By Melinda Young

Healthcare workers need psychological support during and after the pandemic as they cope with moral injury, acute stress reactions, burnout, depression, anxiety, and post-traumatic stress disorder (PTSD). A group of researchers published pragmatic recommendations for organizations about how to support their workers during the COVID-19 crisis.1

Hospital Case Management asked the investigators about moral injury and their recommendations in this question-and-answer story. The researchers, who sent their answers via email as a group, are as follows:

  • Michael D. Christian, MD, MSc, FRCPC, research and clinical effectiveness lead, London’s Air Ambulance, Bart’s Health Trust, London
  • Esther Murray, CPsychol, AFBPsS, SFHEA, senior lecturer in health psychology, Centre for Medical Education, Barts and the London School of Medicine and Dentistry, Queen Mary University of London
  • Matthew Walton, MA, MB, BChir, DiMM, foundation year 2 doctor of accident and emergency and intensive care unit, National Health Service, London.

Hospital Case Management: What is moral injury in the context of healthcare workers and the pandemic? Why are healthcare workers more likely to experience moral injury during the COVID-19 pandemic than during other crises?

Christian, Murray, Walton: Moral injury is present when there is a betrayal of what is right, either by the self or by someone in legitimate authority, in a high-stakes situation. While the coronavirus we are currently dealing with is a sort of natural disaster, the reactions of those in legitimate authority have, in many cases, involved a betrayal of what’s right. At an individual level, clinical decisions will have to be made — and will continue to be made — that contravene the morals of those making them. These decisions are supported by protocol, but they differ from usual practice and guidelines pre-COVID-19. In many countries, governments have been slow to act, and there have not been coordinated plans to encourage as many citizens as possible to shelter in place. Equipment has been lacking, and testing inadequate. Healthcare workers across the world have been watching this pandemic unfold and calling out for something to be done to protect populations. They have not been listened to, which is a form of betrayal.

We do not know that staff would be more likely to suffer moral injury in the COVID-19 pandemic than any other crisis, but what we will see now is far more people experiencing it, as so many more are exposed. What the pandemic has done is to deliver a threat on a huge scale. Because of the time scale and the fact that we have been able to watch it spread, it is much clearer that there has been a betrayal of what’s right, in a high-stakes situation, by people in legitimate authority.

Hospital Case Management: Your paper notes that PTSD might affect frontline staff at a higher rate than usual during the pandemic. Why is PTSD a particular danger for people dealing with COVID-19 patients? When is it most important that leaders screen and assist staff at risk of or experiencing PTSD?

Christian, Murray, Walton: PTSD can be caused by being involved in a traumatic event, witnessing it, or hearing about it from someone who was there. There is a dose-response effect. If you take all this in combination, you can see how there will be an increased risk with so many adverse events, both at work and in the personal sphere, repeatedly and over time.

Leaders should be aware of the mental well-being of all members of their team, whether directly or indirectly. If not by screening for a specific illness, staff can be made aware of prolonged and extreme stress reactions in themselves and their colleagues, and they could be encouraged to complete self-tests and take up offers of support if there are any concerns.

Most people will ultimately be OK, even though many people will suffer acute stress responses — some of which can be quite profound. The most likely outcome is that these [responses] will resolve by themselves over time, especially where staff have access to good peer support, wider social support, and effective, containing leadership.

What leaders can remember here is that while they can’t address the primary stressor — that is, the pandemic itself — they are in a good position to address the secondary stressors that compound staff distress in a crisis. Secondary stressors include those stressors that arise as a result of the crisis itself. In the current situation, leaders can help ensure [schedules] allow for sufficient rest and that housing and occupational health issues can be swiftly and efficiently resolved.

In terms of when leaders should intervene, there should be plans in place to safeguard staff well-being at all times. It also should be noted that social support is one of the most powerful tools we can use to prevent traumatic experiences from making people ill. Strong relationships within teams; provision of appropriate services; and clear, concise, and transparent communication all improve the individual’s sense of safety and value at work, which in turn helps them to recover from traumatic experiences.

Hospital Case Management: In your paper, you suggest drop-in sessions with psychologists/psychiatrists and providing support to staff in isolation. How might hospitals best provide these interventions during and after the crisis?

Christian, Murray, Walton: There is no one-size-fits-all model of psychological support, in a crisis or in more peaceful times. There have been some lovely examples of spaces created where peers can meet, offload, and decompress, such as Project Wingman, recently run by British Airways. (Details are available at: Other organizations have set up more formal systems, such as confidential phone support staffed by inpatient psychiatric nurses, or even weekly psychology sessions. (Find out more at: Informal support networks also should be encouraged; for example, mutual phone support networks for those in quarantine.

It is extremely important that the culture of the workplace supports staff in accessing psychological support. That means senior staff need to be modeling the use of psychological support services and bringing others with them. They need to discuss the importance of psychological support for everyone who needs or wants it, and share their own strategies for maintaining their well-being.

The organization can reduce barriers to attendance, too. For example, they can create paid and protected time slots in staff work schedules. Improved utilization may actually improve cost-effectiveness of such services.

It will be useful to inform staff of the usual reactions to traumatic events, what they might expect, and how they might deal with it. It also is important to make clear to staff that systems in place now will continue when the immediate crisis has passed. In this way, institutions can ensure support not only to see staff through what might be a prolonged recovery/processing period, but also that these systems form part of the culture of the hospital or primary care facility.


  1. Walton M, Murray E, Christian MD. Mental health care for medical staff and affiliated healthcare workers during the COVID-19 pandemic. Eur Heart J Acute Cardiovasc Care 2020;2048872620922795.