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What is moral injury, and is it affecting hygienists?

March 1, 2020
Distinct from burnout, moral injury occurs when a dental hygienist is pressured, directly or indirectly, to transgress ethical standards.

Many hygienists relish clinical practice while others lament their chosen profession. The lamenters often cite burnout for their lack of enthusiasm. Burnout can manifest itself as depression, loss of appetite, anger, insomnia, forgetfulness, impaired concentration and attention, as well as many other signs and symptoms.1 Burnout is defined by Merriam-Webster as “an exhaustion of physical or emotional strength or motivation, usually as a result of prolonged stress or frustration.”2 While burnout exists, and changing routines or positions can often solve the malaise, sometimes change does not satisfy the desire for something more. 

Hygienists are the frontline providers of oral care, and they care deeply about providing the best for their patients. When confronted with numerous obstacles, such as lack of treatment time or missed or overdiagnosed treatment, a hygienist may experience what our colleagues in the medical profession have named moral injury

What is moral injury?

Moral injury describes the mental, emotional, and spiritual distress someone feels after perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.3 Surveys in other health-care professions show that more than 50% of physicians admit to at least one symptom of burnout or moral injury, and many are relocating in the hopes of finding a better practice climate. They’re also exiting clinical practice through early retirement, moving to administration, or leaving medicine altogether.4 Similar studies in other health-care arenas find comparable statistics. 

Moral injury was first described as soldiers’ reactions to war as part of what is now called posttraumatic stress disorder (PTSD). Although first recognized in World War I veterans, recent psychological clinicians use moral injury to describe why some veterans respond to PTSD treatment and others do not.4 While hygienists and other dental team members are not dealing with the ravages of war, not being able to provide the high quality of care that brought them into dentistry can take its toll. 

Those with personalities that are drawn to dentistry and dental hygiene join the profession because they want to help people. Making a good living while practicing clinically part-time initially attracts many hygienists, but the demands of the clinical educational process instills the desire to provide the best oral and systemic health care to patients. Yet once they enter the real world of dentistry and are confronted with often business-oriented, profit-driven practices, hygienists are faced with conflicting interests of providing quality care or the practice profitability. 

When hygienists become conflicted

Hygienists are taught the American Dental Hygienists’ Association Code of Ethics, which includes the ethical behaviors of autonomy, confidentiality, societal trust, nonmaleficence, beneficence, justice, fairness, and veracity. Autonomy is to guarantee the self-determination of the patient, confidentiality is to hold information entrusted to the hygienist by the patient in confidence, and societal trust is to ensure trust between patients, society, and the hygienist. Nonmaleficence is the code that hygienists are bound to do no harm to the patient, while beneficence is to provide care that benefits the patient. Justice, fairness, and veracity remind the hygienist to provide fair and truthful care to the patient.5 

Yet when a practice model crosses the ethical boundaries that a hygienist has set for him or herself, moral injury can occur. Inner conflict and turmoil can create emotional responses that include shame, guilt, anxiety, anger, withdrawal, and self-harming, or self-handicapping behaviors (sabotaging relationships or substance abuse).6 Hygienists often don’t realize that a moral injury has occurred because there is little literature available. They may believe that burnout is the cause if they show signs of physical, mental, or emotional exhaustion, shame and doubt, cynicism, failure, and helplessness.7 Yet it is moral injury that is causing the symptoms. 

How can hygienists deal with moral injuries?

With the advent of the American Academy of Periodontology (AAP) and European Federation 2017 Periodontal Guidelines, hygienists now have a source to discuss with dentists and other team members about the appropriateness of periodontal therapies. Although not currently widely utilized, the AAP guidelines offer a roadmap to ensure that evidence-based dentistry is appropriate for patient care. Informing patients of their stage and grade of disease allows hygienists to follow the ethical responsibilities of care. Patients understand staging and grading from medicine, so educating them about their periodontal status can be an easier conversation. 

A solution to the time crunch experienced daily by hygienists can involve practicing an analysis of all hygiene procedures. A procedure analysis involves documenting the actual time it takes to complete patient care from the moment a patient is taken from the reception area to the time of dismissal and operatory turnover. The analysis should be done on a variety of days and with a variety of patients and procedures. The data collected can be used to analyze the appropriateness of the allotted time for the patient services. With the data, hygienists can document the amount of time that procedures are actually taking versus the time allowed. By offering this data, hygienists can help the team understand the hygiene process. 

Even with these solutions there are a number of other areas in hygiene practice that can cause moral injury. This article is not intended to delve into all of the possible options that can cause moral injury, but rather to bring into focus the root cause of the feelings that someone may be experiencing. Many professionals do not speak up about this since the potential moral or legal implications can be devastating. Discussing issues or concerns with a professional counselor often helps, yet moral injury is an area that is still in its infancy. 

Some research has shown that a cognitive behavioral therapy (CBT) approach that addresses self-forgiveness and adaptive disclosure can be effective. Adaptive disclosure is when those being counseled take part in exercises involving imagined conversations with a forgiving moral authority.8 Analytical storytelling, writing, art, and volunteering also often help heal the morally injured. 

At their graduation or pinning, every hygienist recites the Dental Hygiene Oath: “In my practice as a dental hygienist, I affirm my personal and professional commitment to improve the oral health of the public, to advance the art and science of dental hygiene, and to promote high standards of quality care. I pledge continually to improve my professional knowledge and skills, to render a full measure of service to each patient entrusted to my care, and to uphold the highest standards of professional competence and personal conduct in the interest of the dental hygiene profession and the public it serves.”9

As dental professionals we must refuse to accept any position that compromises or erodes our relationships with our patients or our oath. Saying “no” to what is sometimes asked of us can release the bonds that moral injury can inflict. It is often difficult to say no, but the consequences of continuing to practice in compromising situations can result in harm to patients, the practice, and ourselves. The adage, “Before you can help others you must first help yourself” is the ultimate remedy to moral injury.


1. Bourg CS. The tell-tale signs of burnout … do you have them? Psychology Today website. https://www.psychologytoday.com/us/blog/high-octane-women/201311/the-tell-tale-signs-burnout-do-you-have-them. Published November 13, 2013.

2. Burnout. Merriam Webster dictionary website. https://www.merriam-webster.com/dictionary/burnout.

3. Talbot SG, Dean W. Beyond burnout: The real problem facing doctors is moral injury. https://www.medicaleconomics.com/med-ec-blog/beyond-burnout-real-problem-facing-doctors-moral-injury. Published March 19, 2019.

4. Dean W, Talbot SG. Moral injury and burnout in medicine: A year of lessons learned. https://www.statnews.com/2019/07/26/moral-injury-burnout-medicine-lessons-learned/. Published July 26, 2019. 

5. Manookian AM. Ethics in dental hygiene. DentistryIQ website. https://www.dentistryiq.com/dental-hygiene/career-development/article/16360629/ethics-in-dental-hygiene. Published May 21, 2014. 

6. Maguen S, Litz B. Moral injury in the context of war. PTSD: National Center for PTSD. US Department of Veterans Affairs website. https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp. Updated October 14, 2019.

7. Gorkin M. Four stages of burnout and key strategies for rejuvenation, prevention and speed. DCjobs website. https://www.dcjobs.com/employment-resources/detail/four-stages-of-burnout-key-strategies-for-rejuvenation-prevention-and-speed/331. Published March 2, 2004.

8. Williamson V, Murphy D, Greenburg N, Stevelink S. Moral injury: Violating your ethical code can damage mental health—new research. The Conversation website. http://theconversation.com/moral-injury-violating-your-ethical-code-can-damage-mental-health-new-research-115654.

9. Carr M. Ethical decision making in hygiene. Dimensions of Dental Hygiene website. https://dimensionsofdentalhygiene.com/article/ethical-decision-making-dental-hygiene/. Published May 1, 2017.

Ann-Marie  C. DePalma, MEd, RDH, CDA, FAADH, FADIA, is a technology advisor for Patterson Dental, a writer for RDH magazine, and an author in dental hygiene textbooks. She is the 2017 Massachusetts College of Pharmacy & Health Sciences Esther Wilkins Distinguished Alumni recipient. DePalma is a continuous member of the American Dental Hygienists’ Association and an active member of the Massachusetts Dental Hygiene Association.