Head to the Heart January 15, 2024

Hospital design should care for health workers and patients in equal measure

By Wendy Dean, M.D.; and Simon G. Talbot, M.D.

The notion of “moral injury” expanded the conversation about health worker distress in 2018, when an article we published in STAT News First Opinion went viral. Originally developed by researchers working with combat veterans, the concept of moral injury is the experience of betrayal, by a legitimate authority, in a high stakes situation that causes one to transgress deeply held moral beliefs and expectations.


Applied to healthcare, those deeply held beliefs are the oaths clinicians make when entering their professions to put patients first. As we phrased it in our article: The moral injury of healthcare is not the offense of killing another human in the context of war; it is being unable to provide high-quality care and healing in the context of healthcare.

Since the article went viral, we’ve expanded our work on moral injury to include a nonprofit, a podcast, and a book. The term has also proven to be a deeply resonant way of framing distress in healthcare for clinicians. One physician, who burst into tears at a recent book signing, encapsulated the feedback we have heard from thousands of physicians, nurses, physical therapists, social workers, and others in the last five years: “I finally feel seen, like I have the right language for my experience.” Our subsequent research—and that of others—confirms moral injury and burnout are distinct conditions, though they often occur together. Also interesting, though not surprising, is that non-clinicians experience this type of distress, too. Preliminary evidence suggests 40% of healthcare leaders and executives endured some level of moral injury during the pandemic. They knew what their workforce needed, yet they could not provide it.

"Workspaces that enhance the ability of our caregivers to succeed, partner, and relate are critical to the fabric of our workplace culture.”
Mark Fryar, Director of Campus Planning, Baylor Scott & White Health

Addressing moral injury is not a substitute for attempts to address the causes of burnout—administrative overburden, clumsy electronic medical record systems, mandatory overtime, and the like. Instead, effectively reducing health worker distress means addressing the betrayals or relational ruptures of moral injury, too. Those betrayals were highlighted during the COVID-19 pandemic when the practices health workers and a 2006 Congressional Business Office report had warned about—paring staff, supplies, and space to the bone to maximize hospital margins—left them ill-prepared to respond to surges in demand. Between 2020 and 2022, health workers lived through the nightmare they had presaged, and many were embittered by the experience. They exited jobs feeling deeply distrustful of their leadership. Staff are the most valuable and costly asset in any health system. Rebuilding trust with the workforce and creating morally centered organizations are critical for the future of healthcare.

The built environment is, similarly, often an example of inadequate design and a betrayal of the workforce. Workers from too many hospitals and healthcare systems tell us that their facilities failed to make space for them. Literally. Radiologists run stairs all day because there is no workstation near the interventional suite. Surgeons don’t have access to computers or restrooms near the operating rooms. Nurses spend half their days perched at a mobile computer cart because their charting space was appropriated for family respite areas. Clinicians are hot-desking in bullpens of workstations without private space for patient calls or a distraction-free zone for the deep work of analyzing difficult cases. And no one has a quiet, private place to meet with colleagues, grab a bite to eat, or to process difficult patient outcomes. The more energy health workers put into managing a suboptimal environment, the less they have to invest in patient care. But it’s also a clear message to them about how the organization values their work and their well-being.

"At Children’s Health, we have recognized the detrimental effects of moral injury and have implemented a team of trained personnel who can respond to staff in need of support. Called RISE for resilience, integrated ethics, staff support, and engagement, it has become a mainstay among our tactics to support staff.”
Joe Don Cavender, Executive Advisor, Children’s Health

We know that morally centered organizations—those less likely to cause moral injury—promote stronger relationships and deeper trust. They recognize, as one healthcare leader told us, that if they’re doing their job well, they’re “taking care of the people who take care of patients.” This means designing healthcare delivery spaces for workers, who spend thousands of hours in those spaces every year, as much as for their patients. The leaders of those organizations want to learn from their mistakes, seek candid feedback, take prompt corrective actions, and engage the workforce in decision-making.

Designing different spaces to build trust with a sustainable workforce starts at the earliest steps in the process. Soliciting feedback from a broad swath of the workforce, with detailed notes from varied sectors, is essential for workers to feel their needs have been heard and considered. Adapting plans based on worker feedback—changing the location of a restroom or a supply closet; upgrading ventilation; adding windows, workstations, or dimmable lights; protecting separate outdoor green spaces for patients and staff; or putting radiology adjacent to orthopedics and the breast care center so clinicians don’t have to send patients on painful or immodest treks for imaging—garners significant good will. As the workforce sees their recommendations appear on changing blueprints, their perceived value to the organization and contribution to better care increases. Furthermore, if leaders recognize that return on investment per square foot will be dwarfed by staff turnover costs, the argument for high-quality space where staff can congregate for collaboration and respite is easier.

"We’ve seen a huge positive impact by investing in environments that support our caregiver’s wellness. We launched a philanthropic initiative to imbed respite rooms in patient units for staff to conveniently find a moment of peace at the times they are most needed."
Rachel Jenner, Senior Director of Planning and Design, Swedish

The built environment can never wholly mitigate a human relations issue like moral injury. However, leadership commitment to designing workspaces that maximize the performance, efficiency, health, and sustainability of the workforce will foster a good reputation with workers. A healthier, more satisfied workforce that finds it easier to deliver high-quality care will have more satisfied patients with better outcomes—and lower turnover. This, in turn, supports the strategic, financial, and operational goals of the organization and represents wins for every healthcare stakeholder.