Images of distraught, exhausted doctors and nurses fighting to save the lives of Covid patients have shocked the world in the past year. These medics faced some of the most difficult decisions of their careers when hospitals became overwhelmed and equipment ran out. Who to ventilate? Who to give a bed?
It might not be a case of life or death, but many of us compromise our moral values in the workplace, from the HR manager who has to let go decent staff to the lawyer defending someone she knows is guilty. The consequences can have a serious impact on health and wellbeing.
This was Dave Nilsson’s experience at the start of the pandemic when his digital marketing company suddenly became overwhelmed with work. As director, he felt duty-bound to honour the deadlines already promised to clients, but this meant asking his team to work extra hours while they were still adjusting to the challenging circumstances of the health crisis. “Even though I had the authority to ask people to work extra, I didn’t have a good feeling about it. I started to overthink and re-analyse things,” he said.
These uncomfortable feelings intensified as Nilsson became aware of the personal issues his team members were experiencing. “[One employee] didn’t turn up because they had a big fight at home, and somebody else had a break-up,” he said. “The volatile nature of the pandemic meant that if something like this happened, it felt more amplified and induced more stress. It was an emotionally challenging time for everyone and I had the feeling that I might be contributing to more stress for my employees. I felt guilty.”
Moral injury or burnout?
When our ethics are compromised at work, it can feel uncomfortable. If they are compromised too much, our feelings can develop into something much more painful. According to Professor Neil Greenberg, a forensic psychiatrist and researcher at King’s College London, moral injuries cause deep psychological pain and shake the foundations of how we view ourselves as individuals. “A morally injurious event just doesn’t fit with your belief systems, which are the way that we understand how the world works,” he said. These feelings of deep discomfort can be hard to shake. “The more you think about it, the more it doesn’t make any sense, the more it shouldn’t have happened.”
The term moral injury was first coined in the 1990s to describe the painful sense of moral disorientation felt by the military returning from war. Later, the term was also used to describe the experience of healthcare workers facing similarly distressing circumstances.
Among healthcare workers, moral injury is often mistaken for burnout, yet there are significant differences between the two occupational phenomena. Burnout is described by the World Health Organisation as a reaction to “chronic workplace stress” whereas studies define moral injury as “the anguish that occurs in response to moral adversity”. There is a sense that someone knows what to do, but cannot do so because the situation is out of their control. This can cause intense feelings of anger, guilt and shame, which can lead to serious psychological issues including PTSD, depression and suicidal thoughts.
The pandemic has highlighted moral injuries experienced by frontline workers such as healthcare workers, social care workers and prison staff, but it’s not only employees in highly stressful work contexts who are affected. Greenberg says anyone can experience a moral injury if they are exposed to a situation that “strongly clashes with their beliefs” such as being consistently passed over for promotion in a way that you feel is unfair. “You’re just tired of that,” he said. “For you, what’s happened is not right. Potentially over time that can start to seriously affect the way you feel about the world, and also about your job.”
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Moral distress vs. moral injury
A 2016 Harvard study found that breaches of our values are relatively common in the workplace. Some 41% of workers reported seeing ethical misconduct in the previous 12 months and 10% felt organisational pressure to compromise their ethical standards. But not all of these situations that cause moral distress result in moral injury.
Greenberg describes a scale of morality in the workplace: at one end are people who feel well; at the other are those experiencing moral injury. In the middle there are shades of moral distress. “We all in the world have our set of beliefs that we establish about what’s right and wrong,” he said. “When something happens that you think is wrong, it can cause you to experience distress symptoms, which many, many people probably do have.” The distress is based on two questions: “Did I do the right thing?” And, “Should that have happened?”
One study found that ICU nurses affected by moral distress were likely to experience adverse effects on their wellbeing and self-image. It can also affect motivation, as Petra Odak found when she worked as a social media manager. It was her first professional role, and she found herself morally compromised when one of the client accounts she managed received frequent online complaints from customers—which she completely agreed with. “The client wouldn’t allow us to ever admit a mistake or agree with the customer,” she said. “It was against all the rules that I learnt in my marketing studies at university.” And it made her feel bad. “I didn’t feel like myself,” she said. “I did it because the client asked for it and that was my duty, but I wasn’t happy. I was just doing the job.”
What does moral injury feel like?
Jennifer was no stranger to dealing with ethics in her role as assistant director of student conduct at a university in the US. Her job entailed investigating ethical issues on campus to establish whether university rules had been broken, from underage drug and alcohol use to sexual misconduct. However, Jennifer struggled with the fact that her decisions had a long-term impact on young lives. “I had to make decisions that ruined the future education of students,” she said. “There could be very severe punishment, including expulsion, suspension, or losing a scholarship or student housing.”
Jennifer said delivering investigation outcomes to students was “always a tense time”, but this moral distress evolved into moral injury when her own conduct was called into question publicly and painfully. “A group of students publicly came after me and questioned my competence,” she said. “They posted flyers all around the campus asking for me to be fired.”
University administrators found that Jennifer had acted correctly, but the experience was deeply painful. She felt angry and ashamed at the unfairness of the situation. “I began drinking more, I couldn’t sleep because I was so upset by having to go back to work every day,” she said. Her relationships with friends and family suffered. “I just wanted to leave my job and find something else but I was so depressed. Nobody would have hired me because I was such a mess.”
Healing the wound
Dr Amy Bradley of Hult International Business School specialises in compassion and engagement at work. She believes moral injury has such a profound effect because it has a drastic impact on our resilience levels. “Our personal resilience is most depleted when our sense of purpose is the source that’s being stretched,” she said. Greenberg agrees that the impact can be severe. “It is a wound, and of course the challenge is, how do you get that wound to heal?” he said.
Put it in context
According to Greenberg, people experiencing moral injury may blame themselves or those around them for events that caused distress, but often “there is no right answer”. Part of healing is finding a way to accept “what sounds quite a depressing position—which is accepting that actually, the circumstances were pretty rubbish. But everyone was in that same storm together and trying to do their best.” This helped Nilsson temper his feelings of guilt for asking employees to work overtime. He reasoned that while the extra workload could cause stress, failing to deliver to clients could have the same effect.
It’s good to talk
Bradley suggests talking through the painful event with those you trust, inside and outside work: “[It] can also help you see these experiences through a different lens to your own.”
Nilsson opened up to his team. “It started with feedback on the situation where everyone had their input about what they were struggling with,” he said. “In response to that, I communicated about my mental state too and instilled them with a sense that we were all in the same boat.”
Treat it as a learning experience
Ultimately, Bradley believes that self-reflection on a moral injury can have a transformative effect. “These moments of discomfort, in many ways, can hold the most learning for us. If we just take the time and space to reflect on them.” This was the case for Odak. “At the time I was just starting my career, I would listen to everything that people said. Now, years later, I would fight more for my opinion,” she said.
Jennifer has taken this to another level by starting a company that specialises in reputation repair coaching. After her recovery, she felt the desire to “help other people move through the experience and regain their confidence”.
It brings her job satisfaction as well as putting her own moral injury in context. “It helps me regain my confidence in knowing that I can affect people’s lives in a very positive way,” she said. “And it has also helped me with my own healing because I hear other’s stories. It makes me step back and say, okay, in the big scheme of things, what happened is really not that devastating.”
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