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Support needed to tackle stress, burnout and moral injury

It’s time we took better care of health workers, writes Dr Karen Michell, IOSH Research Programme Lead on occupational health, as we mark International Stress Awareness Week (1-5 November 2021).

What is stress? Well, some stress can actually be beneficial, or ‘good stress’, whether it be psychosocial, physical (exercise) or biochemical. This type of stress is known as ‘eustress’, where the cognitive response to stress is healthy, or gives one a feeling of fulfilment or other positive feelings. Imagine a job interview, an exam or some kind of sporting challenge, for example, bringing out your full potential.

But stress can often be more negative, where a situation can get on top of an individual and overwhelm their potential, even their ability to function.

For the past two years, almost all of us have experienced the most unprecedented stress levels for which we were ill-prepared. We have had to cope with varying situations (lockdown, working from home, home schooling) in forging our path through the pandemic.

But spare a thought for all those around the world who kept our health services running, for whom there was no option but to go to work to treat those infected with the SARS-CoV-2 virus, who put their lives at risk every day to care for contagious patients, often with insufficient or the incorrect PPE. They did all this while feeling exhausted, taking decisions that often conflicted with their own judgement, coping with death and morbidity on a scale not seen in our lifetime. For these workers it has been a case of ‘stress on steroids’, leading in many cases to burnout and moral injury.  

Burnout is defined as a form of exhaustion caused by constantly feeling swamped and is the result of excessive and prolonged emotional, physical and mental stress[1].

There is no denying the limits to which health professionals were pushed during the pandemic. Moral injury may be experienced when a person perpetrates, witnesses or fails to prevent an act that conflicts with their own moral values and beliefs[2].

During the pandemic, this has included health professionals having to make decisions on the survival of others, having to balance caring for patients with Covid-19 against protecting their own families and/or the allocation of restricted resources.

Health workers are used to having to deal with a high level of job stress as they are expected to solve problems on the hoof and often make life or death decisions quickly, while dealing with the demands of managers and heavy workloads, plus demands from patients and their relatives who are themselves stressed.

I am and always will be a nurse at heart and the consequences of stress and burnout were a reality for me, not once but twice. You would think that a health professional would learn from their experiences and would be better positioned to prevent these situations, but it is the characteristics that make us good carers that make us prone to burnout and moral injury. If I was making mistakes at work, I was not aware of it but those around me were. For me, the consequences of burnout included sleep deprivation, irritability and physical manifestations through constant headaches, musculoskeletal pain and ultimately respiratory ill health. But through it all the call to duty and the unwillingness to let others down became my own undoing. It took a comment from a concerned pulmonologist to make me see the light of day. I can still hear his voice, saying: “You may well feel you can cope with your stress but your body is sending you messages telling you to reset, which you should not ignore.”

I am one of the lucky ones as I have succeeded, with help, to manage and control my stress levels. It did not mean I stopped working; in fact, I have gone on to complete a PhD and many other significant professional achievements, but while taking better care of myself and learning to listen to those around me who can see when I start to push the limits again. The easy changes included taking coffee breaks with peers and friends, going on long walks or gym workouts and taking on a new hobby. Other changes which took more effort meant restricting the number of hours I work in a day, finding forums where I can express my concerns safely, self-reflection and being realistic about what I can achieve.  

Other strategies that can help to prevent burnout and moral injury, include: recognising hard work; providing nurturing environments and a supportive organisational culture, which includes debriefing sessions, better planning and preparation of staff allocations; allowing joint decision making to remove the feeling of sole responsibility; peer support; the early detection of psychological stress; and taking regular breaks at and from work to allow for recovery.

The impact of the pandemic on our health professionals is evidenced in the literature. The consequences of our not addressing these health concerns may well be damaging to health systems globally as we see high absenteeism; rising attrition rates as staff leave health care; increased presenteeism; poorly motivated staff; a decline in the quality of care; and long-term health problems in health workers.

If we expect continuing good quality care from our health professionals then we need to provide them with ways to manage stress and address the high psychosocial stress levels they are subjected to.


Dr Karen Michell
IOSH Research Programme Lead (Occupational Health)



  1. Rowlands, SL. 2021. Understanding and mitigating moral injury in nurses. Available at: https://journals.rcni.com/nursing-standard/evidence-and-practice/understanding-and-mitigating-moral-injury-in-nurses-ns.2021.e11703/abs Accessed 29 October 2021.

  2. Welsh Government. 2021. Technical Advisory Group: moral injury in health care workers during the COVID-19 pandemic. Available at: https://gov.wales/technical-advisory-group-moral-injury-health-care-workers-during-covid-19-pandemic-html. Accessed 29 October 2021.


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