What is the treatment approach for moral injury?

Treatment Approach for Moral Injury

Organizations must implement multi-level interventions that address both individual healthcare worker support and systemic factors, with emphasis on accessible mental health resources, workload reduction, and inclusion of frontline staff in decision-making processes. 1

Organizational-Level Interventions

Mental Health Support Infrastructure

• Station mental health services near the workplace to allow drop-in sessions, embed mental health professionals directly within healthcare teams, and provide virtual mental health services to increase accessibility during crises 1
• Mental health interventions must be voluntary, free of stigma (both from others and oneself), utilize peer support, and be both supported and modeled by senior leadership 1
• Provide early identification of individuals exhibiting signs of depression, anxiety, and stress reactions through regular check-ins, debriefing sessions, peer support networks, and formal mentorship programs 1

Addressing Root Causes of Moral Injury

Organizations must directly address sources of moral distress or injury by including frontline healthcare workers in organizational decision-making and involving administrative leaders on the front lines 1. This is critical because moral injury arises when superior actions or system policies undermine professional obligations to prioritize patient best interests 2.

• Eliminate or reduce nonessential tasks, redundant or excessive documentation, and avoid mandating overtime to decrease workload 1
• Promote autonomy and empowerment at the bedside by decentralizing decision-making and bringing it to the bedside 1
• Ensure transparency on end-of-life decision-making during times of excessive strain 1
• Triage and fair allocation of resources should be made by a dedicated triage team composed of experienced clinical staff removed from bedside care, working in collaboration with administration 1

Workplace Environment Modifications

• Establish a positive and supportive work atmosphere that avoids isolation and promotes a sense of community 1
• Humanize healthcare workers and acknowledge their vulnerabilities 1
• Destigmatize the need for mental health support 1
• Provide support, protection, and respect for healthcare workers experiencing burnout 1
• Promote joy and safety in clinical work 1

Individual-Level Support

High-Risk Population Targeting

Target populations at high risk of moral injury for early assessment and intervention, including: 1

• Less-experienced workers/staff in-training
• Those with direct contact with affected patients (particularly ED and ICU bedside nurses)
• Healthcare workers involuntarily deployed to work
• Those without strong social support at home
• Those with significant family and childcare needs

Self-Care and Recovery

• Ensure compliance with mandated rest periods and adequate respite between day and night shifts 1
• Provide strict adherence to 12-hour shifts, including sign-out times 1
• Offer opportunities for staff physical fitness 1
• Provide mental health breaks and/or debriefs following stressful events (such as workplace assault and peer illness or demise) 1
• Develop programs for family support, including childcare and meals 1

Communication and Decision-Making Strategies

Use structured communication frameworks and decision-making strategies to minimize subjectivity and ensure patients or surrogates express preferences, values, and desired goals of care 1. This approach benefits collaboration among healthcare professionals and with patients and families, reducing moral distress 1.

• Focus on task-oriented actions, planning, and problem-solving rather than emotion-oriented solutions 1
• Provide timely, transparent communication at all times through situation reports 1
• Develop methods for staff feedback on supply shortages and triage 1
• Ensure different viewpoints of ICU healthcare professionals are taken into consideration to improve ethical culture 1

Community and Team-Based Approach

Moral injury requires a community approach for healing, as complex social factors lead to moral injury 3. Veterans recognize that a team-oriented and multidimensional approach is essential for addressing underlying causes 3.

• Encourage talking openly about the experience of moral injury 4
• Build networks of support and break free from stigma of needing assistance 4
• Be proactive in seeking help 4
• Recognize that moral injury involves feelings of helplessness, guilt, wide-ranging negative consequences, diminished self-esteem, isolation from others, and spiritual distress 4

Common Pitfalls to Avoid

• Do not rely solely on individual-level interventions when systemic factors are the primary drivers of moral injury 2
• Avoid placing triage decisions on bedside clinicians, as this contributes to moral distress 1
• Do not implement mental health resources that are difficult to access or carry stigma 1
• Recognize that moral injury goes beyond burnout symptoms and incorporates existential threats to professional identity 2

Treatment Considerations

While evidence-based treatments for PTSD may address some aspects of moral injury, there is debate about their effectiveness for moral repair specifically 5. Because moral injury relates to ethical behavior, meaning attached to events, and perceptions of self, interventions should incorporate moral philosophy and spirituality 6.