Understanding Moral Injury

What is a Potentially Morally Injurious Event?

Morals have an internal source which are generally formed from a person’s values and strongly held beliefs and are the fundamental rules by which a person judges between “right and wrong”. These beliefs are shaped by personal factors such as our upbringing and experiences, gender, race, sexuality and ethnicity, among others. We often draw on our morals to drive decisions, particularly to help govern our behaviours in certain types of challenging contexts or situations.

Potentially morally injurious events (PMIEs) are events that violate these deeply held values and beliefs, and often leave a person with a deep sense of unease or a feeling that something just isn’t right. It is important to understand that colleagues or leaders may not be able to predict if an event will be morally injurious to an individual as so much depends on one’s own sets of beliefs, values, and personal experiences.

PMIEs generally fall into one of three categories: acts of commission, acts of omission, or acts of betrayal. An act of commission is when someone does something that violates their own deeply held values and beliefs of right and wrong. An act of omission is when someone should have done something in alignment with their values but did not. Finally, an act of betrayal is when an individual feels betrayed by others, often a higher authority, who either acted, failed to act, or compelled someone to act contrary to their values.

Examples of PMIEs within a military setting can include: witnessing the suffering of others, not being able to protect others, observing exploitation of vulnerable peoples without being able to act, having to choose how to allocate limited resources, and unethical or immoral actions of self or team members. Any of these situations may result in moral stress, distress, or injury.

What is moral stress?

Moral stress is a normative response when confronted with choices and actions that compromise our values and beliefs, referred to as a moral challenge. Moral stress occurs commonly, and for the most part causes minimal harm or impairment.

What is moral distress?

Moral distress is a negative stress reaction that may develop following exposure to a moral challenge. The factors that influence whether moral stress transforms into moral distress include our ability to identify the moral stressor, and the intensity, frequency, and duration of the PMIE.

Moral distress is characterized by short-term feelings of frustration or helplessness that have a moderate impact on individual functioning. However, even moderate moral distress can impact performance and organizational commitment.

What is a moral injury?

A moral injury is a severe stress reaction following the experience of an event or a recurrence of situations that contradict an individual’s moral beliefs. Moral injury is characterized by enduring feelings of guilt, shame, disgust, anger, contempt, and hopelessness. In severe cases, this may lead to suicidal thoughts and suicide attempts. Moral injury appears to impact one’s capacity for trust and elevate despair. A small but important number of people who experience a moral stressor or morally injurious event develop a moral injury.

What are possible indicators of moral injury?

In addition to movement to the right on the mental health continuum, possible emotions and reactions specific to moral injury include:

• Intense emotions such as guilt, shame, anger, remorse, disgust, betrayal
• Feelings of worthlessness, helplessness, and powerlessness
• Diminished trust in self and others
• Self-destructive behaviours such as poor self-care, substance abuse, recklessness
• Ongoing questioning of core beliefs about self, others, the world, and spiritual beliefs
• Inability to integrate new beliefs, ongoing rumination.
• Inability to resolve difficult emotions (i.e. shame, guilt, anger, contempt).
• Inability to connect with people, places or things that give your life meaning.

What can individuals and leaders do to prepare for and mitigate the impact of potentially morally injurious events?

An awareness of one’s own values, understanding the values of others, being able to recognize situations where values may be at risk, and identifying and discussing moral dilemmas, can help build moral competence and potentially reduce moral distress.

Tips that can help include:

• Take time to reflect on values, beliefs and principles. Ask yourself: Why am I doing this? What does it mean to me?
• Understand operational context and rules of engagement in advance of a given task.
• Anticipate and discuss potential challenges with teammates and leaders and plan ahead of time how you will cope with these situations.
• Employ performance and resilience strategies to manage activation and regulate emotional responses, such as the Big Four skills (goal setting, tactical breathing, self-talk, visualization).
• Ensure you are engaging in active recovery strategies to maintain optimal health in all domains (physical, social, mental, emotional, and spiritual).
• Ensure adequate sleep to support decision making.
• Develop a network of individuals who can provide you support and to whom you can provide support.
• Have confidence in your training and experience.
• Discuss moral dilemmas and conflicts as they arise with teammates and leaders. Acknowledge any difficult emotions.
• If you think that you may be impacted by moral distress or injury, please reach out to a health care provider. They are in the best position to assess your situation and ensure that you are connected with the appropriate resources.
• Show yourself compassion and kindness.

Leadership actions to mitigate the impact of moral injury.

Leaders influence others through both their personal attributes (who they are) and their behaviour (what they do) and  are in a unique position to shape how stressful experiences are interpreted and understood (purpose and meaning). Leader support is critical and often all that is required to maintain morale, motivation, and well-being during times of physiological and psychological stress.

1. Identify morally challenging situations and understand the potential impact these can have on individuals’ mental health and readiness.
2. Focus on daily actions that will build strong unit cohesion and morale and promote trust in the work environment and leadership.
3. Communicate what you know and let them know when you don’t know the answer. How leaders communicate has a significant impact on how personnel respond to events.
4. Check in regularly and allow people to talk if that is what they need. Encourage and facilitate social support. Connecting with others can help prevent people from feeling isolated and alone.
5. Model expected behaviors and a consistent ethical climate.
6. Facilitate discussions about moral stressors and moral decision making in training. Use scenarios to consider possible responses and build moral competence.
7. Prior to deployment or operations, understand the operational context and identify the potential moral challenges of the environment. Plan and discuss strategies to cope with and respond to these types of events.
8. Focus on the basics. When people take care of themselves physically, they are better able to manage stressful demands. Encourage good nutrition, provide opportunities for physical activity, and prioritize sleep. Sleep is key to ethical decision making, and members practice better sleep habits when their leaders emphasize its importance.
9. Regularly take time to evaluate and acknowledge your team’s stress level, and remember that there are individual differences in how people respond to stress.
10. Following an PMIE early intervention can make a difference. Leaders must proactively initiate difficult conversations. Respond to adverse events using the AIR: Acknowledge that an event of significance happened. Inform team of possible reactions and remind of healthy coping strategies. Respond by checking in over the following days.
11. Be aware of the resources available to you and your team and know how to access them. If you think that a team member may be impacted by moral distress or injury, connect them to a health care provider. They are in the best position to assess your situation and ensure that you are connected with the appropriate resources.

*References used to develop this handout can be requested from HRM.R2MRDevelopment-RVPMDeveloppement@forces.gc.ca