotional, psychological, and often spiritual response that can occur following events that violate a person's moral or ethical code. Potentially morally injurious events include acts of omission or commission, or betrayal by a trusted person in a high-stakes situation. Many physicians and other front-line teammates working during the COVID-19 pandemic experienced moral injury because they perceive that they received inadequate protective equipment, or faced overwhelming workloads such that care delivery fell below their normal standards.
Morally injurious events threaten one's deeply held beliefs and trust.
It is important to recognize that moral injury remains commonplace in EM (and elsewhere in medicine and beyond) beyond the pandemic. As leaders, we must recognize (for ourselves and others) that morally injurious events can cause profound feelings of shame and guilt, and alterations in cognitions and beliefs (i.e. “I am a failure”, “I am alone”, “no one cares about me”), as well as many maladaptive coping responses including social withdrawl, substance use disorder, etc.
It was in this conversation about moral injury, trust, and creating a worthwhile organizational culture that many shared of the Sisyphean challenges faced every day. Many expressed a powerful esprit de corps through the early parts of the pandemic. They felt a calling to serve. A desire to be on the frontlines despite uncertainty. Despite a lack of optimal supplies. Despite the risk inherent in being present for those in need. However altruistic, the ability to maintain such a dedicated mission focus requires an organizational culture of unwavering support. A recognition of the inherent psychological, physical, spiritual, and emotional challenges with navigating clinical uncertainty on a daily basis.
Now as the tsunami of the past few years has dissipated, many feel left behind amidst the debris of a system facing new complexities, decreased capacity, depleted workforce, and increasing acuity. Many shared of the exhaustion they feel daily. Others of the defeat when walking through a burgeoning waiting room on the way into another shift. Still others shared of the incredible desire to create a greater culture of care that prioritizes patients and shared responsibility. That aligns like-minded individuals around team-mindedness, built on trust, dedicated to intentional communication, encouraging accountability, and centered around a commitment to patient care.
I sensed many emotions through visual expressions paired with the words that were shared. Exhaustion. Sorrow. Compassion. Abandonment. Opportunity. There were some that recognized the need for change and willingly embraced that call. Others were at a point of needing time for personal healing and restoration. Regardless, all spoke of the moral injury felt due to the inability to serve those for whom they have dedicated their clinical career. An inability borne of system failures outside of their control. For some a pervasive hopelessness. Although for some, an opportunity to start again.
Where are you?
In need of a time of healing or restoration? If so, take that time – seek help and know you are not alone. Self-care is not selfish. You deserve it. Moral injury doesn’t have to define you. Struggling with the belief that change is possible? Again, you are not alone.
Belief.
It is what anchors you for something greater. It is what allows you to persevere despite oncoming obstacles to create that desired future state. Easy, it is not. Are those you serve not worth it as well? Regardless of the challenges you are facing, your ability to maintain resolve, to remain resilience comes back to what anchors you – and what you believe. What is that for you?
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Reflecting on this conference experience, one thing became vibrantly clear – the challenges I face are shared with many. Moral injury in healthcare (and in life) is real. The circumstances might differ, but the impact and opportunity remain similar. How we choose to respond is very personal and predicated on myriad influences. It comes from belief, it is fostered by your ‘why’, is founded on trust, and it is supported by a collaborative culture of care.
In the coming posts, we will be examining how creating positive organizational culture is transformative for all. Thank you for joining me on this journey.