Why It Matters
During the COVID-19 pandemic, health care workers have often been called “heroes” going “into battle.” In her work, Wendy Dean, MD, has found nuanced and troubling comparisons between the health care workforce and military veterans. As President and Co-founder of Moral Injury of Healthcare, Dean has written and spoken extensively about moral injury — a concept first used in reference to Vietnam War veterans — and its prevalence in health care. In the following interview, she discusses what will be more effective than treating burnout and moral injury as issues specific to individuals. Dean was a keynote speaker at the IHI Patient Safety Congress.
How do you define moral injury in health care?
There are the standard definitions which I’ll come to in a second. But I think the easiest way to understand it in a colloquial sense is that it’s simultaneously knowing what your patients need and being unable to get it for them because of constraints outside of your control. That’s what we hear over and over again, from all kinds of clinicians. Whether they’re nurses, social workers, physical therapists, or physicians, they say, “I know what I should be doing. And I can’t do it because this thing or the other is constraining me.”
There are also two formal definitions. One of them is from Brett Litz. He said that moral injury is perpetrating, failing to prevent, or bearing witness to an act that transgresses deeply held moral beliefs. In health care, those deeply held moral beliefs are the oaths that we took to put our patients first.
The other definition is by Jonathan Shay from 1994 when he published Achilles in Vietnam. He said that moral injury is betrayal by a legitimate authority in a high-stakes situation. In health care, we see both of those definitions playing out.
How is moral injury in health care different from burnout?
Although one may lead into the other, they are not the same thing. There are a lot of roads that lead to burnout, but the highway is moral injury.
When you go into work every day, and you know that you’re going to have to fight to get your patients what they need, that is exhausting — the first symptom of burnout. When you find that day after day, you’re only partially successful at getting your patients what they need, it makes you feel very ineffective. That’s the second symptom of burnout. If that happens often enough for a long enough period, you start having a hard time watching your patients suffer. You start to distance yourself from them because it’s painful to stay engaged and empathic when you know that they’re going to suffer. So, you depersonalize, which is the third symptom of burnout.
I get very worried when we ask people to be more empathic because sometimes that distancing is the only protection they have left. If we take that away, we potentially leave somebody without any psychological defenses, which is a risky thing to do.
What are some parallels you see between the moral injury experienced by war veterans and health care professionals?
I used to work for the US Army — not clinically, as a psychiatrist — but I had a firsthand view of how they were addressing the suicide crisis in service members during the wars in Iraq and Afghanistan. I started to see some real parallels, but I was unwilling to make that connection because I’ve never worn a uniform and couldn’t speak authentically about the comparison. But a paper came out from Duke recently that compared the two experiences.
The study found that health care workers [during the COVID-19 pandemic] and military service members suffer moral injury at similar rates. I’ve seen that, for both health care workers and service members, the individuals were put in situations where they felt that their leadership may have been making decisions that weren’t in their best interest, put them in harm’s way, or kept them from being able to provide the care they wanted to provide. For example, early in the pandemic, there were stories about some organizations that asked their workforce not to wear N95 masks so they wouldn’t frighten their patients. With that one request, they were being put at higher risk while also being asked to put their patients at higher risk.
Will focusing on the resilience of the health care workforce address moral injury?
There are a couple of ways to understand this. We’ve all suspected for a long time that health care workers are very resilient, but we never had the data to prove it until Colin West and his colleagues came out with a paper in JAMA in 2020. They validated that physicians are significantly more resilient than the average US worker.
I would go beyond physicians. I think most people who work in health care are resilient. This means that we may be hitting a point of diminishing returns by trying to increase resilience in an already very highly resilient population. It’s also important to consider that the high level of resilience has not fixed the crisis of distress in health care. West and his colleagues found that even a high degree of resilience didn’t protect physicians from what they were calling burnout.
I think there’s something else going on. Training individual resilience assumes an individual frailty. But moral injury is a systems problem. This means that making the individual walls of the house of health care stronger may not help us. We’ve already made them strong enough. We need to fix the whole system. Or, to use another analogy, we have a health care workforce full of high-performance Lamborghinis. We ask them to go out on roads with potholes and fallen trees. To let the Lamborghinis perform to their full potential, we need to fix the potholes and clear the trees.
How can we create a system in which the wellness of patients correlates with the wellness of health care providers?
We have to do it on multiple levels at once. We’ve tried fixing distress in health care by addressing the individual for a long time, and it hasn’t worked. I think almost every day about conversations that [fellow Moral Injury of Healthcare co-founder] Simon Talbot and I have had with [IHI President Emeritus and Senior Fellow] Don Berwick. The first thing Don said that has stayed with me is that we cannot make progress if we aren’t co-producing solutions. One piece of one organization can’t fix the whole. We all need to work together.
The other thing Don did was pose important questions: What are we — administrators, clinicians, and patients — promising each other? What are our expectations? What are our goals? How can we help each other get there? How can we break down all the barriers to the conversations we need to have? How can we move towards something different?
How have your discussions about moral injury changed during the pandemic?
The discussions have gotten bigger and more urgent, but it’s striking to me how similar they are to the ones I had before the pandemic. I recently went back and reviewed testimony that I provided to the New York City Council Committee on Hospitals on February 24th, 2020. It was right before the city shut down. The hearing was on safety in New York City emergency rooms. The recommendations I made then are the recommendations I make now, and it’s all about supporting the health care workforce, asking them what they need to be successful, and delivering what they need whenever possible.
There have been patterns through the pandemic, and for the past couple of months I’ve been hearing some themes over and over: I just want to be somebody’s doctor, and I can’t be that in health care right now. I’m a data clerk. I’m a coordinator. I’m not taking care of patients. I want to get back to healing.
I worry that the people who may be able to make the most difference [in health care] think that all we have to do is get past the pandemic and back to “business as usual.” But business as usual was never good enough, so it won’t be good enough after the pandemic is over.
The pandemic has shown us that we don’t have to do things the way we’ve always done them. When we don’t allow ourselves to be bound by the constraints of the past, we can make significant change quickly. We would do well to remember that health care is capable of rapid change.
Editor’s note: This interview has been edited for length and clarity.
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Moral Injury of Healthcare white paper: How reframing distress can support your workforce and heal your organization