A Broken System: Burnout vs. Moral Injury

The Little Physio
Mar 22, 2019
3 min read

Updated: Mar 28, 2019

Burnout! We’ve heard a lot about this in the recent posts and there has been attention on burnout in the last few weeks on social media. One item which caught my attention was a video raising the issue of burnout in healthcare and how the system is the causal factor.

Moral Injury versus Burnout

The video acknowledges the widespread occurrence of burnout and expresses that burnout should be regarded as moral injury instead. Moral injury is described as a “cluster of symptoms...that result from personal experiences, which violate a person’s deepest and most closely held values and principles”, and is more often used in relation to post-traumatic stress disorder.

The presenter suggests burnout is not the correct term to use as it has a victim mentality approach, painting the burnt out individual as one who lacks resilience, resources and strength. Rather than lacking these skills and attributes, they suggest it is the system grinding individuals down to mere skeletons because of conflict between their own morals and values versus what is required of them at work.

With this I whole-heartedly agree. Many of my work colleagues and those whom I studied with are independent, resilient and strong minded individuals. For people to thrive at work and at home, burnout should not be associated with a stigma. Burnout or moral injury is very real and can only be addressed with open and honest communication about the causes.

As a way to address this moral injury and moral conflict, health and wellness retreats and programs are being implemented in healthcare settings. The presenter disapproves of health and wellness implementations in the healthcare setting, suggesting these measures are only ‘bandaid’ approaches and do not address the true issue - the organisations and the wider system.

With this I also agree. We can equip people with resources to manage stress, burnout and compassion fatigue all day, however, if we do not make systemic and organisational changes, are we not just running around in circles?

Why Is There Moral Conflict?

The moral conflict exists between the patient, the clinician’s self and family, and the employer. Here are some examples I can think of that some physiotherapists and other health professionals might face on a daily basis.

Working hours that does not allow for quality time with family
Needing to hit productivity goals to be financially stable for themselves and their family but this then is in conflict with family time if work hours are not amenable to work-life balance
Meeting KPIs or billing a certain amount per patient being in conflict with whether the patient really requires further treatment (e.g. using manual therapy in order to bill more as opposed to heading straight into active rehabilitation (i.e. evidence based practice))
Knowing a patient requires more rehabilitation but they need to be discharged to meet government set discharge targets
Having a huge caseload to see in one day because it meets productivity goals, provides financial stability but leaves you feeling exhausted...then being unable to truly be present for your partner and children outside of work

As physiotherapists, and likely within other healthcare occupations, we seek to be a physio because of a desire to help and care for people to the best of our ability from the heart within us, and from the skills and knowledge accumulated through years of study.

So, moral injury can occur when the altruistic intention is in conflict with things such as productivity goals, key performance indicators and business oriented and profit driven tactics. This could be in a public or private setting.

Final Thoughts

I am not here to argue if moral injury or burnout is the right terminology. Whichever way you want to define it or name it, burnout/moral injury is a huge and existing problem affecting clinicians mental and physical health. And whilst we strive for change to happen so that there is conflict resolution between patient-clinician-employer, whilst we try to address the system that is slowly quashing passionate physiotherapists and other healthcare workers, we still need strategies to manage burnout/moral injury we will inevitably and unfortunately experience. Thus, if mindfulness, meditation, journaling, lavender oil or having a dancing ritual is what is necessary to get you through the day, then so be it as it is for the greater good...until that time comes when there is a shift in the system.

I do hope that one day, in the not so distant future, our entire healthcare system is balanced out in domains of equality, kindness and empowerment for patients, clinicians, employers and organisations so that healthcare workers across all fields are happier and healthier.