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Caring Should Not Require Moral Compromise: Moral Injury in Carers & Health Workers

Writer: Tess Howells
Tess Howells
Sep 4
5 min read

Updated: Sep 5

How self-reflection can help carers reclaim their vital health.

I talk a lot about chronic stress and eventual burnout, but what we haven’t talked about - either here or in workplaces and carer support organisations - is moral distress, or moral injury.


What is moral injury?

Moral injury describes the distress that can be felt when a carer’s deeply held values or sense of what is right, are violated, or when they are prevented from acting in accordance with those values.

The term was first coined to describe what soldiers returning from war often reported - distress about having been ordered to take an action that deeply violated their human values.

Brett Litz and colleagues in their influential 2009 paper, Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy, described moral injury as arising when someone perpetrates, fails to prevent, or bears witness to acts that transgress deeply held moral beliefs and expectations.

Moral injury is now discussed not only in relation to soldiers, but also among healthcare professionals, first responders, journalists, humanitarian workers and carers - people who may be placed in situations where they cannot act according to what they believe is right.


Moral injury is not the same as burnout

Moral injury is different to burnout, though the two often co-exist.

We know that burnout results from chronically high levels of stress, relentless demands and exhaustion.

Moral injury involves something more - a conflict between what we believe should happen and what we are able, or instructed, to do.


My own experience of moral injury

I have experienced this a few times in my professional career.

On one occasion, an educational institution I was working for wanted to use my experience, association and good reputation with local Aboriginal people to seek funding for a multi-million dollar human rights project. After several denied requests to view the budget, I eventually found out that most of those dollars would end up in the organisation’s coffers as “administrative fees” and would deliver very little for the Aboriginal communities.

I resigned.

And when I worked in offshore detention centres on Manus Island, Papua New Guinea and Christmas Island - I found the conditions in which the detainees were being treated and the way we were expected to interact with them (eg. referring to them by their boat identification number rather than their name) deeply violated my humanitarian principles.

The result?

I, and many of my colleagues, were diagnosed with PTSD on our return to Australia.

I suspect this is what is contributing to the current high levels of graduate nurses leaving within their first year of taking up their positions.

Four years of training and practical learning about what good nursing looks like, only to experience limitations in how you can actually deliver the type of care you believe in.

It may explain the loss of health practitioners, teachers, support workers and aged care workers from these vital services across the country, and from rural areas in particular.


When the system is part of the problem

Moral injury occurs when you know what should happen, or how caring should be done - but you feel powerless to enact it, because you are told adequate resources, equipment, services or funding are simply not available.

Or sometimes clinical staff are directed by non-clinical members of boards and leadership teams to deliver services that help achieve budget or shareholder goals but are felt by caregivers as compromises to our standards of care.

As carers, we are attracted to the helping professions because we want to help others, we want to relieve suffering and practice compassion.

When external circumstances prevent us from doing that, we suffer internal conflict - an increasing moral and ethical dilemma for us - between what we believe is the right way to show care and compassion and what our organisational leaders are asking us to practice.

We try to accommodate limitations without impacting our clients or patients. We attempt to negotiate with managers. We undertake tasks in our own time. Sometimes we even provide the resources ourselves at our own cost.

We fill the gaps for as long as we can, but ultimately we feel like Sisyphus - relentlessly pushing boulders uphill until we collapse in despair and hopelessness.


What moral injury sounds like

Common thoughts include:

  • I couldn’t do what I knew was right.

  • I was forced to do something that violated my values.

  • I failed someone who depended on me.

  • Someone else’s needs were sacrificed because the system gave me no alternative.

  • I have betrayed my own values.

  • The people or system that should have protected us failed us.

These thoughts can cause immeasurable psychological distress, sometimes unbearable.


Unpaid carers experience it too

Unpaid carers too experience the same moral dilemma, when they must routinely engage with government departments and agencies to get the support and resources that they know would make a difference to their loved one, but feel unheard and unsupported.

They will also attempt to fill the gaps created by inadequate funding, services and recognition, feeling forced to step into the roles of the nurse, the advocate, the driver, co-ordinator, financial manager, administrator and crisis responder.

Is it any wonder that burnout is such a critical issue in our health and social services sectors and in informal caregiving?

 

We must work together to change this

We know enough now about burnout and moral injury to recognise that we are damaging the very people that our health system relies so heavily upon.

We must work together to change this.


If you recognise yourself in this, you are not alone.

My Carer Fatigue and Burnout course and workshops give carers and health workers practical ways to protect their own wellbeing while the bigger changes are fought for.




Commonly Asked Questions About Moral Injury & Distress


What is moral injury?

Moral injury is the distress felt when a person’s deeply held values, or sense of what is right, are violated, or when they are prevented from acting in line with those values.

The term was first used to describe soldiers returning from war, and is now applied to healthcare professionals, first responders, humanitarian workers and carers.

 

How is moral injury different from burnout?

Burnout results from chronically high stress, relentless demands and exhaustion. Moral injury involves a conflict between what you believe should happen and what you are able, or instructed, to do.

The two often co-exist, but they are not the same thing.

 

Can unpaid carers experience moral injury?

Yes. Unpaid carers face the same dilemma when they know what would help their loved one but cannot get the support or resources from government departments and agencies, and are left to fill the gaps themselves.

 

What does moral injury feel like?

Common thoughts include “I couldn’t do what I knew was right”, “I failed someone who depended on me” and “The system that should have protected us failed us”.

These thoughts can cause severe psychological distress.



Where can I learn more about Thrive Positive Psychology?

For more information about stress, burnout, radical self-care and how to support yourself in your caregiving role, visit:



Or sign up for Tess' online, self-paced Carer Fatigue & Burnout Course. You can download a FREE preview here: https://www.thrivepositivepsychology.com.au/courses


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