This post reflects part personal reflection and part call to action as I reflect and write in response to the tragedy of Dr. Lorna Breen whose loss of life starkly indicates that we have much to address on behalf of healthcare professionals who were already struggling to meet financially-driven system demands while maintaining personal integrity in their commitment to excellence of care. I did not know Dr. Breen personally but I work with physicians, nurse practitioners, nurses and other healthcare professionals who have been wrestling with difficult decisions, pressures and burdens prior to the global pandemic heaved onto the healthcare scene in early 2020.
The construct of moral injury gained attention among mental health professionals working with combat Veterans who benefited in part from the treatment of Post-Traumatic Stress related issues such as nightmares, hypervigilance and avoidance but continued to struggle with deep emotional wounding. Earlier work by Dr. Nash, Dr. Shay Dr. Tick and others prompted on-going research and care for this construct, which thankfully continues to develop (e.g. Brite Divinity School, the work of Dr. Litz, Dr. Currier). The Veterans I was honored to work with shared courageously their residual shame, guilt and anguish and together we considered how to struggle well through their experiences of betrayal by chain of command, betrayal by their country (particularly the Vietnam-era Veterans), and betrayal of self – what they described as deep inner conflict around deeply held values of life and defense of the vulnerable and sacrifice. These values that were threatened by the conflicting moral ethic of war and what constitutes victory or defeat at great cost in death and in wounded life for survivors and their loved ones.
At our hospital, we co-developed a group intervention led by mental health providers and chaplains to provide a safe forum for sharing these experiences and emotions with others who understood them. And as facilitators, we verbalized hope that our presence could represent a bearing witness to the on-going grief our soldiers carried on our society’s collective behalf. Through shared experience, honoring of painful stories, lament, thoughtful and deliberate acceptance and forgiveness of self and others, I recognized that moral injuries, or soul wounds as some refer to them, ask us to listen well and deeply, to acknowledge limitations of understanding, and to exhibit humility and respect for the existential elements.
In my work with healthcare providers I hear their painful stories and lament as well- grappling with pressure to perform procedures with which they do not agree, navigating the ever-increasing load of the Electronic Health Record, contending with the tension of keeping RVU’s (workload numbers) in the administratively-deemed ‘satisfactory’ level while attending well to patients and their families, I bear witness to their stories, look at and honor with them the anger and sadness and loss of their professional vision and purpose, the toll of emotional exhaustion and the consideration of job or career changes when explored alternatives and interventions come up short. These are not issues that can be attended to simply and in fact reducing the response to suggestions of more yoga, exercise and clean eating fail to acknowledge the depth of impact and wounding.
Dr. Breen’s life was lost in the midst of a healthcare crisis that entered an already fractured system. The physician suicide rate was troubling before the pandemic and is a complex issue requiring nuanced depth of response. The work has begun (e.g. the work of Dr. Dean and Dr. Talbot) towards integrating well what our Veterans have taught us about moral injury and how to apply these hard-earned lessons to supporting our healthcare providers as well. But there is much more to do.
Yes, resilience is needed and continues to evidence burnout mitigation. Resilience overlaps with post-trauma growth and post-stress growth as well, but to limit our response to bolstering individual resilience is short-sighted. Personal factors certainly are important to address. But resiliency applies to organizations, systems, teams and leadership as well.
- Are leaders knowledgeable of factors contributing to healthcare-related moral injury?
- Does organizational transparency and two-way communication foster attention to moral injury related factors and supporting providers appropriately?
- Do we know how to support healthcare professionals? Have you asked them?
- Are support opportunities available and more importantly, time to attend support opportunities?
- Do providers have ‘permission’ to process decisions, intrinsic conflict? Is there a safe venue available for this?
- Are we willing to consider all of the agendas driving the healthcare landscape and how some are contributing to moral injury among our healthcare providers?
- Are metrics related to patient satisfaction and physician satisfaction given as much focus as dollar per procedure codes?
- Support professionals must be willing to address the deeper levels of impact, which include existential and spiritual aspects of the person. This is a long-term challenge for mental healthcare and becomes even more important when addressing the whole person in light of moral injury.
The COVID19 war will have far-reaching implications- not only for the on-going grief of those who have lost much, including loved ones, and the on-going questions and concerns related to balancing the economic burden and safety of our citizens.
And there are implications for our healthcare team at large confronting the additional challenges of their own soul wounds in the midst of the fight… that we would honor and bear witness to their stories as well.