Burnout and moral injury are driven by a set of complex and intersecting factors. Overarching Environmental Factors contribute to Relational and Operational Breakdown. Relational Breakdown recognizes the distrust, values conflicts, lack of control, and inequities experienced in work and learning environments. Operational Breakdown is seen in a lack of physical and mental health safety, excessive work demands, and inefficiencies. Often, operational breakdown has been the focus of interventions5,6; however, burnout and moral injury will not be fully addressed without repairing distrust and other relational challenges.7,8
While burnout and moral injury manifest in work and learning environments, they often originate in the larger context of public opinion and prevailing cultural practices within society, such as politicization, which is the act of making health and public safety-related activities and events political in nature, and structural discrimination and racism.9
Burnout and moral injury also originate in healthcare and public safety systems at large, which include federal, state, and local governments as well as other overarching institutions that influence healthcare and public safety services. Policies and regulations put in place by systems influence healthcare and public safety practice in direct and indirect ways. Additionally, the market economy in the U.S. impacts insurance reimbursement practices, the pricing of medications, staffing decisions, and other aspects of healthcare and public safety.10
Leadership, policies, and decisions and practices surrounding measurement and accountability within hospitals, public health departments, nursing homes, fire and police departments, emergency medical service (EMS) providers, education and training facilities, and many other institutions contribute to the organizational drivers of burnout and moral injury.
Finally, the culture, supports, workload and workflows, and communication that occur within hospital units, outpatient departments, local fire and police stations, classrooms, and other areas in which healthcare and public safety services are learned and provided serve as the work and learning environment contributors to burnout and moral injury experiences.
Addressing these environmental factors will require critical appraisal and change of existing policies, as well as new policies and investments to protect and improve the well-being of health and public safety workers and learners. Explore strategies:
Relational breakdown is core to the experience of burnout and especially moral injury.11-13 Establishing trust – built on worker and learner voice, aligned values with patients and communities at the center, and equitable work and learning environments – provides an essential base from which to address the operational breakdown of burnout and moral injury.8,14,15
Rebuilding trust will require strategies to engage and protect workers and learners, support and develop leadership, establish shared governance structures, align values, address inequities, and establish measurement and accountability for well-being. Explore strategies:
A number of factors contribute to burnout and moral injury due to operational breakdowns, including lack of physical safety16,17; stigma and inadequate supports for mental health and stress/trauma18-20; excessive physical, emotional, and cognitive work demands21-23; and operational inefficiencies from chaotic workflows and administrative requirements.4,24,25
Resolving operational breakdown will require using relational strategies to engage workers and learners in designing workflow changes, safe staffing procedures, and appropriate resources and policies for workers and learners to effectively take care of their mental health and reduce stress. Explore strategies:
While burnout and moral injury are driven by societal & cultural, systems, organizational, and work & learning environment factors, we recognize individuals experience the effects of burnout and moral injury differently based on their personal/family demands and lived experiences of trauma, discrimination, and social vulnerability which they carry with them into the work and learning environment.26,27
The moral injury process starts with betrayal, the sense of being harmed by the actions or omissions of a trusted individual or institution.28,29 Betrayal then leads to transgression, a breach of accepted social codes or laws, including moral standards. Sometimes, betrayal is not recognized until after the transgression occurs. The continuum of moral injury describes a range of experiences, from moral dilemma to moral distress to moral injury.30 This framework focuses on the experience of workers and learners who progress to moral injury. (See definition of moral dilemma, moral distress, and moral injury in our glossary [link to website glossary].
Moral injury can result in worker and learner feelings of anger, frustration, shame/guilt, and a sense futility.18,29,31,32
Burnout has been classified as an occupational phenomenon and defined in the International Classification of Diseases (ICD-11) as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.”33 Like moral injury, burnout operates on a continuum, meaning that varying degrees of symptoms and presentations exist as workers and learners move from engaged to burned out.34 Burnout has three hallmark features:35
The connection between burnout and moral injury is not entirely known. They appear to represent separate but related phenomena.36
The impacts of burnout, moral injury, and related harms among workers and learners in health and public safety are inequitably experienced based on occupation, gender, race, ethnicity, employment setting, and other factors.37-41 Workforce shortages disproportionately harm lower socioeconomic, rural, and marginalized communities and the organizations that serve them, contributing to further disparities in access, quality of care, and health and wellbeing outcomes for vulnerable populations.42,43
Burnout is associated with physical and mental harms for workers and learners, including increased risk of occupational harms (e.g., needle sticks, sleep disruption),44,45 mental health symptoms (e.g., PTSD, depression, or suicidal ideation),46-48 and substance use.49,50 Moral injury has also been associated with psychological harms,51 and moral distress, a precursor to moral injury, has been implicated in physical and mental harms for nurses, including experiences of intense stress and possible worsening of underlying health conditions.52,53
Relational and interpersonal challenges can occur because of burnout and moral injury. Tensions, betrayal, exhaustion, and other symptoms of burnout and moral injury can disrupt relationships and communication with colleagues, supervisors, and patients/communities.54,55
Burnout and moral injury also result in career harms, including greater intent to leave a job, turnover, and decreased performance.45,56,57 In health professions students, burnout increases the likelihood of intent to drop out of training.58
As burnout and moral injury cause workers to leave their jobs, staffing shortages necessarily lead to poor access to care and quality of services for patients and communities. Additionally, worker and learner burnout has been shown to reduce empathy, magnify racial bias, and increase the risk of errors and other threats to patient safety, leading to further reductions in quality of services.11,59-62
Workers experiencing burnout and moral injury leave their jobs at higher rates,45,56,57 and learners experiencing distress may also drop out, diminishing the pipeline of new workers.58 All of these add to recruitment and retention challenges experienced by organizations and the resultant decrease in quality and lower patient satisfaction ratings, which can affect their reimbursement from private and government payers.63 Health worker turnover also increases expenses for organizations, hurting their bottom line and diverting resources away from patient care.64-67
Reduced access and quality diminish the public’s trust in health and public safety institutions, which then leads to worsening patient and community health outcomes, increased health disparities, and an ongoing cycle of harm for workers, patients, communities, and society.68-71
The outcomes of burnout and moral injury further perpetuate their drivers, effectively creating a negative cycle. For instance, as recruitment and retention challenges worsen in organizations, workers may be required to work additional hours or complete tasks for which they were not properly trained. Under such conditions, workers may experience increasing moral injury and burnout due to the excessive work demands, values conflict, and increasing distrust, ultimately leading to turnover and worsening recruitment and retention challenges.