National Wraparound Initiative's Wraparound Blog

Moral Injury and Our Youth and Family Workforce

November 02, 2024 | NWI

Moral injury is a condition that can occur when an individual “bears witness to, perpetuates, or fails to prevent” an event that violates their values or beliefs.

Moral injury was originally described as a type of trauma experienced by military personnel. But in her excellent book, If I Betray these Words, Wendy Dean, MD, elegantly describes how moral injury can also be experienced by physicians who are forced to violate their sacred oath: To put the needs of patients first.

What leads to moral injury among doctors? In America’s current healthcare system, healthcare workers are increasingly forced to put the priorities of insurers, managed care, electronic health records, and other entities before the needs of the people they are treating.

The impact has been tragic: Thousands of our most talented and dedicated physicians are leaving the practice of medicine. Family practice doctors working in underserved and rural communities are the most likely to be injured – both financially and morally.

Because they are least able to return a profit to their employers and to insurers, these practitioners who are most desperately needed are also the ones who are most likely to abandon their calling.

Unfortunately, these repetitive insults also afflict members of our youth and family behavioral health workforce. Whenever a clinician has to spend more time with an EHR than with a family, or a peer support specialist cannot find a provider who could meet a family’s needs, or a care coordinator is denied $100 in flexible funds to get a youth in an after-school program, we risk moral injury. When these injuries amass, these invaluable members of our workforce can be driven to leave the field.

We often use the term burnout to describe this phenomenon. But as Dr. Dean describes, “burnout” suggests a lack of resilience, a problem that lies within the individual.

Moral injury is a more accurate term for this escalating tragedy. Moral injury locates the source in our systems – our fiscal and policy structures – and in the profit-driven forces that we have allowed to dictate the kind of care we provide.

What can we do to build systems of care that can forestall or even reverse this affliction? There are policy and financing strategies that have been shown to promote better care for youth and families. Our team’s research on care management entities, for example, has shown that more innovative, flexible, and tailored policy and financing mechanisms at a system level are associated with better fidelity to the Wraparound principles, and thus, better care for youth and families.

We believe that these system- and provider-level strategies also can help our care providers feel more effective at providing families with the help they need – which is the calling that led them to enter the field in the first place.

Currently, researchers affiliated with the National Wraparound Initiative are asking these questions, and many others, with a national study of the Wraparound workforce. We are asking hundreds of providers in dozens of provider organizations what keeps them going… or what makes them contemplate leaving.

In the coming months, the National Wraparound Implementation Center will also be hosting a series of webinars on these topics, including a session on state- and system-level strategies to achieve better adherence to the Wraparound principles and high-quality systems of care.

Also in the Spring, we will present the results of our workforce study, with implications for states and provider organizations.

And, all the above will be presented and discussed at July’s bi-annual Training Institutes, at which you can attend sessions on these topics and much more.

Across all these events, our youth and family workforce will be a common theme. We believe that part of holding managed care and provider organizations responsible for high-quality care to families includes providing supportive working conditions for their staff.

One way or another, we are all responsible for preventing the infliction of moral injury on the invaluable resource that is our care providers.