Lessons from a different war for preventing moral injury among clinicians treating Covid-19

One week after President George W. Bush declared war in Iraq in 2003, I was deployed there as an Army nurse.

During my year in the war, I kept a daily journal of the fear I experienced and the injuries and deaths I witnessed. But on the last day of my deployment, I ripped it up and threw it away. Now that I’m in the fight against a different and invisible enemy, the SARS-CoV-2 virus, in a major medical center in the Northeast, I wish I still had that journal.

I got rid of it because I didn’t want those terrible experiences following me. What I didn’t know at the time was that part of my trauma was due to something called moral injury, a term first used to describe why some Vietnam veterans had great difficulty adjusting to being home after the war. The term became popular among those working in health care after a 2018 STAT article, “Physicians aren’t ‘burning out.’ They’re suffering from moral injury,” went viral.

The authors, Simon G. Talbot and Wendy Dean, defined moral injury as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” This resonated with those working in health care because it turned burnout, which is an individual problem, to moral injury, which is a systemic problem.

Now we are at war again, with a pandemic as the enemy and health care workers on the front lines. Moral injury will undoubtedly occur. Health care workers will be strained. They will see people die under terrible circumstances. They may have to make heart-wrenching choices, like who gets a ventilator and who doesn’t. They will take care of people who were careless with social distancing.

Clinicians will be stretched and assigned to do work in areas they have never covered before. They may be scared to come home and hug their kids, fearing that they will infect them. Like soldiers in armed combat, they will be fearful for their lives. Despite the constant terror, they must keep working and providing care.

With health care systems in crisis mode, a few basic components of military training can help clinicians cope with these unprecedented circumstances.

Recognize and acknowledge. Starting in basic training, individuals in the military learn they will have to make hard decisions and see things that will be difficult to process. It’s important for health care providers to recognize that a situation is terrifying and that, due to staffing or supply issues, they may have to do things that go against their deeply held moral beliefs. In such situations, recognize that what you are doing is frightening. Name it. Once we get on the other side of this pandemic, the acts of recognizing and naming will help individuals pick up these complex emotions and experiences and start to process them.

End-of-shift campfires. The military has turned what started as soldiers informally sharing their thoughts about a battle around a campfire into a more formal exercise. The debriefing process gives those in combat a way to voice their experiences. This allows them to purge some of the emotional burden and share with others to normalize the fear and anxiety. In the Covid-19 pandemic, a similar kind of end-of-shift debriefing could be helpful, as could setting up virtual support groups among staff.

Rely on battle buddies. An important part of basic training is being assigned a battle buddy. This is someone you watch out for and keep tabs on during battle, and who does the same for you. This person, who is in the trenches with you, understands what you are going through. Pairing clinicians with battle buddies can give them this kind of deep, durable support better than a partner or a friend can. Battle buddies check in on each other frequently, send texts to brighten each other’s day, and be there when it’s time to vent.

Improvise, adapt, and overcome. This common Marine mantra is more important now than ever. Times of scarcity make improvisation and adaptation necessary to provide the care that people need. Systems will need to adapt their health care workforce and processes of care. Keeping this phrase in mind can help health care workers surmount barriers and be certain that we will ultimately overcome this crisis.

Taking these steps now will help soften the blow when things normalize and the health care system returns to peacetime functioning. It’s of utmost importance to keep clinicians healthy in both body and mind so they can care for others. Lessons from the military can help minimize the scars left on health care workers from their time in the Covid-19 battle.

Rachel Smith is a physician assistant, a clinical implementation specialist at Ariadne Labs, and a doctoral student in public health at Johns Hopkins Bloomberg School of Public Health.