Clinician wellness should be a shared responsibility between individuals and institutions. Beyond facilitating clinician resilience, institutional transformation is needed.
Lifelong Learning in Clinical Excellence | November 3, 2020 | 4 min read
By David Kopacz, MD, University of Washington
When burnout is caused by systemic, institutional variables it becomes moral injury. We often hear that the way to deal with burnout during the pandemic is to build resilience, meditate, and do yoga. However, a recent paper published in JAMA shows that healthcare professionals can be resilient and still be burned out. Many who study burnout are finding that system-level variables may be more important than individual-level variables. Thus, the system is causing burnout, it’s not the fault or deficit of the healthcare professional. Drs. Dean, Talbot, and Dean put it this way, “The solutions reside not in promoting mindfulness or resilience among individual physicians, but in creating a health care environment that finally acknowledges the value of the time clinicians and patients spend together developing the trust, understanding, and compassion that accompany a true relationship.” While I support engaging in wellness and self-care activities, these alone will not fully address the burnout pandemic.
“The solutions reside not in promoting mindfulness or resilience among individual physicians, but in creating a health care environment that finally acknowledges the value of the time clinicians and patients spend together developing the trust, understanding, and compassion that accompany a true relationship.” – Drs. Dean, Talbot, and Dean
“Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs.” The concept of moral injury comes from combat veterans and has recently been applied as an alternative term to burnout for clinicians. In healthcare, moral injury focuses on the institutional environment and clinical and ethical double-binds it creates for the healthcare professional. Talbot & Dean have been leading much of this work with several papers on moral injury in physicians. ZDoggMD has further given voice to collective frustration and pain in his video, “It’s Not Burnout, It’s Moral Injury.” When clinicians feel conflicting loyalties to clients and the pressures of the institution, the EMR, and productivity metrics, they’re caught in an impossible double-bind situation. The perspective of moral injury shifts the emphasis from burnout being a “fault” or “lack of resilience” of the individual clinician to a systems perspective. Rather than saying 30-50+% of individual clinicians have a problem, instead we ask what’s wrong with the system that’s creating a pandemic of clinician suffering?
The COVID-19 pandemic is a good example of moral injury. Healthcare professionals are supposed to put the well-being of their patients first and their own welfare second. We signed up for this and we know it’s part of being a professional. But professionals feel they’re needlessly being put at risk for the lack of inexpensive PPE supplies.
We can think of a spectrum of the costs of caring from growth-promoting eustress to suicide. Below is a list of 15 different concepts that have been used to describe the effects of occupational stress in healthcare:
4. Compassion fatigue
5. Secondary traumatization
6. Vicarious traumatization
7. Second victim syndrome
8. Post-traumatic Stress Disorder
9. “The Doctor’s Disease”
12. Moral distress
13. Moral injury
14. Soul loss
Dr. Cynda Hylton Rushton has spent her career studying the concept of moral resilience in healthcare professionals. She recommends starting with individual self-care skills like yoga and meditation, but she also calls for systemic reform of healthcare institutions. “Addressing moral distress . . . requires attending to a multiplicity of relational, organizational, institutional, and psychological factors.” She sees developing moral resilience as a function of the individual and institution working together to create a moral, healing environment. “The goal is to support clinicians to transform their moral suffering with the capacities of moral resilience so that they can serve the people they are dedicated to with greater compassion, wisdom, and ease. This cannot occur without fundamental shifts within our healthcare organizations and society.”
“The goal is to support clinicians to transform their moral suffering with the capacities of moral resilience so that they can serve the people they are dedicated to with greater compassion, wisdom, and ease. This cannot occur without fundamental shifts within our healthcare organizations and society.” -Dr. Cynda Hylton Rushton
As healthcare professionals, we need to go beyond being technicians following orders and protocols and reclaim the status of true professionals. Being a professional includes medical activism—moving beyond the clinic walls to diagnose and treat institutions and the public health of society.
Re-moralizing your self
The antidote to moral injury and demoralization is re-moralizing your self, building moral resilience. This means acting at the individual, clinic, and institutional levels to transform moral suffering through moral repair and moral growth into moral resilience. The challenge is to work with suffering without shifting into either self-blame or blaming others—that locks you into a victim-victimizer dynamic. As Palmer tells us, “institutions are us.” Every level needs to transform in order to transform healthcare.
7 things you can do for your self:
1. Connect to yourself
2. Learn and practice self-care skills
3. Engage in reflective practices like creative writing
4. Reconnect to your healing vision—why did you go into healthcare?
5. Read inspiring physician narratives
6. Develop a counter-curriculum of re-humanization
7. Practice non-duality—reflect on how we’re all interconnected and all interrelated
3 things you can do in your clinic or hospital:
1. Connect to colleagues
2. Be human with clients and patients
3. Identify clinic-level causes of moral distress and work with colleagues and leadership to ameliorate or transform
5 things you can do at the institutional level:
1. Identify systemic causes of individual and clinical distress
2. Work with leadership, volunteer for committees, and take on leadership positions
3. Study processes of social change and transformation
4. Remember you are ultimately working for humanity
5. Work for a compassion revolution in healthcare