Burnout, moral injury and moral distress are bubbling up in the workplace. But how are these concepts connected?
Sharing this IOSH Magazine Article
The concept of burnout was not new to OSH professionals and employees when the World Health Organization (WHO) defined it as an occupational phenomenon in the 11th Revision of the International Classification of Diseases (WHO, 2019), but the concepts of moral injury and moral distress may be much less familiar.
Research on these ideas has typically only been undertaken into the experiences of people working in the military and healthcare – those who are required to make decisions with life-or-death implications. But now the impact of moral injury and moral distress is beginning to be explored in the wider workforce.
The term ‘moral injury’ was coined by psychiatrist Jonathan Shay in 1994 following his work with traumatised Vietnam War veterans. Defined as ‘a strong cognitive and emotional response that can occur following events that violate a person’s moral or ethical code’ (Williamson et al, 2021), moral distress is seen as the precursor to moral injury – which is when it is experienced repeatedly and with long-lasting effects (Lewis et al, 2022).
‘Moral injury happens when somebody has witnessed or failed to prevent an action or situation at work that goes against their own values or beliefs,’ says Cara de Lange, CEO of mental health and wellbeing consultancy Softer Success. ‘This hasn’t really been looked at in a business setting. We came across more and more clients in situations like this and decided that we needed to do some research into it. There seems to be more trauma-infused burnout that is linked to moral injury as an effect of things that have been happening over the last couple of years.’
Dr Rachel Lewis, co-author of the report and reader and programme director at Birkbeck, University of London, says it’s clear that moral injury at work is a global issue and is not restricted to war zones or hospital wards. ‘Given that it is linked to a range of outcomes, including turnover and burnout, it is something organisations need to understand and take action to avoid.’
Psychological safety
THE ROLE OF OSH PROFESSIONALS
In terms of ‘moral-injury-induced burnout’, this feels like it aligns more with safety culture and climate, and is no different to psychological safety. As with any potential health and safety risk, understanding the causes and potential mitigation is important. However, this isn’t any different in terms of management – it’s about stress risk management, enabling effective communication andengagement with staff, and promoting psychological safety.
You need to address the organisational nature of the problem if you want to help the individual. OSH professionals need:
- Self-awareness, as they may often be the victim
- Knowledge of the causes of moral injury and burnout and interventions/treatment
- Access to psychological support for at-risk workers
- Good communication skills so they are able to have conversations with both management and workers to address the underlying cause
- The ability to work with others to identify and manage the problems
- The ability to be fair and compassionate
DEFINITIONS IN HEALTH AND SAFETY
Dr Karen Michell, IOSH research programme lead, occupational health, has seen examples in OSH settings when contractors and subcontractors are paid bonuses if they have injury-free projects.
‘So, in some cases where an injury then happens, the employer fails to disclose it to the client in an effort to secure the bonus,’ she says. ‘The worker is then left in an unfavourable situation and the OSH practitioner feels helpless to do anything.’
“MORAL DISTRESS HAS BEEN INCREASING OVER THE LAST SIX TO NINE MONTHS AND WILL INCREASE EVEN MORE”
Moral distress was traditionally explained as the ‘injurious impact on a healthcare worker who saw a person die because they did not have the resources to assist them’, Karen says. ‘We now understand that where an employee witnesses or prevents an action that goes against their morals – such as nepotism or corruption – over which they have no control or ability to intervene, they are experiencing moral distress.’ This could mean discriminatory behaviour, a failure to respond to complaints or whistleblowing, or a failure to comply with legislation.
Lewis et al (2022) found that moral stress and injury in business settings led to stress and burnout, and physical health repercussions. Many sufferers left the organisation, either immediately or after a period of reflection.
TACKLING MORAL INJURY
Cara uses the analogy of a glass of water on the verge of overflowing. ‘We start off with the pandemic, then the Ukraine war and the cost of living crisis and uncertainty. Not only are people scared, but there’s also a feeling of change and a shift in what they want from life and their values. If this goes on for too long, and it’s not responded to, it turns to moral injury and we see burnout happening.
‘Moral stress and moral injury have been increasing over the last six to nine months and will increase even more. Hence the need for workplaces to change.’
But unlike the burnout that comes with overwork, moral stress and moral injury are more complex to tackle. This means that they are not given the same focus, often going undiagnosed and untreated, according to Karen.
‘The events experienced and witnessed are often beyond the control of the individual, but still cause internal moral conflict,’ she says. ‘For example, victims will often not share their experiences because they feel guilty and ashamed for letting the situation happen.’
Ann Diment CFIOSH, health and wellbeing officer at Somerset Association of Local Councils in the UK, points out that OSH professionals are probably more at risk of this kind of stress and injury than others. ‘I’d had so many experiences previously of being a target of harassment or bullying, or being ignored completely for trying to get people to adhere to the organisation’s principles,’ she says.
TOP TIPS
HOW OSH PRACTITIONERS CAN HELP TO DRIVE CHANGE
- Make whistleblowing services and fraud hotlines for anonymous reporting available
- Check in with staff to find out how they are feeling
- Ensure that policies apply to all, protect the vulnerable and are enforced
- Ensure rules and procedures are clear, concise and enforced fairly
- Ensure there is clear communication that includes allowing staff to raise concerns knowing these reports will be taken seriously
- Discuss the topic openly so workers understand it is a reality and can contextualise their emotions and feelings
- Ensure the supply of resources including PPE and anything else that is needed to create a safe and healthy workplace
- Ensure workers are well trained on processes and procedures. Planned observation will help verify their understanding of their role and responsibilities
- Train managers to identify and cope with scenarios that may lead to moral distress or burnout.
OSH’S ROLE
Knowing the difference between burnout and moral injury is the first step for OSH professionals to take to tackle these issues, Karen says. ‘They need to understand what the risk factors are for each of the problems, noting there may well be overlap in some areas.’
For example, moral injury may stem from the consequences of a lack of human and physical resources needed to protect workers; failure to apply policy consistently; performing normal activities in challenging circumstances; loss of life through a workplace accident; or a lack of social support, Karen says. ‘However, burnout may be the result of a lack of autonomy, poor working conditions, poor organisational culture, bullying or long working hours.’
Building a positive safety culture, and improving sustainability and equality, diversity and inclusion is a key part of OSH professionals’ role in tackling the issue. IOSH’s Catch the Wave programme aims to help businesses put OSH at the heart of their sustainability efforts through tools, learning and guidance, as well as its new ethical practice module in Blueprint.
Karen says that OSH professionals should understand the circumstances workers find themselves in – for example, low-income and vulnerable workers often must choose between the financial consequences of losing their job and the moral imperative of doing the right thing by raising a complaint.
‘Include an assessment of these risks in the risk assessment and report to the powers that be,’ she says. ‘These less tangible risks are seldom included in risk assessments, and this may well be because we are unsure how to manage them and have no solution. Or there may be organisational pressure not to include them.’
At an organisational level, Cara suggests looking at policies and systems to see if they could cause moral distress and burnout. This includes measuring levels of wellbeing, developing a binding mission statement from the top of the organisation that commits to addressing any issues that impede wellbeing, and having wellbeing as a business goal.
GLOBAL VIEW
BIG PICTURE ON BURNOUT
The rise in stress caused by moral injury has global relevance.
‘People who go off to war are exposed to moral injury,’ Karen Michell says. ‘Healthcare workers in low- and middle-income countries are very likely to be presented with situations where they lack resources to render the level of care they would like to.
‘Based on reports of poor governance, corruption and lack of resources in low- and middle-income countries, there is the potential for moral injury across the globe.’
EU-OSHA works to prevent psychosocial risks at work, including stress, third-party violence and harassment. ‘The latter two can be contributory factors to work-related stress,’ says Tim Tregenza, senior network manager. ‘The worker need not be the direct target of such violence or harassment, as they can be a witness.’
Sarah Copsey, senior project manager at EU-OSHA, says the response must start with recognition of the issue and commitment to addressing it. ‘Moral injury is no different,’ she adds. ‘Although it is only recently getting more recognition, it should not be news, for example, that frontline workers find it stressful if they can’t deliver the services they believe they should be providing.’
TOOLS AND SKILLS
Ann says that a trauma-informed approach is crucial to any treatment of stress and burnout. ‘Your own moral beliefs or expectations are formed by family and cultural influences and past experiences, and that can vary between individual workers,’ she says.
‘When we talk about stress risk assessments they tend to be very generalised so they need to take a more individual approach, as responses to the same stressors will differ according to our beliefs and expectations.’
She says listening, collaboration and co-production skills are crucial. ‘If you really understand the individual worker on the team, how they connect with their emotions and how they communicate, you can actually see where there might be risks of them experiencing a moral injury or being at risk of burnout. We need to treat them as whole people and not just their role.’
Construction company Tideway works with the Mates in Mind charity, which focuses on recognising the causes of mental ill health and addressing them, rather than just training more mental health first aiders. ‘While there has been increased focus over the last five years on improving mental health within construction, the actions taken are not impacting the outcomes,’ says Steve Hails CMIOSH, business services and health, safety and wellbeing director. ‘Yes, we are on the journey to addressing the stigma associated with poor mental health, but there continues to be a concentration on reactive measures
‘Without proactive action on the actual causes of poor mental health – and, in this case, burnout – we will never create the environments that allow individuals to thrive while at work.’
Some of the tools and skills needed for companies to manage moral injury, such as incident management, risk management, building a strong safety culture and improving sustainability, sit within IOSH’s competency framework.
‘It is now a case of having a better understanding and an increased focus on sustainability and good governance as part of the business process, which has led us to question the impact these negative behaviours have on workers. It is important to remember the condition stems from the workplace,’ Karen says. ‘If you do not sort out the workplace, the issues will continue to perpetuate.’
And OSH professionals, given their skills, knowledge and experiences, are perfectly placed to play a leading role in addressing these systemic issues.
GLOBAL VIEW
BIG PICTURE ON BURNOUT
The rise in stress caused by moral injury has global relevance.
‘People who go off to war are exposed to moral injury,’ Karen Michell says. ‘Healthcare workers in low- and middle-income countries are very likely to be presented with situations where they lack resources to render the level of care they would like to.
‘Based on reports of poor governance, corruption and lack of resources in low- and middle-income countries, there is the potential for moral injury across the globe.’
EU-OSHA works to prevent psychosocial risks at work, including stress, third-party violence and harassment. ‘The latter two can be contributory factors to work-related stress,’ says Tim Tregenza, senior network manager. ‘The worker need not be the direct target of such violence or harassment, as they can be a witness.’
Sarah Copsey, senior project manager at EU-OSHA, says the response must start with recognition of the issue and commitment to addressing it. ‘Moral injury is no different,’ she adds. ‘Although it is only recently getting more recognition, it should not be news, for example, that frontline workers find it stressful if they can’t deliver the services they believe they should be providing.’
REFERENCES
Asana. (2022) Anatomy of work special report: the unexplored link between imposter syndrome and burnout. (accessed 15 December 2022).
Cotton J. (2022) How to avoid burnout as an employee. Glassdoor. (accessed 15 December 2022).
Deloitte. (2022) Mental health and employers: the case for investment – pandemic and beyond.(accessed 15 December 2022).
EU-OSHA. (2022) The Flash Eurobarometer – OSH pulse survey. (accessed 15 December 2022).
Lewis R, Agate C, Nielsen K et al. (2022) Developing an understanding of moral injury in business settings. Affinity Health at Work. (accessed 15 December 2022).
Shay, J (1994). Achilles in Vietnam: Combat trauma and the undoing of character. New York, NY: Scribner.
Williamson V, Murphy D, Phelps A, et al (2021). Moral injury: the effect on mental health and implications for treatment. Lancet Psychiatry.
World Health Organization. (2019) Burn-out an “occupational phenomenon”: International Classification of Diseases. (accessed 15 December 2022).