So I have no disclaimers or any conflicts with this talk. Our learning objectives, of course, we're going to talk about moral injury. I will be discussing the scales, how to assess, and the signs and the symptoms and the impacts of moral injury today. Morally stressful events leading to moral distress has become the focus in the wake of the COVID pandemic due to the lack of resources and the changes in our clinical practice. The concept of moral injury, as Ron was just talking about just a little bit ago, that it goes back to the military veteran literature, which defines it as a wound that results from doing something that violates one's own ethics, beliefs, ideas, or attachments. Primarily focused on the military-related issues, some of the events occurring would be injuring or killing combatants, failing to protect fellow soldiers or civilians, or betrayed by a leader or a fellow service member, or a fellow service member that holds legitimate power. Moral injury was introduced by the Veterans Affairs psychiatrist Jonathan Shea to describe an experience not adequately described by post-traumatic stress disorder. Whereas post-traumatic stress disorder originates from frightening or dangerous events, Shea identifies moral injury as a psychological trauma resulting in a betrayal of what is morally correct by someone that holds legitimate authority or in a high-stakes situation. How do I go back? Oh, shoot. Sorry. I'm sorry. I clicked it too fast. My apologies. OK. OK. I'm pushing buttons too fast. My apologies. OK. Liz and colleagues describe exposure to potentially morally injurious events that may lead to a wide range of biological, psychological, or spiritual outcomes, ultimately manifesting in a severe distress or functional impairments known as moral injury. Moral injury occurs in health care workers that bear cause, bear witness to, or prevent the act that transgresses our deeply held moral beliefs and ethical principles. Autonomy is one of the ethical principles in the health care workers that struggle during the COVID pandemic in this respect of a person's freedom to choose what is right for them. It was difficult for some of the health care workers to let the patient's freedom of not to get the COVID vaccine and for some organizations requiring health care workers to get the COVID vaccine and making it very, very difficult for those that refused to have the vaccine and continue to work. Beneficence is being aware of a person's culture and religious belief, which will help determine the good towards onto them. Beneficence has been compromised greater engagement with leadership to design improved systems, which is more likely to result in less burnout and a reduction of workload or decrease administrative burdens. No more of a sense to do no harm was developed not only to protect patients, but health care workers as well. And justice is to treat and provide care to all patients. Justice also impacts health care workers, and the team members deserve equal chances of assisting in the decision making process. In health care, we are expected to hold strong moral beliefs in where the moral compass and held high ethical standards to take care of our patients. When our morals and ethical standards are being violated, moral injury can be the end result. Moral injury in health care context is solely rooted in the guilt related to experiencing conflict between what is known for the best care of the patient, but being unable to adequately take care of our patients due to the constraints beyond our control. Moral injury is not a new concept. As a service member in non-war time in Guantanamo Bay, Cuba, there was an influx of patients, refugees, Cuban and Haitian refugees. The medical staff and supplies were very limited then. And I think that medical staff and the soldiers, some military staff had conflicts with taking care of the patients with the same acuity. Do we take care of the service member, or do we take care of the refugee first? The Ebola outbreak in 2014 in West Africa, the case fatality was 50%, and that included health care workers taking care of those patients. There are many countries where patients have to pay prior to services rendered. Some patients are still waiting years for their surgery that they've already paid for. Some patients that are requiring blood transfusions must ask the family member to give them those transfusions for them to receive the care. These are just some examples of what health care workers have been exposed to and struggle with moral injury. Moral injury is not a benign syndrome. Moral injury has been associated with numerous mental health outcomes, including depression, anxiety, increased risk of suicide. Now for some, violating one's moral beliefs in a high stakes situation can be very debilitating in their functioning of their life. However, others are affected, and it's disturbing, but they can continue with their functioning. Symptoms of moral injury are emotions of anger, shame, guilt, and have strong negative beliefs to oneself and others. It can lead to estrangement and risky destructive behaviors that can be in such a severe magnitude that can impact and cause chronic symptoms and with clinical relevance. There are three scales. Two are military. One is the military injury scale, and the other one is the expressions of military scale. Most recently, the moral injury scale for health care workers is defined by Mentory and Colleagues. They developed this scale for health care workers during the COVID pandemic to assess and identify clinically significant moral injury and to evaluate interventions for the health care workers. Although that there has been progress in screening for moral injury for former and current military personnel, there still remains a large gap between what is known with the occurrence of the moral injury and the medical malpractice. There still remains a large gap between what is known with the occurrence of moral injury against physicians, nurses, and health care workers in working long hours in high-stakes situations. The scale was introduced at the Duke University Health Care System. They sent surveys out to physicians and nurses. They assessed 10 dimensions of moral injury based on the writings and the research of experts. They assessed betrayal, loss of trust, forgiving religious struggles, and loss of religious faith. Currently, this is the only scale that measures the psychological and the religious symptoms of moral injury that can be so significantly functional impairment with family, social, and occupational functioning. They found that the moral injury symptoms assessed were positively associated with health care workers in making medical errors, which suggests that moral injury can be the cause or the consequence of these clinical mishaps. It is strongly associated with clinical burnout. For the diagnostic criteria, currently, there's not a gold standard in treating moral injury. This is particularly problematic because there are currently wide-varying uses of the term without clear agreement of what it is and what it is not. For some scholars, they've argued that moral injury has a formal psychological diagnosis, and others have decided or proposed an injury syndrome, identifying system domains of the diagnostic criteria. Another possibility is to consider it as a trauma characterized by different predominating emotional stress, and to evaluate how trauma subtypes might clinically or respond differently to existing treatments. There is no question that moral transgressions affect health care workers' moral well-being. Moral injury is strongly associated with clinical burnout and job abandonment. There is a difference between burnout and moral injury, as burnout is within oneself, while moral injury is associated with constraints within the health care system. Moral injury has plagued health care workers well beyond before the pandemic. The economic and institutional pressures have exposed health care workers with conflicts, knowing what is best for the patients, but unable to provide those due to the constraints beyond their control. These conflicts have affected health care workers at the point of some have left the profession. One physician was my physician, and she actually left to be a stay-at-home mom. There was another physician that I know that left the profession, and she is a life coach virtually. For some nurses left the organization, left their retirement to be a travel nurse to get paid higher due to the balance of frustrations within the health care organization. The cost of turnover is not just monetary. It involves morale, productivity, burnout, and most importantly, safety concerns with adequate staff. The relationship between organizational factors and moral injury among health care workers is a result of betrayal by leaders that hold authority, particularly in high-tense work environments. Breaches of trust by the leaders intentionally or unintentionally through organizational policies and practices can erode patient satisfaction or work engagement. Moral injury does exist in the health care organizations. Leadership should acknowledge the impact of moral injury between their health care workers and their organization. Leaders should develop trust, be committed to the health care employees, and provide effective practices within the health care system. And this should provide family health care satisfaction and retention and ultimately improve patient care. Thank you.

moral injury

healthcare workers

ethics violation

COVID-19 pandemic

resource constraints