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June • 29 • 2022

Understanding Moral Injury and Its Impact on Healthcare Providers


By Coverys Risk Management



Healthcare worker stress has reached crisis levels. Moral injury and burnout can have significant personal and professional impact, but strategies can help minimize these effects.

Healthcare providers were experiencing high levels of stress and burnout prior to the COVID-19 pandemic. In fact, a 2019 paper (published by the Harvard T.H. Chan School of Public Health, the Harvard Global Health Institute, the Massachusetts Medical Society, and the Massachusetts Health and Hospital Association) concluded that physician burnout is a public health crisis.

Then in 2020, the COVID-19 pandemic forced healthcare providers to rapidly grapple with difficult decisions in an unsettlingly new context according to the BBC. This created new types of anxiety, stress, and burnout that can profoundly impact healthcare providers in both their professional and personal lives, as discussed by Mental Health America.

The Harmful Effects of Suppressing Emotions

Healthcare providers are trained to use rational thinking; however, decision-making involves both emotional and rational processes. In Combining Emotion and Reason in Decision Making, Robert Frolichstein, MD, explains, “To make affective decisions, we must be able to recognize emotions in our self and understand that emotions are influencing our opinions and decisions. We must balance this with the rational influences on our decisions.”

When faced with anxiety and stress, healthcare professionals may suppress emotions as a coping mechanism, but emotional suppression has been linked to negative effects. Emotion Suppression and Mortality Risk Over a 12-Year Follow-up by Chapman et al., published in the National Library of Medicine, concludes that suppression of emotions is associated with risk for earlier death. Pent up emotions may also contribute to poor decision-making.

The Risk of Moral Injury

According to the Moral Injury Project at Syracuse University, moral injury refers to “the damage done to one’s conscience or moral compass when that person perpetrates, witnesses, or fails to prevent acts that transgress one’s own moral beliefs, values, or ethical codes of conduct.”

An article by Watson et al., published by the U.S. Department of Veterans Affairs, explains that moral injury can occur when individuals engage in, fail to prevent, or witness something that goes against their beliefs. It can also occur when they need to make decisions where all options have a negative outcome or when they are betrayed by the people they trust. The impacts can be significant, potentially including feelings of guilt and shame, as well as changes in sleep and behavior, mistakes, compulsive behavior, isolation, and a weakened sense of empathy. When moral injury is connected to feelings of betrayal, diminished confidence in leaders and anger or resentment may also follow.

According to a report published by the Welsh government, moral injury can contribute to PTSD, stress, low morale, and hostility. Furthermore, healthcare workers may have increased risk of moral injury during the pandemic, for example, when they are present at a patient’s death but loved ones are not, when they are tasked with allocating restricted resources to severely unwell patients, or when they feel let down by others in terms of safety measures.

Short-Term Approaches

Short-term approaches are not prescriptions for treating burnout, anxiety, moral injury, or PTSD, and they cannot replace safety guidelines. However, these strategies may help support and strengthen healthcare providers who are grappling with these issues.

Short-term approaches can include personal, group, and peer strategies.
  • Personal: Counseling and coaching may help individuals cope on a personal level. Additionally, individuals can adopt micropractices, which take only a few moments and can include mindfulness and breathing exercises, as well as gratitude lists. Research from UCLA shows how putting feelings into words, or affect labeling, can disrupt amygdala activity, while research from Robert A. Emmons and Michael E. McCullough, available from the National Library of Medicine, shows that consciously focusing on gratitude may provide emotional and interpersonal benefits. Research from Hopper et al., also available from the National Library of Medicine, shows how diaphragmatic breathing can reduce physiological and psychological stress.
  • Group: Team debriefing and interprofessional support groups may help. A study from West et al., available from JAMA Network, found that interventions for physicians based on small-group curriculum can improve meaning and engagement and reduce depersonalization.
  • Peer: Peer support and mentor/mentee relationships can add another layer of support.

Long-Term Strategies

Many healthcare professionals are already dealing with burnout, trauma, moral injury, and PTSD. An article on treating trauma in frontline medical staff explains how medical facilities are expanding treatment options for their staff in light of the mental health impacts of the pandemic. These workers may need ongoing help from counseling, support groups, and cognitive behavioral therapy.

Burnout and moral injury are too serious to be ignored. Healthcare providers need to find healthy ways to unwind, such as yoga, writing, a new hobby, mindfulness, and meditation. They can embrace both long-term and short-term strategies and strive for appropriate work-life balance.

Managers and supervisors can help by looking for signs of burnout and moral distress and responding appropriately. Our Burnout and Moral Distress Checklist and Work Sheet for Managers helps managers and supervisors identify the signs of burnout and moral distress and provides approaches to address these concerns.
This article was, in part, based on the Coverys presentation “Moral Injury,” presented by Josh Hyatt, DH.Sc., MHL, MBE, DFASHRM, CPHRM, HEC-C.

Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances. 


  • Risk Management & Patient Safety