Moral distress & injury

Moral distress is usually thought of as the emotional distress that arises out of feeling unable to do what you believe is right, feeling uncertain about what is the right thing to do, and/or being in conflict with others about the right course of action. Although moral distress can be a driver for right action (for example, stepping up and acting as an advocate for a patient), it often leads to negative consequences such as the decision to leave a post, withdrawal from patients, or burnout. Moral distress is usually felt most acutely by healthcare workers who have prolonged and close contact with patients and who witness extreme suffering. Moral injury goes beyond psychological harm and has a profound existential dimension, leading to a radical disruption of one’s moral framework and how one views oneself, others and the world.

Key points:

  • Moral distress refers to the emotional distress that arises out of feeling unable to do what you believe is right, feeling uncertain about what is the right thing to do, and/or being in conflict with others about the right course of action.
  • Moral injury can arise from moral distress. Moral injury goes beyond psychological harm and has a profound existential dimension leading to a radical disruption of one’s moral framework and how one views oneself, others and the world.
  • This page provides links to key resources on this topic.

Covid-19, moral distress & moral injury

The patient is at the heart of clinical healthcare workers’ obligations, which carry the imperative to provide safe and compassionate care. The covid-19 pandemic, however, forced healthcare workers and leaders to intermittently shift their priorities from patient-centred care to public health focused measures. These changes have impacted on society in profoundly different ways. They have led healthcare workers to make decisions about provision of care and treatment in ways that are either unusual or that would be inconceivable in the normal run of things. These challenging demands are amplified by the lack of recovery time, the feeling that work is relentless, and the fear that there is no clear end in sight – as further ‘waves’ become a distinct possibility.

We are already aware of the ethical challenges and dilemmas that arise in the context of the pandemic. For example, difficult decisions have been made about the allocation of finite resources, the prioritisation of patient care, the provision of care with insufficient PPE (personal protective equipment), and the necessity of working outside of one’s usual area of expertise. Equally challenging situations have related to issues such as preventing relatives from being with their loved ones when critically ill or dying, and balancing personal and professional obligations with a potentially higher risk of exposure to infection at work.

As a result, many individuals will be feeling unusually high levels of painful negative emotions, including guilt, shame, anger, and frustration. People may also be feeling conflicted, uncertain or powerless. These feelings may be a sign of ‘moral distress’ or, if persistent, of ‘moral injury’.

Moral distress & moral injury

Moral distress is usually thought of as the emotional distress that arises out of feeling unable to do what you believe is right, feeling uncertain about what is the right thing to do, and/or being in conflict with others about the right course of action. Although moral distress can be a driver for right action (for example, stepping up and acting as an advocate for a patient), it often leads to negative consequences such as the decision to leave a post, withdrawal from patients, or burnout. Moral distress is usually felt most acutely by healthcare workers who have prolonged and close contact with patients and who witness extreme suffering.

Moral injury goes beyond psychological harm and has a profound existential dimension leading to a radical disruption of one’s moral framework and how one views oneself, others and the world. One’s whole system of values, and clarity about what is right and wrong, are affected. Betrayal and loss of trust are key features. Moral injury can develop from a single episode or from the longer-term damage sustained from experiencing multiple morally distressing events – in particular, perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held beliefs and expectations.

Moral distress is a normal response to challenging ethical encounters, but failing to address moral distress and moral injury can lead to negative consequences, such as impaired resilience, reduced capacity to be compassionate, withdrawal from patients, worsening mental health, and the intention to leave one’s place of work or profession.

Moral distress can build into a ‘crescendo’ effect, leading one to react more strongly to similar events in the future. It may lead to profound demoralisation, cynicism and detachment, and may be a precursor to moral injury. It is therefore important to be mindful about the effect that moral distress or injury might be having on healthcare staff, and to seek ways to address it. As an act of self-care, it is important that you can identify the signs and symptoms of moral distress or moral injury in yourself or others, take steps to seek support and mitigate the harmful consequences and to engage in moral repair. This repair enables you to work out ways of understanding the new situation you are in and to develop novel and appropriate tasks and strategies to move forward – in other words to rebalance yourself and even to develop post-traumatic growth. The Moral Distress Pocket Card outlines signs and symptoms to recognise moral distress.

Clinical scenarios

Examples of clinical scenarios that may give rise to moral distress or moral injury during the covid-19 pandemic include:

  • When the need to provide patient-centred care conflicts with the need to protect the population. “When I tell patients that they can’t have any family to visit them I feel like I’m adding to the torture. Like I’m a torturer.” 
  • When the delivery of patient care can cause harm to healthcare professionals and their families. “When I get to a cardiac arrest and need to gown up before going in, I feel like I’m letting them die. It keeps me up at night”. “What if I infect my family. I’ve decided to stay living at home, but what if I regret it?” 
  • Lack of sufficient resources, for example PPE, ventilators, sufficient staff with sufficient expertise. “It kills me when I think of the decisions I’ve had to make” 
  • When there is insufficient evidence to support effective treatment of covid-19. “Too many people are dying. I feel useless” 
  • When policy dictates practice that conflicts with the values of the individual healthcare worker or conflicts with the decisions that they would have made independently. “It’s not right. I shouldn’t have to….” 

Steps to address moral distress or moral injury

When trying to address feelings of moral distress or moral injury, it is first important to recognise that having these feelings does not in itself indicate a personal failure on your part. Remember that many of the situations you are in will involve genuine moral dilemmas, where you are ethically obliged to do two things but cannot do both. Although you have to make a choice, whatever you choose will likely result in feelings of guilt and having done something wrong. These feelings are termed ‘moral residue’, and are a normal and unavoidable feature of being part of ethically challenging decisions.

Steps for individuals:

In addressing moral distress or moral injury, it is important to deal with the moral event(s) that causes distress or injury. To do this you might consider:

  • If this relates to ongoing patient care, talk with a colleague, senior colleagues and/or the rest of the healthcare team about the moral issues involved.
  • If this relates to a previous experience, you might consider talking to a colleague or senior colleague about the moral event to gain a wider perspective.
  • Taking the case to a clinical ethics committee or ethics specialist to discuss the ethical issues.

Steps for organisations:

Organisations should:

  • Ensure that there is good multi-professional communication. Senior managers and clinical leads need to be aware that their decisions have practical implications for how staff (both within and outside of the leader’s profession) are able to care for patients.
  • Consult staff from all grades in policy-making decisions that are critical to patient management. Include representatives from all professional groups whose care for patients is impacted upon.
  • Be transparent and communicate the justifications for policies that are at risk of causing moral distress or moral injury.
  • Moral distress (and moral injury) can be likened to the ‘canary in the coalmine’. Listen to your staff. Sometimes moral distress and moral injury can be indicators that policy or practice ought to be changed.

Seeking support:

In addressing moral distress and moral injury, it is also important to seek support for the psychological distress that you experience due to the moral event:

  • Consider speaking with your Employee Assistance Program (EAP) and/or Occupational Health department
  • Some hospitals or Trusts have Clinical Psychologists able to offer psychological support to teams.
  • Schwartz rounds or Team Time (an online version of Rounds) provide a supportive safe space for talking about the emotional and moral aspects of your work.

Good teamwork, supervision and peer support have been shown to be key to maintaining morale and resilience, as well as sustaining self-care strategies in daily life. These include adequate sleep, exercise, healthy food, and keeping connected with family and friends. Practise calming strategies that work for you (e.g., mindfulness, slow breathing). Take breaks when needed and don’t hold back from seeking support when you feel you are having difficulties coping – this is normal. A key element for coping with adversity and thriving, not just surviving, is self-compassion – being kind to yourself as well as to others. Your own institution may have further resources to support you and there is an abundance of self-help tools, advice and information on the internet for support and maintaining resilience.

Speaking up:

If you believe that you have witnessed serious transgressions in the provision of compassionate and competent care and wish to report this, you may be able to approach your organisation’s Freedom to Speak up Guardian, who will provide confidential support and take matters forward on your behalf, ensuring that your anonymity is preserved and that you do not suffer the threat of retaliation or discrimination as a result. If your organisation has not got a Guardian, you can contact the Speak Up helpline online here or telephone directly (0800 0724 725).

Further resources

  • Please visit Downloads for further resources, including a moral distress pocket card. This card was developed for use in the Cleveland Clinic (USA) and the resources listed on it are specific to that organisation. This card may be used by other healthcare organisations to help healthcare workers recognise moral distress and know which support resources to seek. The card may be edited in Adobe but the author requests that edits only be made to the blue box of resources to preserve the integrity of the card.
  • Academy of Royal Colleges covid-19 Mental health & wellbeing for healthcare professionals resources: here
  • BMA Free, confidential 24/7 counselling and peer support for doctors and medical students (whether a BMA member or not): here
  • #Caring4NHSPeople wellbeing webinars: here
  • Compassionate well-being: here
  • Doctors support network: here
  • DocHealth is a confidential, not-for-profit, psychotherapeutic consultation service for all practising doctors. It is delivered by Consultant Medical Psychotherapists based at BMA House in London. here
  • Intensive care wellbeing resources: here
  • King’s Fund: here, plus information on managing anxiety about loss, here
  • Mindfulness and coping strategies: here
  • Moral Injury, information for organisations: here
  • Nuffield Health Guidance: here
  • Practitioner Health Covid-19 NHS workforce wellbeing: here 
  • Psychological support for NHS staff (free): here
  • Resilience toolkit (free): here
  • Schwartz Center for compassionate healthcare: here
  • Self-care during the pandemic (BMJ blog): here
  • Self-compassion: here
  • Self-help resources (free) tailored for the pandemic: here
  • Support the workers (an international group of experts in disaster response, crisis psychology, high pressure decision-making and human performance and health under conditions of extreme stress; their resources include information about moral injury): here

Acknowledgements: UKCEN thanks the following, who prepared this information for and on behalf of UKCEN in 2020: (in alphabetical order) Paquita De Zulueta, Jonathan Ives, Georgina Morley, Anne McNiven, and Aileen Walsh.  

We partner with the Institute of Medical Ethics (IME), an organisation which is dedicated to improving education and debate in medical ethics. Visit the IME website