A guide to supporting staff with post-pandemic moral loss

Much of the focus on the state of health services since the height of the pandemic has been on healthcare financing, workforce shortages, and physician burnout – but what about the moral distress healthcare workers have experienced?

CREDIT: This is an edited version of an article that originally appeared on BMJ

Rallying cries to learn from the COVID crisis call for regeneration, transformation, and systems change. Such language is ambitious and aspirational, and is largely directed at policy makers, institutions, and health systems. 

Although structural changes to ease the burden on healthcare workers and ensure they do not experience the particular traumas of the COVID-19 pandemic again are important to help healthcare workers recover, post-COVID regeneration needs to acknowledge, take seriously, and respond to the moral dimensions of frontline health workers’ experiences during the pandemic. 

Approaches such as facilitated ethics discussions can help clinicians to acknowledge and process their struggles and should be an integral part of COVID recovery efforts.

 Moral dimensions arising from the pandemic

When clinicians’ agency is constrained or undermined, as occurred in the pandemic, a sense of moral disorientation arises involving a loss of coherence between their sense of moral identity and imposed workplace requirements.

In the early phases of the pandemic, clinicians faced overwhelming numbers of patients, distressing triage decisions, and anxiety about their own and their family’s wellbeing.

Across all areas of clinical practice, clinicians had to pivot from their ethical orientation of individual based patient centred care to accommodate public health ethical values of protecting population health and safety.

Governments and hospital leaders imposed constraints related to infection control, including personal protective equipment, visitor restrictions for inpatients, and disruptions to established and evidence based clinical care pathways. 

Caring for patients in ways that conflicted with fundamental health ethics values of patient centred care was distressing for clinicians, inducing feelings of shame and guilt and a loss of moral identity. 

This leads to an erosion of trust in self and in leadership, feelings of professional powerlessness, and loss of professional integrity to be able to perform their role in accordance with their values. 

Strategies to repair moral loss

Responding to moral injury requires strategies directed specifically at moral repair—for example, by acknowledging the norms that have been violated and listening to and validating emotions of guilt, shame, and resentment.

In healthcare, interventions that have been reported as mitigating moral distress include educational interventions, facilitated discussions of 30-60 minutes, specialist consultation services, multidisciplinary rounds, self-reflection, and narrative writing.

Evidence is emerging linking workplace supports in the form of facilitated ethics discussions to increased moral agency and professional integrity for individual clinicians. This, in turn, empowers them to provide feedback and take on advocacy for change within their clinical community and at a systems and health policy level.

Facilitated clinical ethics discussion and debrief give clinicians an opportunity to name and process their reactions and experiences, to hear from others and therefore situate and make sense of their own experiences, and to make connections between their feelings of moral distress and possible causes. 

Clinicians being able to name the ethical values they believe were being promoted, balanced, or traded-off and identify the constraints placed on them as decision makers, validates their experiences of moral loss and distress, normalises their responses and feelings, and creates a safe space for nurturing the understanding and fostering the resilience required for professional growth and repair to occur despite repeated adversity.

Such discussions require a facilitator with specialised clinical ethics expertise who understands the scope and limits of their role, including the potential beneficial and adverse effects of the facilitation approach. 

Not all health institutions have this expertise readily available. These discussions also take time, which is scarce in healthcare settings. However, the potential ongoing damage from failing to acknowledge feelings of resentment in staff who experienced a lack of support from health leaders is more burdensome than the repair work, especially as moral distress contributes to staff attrition.