By: Elizabeth Perazza
Back to 2009 after 8 years of experience as a Board-Certified Urologic Surgeon, I was told by a supervisor that I was not contributing to the training program. This supervisor’s opinion led to a plan that resulted in my removal as faculty of the training program. I was 1 of 3 female urology attendings amongst 20-25 male attendings.
For years in therapy with mental health specialists, I was able to overcome feelings of shame, inadequacy and incompetence that subsequently threw me to a diagnosis of adjustment disorder with depressive features.
Moral injury is defined as the profound psychological distress that results from actions, or the lack of actions, which violate one’s moral or ethical code. Morally injurious events can include acts of perpetration or omission, or experiences of betrayal from leaders or trusted others. Moral injury is not a mental illness, although experiences of potentially morally injurious events can lead to negative thoughts about oneself or others, as well as deep feelings of shame, guilt or disgust which can lead to the development of mental health problems.
Morally injurious experiences and the resulting guilt, shame or anger may contribute to stress reactions such as:
- changes in sleep
- significant and persistent negative changes in behavior or habits
- difficulty concentrating
- increasing mistakes
- compulsive addictive behaviors for example (overworking, overeating, drinking)
- weakened sense of empathy or compassion
If the morally injurious situation was also a traumatic event, it can lead to symptoms of PTSD.
Soon after I became separated from the faculty assigned to train Urology residents, I became more isolated, as described above. I did not find anyone in my workplace that was able to help me fight against the morally injurious event of my separation from the residency in an unjust and prejudiced manner.
Unfortunately, there are no well demonstrated strategies established to prevent moral injury.. A Systematic review published in July 2020 summarized the evidence regarding mindfulness and compassion related qualities of healthcare professionals and quality of life. Compassion related interventions including loving-kindness meditations were found to be effective at improving quality of life.
To heal from a moral injury there is a need for communalization of trauma and ethical listening.
Creating the organizational conditions for a moral and ethical culture-one that acknowledges the ubiquity of moral challenges in healthcare- is essential for combatting moral distress.
A moral and ethical culture includes communication, emotional support (t, education, bereavement support, and openness to conversations about ethics.
Organizational designs can bring such practices to light and help workers see morally distressing events as organizational and occupational concerns rather than as personal failures.
Although moral distress is unlikely to be eliminated, organizations must apply strategies and organizational designs to develop strong cultures of communication and psychological safety.
Thankfully, fast forward 14 years after my removal as faculty of the only Urology Program in our country, (the program where I graduated from in 1999), my professional career has grown. I am under psychological therapy but do not use psychotropics. Our training program still has 3 Urology female attendings but there has been a slight increase in female residents.
I hope that the readers of this blog will be able to identify with my story and that it will help create awareness of morally injurious events in our profession.