Holding space for moral healing in long-term care

Posted On: November 17, 2023

By: Kate Dupuis, Jane Kuepfer, Scott Mitchell

COVID-19 pandemic and long-term care

During the COVID-19 pandemic, team members working in long-term care homes were often required to perform duties outside of their typical day-to-day responsibilities. With limited access to vendors, visitors, and even some part-time team members being restricted from entering the long-term care homes, it meant front-line team members were expected to take on new roles – such as entertainer, confidant, spiritual care provider, and even, in some cases funeral director – while navigating their own fears and negative media coverage of their workplaces, with limited support or guidance from colleagues or leadership.

This led to an increase in mental health concerns, burnout, high staff absenteeism, and poor team member retention.

Team members were called upon to make rapid modifications to practice in order to best serve the needs of their residents while navigating and respecting constantly changing public health regulations. This left team members with little time and capacity to take care of their own mental, emotional, physical, social, and spiritual health.

We know the pandemic disproportionately impacted people living and working in long-term care homes. We also know the majority of deaths during the early waves of the pandemic were among long-term care residents, with many being physically separated from the comfort and care of their family and friends during their final moments.

Today, nearly two years following the height of the pandemic, many long-term care homes continue to be affected by it, with dozens of outbreaks occurring each week in homes across Ontario. Making it difficult for staff to see an end to the restrictions, and many feeling helpless because there is no finish line in sight.

Team members working in long-term care homes often feel an increased burden due to the nature of their work and the emotionally intimate relationships they develop with residents. This is in stark contrast to acute care partners where a patient may only be at a healthcare facility for a short-time without the opportunity to develop a close relationship with the person and/or family, friends, and care partners.


Moral distress and injury

With so much uncertainty and the need for rapid responses to emergency situations, many team members working in long-term care homes were called upon to act in ways that is inconsistent with their training, experience, and own moral and ethical belief system.

For example, team members recount harrowing stories of having to isolate people living with dementia who simply could not understand what was happening to them, or of trying to explain to distressed family members why they were not allowed an in-person connection with their dying relative.

Research shows these heart-wrenching experiences led to moral distress for many long-term care team members. Moral distress is defined as a feeling of incongruence between what you are required to do, and what your heart and soul are urging you to do. If left unchecked, this feeling can become more severe and lead to “moral injury,” which has often been linked to burnout, trauma response, and post-traumatic stress disorder (PTSD).

Team member well-being is closely related to staff retention. Given the ongoing staffing crisis in long-term care, it is crucial we address moral distress and injury as a targeted strategy to better support our existing workforce and ensure we set up morally safe workplaces to welcome and nurture new team members.


Supporting moral healing and moral resilience

When attempting to support healing from “moral distress and injury”, it is first important to acknowledge the feelings and experiences of people working in long-term care homes. Team members must know they are not alone and the situations that placed them at risk of feeling shame and guilt, and of experiencing “moral distress and injury”, are not their fault.

In fact, their feelings are a sign they are good people and quality healthcare workers, who truly care for their residents. They do not have to hold onto these feelings, and experience this soul damage, alone.

The current situation in long-term care homes may be difficult but it is not hopeless. We have learned so much during the past three years. There are evidence-informed strategies to help people move forward, strengthen their moral resilience, and support moral healing even in the context of ongoing uncertainty and restrictions in the workplace.

Providing dedicated time and space in which team members can process their experiences is a crucial part of moral healing. First and foremost, it is important to acknowledge both how and the high rate of resident loss in many long-term care homes.

Government restrictions prevented many homes from being able to honour a deceased resident with the typical rites and ceremonies related to their passing, such as a dignity walk, or draping the person with a dignity quilt. Following the lifting of many restrictions, spiritual care providers in many long-term care homes were able to help team members remember in a meaningful way. If this hasn’t happened yet, it’s not too late.

There are many ways to honour residents who have passed, including:

  • Creating a memory board
  • Tree of Life
  •  Memory gardens
  •  Candlelit ceremony to honour each resident

Scheduling regular, dedicated time to discuss morally complex issues can also be very beneficial for team members, supporting their well-being and creating a cohesive environment. Experiencing management presence and support “on the floors” helps to build a sense of understanding, trust, and teamwork. If possible, set aside time for Moral Office Hour, where staff can speak to a member of the leadership team about any moral tension they may be experiencing. We acknowledge this may be difficult to organize for all roles on all shifts. Some alternatives may include:

  • A Moral Healing Book that is stored in a communal space, for staff to write down their experiences and then colleagues can respond in writing at a later time with their own suggestions.
  •  A text-message system with staff, prompting them to share situations they have had difficulty with on a daily/weekly basis.
  •  Team huddles
  • A buddy system to facilitate one-on-one conversations among peers.

Moving forward, leadership should also think about how to ensure their workplace is morally safe for the existing workforce, as well as ways to share information about moral health when recruiting and onboarding new team members.

In this way, a community of moral resilience can be formed and fostered within the home, with peers assisting one another through difficult situations. Our ultimate aim should be to reduce or even eliminate the risk of moral distress in the workplace. To this end, the authors recently organized the first-ever Think Tank on Moral Distress in LTC at the Schlegel-UW Research Institute for Aging in Waterloo, Ontario. We brought together researchers, policy makers, care providers, and knowledge mobilization practitioners to share their own experiences and research. We continue to explore opportunities for future research, clinical practice, and collaborations that will enable us to work closely with front-line staff and leadership to address this important issue in long-term care.




Kate Dupuis (PhD, C.Psych) is the Schlegel Innovation Leader in Arts and Aging at Sheridan Centre for Elder Research and the Schlegel-UW Research Institute for Aging (RIA). Jane Kuepfer (RP, MDiv, PhD) is the Schlegel Specialist in Spirituality and Aging at Conrad Grebel University College and the RIA. Scott Mitchell (BA) is a Knowledge Broker at the Ontario Centres for Learning, Research and Innovation in Long-Term Care (Ontario CLRI) at the RIA.

About the Ontario Centres for Learning, Research and Innovation in Long-Term Care

The Ontario CLRI is funded by the Ministry of Long-Term Care, and hosted at Baycrest Academy for Research and Education, Bruyère Research Institute, and the Schlegel-UW Research Institute for Aging.

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