by Duangphorn Wiriya | Unsplash
The COVID-19 pandemic has put an immense strain on health care workers worldwide. Caregivers are being stretched to their mental and emotional limits.
One aspect of this strain is moral injury. The Moral Injury of Healthcare, a non-profit organization addressing the crisis of clinician distress co-founded by Wendy Dean, MD, defines moral injury as occurring “when clinicians are repeatedly expected, in the course of providing care, to make choices that transgress their long standing, deeply held commitment to healing.” Moral injury is the result when care providers feel compelled to go against the oaths caregivers take to do no harm and act in the best interests of patients.
Dean and Cynda Rushton, PhD, RN, FAAN, a professor of nursing and pediatrics at the Johns Hopkins School of Nursing and co-chair of their hospital's Ethics Committee and Consultation Service, discussed the topic of moral injury as featured guests on the July 10 Caring for Caregivers Special Call Series: Transforming Moral Distress into Moral Resilience, presented by IHI in partnership with Wellbeing Trust.
Finding enough time to make personal connections with patients, providing equitable care, and seeing suffering that cannot always be prevented or treated are familiar causes of moral distress. The focus of health care systems on productivity, said Dean, can “[make] it very difficult for us to do what we know is right for our patients.”
The COVID-19 pandemic has exacerbated chronic challenges and given rise to new ones. The influx of very ill patients has pushed health care systems and providers beyond their normal capabilities and typically available resources. For example, providers with inadequate personal protective equipment have had to choose between getting physically close to a patient to provide the kind of care they feel morally compelled to give or prioritizing their own health, safety, and well-being. Making these difficult decisions may go against what it means to an individual to be a good caregiver. As the pandemic drags on, the hurts only compound.
The answers to moral distress and moral injury are moral repair and moral resilience. Moral resilience, Rushton explained, is the “invitation to harness our inherent goodness, wisdom, and values” so we can preserve and restore our integrity. According to Rushton, moral resilience is “not about putting a positive spin on a bad situation and overlooking it. In fact, it’s the opposite.”
Rushton and Dean shared their advice for building moral resilience on a range of levels. On the individual level:
- Build a daily mental practice. This can be anything that allows you to acknowledge and move through pain and connect with your values and sense of purpose. Rushton shared that she stops to take a breath before she enters a patient’s room to “intentionally pause and remember why I’m here.” She added, “it’s easy to get distracted in the midst of chaos.”
- Take action. Dean recommended finding ways to create a positive impact, even if it’s doing something to make one patient more comfortable. This can also include advocating to implement a systemic change to improve the moral experience of caregivers.
On the interpersonal and community levels, Dean had the following recommendations:
- Find a “buddy.” Dean has had success implementing Battle Buddy programs that pair staff who can lean on one another for advice, support, and empathy. She also recommended that this Battle Buddy not necessarily be someone that the caregiver works closely with every day, since co-workers may be experiencing similarly high levels of stress. The Battle Buddy may instead be a colleague within the caregiver’s hospital system who is in a different geography or a friend from nursing or medical school who works in a less COVID-19 affected area.
Rushton and Dean had the following advice for building resilience at the system-level:
- Start with organizational values. Rushton advised using organizational values to guide priorities. To “align clinician values with organizational values,” identify what’s getting in the way of allowing clinicians to practice in accordance with their principles.
- Build partnerships between administrators and clinicians. Dean spoke of the need for a health care “house united,” with strong partnerships and understanding between the administrative and clinical sides. To solve problems and create an environment in which caregivers can thrive, she recommended utilizing administrative/clinical dyads for decision-making.
Another guest on the Caring for Caregivers call, IHI President Emeritus and Senior Fellow Don Berwick, noted that it was important to remember that moral injury “has been a chronic issue, not just an acute one” during the COVID-19 pandemic. Therefore, the journey to moral repair and resilience is a long one, and health care organizations should be prepared to support their caregivers through this process for years to come.
Julia Nagy is an IHI Project Manager.
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The free IHI Virtual Learning Hour Caring for Caregivers special series is delivered in partnership with Well Being Trust. This bi-weekly series will run every other Friday until September 11, 2020 from 10:00 – 11:00 AM ET. Learn more and register.