Moral distress and moral injury

“By their nature, doctors always want to do the right thing and find solutions to problems. When
you cannot do that, due to circumstances beyond your control, it is extremely distressing.”
BMA survey, 2021
Working as a clinician in primary care involves trying to offer the best possible care we can, and making serious deci-
sions with significant consequences for patients’ health and wellbeing, while operating within an imperfect system –
one that simply does not have infinite access to time, resources and trained professionals.
As clinicians, we may experience a heavy toll from working within a system in which it may be impossible to provide
the standard of care we would wish to. This article will summarise the concepts of ‘moral distress’ and ‘moral injury’,
and how we can protect ourselves from harm as a consequence.
This article is based on: BMA (2021): Moral distress and moral injury: Recognising and tackling it for UK doctors.

What is moral distress?

• Moral distress refers to a sense of emotional or psychological unease or discomfort which arises when health pro-
fessionals feel obliged or compelled to behave in ways that conflict with their personal beliefs, ethics or morals.
• There are many reasons we might be unable to provide the level of care we wish to, and which may make us at
risk of experiencing moral distress. These include:
o Lack of staff or resources to provide care to acceptable professional standards.
o Feeling helpless or powerless, or lacking agency to make appropriate decisions for patients.
o Witnessing poor standards of care, or knowing that care pathways are inadequate.
o If we experience personal mental or physical fatigue.
o Struggling with time constraints, including being unable to provide timely assessment or treatment, or lacking
time to provide sufficient emotional support to patients or colleagues.
o Coping with impossible situations with no ‘right’ answer, managing complex cases with limited resources, and
end-of-life care.
o Working within a team or organisation that does not encourage ‘speaking up.’
• Moral distress is more likely to occur if we perceive a problem as avoidable, or feel powerless to change it, and
with repeated exposure to difficulties.
• It can also occur when we observe other people’s moral transgressions, or when we feel betrayed by others, in-
cluding leaders, politicians and the wider health service.

What is moral injury?

• Moral injury can arise where sustained moral distress leads to impaired function or longer-term psychological
harm to health professionals. Thus, moral injury moves from coping with a situational problem to experiencing
significant personal harm as a consequence.
• Clinicians experiencing moral injury may develop profound feelings of guilt and shame, or a sense of betrayal and
anger.
• Moral injury is not a form of mental illness, but it can increase the risk of a range of mental health problems, in-
cluding burnout, depression, PTSD and suicide.

What factors contribute to the development of moral distress and moral injury?
• The terms moral distress and moral injury may be new to many clinicians, but the feelings have been present for a
long time. Years of underfunding, increasing layers of bureaucracy and lack of autonomy for health professionals
have all contributed to the development of a myriad of problems.
• This is not unique to the UK. Research suggests there is a rising prevalence of moral injury in healthcare workers
across many countries.
• Factors such as equality and discrimination may also play a role. Doctors from ethnic minority backgrounds are
more likely to report experiencing moral distress, and those with disabilities are more likely to feel that moral in-
jury resonates strongly with their personal experiences at work.

Moral injury and the COVID-19 pandemic

• The risk of moral distress has considerably increased for many clinicians during the COVID-19 pandemic.
• One of the many impacts of COVID-19 has been to highlight and aggravate existing deficiencies in the UK health
system, including a lack of resources and problems with staff numbers.
• Many clinicians found themselves working under extraordinary, constantly evolving, conditions during the pan-
demic. And, particularly in hospital settings, many were also thrust into situations which did not complement their
expertise, often with inadequate equipment and protection.
• In primary care, the pandemic has necessitated working in different ways, many of which have fragmented pri-
mary care teams and increased the sense of isolation of many clinicians, even when making complex or difficult
decisions.
• Telephone consultations can be a highly effective way to triage demand, but can also prove deeply frustrating at
times. Trying to make safe clinical decisions with limited face-to-face contact with patients may increase the risk
of moral distress.
• Nevertheless, while COVID-19 may have exacerbated and aggravated the issue of moral distress for many UK clini-
cians, it did not create it. The issue existed before the pandemic and undoubtedly will exist after. “This was a seri-
ous problem way before the pandemic; the pandemic has merely highlighted the problem.” BMJ Leader
2020;4:224-227.

How to manage moral distress and moral injury

It is essential to mitigate the risks of moral distress and moral injury as much as possible, both for the wellbeing of
clinicians and for the patients we treat. There are several ways to do this:
Wider organisational change
• In many cases, the only effective solution is to make structural and organisational changes that minimise clini-
cians’ exposure to situations that risk triggering moral distress or injury.
• This creates a fundamental platform for wellbeing for clinicians, as well as offering optimal care for patients.
• Examples include the provision of adequate funding and resourcing, appropriate levels of staffing, developing an
open culture in the workplace, and providing support and empowerment for clinicians.
Within your team
• We can also take active steps to reduce the risk of moral distress and moral injury by making changes within our
practice teams. This includes taking steps such as:
o Talk openly about moral distress and its impact within your team. It’s often helpful to know that you are not
alone in struggling with these feelings. Talking explicitly about moral distress and moral injury will help you
and colleagues increase awareness and understanding, so it feels less confusing or overwhelming.
o Leaders and managers check-in and acknowledge challenges. Leaders and managers should take an active
role and check-in regularly with their teams, ensuring that everyone feels seen and heard. This should include
explicitly acknowledging the challenges that are inherent within many aspects of primary care.
o Strengthen support within your team. This may be formally through practice meetings, Balint groups or peer
support networks, as well as informal support and discussion with others in your team.
o Actively seek advice from colleagues. It can be helpful to collaborate and seek advice when making difficult or
complex decisions about patient care with limited resources. This may be through regular practice meetings or
by working collaboratively with other clinicians who may be involved with the same patient.
o Encourage clinicians to speak up. Empowering individuals to speak up when they notice moral distress and
moral injury can help foster a greater sense of support, and can also lead to real change as problems are iden-
tified and discussed more openly.
Individual self-care
• In parallel with structural and organisational change, there are also strategies we can take to look after ourselves
and minimise the risk of moral distress and moral injury.
• This involves actively practising self-care: making choices that care for you, alongside your patients and col-
leagues, both in your work and home life.
Microskills for clinician self-care
• Keep a balance between your emotion systems, using your drive system wisely to engage in meaningful activities
such as social interaction and physical activity, while finding sufficient time for rest and recuperation. See our arti-
cle on Self-care and compassion: the three circles model.
• Foster a sense of compassion towards yourself and anyone else who is struggling with the challenges that you are
facing. Can you wish yourself well: recognising how hard it is to work in primary care, and acknowledging the im-
portance of your professional values and sense of ethics which may be triggering a sense of moral distress? Now
try to broaden your perspective and offer yourself support, encouragement and kindness as you deal with these
challenges.
• Encourage a sense of gratitude. Focusing on small things that you appreciate and can feel grateful for in your
daily life can foster positive emotions and strengthen your sense of meaning and purpose. Try writing down 2–3
things daily that you appreciate or feel grateful for in your life.
• Notice any personality traits, such as being a chronic hero or an imposter, which may make us vulnerable to
stress, burnout and moral distress and injury. Are you struggling with excessive guilt and personal responsibility,
or setting yourself unreachable expectations or targets for patient care? We discuss this more in our article on
Strengths and vulnerabilities in clinicians.

Mindful check-in or ‘STOP’

If you are getting stuck or overly preoccupied with feelings of guilt or thoughts about a possible experience of
moral injury, try a mindful check-in or ‘STOP’:
• Stop and press pause – notice that this is a moment of moral distress that is affecting you.
• Take a few slow breaths, focusing on the exhale.
• Observe inside and outside. Ask yourself: What am I thinking or feeling right now? How am I behaving or act-
ing?
• Proceed… What would be the most helpful thing to focus on at this time? Can you move on to do this with your
full attention?
 Moral distress and moral injury
• ‘Moral distress’ relates to a sense of psychological unease which arises when we feel obliged or com-
pelled to behave in ways that conflict with our personal beliefs, ethics or morals.
• If this distress progresses to involve impaired function or longer-term psychological harm to health
professionals, we have experienced ‘moral injury’.
• Factors that contribute to moral distress and injury include lack of staff and resources, witnessing
poor standards of care, and lack of time.
• The most important strategies for reducing the risk of clinicians experiencing moral distress and in-
jury relate to wider structural and organisational changes that minimise exposure to situations that
trigger a sense of moral injury.
• Personal skills for coping with moral distress and injury include actively practising self-care, and mak-
ing choices that care for yourself alongside your patients and colleagues.
• Have you experienced a sense of moral distress? What was the situation? Who and what was in-
volved in this reaction?
• How did you personally respond to the situation? What thoughts or emotions arose?
• Can you use any of the self-care microskills to help you process and make sense of your experiences?
• What improvements could you make within your team to help you collectively cope with experiences
of moral distress more effectively?

This article was published 02/03/2023. We make every effort to ensure the information in this article is accurate and/ correct at
the date of publication, but it is of necessity of a brief and general nature, and this should not replace your own good clinical
judgement, or be regarded as a substitute for taking professional advice in appropriate circumstances. In particular, check drug
doses, side-effects and interactions with the British National Formulary. Save insofar as any such liability cannot be excluded at
law, we do not accept any liability for loss of any type caused by reliance on the information in this article