Is ‘moral injury’ in the workplace the new burnout?
Our relationship with our jobs isn’t just about pay, conditions and work-life balance – it’s about our values, says Kate Bussmann
‘You feel complicit. It had an impact on how I viewed myself. My mental health suffered’
‘My low point was telling an elderly lady she might have cancer but I couldn’t say when we’d see her’
Sonia Howard (not her real name) was barely a month into her dream job as a project manager at a children’s charity when she discovered that all was not as it should be. For one of her first tasks, she was asked to compile a report to submit to the government department that funded its operations, but when comparing it with their internal reports, Sonia could clearly see she was being told to claim for more money than the charity had spent. Assuming there had been a mistake, she pointed out the “error” to a colleague.“She shrugged and said, ‘We always add some fairy dust.’”
Sonia was shocked. “They were falseclaiming government funding – and not a small sum. I realised that over a year it would add up to hundreds of thousands of pounds of public money.”
After Sonia confided in her husband and friends, her initial impulse was to blow the whistle. “You see all these people senior to you who know what’s happening – they either don’t care or perhaps they were creaming money off the top,” she says. “I felt I should whistleblow, but I knew that if I did, the whole organisation could fold and there were all these people that I worked with who were good, decent people just trying to pay their mortgages and look after their families. Plus, it wouldn’t just have affected them: the services the charity provided to disadvantaged children would have shut down and those communities would suffer, too. Would I want that on my head?
“But on the other hand, I was thinking, what are my ethics? What am I about if I don’t challenge this? You feel complicit: you’re responsible either way. It had an impact on how I viewed myself.”
Her impossible dilemma exacerbated the depression and anxiety she had experienced in the past, and she struggled with sleepless nights, trying to work out what to do. Eventually, she decided her only option was to leave. “My mental health really suffered, but even though I hated it there, I couldn’t just quit – I had my own bills to pay and the jobs market wasn’t great at the time, so I spent the next 18 months trying to get out of there,” she says.
Even after leaving, however, the feeling of disillusionment stuck with her. “I’d always wanted to work for charities and not-for-profits, but I became much more cynical.”
There is a little-known term for what Sonia experienced: “moral distress”, defined as the unease experienced when you cannot do what you know is right. At its worst, it can develop into what is called “moral injury”, which can lead to longer-term psychological harm. But while the terms may be unfamiliar, the ethical catch-22 they describe is familiar to many – as are the feelings of profound guilt, shame and anger that can result.
The concept of moral distress was introduced in the 1980s to describe the psychological conflict nurses experienced when “institutional constraints” prevented them from pursuing the right course of action; later, in the 1990s, “moral injury” was coined by US psychiatrist Dr Jonathan Shay to describe the trauma he saw in military veterans who had witnessed a betrayal of what they felt was right or followed orders they felt were morally wrong. Think of the crumpled faces of the young Russian soldiers in Ukraine when they realise they’ve been fighting on the wrong side, or the astonishingly brave journalist Marina Ovsyannikova, who held up a sign on live Russian TV telling viewers: “They lie to you here.” In a statement recorded before her arrest, she described the emotions that led her to take action: “Unfortunately, I have been working on Channel One, producing Kremlin propaganda,” she said. “I am now very ashamed of this.”
For those who have found themselves on the frontline of a different kind of battle, the war against Covid, moral injury has been all too common. Dr
Emma Hepburn, the clinical psychologist known to her 136,000 Instagram followers as @thepsychologymum, has recently worked in staff support. “Anecdotally I’ve heard more people speak about moral distress and injury,” she tells me. “A clear example of this was patients being unable to see their loved ones face-to-face when unwell or dying, which was very distressing for families and the healthcare workers supporting them.”
Moral injury can also be mistaken for burnout, which is caused by chronic stress in the workplace, but, says Dr Hepburn, it is more specific. “It’s about experiencing situations which violate a person’s values, beliefs or ethics, which can include witnessing, engaging in and failing to stop a situation, or betrayal by a trusted person, which can include their organisation.”
While it is not a diagnosis in itself, the effects of moral injury can include feelings of guilt, shame, betrayal and anger, she says. “And because the experiences have challenged [a sufferer’s] beliefs or assumptions, this may impact on their thoughts and beliefs about themselves, other people and the world. They may turn to unhelpful coping strategies such as drinking or withdrawing from social situations, and as moral injury is linked to mental health difficulties, it is important to look out for signs of depression, which can include low mood and suicidal thoughts, and also PTSD, which may include flashbacks and hypervigilance.”
A British Medical Association survey of 1,900 doctors in early 2021 found that while less than half had heard of the terms, 78 per cent said that moral distress resonated with their experiences at work and 51 per cent said the same about moral injury. Other research has shown that those with a strong ethical code, such as the very religious, are more likely to experience moral distress. The BMA survey also indicated that female doctors were roughly 50 per cent more likely to highlight a “lack of time to give sufficient emotional support to patients” as a factor.
“My lowest point was at the height of the pandemic, having a phone call with an elderly lady whose husband had died four weeks before,” recalls Dr Helen Fidler, a London-based consultant gastroenterologist and member of the BMA consultant committee. “She didn’t have any relatives [sitting in] on the phone call and I had to explain to her that we needed to get her in because she might have colon cancer, but that I couldn’t give her a date when we’d see her. She was in tears and I just felt so helpless. I wasn’t able to give her any certainty. It was really upsetting and at the end of the phone call, I was pretty distressed.
“I’m 59 and I’ve been a consultant for 24 years, so I am fairly experienced, and it’s always been the case that one gets upset if a patient has a bad diagnosis and you have to explain that to them. That comes with the job. It’s an onerous responsibility, and it’s one we take on happily, but things have changed. I think people must be sick of hearing that the NHS needs more money, but what we’re seeing now is the impact of that underfunding.
“Of course, my husband says, ‘You need to leave, don’t work there any more.’ And that’s what’s happening: loads of people are leaving. I’ve stuck with it so far, but I always planned to stay way after retirement age and I don’t think I will now. I’m a bit old and tired, and it’s a little bit too upsetting at times.
“When I applied to medical school, they said, ‘Don’t whatever you do say at interview that you want to help people, because they’re sick of hearing that.’ But that is why I want to do it – that’s what makes the job so joyful and such a privilege. But if you’re working in a situation where there are constraints that prevent you from doing that to the standard you know people are entitled to, it becomes a nightmare. Every single working moment you can find yourself faced with guilt and blame, and anxiety that things are about to go wrong. So rather than it being a positive thing, this responsibility becomes a two-edged sword.”
Of course, it’s not just in life-or-death situations where you can find yourself questioning whether a job aligns with your personal moral compass. And more and more of us are deciding, when faced with those dilemmas, that we just won’t put up with it any more. Brits are quitting their jobs at the highest rate since 2009 – a trend economists have called the Great Resignation. But interestingly, while you might assume that it is about work-life balance or the pursuit of a higher salary, it is our principles and values that are the biggest driving factor. According to a new study by US company Revelio Labs, which analysed employees’ reports on the jobs site Glassdoor, toxic workplace culture is more than 10 times likely than low pay to predict a high attrition rate within a company.
So how can you work out if the culture of a workplace aligns with your own moral compass when you’re looking for a new job? Reviews from current and former employees on sites like Glassdoor are a good place to start, and while interviewing, look for positive signs like an open culture – and red flags like a high rate of attrition.
It is seven years since Sonia left her job at the charity, which has since closed. She now works for an organisation that, while not perfect, is “much more straight down the line”. But the experience has left a mark and she is far more cautious. “In interviews, I ask a lot more questions that unpick the culture of the organisation – and I try to avoid roles where I have to play any part in the financial claims – keep me away from that!”