HEALTH CARE workers who cannot put the needs of their patients first because their energy is being diverted to administrative and regulatory demands in an environment of resource and service reduction, may experience moral injury and burnout.

It is time for the executives in health care organisations, clinical leaders, consumers and political leaders to have respectful dialogue and establish and maintain systems and processes to support health care workers to deliver comprehensive care to patients. Any perception that the consultative process is token in nature will undermine trust and will put the high standards in the health care system at risk.

The COVID-19 pandemic has presented unique challenges to the individual, families and local, national and international communities. Addressing these challenges has highlighted two equally important but seemingly diametrically opposing priorities in health care that broadly shape policy making, namely the current health and safety of the people in the nation versus the drivers that have an impact on our economic future.

This played out at the national level in broad terms as a debate between decisions to prioritise “lockdown” or “opening the borders” and elimination or suppression strategies for COVID-19 in the community. Within this broader context, health care workers are now encountering unprecedented pressure.

The same opposing priorities may be played out at local health boards and health care organisations. Are local health boards scrutinising budgets and reducing or stopping clinical services that run at a loss but the health care workers believe are essential and core business?

The challenge for health care administrators, executives and health care workers is to balance economic accountability with the Australian Commission on Safety and Quality in Health Care (ACSQHC) standard on providing comprehensive care to patients.

Health care workers are paying the price for working in these conditions. The incessant pressure to cut services, to do “more with less” and to fight a system that seems at odds with the health care workers’ primary intent to provide the best health care for their patient creates a workplace that potentially promotes moral injury in these workers.

Moral injury and moral repair were first described as a construct in war veterans who by “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long-term, emotionally, psychologically, behaviorally, spiritually, and socially”. Moral injury threatens the person’s identity and inflicts damage to the moral belief system. In the United States Navy and Marine Corps, the term “inner conflict” is preferred to moral injury. It can manifest as social and behavioural problems, trust issues, spiritual and existential issues, psychological problems, and self-deprecation (here).

This construct was extrapolated to physicians who were “unable to provide high-quality care and healing in the context of health care”. Health care workers may encounter morally injurious events when they cannot “put the needs of the patients first” due to competing drivers of financial constraints, administrative burdens and overcomplicated system “rules and regulations”.

At times, external factors impose extreme time critical pressures on an already stressed health care system. During the height of the COVID-19 first wave, health care workers in many countries experienced and developed moral injury. How can they make a decision as to who can be given an intensive care unit bed when the system is overloaded? How can they come to terms with the reality that there are no beds in the hospital to treat the patient with cancer? Health care workers relied on the support of the organisation to carry out their work.

More commonly, though, chronic issues compounded by the ongoing pandemic threat can result in health care workers experiencing moral injury. Their experience is not helped by the perception that key decision makers in the health care organisation place greater priority on meeting the budget over the delivery of essential health care to patients (here, and here). Experienced health care workers have seen the discordance between recruitment to administrative services compared with patient facing health care workers over the past 20 years.

Decision makers rely on data collected by the burgeoning administrative services to plan the budget. What if the data used to inform budget estimations are inaccurate but still result in reduced services for our patients with increasingly complex medical and social problems? Accumulating challenges in the health care system may lead to health care workers developing moral injury.

The goodwill of health care workers in an overstretched health care system has also been identified as an area of risk. Goodwill is further undermined if health care workers suspect key decisions have already been made before a token consultative process is offered to them.

Administrative burden, overcomplicated rules and regulations and rule-driven health care practices are frustrations experienced by health care workers in a complex health care system. Complicated processes that distract from providing efficient patient-focused care can potentially result in health care workers developing moral injury by taking them away from attending to the patient’s needs. Ofri provides an opinion that complex electronic health records may contribute to the increased workload. In a complex adaptive system, minimum specifications should replace complicated plans.

For health care workers, manifestations of moral injury include anger at executives and managers, disengagement and presenteeism, and conflict between health care workers. They do not feel valued. They complain about the dysfunctional system that promotes a silo mentality where individual units and departments become more concerned about their own survival and existence than the patient. This conflict reduces the effectiveness of highly functioning collaborations between health care workers teams. The characteristics of exhaustion, cynicism, and reduced efficacy all point to burnout.

Conversely, a crisis can inspire positive responses, as was demonstrated in many different ways during the COVID-19 pandemic with reports of innovative solutions to “wicked problems”. Either way, the managers and administrators of health care organisations need to support the health care workers with workable systems. ACSQHC Standard 5 states:

“Leaders of a health service organisation establish and maintain systems and processes to support clinicians to deliver comprehensive care, and establish and maintain systems to prevent and manage specific risks of harm to patients during the delivery of health care. The workforce uses the systems to deliver comprehensive care and manage risk.”

The standard goes on to state that comprehensive care should be delivered if required or requested by a patient. Health care workers will often identify when comprehensive care is required during a consultation with the patient.

Clinical leaders, managers and administrators of health care organisations need to collaborate to strike a balance between fiscal accountability and maintaining safety and quality in health care services. The balance should be reached by respectful dialogue and not be seen to be unilaterally imposed without consultation. This approach is outlined in Standard 5.4 of the ACSQHC standard on comprehensive care. Such an approach should reduce the burden of inner conflict or moral injury on those who are at the public face of health care service.

A disruptive approach, outside the box, to meet this Standard may require clinical leaders, managers and administrators, consumers and political leaders openly consulting together or adopting new frameworks recognising the complex adaptive system in health care.

The health care system also needs care.

Professor Yee Leung is a clinical academic at the University of Western Australia (UWA), Head of Department at the Western Australian Gynaecologic Cancer Service at Women and Newborn Health Service, and a Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Board member. The opinions expressed in this article reflect the views of the author and do not represent the official policy of UWA, Health Department of WA or RANZCOG.





The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.


13 thoughts on “Crisis time for morally injured health care workers

  1. Anonymous says:

    Timely article for me, having decided to leave general practice and medicine last week, after 9 years of fellowship, at the age of 41.
    I cannot provide what I consider adequate patient care within the confines of the medicare system, that implies it wants 6 minute consults, lots of (useless, in my opinion) care plans, and plenty of paperwork in my own time, in order to remain financially viable. Either I conform to 6 minute consults and sacrifice patient care and my own desire to do things properly, or I leave…I chose the latter.

  2. B Cochrane says:

    Thanks for this article, which definitely expresses and explains the sense of helplessness and demoralisation facing clinicians who continually fight to achieve the best health care for their patients. Business cases, requested but never reviewed, waiting for a response that never comes despite multiple resubmissions, over and over again… that’s my experience of the public health system. It’s no wonder that some of us feel defeated.

  3. David Maconochie says:

    I have worked in both systems (NHS UK and Australia) as a junior doctor and as a GP. At present, Australian doctors have a vastly superior working life compared to their UK colleagues, and that is definitely pre-COVID.

    The RACGP are making alarming lurches towards the NHS nightmare by pushing for a capitation style of GP funding (Medical Home), as if the majority of patients with chronic diseases do not already try to stick with the same GP who knows their history. I am thankful I will be well retired and will not suffer the inevitable “unforeseen” consequences. I use quotes, as I can perfectly well foresee some of the consequences.

  4. Anonymous says:

    A key problem sadly is colleagues who join the beaurocracy then contribute to and legitimize the unnecessary complexity contributing to “when they cannot “put the needs of the patients first” due to competing drivers of financial constraints, administrative burdens and overcomplicated system “rules and regulations”.” Third party and workers comp schemes are examples but this occurs throughout your medical working life.

  5. Anonymous says:

    Medical administration, in my opionion, is an inherently corrupt, inept and ignorant enterprise. COVID exposed it in a grandeur unsurpassable. Should we still have the arbitrary power structures borne out of business models including a CEO and their cronies roaming around? Doctors must take back healthcare. Doctors are self-regulating for a great degree; It is these administrators who bully doctors that need to be regulated and held accountable. For a very long time in Australia, regardless of the size of the hospital, wasn’t there just a Doctor as Medical Superintendent and a Nursing Matron? Lets just go back to it for the sake of the future.

  6. Anonymous says:

    Our health system is becoming more like NHS, the failed health system of UK. Apparently NHS is the second biggest public system next to the Chinese army with layers and layers of managers, administrators and bureaucrats.

  7. Dr Bill McNeil OAM says:

    There comes a time when propping up a morally corrupt system implicates those who are associated with its continued existence.

  8. Randal Williams says:

    The rot started in the early 1980s when Australian hospitals increasingly adopted American models of nursing and medical administration. Documentation became more important than actually doing — ” if you haven’t documented it you haven’t done it .” Decision making slowly but progressively devolved from doctors and nurses to administrators and bureaucrats , who now outnumber clinical staff in most Western hospital systems. Processes developed around rigid protocols and other risk-averse approaches to minimise legal exposure. Administrative and bureaucratic jargon took over plain communications. The burden of paperwork has made it increasingly difficult to spend time with patients ( ask any nurse) . Doctors are increasingly overwhelmed by bureaucratic requirements at the expense of their clinical patient interactions. Hard to see where it is going to end.

  9. Dr C. says:

    Very well said. These problems are endured by staff every single day in our emergency departments. Alan Mclean says no doctor shortage ? He should come and work night shifts and weekends in our busy emergency departments instead of all the young overseas trained foreign doctors we keep having to import to keep us going .

  10. Cliff Neppe says:

    Excellent article Yee.
    This is a must read article for all who work in health.

  11. Anonymous says:

    Great article Yee.
    Captures the zeitgeist of many 2020 workplaces and the need for collaborative and supportive work.
    Thank you also for your many many years of fabulous service in our community.
    From a GP.

  12. Alan Robert Mclean says:

    PS: [this is my second comment] I have noticed in a recent “efficiency drive” at the hospital I work at in Adelaide that the emphasis is on seeing patients more quickly, doing less for each individual patient and trying to get patients moving more quickly. The pressure is ‘downward’ toward the activity of the workers [junior doctors and SMPs]. THey are actually not in a position to make a difference as they are working in a big system. The change should be UPWARD toward departmental managers, directors, administrators and hospital CEOs.

  13. Alan Robert Mclean says:

    I agree , I think we spend 40-50% of our time on “maintenence” and 50-60% on production. Doctor shortage in Australia? NO, just a very demanding and inefficient system.

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