New guidance for fighting moral injury during COVID


Aaron Kunkler


New guidance on fighting moral injury for health care workers has been released by the Washington State Department of Health.

Moral injury can occur when health care workers are required to provide care that violates their own moral code, values or expectations. The pandemic has exacerbated existing conditions which could already lead to moral injury, like resource scarcity and conventional standards of care being altered. Additionally, the Department of Health’s guidance states those who have a history of trauma or who have experienced burnout or compassion fatigue may be at additional risk.


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In addition to care alterations and a lack of supplies, health care workers likely have never experienced a disaster as long or broad as the COVID-19 pandemic. Some mental health experts have begun arguing that instead of burnout, moral injury is a better way to describe what is happening to health care workers.

“Assisting health care workers to meet the challenges of their current health care settings calls for practitioners to acknowledge the possibility of suffering from moral injury,” the guidance states.

The state has been studying emotional responses to disasters, and found that after an initial dip in morale following a disaster, and a consequent boost in community resilience, people’s emotional response takes a significant hit before beginning to rebound. Consequent disasters can cause secondary slumps, and illustrated below in a graph from the Department of Health.

Signs of moral injury can include shame, guilt, anger and disgust and lead to depression, PTSD, suicidal ideation, burnout and lowered morale. Psychological risks from exposure to high stress events can be tracked by using PsySTART-Responder, which uses evidence to track exposures and build resilience. After a training on the program, a personal account is created to track exposures and an individual coping plan is created.

Health care leadership can use aggregated information from the system, after it has been scrubbed of identifiable information, to gauge risk levels for their staff and mitigate moral injury.

Coworkers can also help fight moral injury by talking frankly about the challenges of the work and what each team member faces; find team support about morally challenging decisions; and develop peer support groups. The report also encourages health care workers to eat healthy meals, exercise and sleep regularly, reach out to friends and family, set personal boundaries, and rely on spiritual practices that may have been helpful in the past.

For organization leaders, honest communications about the challenges, empowering team members to exercise greater agency, and practicing humility can help moral injury.