Ohio Nurse - March 2021

Page 8 Ohio Nurse March 2021
Moral Injury in the Nursing Workforce
Cynthia Hammond, PhD, MS, RN, and
Shirna Gullo, DNP, MSN, BSN, RN
Kettering College Division of Nursing
Marquis and Houston (2017) emphasized the
prevalence of key terms identified to “describe the moral
indifference, moral uncertainty, moral conflict, moral
distress, moral outrage, and ethical dilemmas” faced by
nurses (p. 85). However, this list of terms did not include
moral injury. Moral injury was coined by the psychiatrist,
Dr. Jonathan Shay. Dr. Shay studied military veterans
that suffered from Post-Traumatic Stress Syndrome
(PTSD). He defined moral injury as a “betrayal of what is
right by someone who holds legitimate authority in a high
stakes situation” (Delima-Tokarz, 2017, p.1). As a result
of this research, Dr. Shay discovered that while soldiers
were in active duty, they could reconcile their own moral
values with military duty but when they returned to
civilian life, the same moral conflicts, caused the soldiers
internal distress or moral injury (Delima-Tokarz, 2017).
The purpose of this article is to discuss and explore
the following questions: Can the same moral injury seen
in military veterans be seen in nurses that fight the battle
of COVID-19 and the regular day-to-day challenges in
healthcare? Are nurses at all levels of the healthcare
organization, at the bedside and in administration having
to face internal and external demands that compromise
quality care, or patient and individual safety that could
lead to moral injury? What recommendations can be
integrated to help identify and intervene early in actual or
potential moral injury dilemmas?
According to the Ohio Nurses Association (2020),
moral injury can be defined as “the feeling that occurs
when we are prevented from doing what we believe
is right. We feel compromised in our ability to practice
as moral agents according to our Code of Ethics.” The
Code of Ethics for Nurses is the profession’s public
expression of those central ethical values, duties, and
commitments (ANA, 2015). Finally, Dictionary.com
(2020) defined moral injury as concerning itself with
right and wrong principles of behavior.
Exactly who or what becomes the compass of
assessing moral principles to determine what is
acceptable behavior by an individual or society?
(Delima-Tokarz, 2017). Perhaps, it is an internal
moral guide that directs how we live our daily lives
and actions? On the other hand, Beard (2019) found
moral principles represent treating others the way the
individual wants to be treated (being treated fairly),
speaking truth and avoid telling a lie (building trust),
avoiding spending what you do not have (living a
personable affordable life), and avoiding taking what
does not belong to you (building honesty). The moral
code is comprised of building blocks that construct
society’s culture (Beard, 2019). If our individual moral
code is damaged, a moral injury has occurred (Delima-
Tokarz, 2017). Therefore, each nurse and nursing
leader can turn to the nursing process which is the
framework at the heart of the provision of nursing
practice to help identify and rectify situations causing
actual or potential moral injury. Utilization of the nursing
process allows the nurse to promptly assess, diagnose,
plan, implement, and evaluate issues directed at
themselves, the patient, co-workers or the organization.
Nurse Burnout Versus Moral Injury
Dean, Talbot, and Dean, (2019) posited that the
difference between burnout and moral injury must
be identified because a better understanding will
reframe the problem and the solutions. The term
burnout indicates that an individual cannot withstand
something in the work environment. “Over the last 10
years, burnout has become a significant psychosocial
problem that is caused by unsuccessfully managed
chronic stress in the workplace. It is a psychological
syndrome characterized by energy depletion, increased
mental distance from one’s work (i.e. cynicism or
negativism), and reduced professional efficacy”
(WHO; ICD-11; 2013; 2018 as cited in Raudenska et al.
(2020). Because burnout is an internal and individual
problem, then a solution to burnout is to fix the internal
deficiency. Alharbi et al. (2019) identified anxiety,
depression, decrease in satisfaction, diminished quality
of care, PTSD, and an increase in suicide rates as
prevalent in healthcare professionals experiencing
burnout. This is contrasted with moral injury, which is a
description of knowing what care is needed for patients
and being unable to offer the care or treatment, due to
barriers beyond the control of the nurse (Dean et al.,
2019).
The moral injury debacle of the COVID-19 pandemic
has placed extreme pressure on the nursing workforce
daily with morally challenging dilemmas (Duhig, 2020).
According to Duhig, the morally challenging dilemmas
are being described as: fear of not being able to
protect the patient or self because insufficient supplies
of personal protective equipment (PPE). Nurses are
not able to provide quality care to patients. Nurses
are taking on roles that they are inadequately trained
to implement. Moral injury can be caused by severe
understaffing, poor team communication, conflict with
physicians about patient care, physician-only input into
clinical decisions, and clashes between physicians
and nurses regarding inappropriate use of resources
(Duhig, 2020).
Moral injury is present among nurses when nurses
feel that high standards of patient care are not being
met, personal values cannot be lived up to, personal
negative feeling of being devalued and voiceless which
can lead to shame or guilt of and mistrust of colleagues
and organizational administrators. The long-term
effects of moral injury can lead to mental health threats
(National Center for PTSD, n.d.). Marquis and Houston
(2017) echoed this point by saying that “nurses are
often placed in situations where they are expected to
be agents for patients, physicians, and the organization
simultaneously, all of which may have conflicting needs,
wants, and goals” (p. 84). Nurse leaders and nurses
need to implement strategies to reduce the incidence of
moral injury.
Nursing Solutions for Moral Injury
Nurse leaders can support nursing teams by
presenting moral injury as a lens to talk about personal
experiences. This informal peer group can be referred
to as “soul repair” (Duhig, 2020, p.1) The overarching
goal of supporting nurses is to move from an analysis
of the problem to a vision of a positive outcome (Duhig,
2020). This change in perspective and shared vision
can lead the nursing organization through the following
recommendations by Duhig (2020) and Dean et al.,
(2019):
• The nurse leader should focus on what small
or large steps can be taken to obtain a sense of
fulfillment.
• The nurse leaders can also reevaluate workflow,
revise team communication, strive to identify and
eliminate episodes of poor time management,
eliminate inefficient use of resources, and curtail
ineffective processes in daily practice and
operations of the departments (Duhig, 2020).
The healthcare team and nursing administrators
must work together to identify the problems that prevent
clinicians and other healthcare team members from
building trust and providing optimal care. The quality
and safety of patient care must be changed to put the
patient first instead of letting business practices drive
treatment options (Dean et al., 2019).
In a recent article by Dean et al., (2019),
recommendations given to address moral injury are
summarized below:
• Invite and expose administrators to the
innerworkings of the clinical environment. The
administrators and the clinician’s make-up the
interprofessional healthcare team. These two
parties must engage each other on a common
ground. If administrators would work a shift with
a clinician in various areas such as a clinic or the
emergency room, they would be exposed to the
challenges experienced by the nurses. These
encounters would expose administrators to the
depth of the challenges that occur in the system.
Clinicians need to be open-minded to see
the challenges from the overall administrative
perspective. Having an understanding from both
perspectives is where commonality and happy
mediums are found, and shared visions are
explored.
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