A Guide to Moral Injury: Supporting healthcare workers during COVID-19

The Centre of Excellence on Post-Traumatic Stress Disorder at The Royal and Phoenix Australia Centre for Posttraumatic Mental Health have published A Guide to Moral Injury and accompanying microsite. They address one of the most urgent and prevalent needs among health care workers during the COVID-19 pandemic: Moral injury.

Moral injury refers to the impact of challenging experiences that upset a person’s value system or moral beliefs. The effects can be enduring, and result in long-lasting emotional and psychological damage.

A Guide to Moral Injury cover

A Guide to Moral Injury serves as a practical resource for health care workers, teams, and organizations. It’s about providing  support at the right time for those who are risking their lives on a daily basis. 

“It’s a call-to-action for workplaces that, if we really wanted to take a ‘New Zealand’ approach to squash the curve, this is where we could get ahead and show true leadership in Canada to really support our workers so that as few as possible make the journey to PTSD and moral injury,” explains Dr. Patrick Smith, CEO of the Centre of Excellence.

Although the term “moral injury” might seem new in the area of health care, it has been studied in a military context, explains Fardous Hosseiny, vice president of Research and Policy at the Centre of Excellence. 

“It’s been in the literature pretty extensively but now we’re finding out that different populations, or anyone who can feel some sort of moral dilemma, will be potentially at risk for moral injury if they’re feeling it on a consistent basis,” he says. “It’s important to note that different populations, different cohorts, are now being affected as well.” 

Moral injury can impact anyone. Smith shares examples of a long term care worker who can’t admit visitors, a social worker who holds the phone while patients share final goodbyes with their family, and a hospital administrator who has to approve redeployment of nurses to centers experiencing outbreaks of COVID-19 knowing what the risks might be. 

Moral injury can also occur when an individual feels betrayed in a high stakes situation or witnesses others behaving in ways they feel are morally wrong.  

“These are unprecedented, challenging times,” says Smith. “The people who trained to serve didn’t train for this.” Smith, who was a vice-president at a major hospital in Toronto during SARS, recalls passing out N95 masks and checking temperatures as staff walked in the door. “It was nothing like this. Sometimes even recognizing that helps. Getting people the support they need now – while they’re going through it – can really help them feel heard, safe, protected, and hopefully cared for.”

Hosseiny adds that people of colour who work in health care settings face heightened moral stresses. He’s working on a soon-to-be-published supplemental document that will propose specific recommendations.

“COVID-19 pandemic has disproportionately affected marginalized communities. They see themselves in the people who are coming in. They identify with their patients, who may remind them of loved ones…. marginalized and people of colour are struggling on an even higher level,” says Hosseiny.

At this time there isn’t a universally accepted “scale” to measure someone who is high at risk for moral injury. Hosseiny is undertaking that research with health care workers. 

"Throughout the COVID-19 pandemic, health care workers have faced the challenge of continuing to provide the high-quality care to which they are deeply dedicated while adapting to an ever-changing situation and keeping their patients, their loved ones and themselves safe,” says Joanne Bezzubetz, CEO and president of The Royal. “This stress can have a profound impact on mental health. The moral injury guide created by the Centre of Excellence for PTSD provides insight gleaned from military and Veterans' experiences to help individuals and organizations support health care worker wellness now in an effort to avoid an onslaught of mental health issues in the future. I encourage health care leaders everywhere to read and act on this important information.​"

Smith says that intervention and support for healthcare staff is critical if we are to avoid the most severe outcomes.  

“We know there are so many things that we can be doing to support them now, so you don’t have that onslaught of PTSD and moral injury. Frankly, if we just took a watch and wait approach, we’d never be able to afford to treat our way out of this after the fact,” he says.

View the Moral Injury Guide and microsite at moralinjuryguide.ca.

Programme Mieux-être - Femme

If you are a health care worker impacted by stress related to COVID-19, you can get simple, fast access to supports and tools for your mental wellbeing through the COVID Frontline Wellness website. 

Details from A Guide to Moral Injury

The guide shows how to implement preventative and early intervention structures to support health care workers and outlines the supports that need to be provided at the organizational, team, and individual levels. 

At the organizational level: 

  • Recognizing the moral stressors that health care workers face due to COVID-19 
  • Promoting a supportive culture, including support services, for staff 
  • Ensuring there are sufficient resources to support the health and safety of informal and volunteer service providers, who also play an important role in health care 
  • Rotating staff between high and low stress roles 
  • Establishing policies to guide staff through ethically difficult decisions 
  • Removing ethical difficult decisions from frontline workers 
  • Arranging rosters for shift workers, with a cycle of morning to afternoon to evening shifts 

At the team level: 

  • Providing strong leadership and establish cohesive teams with high morale 
  • Being prepared to discuss moral and ethical challenges 
  • Helping team members understand moral stressors 
  • Encouraging self-care and help-seeking as required 
  • Celebrating successes, large and small 
  • Connecting staff to further support and counselling, if needed 

At the individual level: 

  • Learning about moral stressors and moral injury 
  • Using relaxation therapy, mindfulness, or meditation to reduce stress 
  • Eating well, get regular exercise, maintain social connections, and get enough rest 
  • Supporting your colleagues 
  • Seeking professional help if you are feeling distressed about what you are going through 

For more information, go to moralinjuryguide.ca.