Brutality, Betrayal, and "Bleeding Hearts": A Mixed Methods Exploration of Moral Injury in Correctional Healthcare

Background & Purpose: Originally applied to military populations, the concept of moral injury is increasingly being applied to those working in healthcare professions. Moral injury has been defined as a deep soul wound (Silver, 2011) that occurs when there’s been a betrayal of what’s right, by a person in authority or by oneself, in a high stakes situation (Shay, 2012). This presentation reviews the mixed methods findings of a national study on moral injury among correctional healthcare workers. It provides insight into the experiences of correctional healthcare workforce beyond the typical concepts of burnout, compassion fatigue, and vicarious trauma by examining how this workforce navigates the dual mandates, double binds, and inhumanities of carceral settings.

Research Objectives: This study examines the issue of moral injury in carceral settings through mixed methodology to gain a comprehensive understanding of these dynamics. Specific attention is paid to how social workers and mental health professionals navigate their ethical codes in inherently dehumanizing environments.

Methods: For this study, a quantitative survey recruited participants (N=124) administering empirically validated scales to include the Moral Injury Events Scale (MIES), the Moral Injury Symptom Scale (MISS), the Oldenberg Burnout Inventory (OBI ), the Critical Incidents Questionnaire (CIQ), The Patient Health Questionnaire (PHQ-9), The PTSD Checklist, the Post-Traumatic Growth Inventory Short Form (PTGI-SF), and more. The qualitative component of the study was developed in accordance with an Interpretative Phenomenological lens. Researchers used purposive and snowball sampling through recruiting at correctional healthcare conferences and through correctional workforce social media pages. Participants were selected from this sample based on range of professional backgrounds and diversity of demographic characteristics. Interpretative Phenomenological Analysis was used to analyze qualitative data for its strength in examining psychological and medical dynamics and for its usefulness in addressing traumatic content.

Results: Qualitative and quantitative findings revealed high rates of moral injury among those working in correctional healthcare. There are five notable thematic findings related to how correctional healthcare professionals (CHPs) experience their work: 1—CHPs experience significant moral and ethical challenges in their clinical practice, 2—CHPs overwhelmingly report that despite these challenges, their work is vital in correctional environments, 3—CHPs experience high rates of “institutional betrayal trauma” exacerbating the “soul wounds” of forensic practice, 4—morally injurious experiences among staff have damaging effects on the treatment of incarcerated clientele, 5—development and cultivation of “moral courage” help CHPs push back against the inhumane conditions of carceral settings.

Conclusions and Implications: The main outcome of this study is that correctional healthcare workers are deeply morally injured by their work, primarily due to the institutional harms of the carceral system. Despite these moral injuries and ethical dilemmas, correctional healthcare workers can and do cultivate moral courage which helps them push back against the harmful carceral system for the betterment of the health and mental health of their incarcerated clientele. Findings suggest that moral repair must take place at the macro, mezzo and micro levels to improve conditions. Further research is needed on the prevalence of moral injury in correctional healthcare.