Understanding moral injury in sterile processing

In 2022, the Bureau of Labor Statistics received 2.8 million reports of workplace injuries with the cost to staff and facilities estimated at $44,000 per medically consulted injury.1 Implementing safety protocols, regular training, and ergonomic assessments can reduce the risk of physical injury significantly. However, there is another type of workplace harm that is not tracked, has limited visibility, and is impacting the high rate of burnout in sterile processing (SP). That is moral injury.

Moral injury is a psychological, social, and spiritual experience resulting from events that transgress deeply held moral beliefs and expectations. In the sterile processing field, moral injury occurs when technicians work under conditions that prevent them from adhering to ethical and professional standards. These conditions often include inadequate equipment, insufficient training, and understaffing, which hinder their ability to provide quality care to their patients. The resulting moral distress can have profound impacts on their mental health and job satisfaction.

A moral injury tale

The following story about Cheryl (the patient) and James (the SP professional) is a composite of the all-too-common moral injuries we see in our departments. Cheryl Parker, a 34-year-old mother of two, was scheduled for a routine laparoscopic cholecystectomy to remove her gallbladder. Cheryl was in good health otherwise, and her surgical team anticipated a smooth procedure with a quick recovery. However, what should have been a straightforward surgery turned into a nightmare due to unseen, systematic barriers in the hospital’s sterile processing department (SPD).

In the weeks leading up to Cheryl’s surgery, the SPD was grappling with a critical issue: the department was not equipped with insulation testers for the inspection step of their laparoscopic instruments. The department initially had three insulation testers, but one was broken, one was lost, and the cord on the third was too damaged to be functional. Proper insulation testing is required to ensure that instruments do not cause internal burns during surgery. Despite weeks of asking for replacements, the staff was told that a new cord was on order and that the capital request for new devices had not been approved yet.

On the day of Cheryl’s surgery, the technicians had no choice but to process the instruments without testing the insulation. Unbeknownst to the team (and the patient) pinholes and cracks in the insulation had developed on multiple instruments within the set. As a result, she experienced internal burns and severe complications from her surgery.

The impact of insufficient resources

Sterile processing technicians rely on having the right equipment, products, and training to ensure all medical instruments are reprocessed according to manufacturers’ instructions for use (IFUs). These instructions are validated to ensure patient safety through a rigorous and evidence-based process. However, when resources are lacking, technicians are forced into compromising situations where they must either attempt to follow the IFUs with inadequate resources or deviate from the guidelines, leading to significant moral distress. It becomes a question of which is the greater harm, for the patient to not receive their surgery due to a lack of instruments, or to provide the instrumentation knowing the risks of not following the IFU.

The aftermath

Cheryl’s surgery initially seemed successful. She was discharged the following day, but within 48 hours, she developed severe abdominal pain and other symptoms indicating internal injury. Rushed back to the hospital, a CT scan revealed burns on her intestines, liver, and within the peritoneal cavity. Cheryl endured multiple rounds of treatment, a prolonged hospital stay, and additional surgeries to address complications from the internal damage.

This devastating turn of events took a toll on Cheryl and her family, causing significant physical, emotional, and financial distress. The hospital launched an investigation to determine the cause of the injuries, which pointed back to the compromised processes in the SPD.

Consequences of an inability to follow IFUs

The inability to follow IFUs has severe ramifications. Primarily, patient safety is jeopardized, increasing the risk of healthcare-associated injuries and infections. Non-compliance with IFUs can lead to failing to meet standards set by regulatory and accreditation agencies. A facility that is cited repeatedly for improperly reprocessed instruments can incur citations, fines, a tarnished reputation, and legal action. The new Joint Commission standards place a special emphasis on adhering to medical device and sterilization equipment manufacturers’ instructions.

The impact on the technician: James’ experience

For James Simmons, the lead sterile processing technician on duty that day, the news was shattering. James had dedicated over a decade to his role, taking immense pride in ensuring the safety and well-being of patients through meticulous practices. The constraints he faced daily—aging equipment, insufficient staffing, and a lack of support from administration—created an environment where he couldn’t always follow the IFUs to the letter.

When James learned about Cheryl’s condition through the Quality Committee’s Root Cause Analysis, he was left with guilt and distress. He replayed the day of her surgery over and over in his mind. Despite knowing the limitations he faced were beyond his control, James couldn’t shake the feeling that he had failed the patient.

Beginning of burnout

The disconnect between a technician’s professional duty to follow IFUs and their inability to do so significantly impacts their job satisfaction. Sterile processing technicians enter the field with a commitment to patient safety and adherence to best practices. When they are continually placed in situations where they cannot perform their duties to the best of their abilities, it leads to chronic stress, frustration, and eventually, burnout. This moral injury manifests as feelings of guilt, shame, and helplessness, eroding their passion for the job.

The Ripple Effect

James’ distress was compounded by the response from hospital administration. Instead of addressing the root causes and providing support, the focus quickly shifted to damage control and assigning blame. James found himself under scrutiny, with little acknowledgment of the systemic issues that had led to the failure.

The incident had a profound impact on the rest of the team as well. James was well-respected and a pillar within his department. Multiple technicians had been trained by him and relied on his experience to navigate day-to-day issues. As his job satisfaction plummeted, the moral injury he experienced led to severe burnout and a ripple effect among his team. Some left and others slowed down. He began to dread going to work, each day feeling heavier than the last. James, who once found meaning and purpose in his role, now struggled with feelings of hopelessness and isolation.

The cost of moral injury

The systemic barriers that contributed to patient harm were not new; there were persistent issues that the SPD staff had raised for years. In cases like this, when the alarm bell goes silent, it may be from fatigue rather than resolution. These incidents highlight the need for healthcare leaders to address barriers, ensuring that technicians can perform their duties without compromising patient safety. By addressing the systemic issues, the facilities can begin to rebuild trust with both staff and patients, ensuring that such an incident will not happen again.

For James, the road to recovery was long. With support, he began to find a path forward, advocating for changes that would protect both patients and the technicians who care for them. His experience underscores the need for change at a root level. To make lasting change, SPDs must leverage the resources they have on hand, including accreditation standards, best practices, and partnerships with Infection Prevention, Risk, and Quality.

Healthcare facilities can mitigate the risk of moral injury by creating a supportive culture where technicians can freely voice concerns about equipment and process deficiencies. This not only enhances patient safety but also improves job satisfaction, boosts retention, and reduces the risk of burnout.

When a patient needs surgery, we don’t expect the condition to resolve on its own. When a sterilizer breaks down, we bring in experts to restore functionality. In a world where surgery doesn’t happen without an SP technician, we can take time, allocate resources, and bring in experts to help address the internal damage that may be below the surface. It is a paramount priority for the patient, the healthcare industry, and above all, the SP professionals who keep us safe.


  1. Injuries, Illnesses, and Fatalities. US Bureau of Labor Statistics, US Department of Labor, 2023, https://www.bls.gov/iif/home.htm.