Moral Injury and Burnout: Surf Therapy for Health Care Providers

Moral Injury and Burnout: Could Surf Therapy Create Resiliance in Health Care Providers

I’ve spent the last 2 months marinating on a new project that I will be launching over the next year or so, Water’s Edge Surf Therapy. Creating this is one of the silver-linings that has come out of a decade-long work burnout and 3 lumbar spine surgeries. While I have shared some about my journey with my back injury (click HERE to read more), I haven’t discussed much publicly that my soul was healing from a serious case of burnout. 

As I worked through a few layers of my healing process, it became pretty clear that a contributing factor to my injury came from not setting boundaries for myself both inside and outside of work. I failed to find balance in my day-to-day life, and after about a decade of trying to keep up, working in an unbalanced health care system, it caught up. 

This past March while taking some continuing education courses, I came across this  from Dr. Z out regarding Dr. Wendy Dean and Dr. Simon Talbot’s current research on moral injury in healthcare providers. 

I felt as though someone finally had verbalized so much of what I’d been experiencing in the formal world of healthcare: Moral Injury. The words kind of made me shudder. At first, my inclination was to object - I mean - I have been burnt out, but I haven't ever personally been on a true battlefield, working with bombs that potentially could explode in my path. So, I initially resisted, a little, using the language Moral Injury, but the more I learned about it, the more I began to understand it. 

Defining Moral Injury: 

Depending on which researcher’s work you connect with, there are a few definitions of moral injury that are floating around. I like to use a hybrid of two researchers Litz et al refers to it as: bearing witness to, contributing to, or being unable to stop acts that transgress deeply held moral beliefs and expectations. Where as Farnsworth et al discusses it as and social, psychological or spiritual suffering as a result of witnessing a morally injurious event or moral pain. 

Burnout in Healthcare 

While many people may suffer burnout for a myriad of reasons, I have begun to believe that much of the burnout we see in the healthcare setting may stem from bearing witness to morally injurious events and moral pain. Over the last few weeks, I logged some serious library time, examining burnout itself, specifically in healthcare providers, who seem to be more prone than other professions. I've chatted some with Dr. Wendy Dean, coauthor of the article, Physicians are not burning out. They are suffering moral injury.  I have bounced this idea off of some friends and colleagues. I've looked outside the USA and seen that this issue of burnout in healthcare providers is pervasive in the UK, New Zealand, Germany, Italy, all over the world.

With quotes ranging between 38- 60+% of all healthcare providers experiencing a severe degree of burnout at some point in their careers, what's the plan? My concern is multidimensional and stems from my own experience of moral injury and burnout (more on that in a minute), as well as being a concerned citizen. 

From a personal perspective, I am worried about the physical and emotional toll that moral injury-driven burnout takes on our frontline healthcare providers. Their quality of life, healthcare outcomes, and emotional wellbeing are at risk. It is often culturally inappropriate for medical doctors, psychiatrists, or nurses to show how they’re really feeling or ask for help, as it can jeopardize licensure let alone the stoic persona stereotype that our on-demand culture has created. Day-in and day-out wrestling with moral conflict and compromised outcomes can erode even the strongest persons’ soul. 

From a business perspective, our broken healthcare system can't afford the staffing losses/shortages for every burned-out care provider to peel off on their own entrepreneurial endeavors to escape the uncomfortable culture at the workplace. Additionally, not every healthcare provider (perhaps not even myself) can afford to leave a steady job with benefits. Health insurance alone costs upwards of $1400.00+ a month for many families if it weren't for employer contributions. Home ownership and other larger purchases tend to require a steady income and job and can be out of reach by leaving a steady paycheck behind. 

Lastly, from a health care quality concern, burnout has been linked to higher rates of medical errors, decreased quality of care, as well as increased cynicism in provider-patient relationships. Many people have experienced some degree of medical error or dissatisfaction with provider concern, and it can significantly taint the experience of having to undergo medical care. 

My Journey With Moral Injury

For me, my journey to burnout in the formal healthcare system culminated in years of 40-60+ hour work weeks, decreasing contract pay due to decreasing insurance reimbursement for therapy services. Despite gaining knowledge and work experience, I earned more money working with certain contract providers when I was fresh out of school than I did with 10 years of experience. I felt frustrated that I was struggling to get by despite investing years of time in my education and hence debt load. 

I felt crunched between providing compassionate care, yet trying to keep up with the continued demands of my employer for my productivity to be 90-93% for years on end. My heart ached some days as I witnessed young stroke patients ‘cut off’ from much needed therapies and treatments while Medicare patients who were end-of-life were scheduled like cash-cows for therapy minutes to be reimbursed.  

Solutions

With a little thought though, after watching Dr. Z's YouTube video, I started thinking about the language moral injury, and thinking about Veterans who experience PTSD. Then I thought of the work that colleagues Carly Rogers, OTR and Betty Michalewicz have done with surf therapy programs. I started considering the work that Dr. Wallace Nichols has done with the Blue Mind Health Movement. I thought about all the positive benefits of surfing with regards to helping people with PTSD and addiction reclaim their lives. It wasn't too difficult to start formulating ideas about how Surf Therapy may be a viable treatment option in the very people who have been looked to for its prescription.  

I have a will, hope and desire to help others who are going through this and don't see a way out. I have the ability to help others connect their healing paths from chronic stress, pain or injury towards a life where they can do good, help others, and still pay their bills. I envision creating community around surfing and the ocean, connecting over experiences, revisiting our own moral values to understand why burnout may be coming up. I hope to further encourage healthcare providers to discover or create an environment that better fits and suits their community’s needs. 

Learn more about my new project vision, volunteering as a surf therapy provider OR participant in our first surf therapy cohort at www.watersedgetherapy.com .

 

  1. Caddick, N., C. Phoenix, and B. Smith, Collective stories and well-being: Using a dialogical narrative approach to understand peer relationships among combat veterans experiencing post-traumatic stress disorder. Journal of health psychology, 2015. 20(3): p. 286-299.
  2. Caddick, N. and B. Smith, Combat surfers: A narrative study of veterans, surfing, and war trauma. Movimento, 2017. 23(1): p. 25-38.
  3. Caddick, N., B. Smith, and C. Phoenix, Male combat veterans’ narratives of PTSD, masculinity, and health. Sociology of health & illness, 2015. 37(1): p. 97-111.
  4. Caddick, N., B. Smith, and C. Phoenix, The effects of surfing and the natural environment on the well-being of combat veterans. Qualitative health research, 2015. 25(1): p. 76-86.
  5. Chambers, C.N.L., et al., Burnout prevalence in New Zealand's public hospital senior medical workforce: a cross-sectional mixed methods study. BMJ Open, 2016. 6(11): p. e013947.
  6. Corrado, B., et al., Burnout syndrome among Italian physiotherapists: a cross-sectional study. European Journal of Physiotherapy, 2018: p. 1-6.
  7. Davis, M., et al., Confronting depression and suicide in physicians: a consensus statement. Jama, 2003. 289(23): p. 3161-3166.
  8. Dean, W., MD and S. Talbot, MD, Moral injury and burnout in medicine: a year of lessons learned  2019, Stat News.
  9. Farnsworth, J.K., et al., A functional approach to understanding and treating military-related moral injury. Journal of contextual behavioral science, 2017. 6(4): p. 391-397.
  10. Fernando, A.T. and N.S. Consedine, Development and initial psychometric properties of the Barriers to Physician Compassion questionnaire. Postgraduate medical journal, 2014. 90(1065): p. 388-395.
  11. Fink, G., Stress: Concepts, Cognition, Emotion, and Behavior: Handbook of Stress Series. Vol. 1. 2016: Academic Press.
  12. Harris, K.B., Working With Addiction Through Surf Therapy: A Phenomenological Exploration of Healing. 2015: Pacifica Graduate Institute.
  13. Hofmann, P.B., Stress Among Healthcare Professionals Calls Out for Attention. Journal of Healthcare Management, 2018. 63(5): p. 294-297.
  14. Kearney, M.K., et al., Self-care of physicians caring for patients at the end of life:“Being connected... a key to my survival”.Jama, 2009. 301(11): p. 1155-1164.
  15. Kumar, S., et al., Burnout and Job Satisfaction in New Zealand Psychiatrists: a National Study. International Journal of Social Psychiatry, 2007. 53(4): p. 306-316.
  16. Lacy, B.E. and J.L. Chan, Physician burnout: the hidden health care crisis. Clinical Gastroenterology and Hepatology, 2018. 16(3): p. 311-317.
  17. Litz, B.T., et al., Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical psychology review, 2009. 29(8): p. 695-706.
  18. Maslach, C. and M.P. Leiter, Understanding the burnout experience: recent research and its implications for psychiatry.World Psychiatry, 2016. 15(2): p. 103-111.
  19. Matos, M., et al., Surfing for Social Integration: Mental Health and Well-Being promo-tion through Surf Therapy among Institutionalized Young People. Journal of Community Medicine and Public Health Care, 2017. 4(1): p. 1-6.
  20. McNitt-Gray, J.L., Kinematics and impulse characteristics of drop landings from three heights. Journal of Applied Biomechanics, 1991. 7(2): p. 201-224.
  21. Ochentel, O., C. Humphrey, and K. Pfeifer, Efficacy of exercise therapy in persons with burnout. a systematic review and meta-analysis. Journal of sports science & medicine, 2018. 17(3): p. 475.
  22. Rogers, C.M., T. Mallinson, and D. Peppers, High-intensity sports for posttraumatic stress disorder and depression: Feasibility study of ocean therapy with veterans of Operation Enduring Freedom and Operation Iraqi Freedom. American Journal of Occupational Therapy, 2014. 68(4): p. 395-404.
  23. Rotenstein, L.S., et al., Prevalence of burnout among physicians: a systematic review. Jama, 2018. 320(11): p. 1131-1150.
  24. Seixas, A., et al., The Prevalence of Burnout in Portuguese Physiotherapists, in Occupational and Environmental Safety and Health. 2019, Springer. p. 591-600.
  25. Shanafelt, T.D., et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. in Mayo Clinic Proceedings. 2015. Elsevier.
  26. Śliwiński, Z., et al., Life satisfaction and risk of burnout among men and women working as physiotherapists. International journal of occupational medicine and environmental health, 2014. 27(3): p. 400-412.
  27. Talbot, S.G. and W. Dean, Physicians aren’t ‘burning out.’They’re suffering from moral injury. Stat, 2018.
  28. West, C.P., L.N. Dyrbye, and T.D. Shanafelt, Physician burnout: contributors, consequences and solutions. Journal of internal medicine, 2018. 283(6): p. 516-529.
  29. Wright, A.A. and I.T. Katz, Beyond burnout—redesigning care to restore meaning and sanity for physicians. New England Journal of Medicine, 2018. 378(4): p. 309-311.

Stay connected with news and updates!

Join our mailing list to receive the latest news and updates from our team. You'r information will not be shared.

Close

50% Complete

Thanks for your interest in Surf Body Connection. Please provide your contact information so we can stay in touch!