Project Work from the XVII Edition of the Master in Applied Narrative Medicine by Marco Pivotto and Lara Pasin
“The health of my patient will be my first concern” (Hippocratic Oath, FNOMCeO).
Anyone who practices a healthcare profession inevitably realizes, over time, that the Hippocratic Oath enjoys excellent ideological health, but does not describe the characteristics of an achievable context in clinical practice. On one hand, the oath is a dominant presence on the ethical stage of a healthcare professional, as well as the moral track of caring actions (at least for those who wear the professional role with honor). Yet the healthcare system increasingly exerts pressure toward stakeholders other than the patient: bureaucracy, digitalization, performance timelines, caregivers, and so on.
Whenever clinical practice is compromised, going against the patient’s best interest, the professional may experience the perception of an assault on their own value system: this is the genesis of a moral injury episode. An inner conflict unfolds between knowing what the patient needs and the simultaneous inability to meet that need through one’s own work — not due to personal incompetence, but due to limiting contextual factors that exceed the professional’s control. Nor is it a phenomenon born from the professional’s inability to ground their ethical code in reality, or from an omnipotent overestimation of their own caregiving abilities, but rather from the fact that what is possible to do is sabotaged by the operational context.
From the individual processing and layering of all the situational distresses that the act of care encounters along the way, a state of profound psychological distress is born: moral injury in its fullest form. From this, consequences for the individual easily follow (guilt toward others and oneself, high self-criticism, depression, anxiety, discomfort, cynicism) and for the patient’s quality of care (loss of the capacity to take charge, loss of moral integrity, lowering of the ethical threshold). These aspects become predictive factors of job dissatisfaction, burnout, and abandonment of the profession. Moreover, moral injury particularly affects those with a higher empathic capacity and a stronger value-driven profile — that is, the very figures who contribute most to the quality of the relationship with the patient in a care setting.
It should be noted that the literature addressing this topic still gravitates heavily toward theoretical framing, but lacks the empirical counterpart of how the phenomenon actually lives in reality. Narrative medicine thus represents an excellent investigative framework, in which professionals can give voice to their lived experiences, their feelings, and can contextualize their difficulties.
The project work born from these intentions makes use of an anonymous Google form titled “Healthcare Professional: What Wellbeing?”, composed of two main parts. The first part aims to collect a few words that, for the participant, gather meaning around the profession (“what words would you choose as representative of your relationship with the profession at this moment?”). The second part uses 4 hypothetical parallel charts of healthcare professionals describing situations rich in moral injury nuances (moral injury is never mentioned, nor the fact that it is the focus of the study, so as not to influence spontaneity or what the professional chooses to focus on). Participants are invited to read them and then provide a written account of their impressions, guided by a semi-structured prompt.
The analysis involved a three-part framework. The written accounts are first analyzed against 39 items divided into the most relevant macro-areas for the investigation: linguistic analysis, relational analysis, representations of the care system, characteristics of moral injury, and Bury’s classification. Second, summary items are created to systematically classify the distance or proximity of a given narrative excerpt to the typical characteristics of moral injury (e.g., “A kind of flattening seems to have come over me” aligns readily with a summary item of higher moral injury density). Finally, a horizontal analysis of common thematic elements is conducted.
The results draw on 16 narratives (nurses, doctors, and physiotherapists) and find that 7 of these present a high density of items linked to the characteristics of moral injury — three in particular with a totalizing imprint of moral injury on the narrative. In the latter case, the phenomenon has infiltrated so deeply as to transform the way the professional describes themselves in the opening words chosen to represent their relationship with the profession: “exploitation,” “devaluation,” “A fish out of water.” A feeling that finds its space for clarification through the various expressive choices scattered throughout the 7 “moral injury narratives”:
“Fleeting contact with the human side”
“often forced to lie or to modulate the truth so as not to compromise the image of the center”
“I often feel I am in a demeaning and sometimes unbearable profession”
“we are thrown into a whirlwind of tasks to perform and there is no time”
“the human being is no longer seen as a person — and already for that reason alone worthy of every value — but as a numerical cog in a system”
“I feel powerless…”
While finding these phrases in the narratives delivers a positive outcome in terms of the project’s objectives, it cannot be said that they paint a reassuring picture of the health of the healthcare professional’s practice. It is the other narratives — untouched by characteristics of moral injury — whose words ask to be heard, in order to honor that perspective which restores value and dignity to the act of care. It is to the feeling of sharing and belonging to the caring profession that the invitation is extended to spread these last words, so that they may serve as a source of reflection and inspiration for whoever wishes to draw from them.
“I love this work even though it is not valued”
“Each of us tries to do their best with what there is”
“Having colleagues by my side who shared my same feelings helped me a great deal and allowed me to find the courage to change things”
“I noticed in myself the difference in working with presence and attentiveness. At the end of the day I feel I have also built a quality relationship, which has a great impact on my own wellbeing and personal satisfaction — because that is where I also meet my own values.”