Open Book


It's Not Burnout! It is Moral Injury: Why Should Regulators be Concerned?

The concept of Moral Injury is relatively new to health care but closely related to the notions of burnout and moral distress. This article is based on a 2020 Annual Meeting Webinar presented by Nancy Kirsch. 


While there is a lot of discussion around burnout in the physical therapy community and health care professions in general, it may be more beneficial to examine moral injury. To understand the difference between burnout and moral injury, we first must understand what causes burnout.

Job satisfaction is a combination of work-life balance, a sense of accomplishment, compensation, growth opportunities, job security, and a positive work environment. The average person spends about a third of their life at work, or about 90,000 hours. Health care providers tend to spend more than a third of time at work, about 111,000 hours, and they tend to spend more time "working" outside of work.

While health care providers often go into the profession eager to serve patients, there are many aspects of the job that can cause them to become disengaged and unsatisfied. These include excessive paperwork, government and payor demands, lack of independence, declining remuneration, and productivity standards. When the system changes so quickly that providers cannot keep up, that also increases uncertainty and dissatisfaction. They often need to do more with fewer resources in an ever-changing landscape.

Job dissatisfaction among health care professionals can have many negative effects on public protection. Patients may experience harm related to provider error, or they may lose trust in the provider. Providers may deal with damage to mental health, substance abuse issues, or even suicide—unfortunately, health care providers have a higher than average suicide rate. Ultimately, this costs the health care system and decreases the ability of the profession to grow.
Before we attempt to address the issue, we must fully understand it. What exactly is burnout? We have been using the term since the 1970s. Christina Maslach initially described the syndrome:

  • Emotional/physical exhaustion
  • Depersonalization
  • Reduced personal accomplishments
  • Feelings of ineffectiveness

The term burnout suggests the problem lies with the individual. Perhaps the individual has realized that the profession they chose is not right for them, causing them to burn out. The individual needs to figure out what the issue is themselves and get back on track. Occupational burnout in the general public is 28 percent, but among physicians it is 44 percent.

However, does burnout really describe what is happening to health care providers? Or could something else be happening? In general, physical therapists are not saying, "I don't want to be a PT," they are saying, "I am not able to be the kind of PT I want to be." There is a significant difference between those statements.
If it is not burnout, what is it? Here is where we look to "moral injury," which is probably a more appropriate term. Moral injury occurs when someone is exposed to Potentially Morally Injurious Events (PMIE). Shay et al. first used the term moral injury in 1998 in reference to the military and Post Traumatic Stress Disorder. The original definition has a few components:

  • Present when there is a betrayal of what is morally right.
  • The betrayal is by someone who holds legitimate authority.
  • The individual is in a high stakes situation.

This can certainly describe some health care situations and environments. When someone witnesses harm, fails to prevent acts of harm, or perpetrates harm, this causes damage to one's conscience or moral compass. For example, if a provider is unable to provide high-quality health care or cannot heal, these actions can conflict with the "calling" many of those who enter health care fields feel.

Unfortunately, conflicts of interest abound. Often the financial goals of hospitals, health care systems, insurers, patients, and, yes, even clinicians, all can work against the primary goal of providing care. Additional obstacles can relate to system conflicts such as electronic medical records, litigation, patient satisfaction ratings, and referrals for financial gain.

Therefore, we are left with an untenable demand. Providers are often asked to act in the interests of some entity other than the interests of their patients.

Compared to burnout, which implies that providers feel overwhelmed because of their position, moral injury shifts the focus. It is not just the fact of being a health care provider; the system and culture are the issues. This whole concept of moral injury is very new, and the application and understanding of it are rapidly evolving. The idea may result in oversimplifications and misunderstandings of the impact of moral injury in health care.

It would be an oversight not to examine moral injury in the context of COVID-19. The pandemic obviously causes many issues for the health care system and health care providers. There is a cognitive imbalance; there is a feeling of total disruption. The onslaught of information is difficult to parse through. Additionally, there was a failure of moral expectations. Some advanced this concept of us all being in this together, yet, are we really in it together if people are not taking personal responsibility? Are we in it together if providers do not have a reasonable patient load, sufficient numbers of respirators, and access to necessities such as personal protective equipment? Those factors result in moral injury, a collapse of moral emotion, and moral fatigue.

Regulators should care about this because reducing moral injury will improve morale. If we improve morale, we will reduce safety risks. If we reduce safety risks, we improve patient care and protect the public. There are significant costs to moral injury. It strains human resources and economic resources. It also undermines the health and welfare of health care providers, adds to a system of dysfunction, and ultimately reduces the quality of the services provided, which undermines patient safety.

So, where do we start? There are temporary measures society can take. For example, Code Lavender teams provided healthy snacks and water and aromatherapy inhalers at the Cleveland Clinic. People sent pizzas to workers during the crisis in COVID-19 in New York. Additionally, things like resilience training, practicing mindfulness, and meditation and relaxation techniques can all help.

However, ultimately, these types of initiatives are Band-Aids. We need changes that are more permanent to minimize moral injury.
There has been a call to expand the traditional "Triple Aim" approach to health care and add a fourth aim:

  1. Controlling Cost
  2. Improving the patient experience
  3. Improving population health care
  4. Address clinician burnout (New)

What could be some of the root causes of moral injury? A lack of resilience or ability to adapt and cope? Unrealistic expectations of what the profession will be like? The overall health care system? The financial reality of the return-on-investment on training and education?

Regulators play an important role because this cannot be done individually; it requires fundamental systemic changes. As a regulatory community, the first thing we need to do is acknowledge that this exists. We need to make providers and students aware that this is not just happening to them. We need to do more research to really understand the root causes and the connections to patient care. We need to encourage remediation to help gain the passion and spark back for what they want to do. As regulators, we need to consider what systemic changes we can make to help prevent and address moral injury. Regulators need to know more. Are PTs and PTAs experiencing the symptoms of moral injury? Do our regulations support or deter healthy practice? What tools can we offer? We need more research to make robust, evidence-driven changes across the health care system.

If we neglect this issue, the short-term effects include depression, substance abuse, and attrition among practitioners, all of which affect patient safety.

The long-term effects are even worse. If self-selection into health care shifts away from those who want to help to those who, by their actions and conscience, are not affected by moral injury, we are looking at a dystopian future of health care.


Nancy R. Kirsch, PT, DPT, PhD, FAPTA

Nancy R. Kirsch, PT, DPT, PhD, FAPTA received her PT degree from Temple University, her Masters in Health Education from Montclair University, Certificate in Health Administration from Seton Hall University, her PhD concentration in ethics from Rutgers University (formerly UMDNJ), and a Doctor of Physical Therapy from MGH Institute of Health Professions. She practiced in a variety of settings including in-patient rehabilitation, acute care, long term care, and home care. She owned a private practice for twenty years and currently practices in a school based setting. In addition, she is the Director of the Doctor of Physical Therapy Program at Rutgers, The State University of New Jersey. Nancy has been a member of the New Jersey Board of Physical Therapy Examiners since 1990 and was chairperson of the board for twelve years. She served as an evaluator for FCCPT. Nancy has been involved with the Federation of State Boards of Physical Therapy in the following capacities: she served two terms on the Finance committee and also served on several task forces, in addition to the Board of Directors. Nancy has been active in the American Physical Therapy Association since she was a student. She served the New Jersey Chapter as Secretary and President, and as a delegate and chief delegate to the House of Delegates. She served the national association as a member of the ethics document revision task force. She also served a five year term on the APTA Ethics and Judicial Committee and the APTA Reference Committee. She received the Lucy Blair Service Award and was elected a Catherine Worthingham Fellow from National APTA and received an Outstanding Service Award and the President's Award from the FSBPT.