Feeling distressed at work? It might be more than burnout

Employees—physicians and fast-food workers, teachers and hotel staff—are resigning in unprecedented numbers, often in distress. Managers are at a loss for how to respond. Attempts to address employee dissatisfaction and burnout with bonuses, mindfulness, and extra time off do not seem to be working well enough; employees continue to quit, sometimes angrily and dramatically, airing a range of grievances on social media.

But what if the problem we typically call “burnout” is not just burnout? What if it is not the other “usual suspects”—depression or anxiety—either? What if it is something that may appear similar, but has a different cause and, if incorrectly addressed, can make individuals feel increasingly worse?

Appropriately dealing with the epidemic of employee anguish and quitting requires correctly identifying its causes and using precise terminology to describe it. And while burnout is by far the most popular explanation of employee distress, in many cases, the problem might be a less known, but more insidious: moral injury. Preliminary data from my ongoing research indicate that, conservatively, the experience of at least 25% of those reporting feeling burned out might be better explained by moral injury. 

Consider the story of someone we’ll call Henry. Henry joined a well-known not-for-profit organization to use his accounting talents in service of a social cause he strongly endorsed. But he discovered egregious donations mishandling—and was told to cover it up. Discovering the embezzlement was bad enough, but now Henry faced a dilemma: blow the whistle on individuals involved and risk a massive backlash against the entire cause he believed in, or keep quiet, save the face of the cause, but become a party to the problem. Henry found himself struggling to sleep at night and controlling his emotions during the day, including anger at organization’s management for tarnishing the cause and shame over his own lose-lose situation. In addition, his health issues that were under control returned with a vengeance.

In another example, “Kim” became a human resources professional because she cared about people. At first, working at an up-and-coming marketing agency was a dream come true. Over time though, she noticed that there was much turnover, and in exit surveys, many complained about being “pushed out” or “bullied out” as soon as they passed the age of 35 or so. A recruiter who brought in replacement talent confirmed her suspicion—there was an unwritten rule to only consider the résumés of those in their mid-twenties. Kim’s supervisor made it clear that if she wanted to keep her job, she would support the company’s “energy.” Raised to respect her elders, Kim was mortified. What was she going to tell her family when they ask, “how’s work?” at the next gathering? Can she even face her family while working for an ageist company?

Moral Injury Defined

The original understanding of moral injury, similarly to PTSD, comes from research on military troops. Understanding this origin also helps understand the distinction between these syndromes. While PTSD might be caused by the threat to one’s mortality, moral injury is caused by a threat to one’s morality, such as harming a child, destroying a school, or a place of worship. Jonathan Shay, who coined the term while working with military veterans, also stressed the role of betrayal by the leadership in high-stakes situations in the development of moral injury. 

Building on prior research and expanding the concept of moral injury to a range of occupations, I suggest that it is part of the broader classification of workplace stress reactions. Briefly, PTSD predominantly impacts the sense of safety, moral injury predominantly impacts the sense of trust and/or self-respect, and burnout impacts one’s sense of engagement and efficacy. While these may co-occur and overlap, causes and effects are sufficiently different and require different interventions. 

The key focus of non-military research on moral injury has been on healthcare workers. Nurses and physicians are significantly distressed by the inability to deliver the care they took an oath to provide due to a global pandemic, severe understaffing, bureaucratic red tape, and the underlying profit-before-the-patient organizational cultures. Approximately one in five healthcare workers have left their jobs since the pandemic started. However, the high prevalence of moral injury in healthcare was well-documented prior to March 2020, and attributed to systemic issues that emphasized efficiency and financial metrics at the expense of physician/patient communication, trust, and overall patient care.

Similarly, educators currently experience deadly impacts of the pandemic and struggle with adequate resources to meet student needs. Yet, even before the pandemic, K-12 professionals reported levels of moral injury similar to that of military veterans, with teachers being distressed when forced to implement poorly researched and potentially harmful curricular and disciplinary practices. 

Moral injury was also found in journalists covering the refugee crisis in Europe and in the general civilian population. 

In the most generic form, applicable across occupations, workplace moral injury is a trauma response to witnessing or participating in workplace behaviors that contradict one’s moral beliefs in high-stakes situations with the potential of physical, psychological, social, or economic harm to others. The focus on high-stakes situations and significant harm allows to preserve the gravity of the concept. 

Injurious events may fall into three categories:

1. Transgressions by others (e.g., managers, coworkers, or clients);
2. Transgressions individuals committed themselves;
3. Betrayal—feeling that managers, colleagues, or policymakers had betrayed occupational values, employees, or clients/customers/students/patients.

Violation of deeply held values can shake the core of an individual’s identity and self-concept. Moral injury may result in a range of feelings, such as guilt, shame, anger, grief, anxiety and disgust. It also often leads to disillusionment in people, particularly in authority figures, and organizations (hence leaving employment in favor of self-employment). Self-loathing, existential, and spiritual crises are also common. Some individuals may develop physical illness or maladaptive behavior (substance abuse, self-isolation). 

The moral injury framework can be applied across a wide range of occupations. In Henry’s case, his managers are committing a financial transgression while also betraying the cause and those the organization is meant to serve. To make matters worse, he is expected to commit the same transgressions. In Kim’s case, the company systemically practices ageism, and she is pressed to betray her values by supporting the system.

Prevention is the best medicine. Amends are the second best

The lack of attention to moral injury and misinterpretation of it as “burnout” results in ineffective ways of addressing the problem. Because many reduce “burnout” to an individual response to demands exceeding resources, person-focused “burnout interventions” suggest “resilience development” via wellness apps and training, or “stress management” via mindfulness and yoga or, in the best-case scenario, time off. However, yoga will not help a doctor who is prevented by insurance regulations from prescribing a life-saving treatment or a teacher ordered to use seclusion and restraint on crying children. Likewise, a wellness app will not help a recruiter instructed to ignore applicants with “too much experience” or with non-Anglo names. If anything, these individual-focused “solutions” to systemic problems only add an insult to moral injury.

Negative reactions to morally injurious situations are not the result of an employee’s “resilience deficiency.” These are normal reactions to systemic ethical violations—and unless these violations are corrected, organizations and entire industries will continue losing talent and public trust. Fixing faulty systems to prevent further damage should be the focus of intervention, along with supporting injured—but not “faulty”—individuals.

The best way to prevent moral injury is to ensure transparent and ethical organizational operations. I suggest that organizations:

1. Track moral injury along with employee satisfaction, burnout, engagement, and other key indicators of organizational health. Careful analysis of this data (when ethically and statistically possible, by units) should inform action in support of the employee wellbeing, as well as organizational ethics.
2. Adopt trauma-informed organizational practices.
3. Provide multiple ways in which employees can voice their concerns effectively and in an environment of psychological safety, and ensure transparent follow-up on ethical concerns.
4. Make ethical considerations one of the key elements of hiring, promotion, and leadership training.

Where moral injury has occurred, re-establishment of trust between organizations and employees and organizations and the community will require a systemic, unambiguous, radical transparency.

1. Organizations may need to make amends to the community, provide and transparently execute detailed plans for addressing prior ethical violations.
2. Whenever possible, allowing employees who suffered the moral injury to actively participate in the restorative process will also help these individuals to rebuild their sense of self-respect.
3. Recovery from moral injury is a complex one. In addition to seeing justice restored, individuals are likely to need psychological and spiritual support for meaning-making and, whenever possible, facilitating post-traumatic growth.

Unfortunately, not all employees who suffered a moral injury will see justice restored in the same organizations where the injury has occurred. And they may come across injurious situations in multiple organizations. Nevertheless, these individuals are not doomed.

Very early in my career, I had a “Henry” experience of discovering a range of misconduct in a charitable organization. Despite reporting, problems were never addressed—in fact, the honest leaders were fired, and the bullying embezzler was given more power. For self-preservation, I learned to separate an organization’s cause from individuals’ misdeeds. Not being involved in unethical behavior allowed me to feel that I could still contribute to the cause and serve people directly despite the problematic leadership. And yet, when I left, I was determined to make my next job “just a job,” without the emotional and values-based investment and the risk of a heartbreak. Being morally injured and still engaged at work is a recipe for pain, like walking on a broken leg. 

But humans are generally not wired for a disconnect; we are wired to seek meaning in what we do, and in a few years, I abandoned the “just a job” mindset. Through other cycles of trust, betrayal, and injury, I arrived at a personal formula of focusing on the direct impact I make even if organizations execute their missions imperfectly, while doing all I can to improve those organizations as an industrial-organizational psychologist. Individuals and organizations are flawed, but we can commit to the process of daily bettering—being and doing better. 

As workplaces experience a “humanity revolution,” it is crucial to understand the moral injury role in employee experience and its impact on employee retention, organizational reputation, and other outcomes. Honest and ethical organizations benefit everyone, and might just be an answer to the Great Resignation—especially when it is, in fact, a Great Disillusionment.

Author’s note: Individuals or organizations interested in participating in the next phase of my research project on workplace moral injury and disillusionment can sign up here. You may also use this form to submit confidential comments on this article.