By Stephanie Gangemi, PhD, LCSW, CCHP
The concept of moral injury, originally studied among military personnel, is gaining recognition as a critical issue in health care – especially in settings as complex as correctional facilities. In an environment where the line between care and punishment is sometimes blurred, correctional health professionals face situations where their duties as caregivers conflict with institutional policies focused on safety and security. That conflict can leave them vulnerable to moral injury: profound psychological distress resulting from actions or inactions that go against deeply held moral beliefs.
A Soul Wound
Moral injury refers to the emotional and psychological suffering that occurs when individuals feel they have betrayed their moral values, particularly when working in high-stakes environments. That could be due to following orders that violate their professional ethical codes or failing to prevent harm due to institutional restrictions. Unlike burnout, which is characterized by exhaustion, and post-traumatic stress disorder, often related to physical danger, moral injury is more closely associated with guilt, shame, and a feeling of having compromised one’s ethical principles.
When health professionals find themselves unable to provide the patient care they know is right or must participate in actions they find morally unacceptable, they experience a “soul wound” that can significantly impact their mental health and their ability to continue practicing effectively.
For the past two years, I served as the principal investigator on an exploratory study on moral injury among correctional health professionals. This phenomenological, qualitative study included in-depth interviews with 25 correctional health professionals across the U.S. Participants included nurses, physicians, mental health professionals, dietitians, recreational therapists, and more. The findings, recently published in the “Journal of Correctional Health Care,” highlight how moral injury manifests in their work.
The interviews reveal that moral injury is not only present in this field but is nearly unavoidable. Participants described working in correctional health care as emotionally taxing, requiring them to constantly navigate ethical dilemmas while recognizing the limitations on their ability to care for their patients. My research assistant, Camille Dysart, and I identified five major themes, which I outline here.
Moral Injury as Occupational Hazard
Moral injury is a part of the job for correctional health professionals. All 25 interviewees reported experiencing some form of moral injury, often describing their work as being emotionally overwhelming and morally complex. They expressed feelings of anger, frustration, regret, shame, and helplessness in response to situations in which their professional roles conflicted with their moral beliefs.
Many participants initially did not have a name for the feelings they were experiencing. Learning the term “moral injury” provided them with validation and clarity, helping them better understand their emotional and psychological responses to their work. Most of those interviewed reported that the concept of moral injury was enlightening. One described wishing their colleagues and leadership knew that moral injury is “truly a wound” and said, “The more it builds up, the bigger the wound gets…and it’s hard to stop the bleeding once it starts.” Another shared that it felt like a “silent injury,” emphasizing that the harm experience is not always visible, even to those around them, which makes it difficult to address or seek help.
Types of Moral Injury: Incidental vs. Cumulative
The study found that moral injuries can be incidental or cumulative. Both types were common among the individuals to whom we spoke.
Incidental injuries occur from one-time, intensely distressing events, for instance, a specific case where a health professional was unable to provide necessary care due to security policies or administrative restrictions. One participant recounted an event in which health staff were forced to administer AED shocks while a patient was kept in metal handcuffs during resuscitation efforts. Medical personnel had requested the handcuffs be removed due to safety concerns about electrical conductivity, but custody staff declined the request, despite the patient’s clear incapacitation. This event left the health professionals feeling distressed and powerless, and it deeply affected their sense of duty as care providers.
Cumulative moral injuries build gradually as health professionals are repeatedly exposed to morally compromising situations. One person described cumulative injuries from repeated exposure to excessive use of force on incarcerated individuals while feeling helpless to intervene. These incidents accumulate, leading to a sense of helplessness, disengagement, and emotional fatigue.
Institutional Betrayal: When Systems Fail
Another major theme was institutional betrayal, which refers to the harm caused when organizations that individuals depend on not only fail to prevent harm but also become complicit in perpetuating it. That betrayal can take many forms, such as enforcing cost-cutting measures that compromise care or creating a culture where health professionals must turn a blind eye to unethical practices to maintain employment. Correctional health professionals often feel let down by the institutions they work for, which fail to protect them or adequately support their need to uphold ethical standards.
One individual described the harms of being forced to work with a patient who had repeatedly sexually harassed her, despite requests for reassignment. Another mentioned how management often ignored his concerns about patient neglect or inadequate care, further deepening the sense of betrayal. Combined with at times being mocked and insulted for showing their patients compassion, these experiences underscore how failure to protect correctional health professionals from harm – and sometimes forcing them to engage in morally compromising behaviors – can erode trust and exacerbate moral injury.
Interplay of Moral Injury, Burnout, and PTSD
Moral injury, burnout, and PTSD are distinct but interconnected experiences. Burnout often results from prolonged stress, while PTSD is a response to traumatic events that threaten physical safety. Moral injury, by contrast, is more about ethical conflict and feeling forced to act against one’s moral beliefs.
The degrees of overlap vary greatly depending on each person’s experience. Some interviewees reported that while burnout left them exhausted, moral injury felt like a deeper wound that shook their very sense of self. Some viewed it as a precursor to PTSD, arising from repeated violations of their ethical standards. “When you have repeated attacks on your values and are being asked (or told) to do things that conflict with your values directly…that’s gonna break a person,” said one.
The Road to REPAIR
Despite grappling with the harms of moral injury, correctional health professionals had valuable insights on how to best improve their working conditions. This road to moral repair involves both personal resilience and institutional change.
The people we interviewed (and the literature on moral injury) stress that moral repair must go beyond individual responsibility and should include a systemic approach that addresses root causes. Many recommended integrating discussions of moral injury into training, increasing support from leadership, and fostering a workplace culture that values “moral courage” – the strength to uphold one’s ethical beliefs in difficult situations. This was frequently mentioned as crucial for correctional health professionals.
Based on these insights, we suggest a framework, using the acronym REPAIR, for addressing moral injury in correctional health care. The REPAIR framework, emphasizing the need for recognition, education, moral courage, accountability, and institutional reform, offers a promising path forward,
Recognition of moral injury: Integrate the concept of moral injury into the lexicon of possible harms, along with burnout, vicarious trauma, and compassion fatigue.
Education about moral injury: Develop and offer structured training to define moral injury and bring it to awareness. Build a “moral injury-informed” culture.
Promote moral courage: Model moral courage from the top down and bottom up. Acknowledge and uphold morally courageous actions.
Acknowledgement and accountability: Commit to developing a culture based on taking responsibility for ethical and moral behaviors. Hire and support leaders who will address root causes and symptoms of moral injury.
Institutional-level interventions: Resist the urge to make moral injury about individual pathology. Leadership accountability is essential.
Reparations: Consult with health professionals about what they need to move toward repair. Do the things requested.
Our study reveals the importance of addressing moral injury in correctional health care, both to support health professionals and to improve the quality of care for incarcerated individuals. For health professionals, understanding moral injury is the first step toward addressing its impacts and working together to create a healthier, more ethically sound environment. Institutions, in turn, have a duty to provide a supportive work environment in which ethical dilemmas are mitigated rather than exacerbated. Building a moral injury-informed culture could lead to improved staff well-being while also creating a more humane environment for all involved.
Stephanie Gangemi, PhD, LCSW, CCHP, is assistant professor in the Department of Social Work at the University of Colorado – Colorado Springs College of Public Service.
For More Information
Gangemi, S. & Dysart, C. (2024). Moral injury in correctional health care. Journal of Correctional Health Care. https://doi.org/10.1089/jchc.24.04.0036
