By Josh Hyatt DH.Sc., MHL, MBE(c), DFASHRM, CPHRM, HEC-C, CPPS and Linda Rowett BSN, RN, CPHRM

Stress and moral dilemmas are not new phenomena in healthcare. Dealing with disease, death and dying, and the myriad social and cultural challenges faced by patients, families, and staff make the delivery of care demanding, even on the best of days. Whether in perpetually high-stress environments or when managing large-scale crises like COVID-19, the negative effects on the individual provider, institution, and patient are real.

Large-scale events and crises create unique types of anxiety, stress, and burnout. For example, in the wake of the COVID-19 pandemic, healthcare workers are facing a multitude of stressors arising from medically managing an unfamiliar virus, unclear treatment protocols, insufficient supplies, staffing issues, infection risks, prevention strategies, and more.

American workers are feeling the social and economic impacts of a national shutdown, financial and job insecurity, and the shift to remote working conditions, all of which directly affect their career, home life, and family dynamics. As recently noted in Risk & Insurance, “These new stressors are hitting employees with burnout especially hard. The chronic workplace stress condition is only being exacerbated by all of the new uncertainty that the virus brings.1

An individual experiencing chronic stress and complex moral decisions can undergo three devastating outcomes: compassion fatigue, moral distress, and burnout. Each of these is unique in its etiology and impact and can occur simultaneously.

Clinical Manifestations of Chronic Stress. The impacts of stress on the body can extend from alterations in homeostasis to life-threatening effects and death. Those who work or live in stressful environments have a higher likelihood of stress-related disorders. Stress triggers or aggravates many diseases and pathological conditions. It can negatively affect brain function, including memory and cognition; weaken the immune response; and affect cardiovascular, gastrointestinal, and endocrine function.8

Culture of Safety. Addressing these phenomena at an institutional level is important to protect your staff, patients, and institution. The cornerstone of this effort is establishing a culture of safety within your institution. A culture of safety exists when “every member of the healthcare team feels safe in voicing opinions and concerns regarding a patient’s plan of care and in which the fear commonly associated with reporting errors or disagreeing with those in positions of authority is eliminated.9

The goals of a culture of safety program include:

  • Providing safe and supportive environments that promote accountability and avoid blaming or shaming.
  • Empowering staff to speak up when concerns are noted.
  • Fostering leadership accountability to acknowledge and address concerns.
  • Focusing on evidence rather than opinion.
  • Maintaining open lines of communication between leadership and staff, as well as interdepartmentally.

Culture of safety principles are also embedded into patient safety and risk management as evidence-based practices and reinforced with Joint Commission Leadership Standard LD.03.03.01 (EP 4 and EP 5).10 Additionally, because of the potential consequences of unmitigated stress, it is essential that we recognize the telltale signs of compassion fatigue, moral distress, and burnout, and provide support to those demonstrating symptoms.

The WHO is developing evidence-based guidelines for mental well-being in the workplace. At a global policy level, WHO's Global Plan of Action on Worker’s Health (2008-2017) and Mental Health Action Plan (2013-2030) outline relevant principles, objectives, and implementation strategies to promote good mental health in the workplace.11

Failure to ensure a culture of safety can lead to:

Impacts and Approaches. Burnout and distress can affect people in different ways, depending on their:
  • Stress management skills.
  • Personal resiliency.
  • Support from family and friends.
  • Sense of psychological safety at work.
  • Work environment.
People also respond differently to intervention approaches (e.g., self-reflection, group and peer support, and counseling or therapy), so it is important to have programs that accommodate everyone. There are three key approaches to address burnout and distress:

1. Acknowledgment is the personal awareness and recognition in policy that the healthcare environment can be high-stress, high-pressure, and high-stakes, and that staff (clinical and nonclinical) face daily situations that challenge both their cognitive and moral reasoning. Examples of acknowledgment include:
  • Awareness of high-risk situations, symptoms, and need for support.
  • Honest communication with team members.
  • Culture of safety surveys that measure burnout and distress to assist in building wellness programs.
2. Short-term approaches provide techniques for individuals to prevent or manage burnout and distress.
  • Techniques to Manage Burnout include steps for developing micropractices, breathing and self-soothing exercises, debriefing, and professional coaching.
  • The Coverys Burnout and Moral Distress Checklist and Worksheet for Managers is available to our insureds on It identifies signs of burnout and moral distress in employees, provides approaches to address these concerns at an institutional level, and serves as a template in having a discussion with staff or a colleague. You can also use these resources for educational purposes.
As a manager or colleague, you may be unsure how to respond to distress experienced by staff or colleagues and interested in developing a program or enhancing an existing program. The above attachments can serve as tools to assist you.

3. Long-term approaches recognize that trauma will always exist, even in the best of circumstances. An institutional commitment to wellness for all staff is recommended. Examples of long-term approaches include:
  • Comprehensive wellness program.
  • In-house wellness interventions (e.g., exercise, meditation, nutrition, stress reduction workshops).
  • Care for the caregiver programs.
  • Employee assistance programs (EAPs).
  • External referral sources (e.g., substance abuse, mental health concerns, suicidal ideations).


The stress associated with compassion fatigue, moral distress, and burnout can negatively affect healthcare providers by creating distractions and imposing substantial emotional and physical tolls on the individual, potentially leading to illness, staffing issues, and loss to the institution. Taking proactive steps to address these conditions may enhance your patient safety and risk management programs by creating better stress coping mechanisms, increased staff satisfaction, and a stronger safety culture.


1. DuChene C. COVID-19 is Exacerbating Employee Burnout. Here’s What Employers Can DO. Risk & Insurance. Published April 28, 2020. Accessed June 22, 2020.

2. The American Institute of Stress. Compassion Fatigue. Accessed June 22, 2020.

3. Jameton A. Nursing Practice: The Ethical Issues. Englewood Cliffs, NJ: Prentice Hall; 1984;6.

4. Figley C. Compassion Fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. Florence KY; Brunner Mazel; 1995.

5. McCarthy J, Gastmans C. Moral distress: A review of the argument-based nursing ethics literature. Nursing Ethics, 22(1), 131-152.

6. Payne K. Ethics empowerment: Deal with Moral Distress. Tennessee Nurse/Tennessee Nurses Association, 74(1), 1.

7. World Health Organization (WHO). Burnout an “occupational phenomenon”: International Classification of Diseases. Health Topics: Mental Health. Published May 28, 2019. Accessed June 22, 2020.

8. Yaribeygi H, Panahi Y, Sahraei H, The impact of stress on body function: A review. EXCLI Journal. 2017;16: 1057-1072.

9. Lauve R, Porto G. Disruptive clinician behavior: A persistent threat to patient safety. Patient Safety and Healthcare Quality. July/August 2006.

10. The Joint Commission. 2012 Hospital accreditation manual. Leadership Standard LD.03.01.01.

11. World Health Organization. Mental Health in the Workplace: Information Sheet. Published May 2019. Accessed June 23, 2020.

No legal or medical advice intended. This content includes general 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.