Moral Hazard Among Health System Workers in the Wake of Climate-Driven Emergency Events

Buse et al. (2025) Journal of Mental Health and Climate Change http://doi.org/10.5281/zenodo.15985301 Moral Hazard Among Health System Workers in the Wake of Climate-Driven Emergency Events Chris G. Buse1*, Kiera Tsakonas1, Simi Badyal1, Tim K. Takaro1 1. Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada ABSTRACT The Sars-Cov-2 pandemic brought attention to moral hazard among health system workers (HSWs). However, empirical investigations of moral hazard in the context of environmental emergencies, particularly those driven by climate change, are limited. This contribution draws from interviews with 28 HSWs from diverse health service roles across British Columbia, Canada to interrogate how moral hazard may be caused or compounded by climate-related emergency events. Findings suggest three discrete pathways by which moral hazard may manifest among HSWs: ethical trade-offs made by HSWs in caring for themselves, their families, and their neighbours versus the populations they are hired to protect; ethical trade-offs stemming from resource allocation and staffing issues that inhibit quality care provision; and the hierarchical organization of health systems and its relationship to societal structures that contribute to climate change in the first place. The paper discusses findings in relation to the moral hazard literature, and implications for research and practice. Specifically, the authors suggest that enhancing upstream attention to the drivers of climate change and person-centred approaches to management may work to limit moral hazard. Keywords: moral hazard; moral injury; moral distress; health system worker; occupational mental health; climate change INTRODUCTION Study Goals and Objectives The Sars-Cov-2 pandemic raised the profile of moral hazard (also ‘moral distress’ and ‘moral injury’) among health system workers (HSWs) and its implications for clinical practice (Riedel et al., 2022; Xue et al., 2022). However, there are few empirical investigations of moral hazard among HSWs in the context of environmental emergencies, particularly those driven by climate change. Indeed, in Canada’s *Correspondence: [email protected] © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. 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EMPIRICAL STUDY Open Access Buse et al., 2025 Page 2 of 17 westernmost province of British Columbia, HSWs—still dealing with pandemic response in 2021—were subsequently challenged by three concurrent, cascading and compounding climate-related emergencies in the form of the Western Heat Dome which resulted in more than 600 direct fatalities (BC Coroner’s Service, 2021), an extreme wildfire season, and an atmospheric river that caused widespread flooding and impacts to critical infrastructure which was at the time the province’s most costly ‘natural’ disaster (Gillett et al., 2022). In this contribution, we report on results from a qualitative study with HSWs from various roles across British Columbia’s health system who not only worked under the constraints of the global pandemic but also the threat of emergency climate-related events. We interrogate their experience of this transition in relation to moral hazard as a unique form of psychological impact among HSWs that is anticipated to increase if the health system impacts of fossil fuel-driven climate change go unattended. We first describe the extant literature on moral hazard, drawing primarily from the literature highlighting HSW experiences during the pandemic. We then describe our methodological approach before presenting results from 28 in-depth interviews with HSWs from diverse roles across the province of British Columbia. We discuss these results in relation to recommendations from the literature with a specific focus on attending to organizational determinants of occupational health, irrespective of HSW job role. Moral Injury, Moral Hazard and Moral Distress on Health System Workers Historically, the concept of moral hazard, moral injury and moral distress are often utilized interchangeably, with near exclusivity to the experiences of military personal. They refer to situations when someone willingly or unwillingly acts in ways that run counter to their core personal and/or professional values at the risk of creating mental anguish or suffering (Jinkerson, 2016). There are, however, competing utilizations of this terminology in the literature. Moral hazard is sometimes utilized to describe an exposure, whereas moral injury and distress often work to capture the impact of an exposure. Hereafter, for the sake of parsimony—and given the exploratory notion of this work as a first of its kind exploration in the context of climate change—we utilize moral hazard as an umbrella term to capture potentially, but also actual injurious events. Moral violations are often associated with a range of emotions including shame, guilt and even outright anger, and increasingly viewed as a “sign of mental health, not a disorder” (Weintrobe, 2021). During the pandemic especially, the concept of moral hazard came to the fore as HSWs dealt with realtime ethical trade-offs in the provision of care, decisions over the deployment of limited resources (e.g. masks, ventilators), and feelings of dehumanization in certain workplaces where they themselves were placed in harms way from a previously unknown threat. The growth of interest in moral hazard has focused on its association with a range of health and workplace stressors for HSWs, issues of staffing and retention, and opportunities for promoting HSW resilience. For example, a mixed-methods study of moral distress conducted in a US hospital system found that distress was associated with fear and anxiety, and betrayal and frustration with leadership, ultimately leading to burnout, financial concerns, and feeling unsupported in job roles. Administrative staff reported higher levels of severe distress than clinical staff, and workplace mental health support buffered against this risk (Atkins et al., 2023). A 2021 scoping review found that moral hazard was related to feelings of conflict between ones values and their actions in ways that produced psychological distress or ethical suffering, where practitioners experienced ‘guilt without fault’, and in cases where there was fear or fallout of inflicting pain on patients through treatment administration (Čartolovni et al., 2021). Buse et al., 2025 Page 3 of 17 The determinants of moral hazard are increasingly studied, but the extant literature often finds disparate results that vary according to context. For example, a pre-COVID-19 systematic review found that moral distress is correlated with organizational environments characterized by a poor ethical climate with low degrees of collaboration, professional attitudes rooted in low work satisfaction and engagement, and psychological characteristics of low degrees of autonomy and feelings of individual empowerment. In an examination of Romanian physicians (half who worked in COVID wards and half who did not), moral hazard did not vary according to gender, specialization, medical unit or age, but largely derived from physical and emotional self-reported impact, again suggesting workplace training and psychological support are key mitigating factors (Maftei & Holman, 2021). However, other research suggests that being a nurse and younger age, widowed/divorced/never married or had direct experience caring for COVID-19 patients had higher odds of moral hazard, but not burnout (Mantri et al., 2021). In yet another study, the prevalence of moral hazard in the workplace was as high as 32.4%, and findings suggested that psychological resilience moderates the effect of years of experience on moral hazard, where predictors included moral resilience, ethical concerns, religious affiliation, and having 20 or more years in the profession (Rushton, 2011). A recent scoping review suggests that moral hazard has several organizational correlates across the literature, including instrumental leadership—a leadership style viewed as less flexible and more oriented towards specific outcomes, low staffing availability, increased workload, restricted resources, and the social and professional supports available to HSWs both at work outside of work (Riedel et al., 2022). Moral hazard was found to be particularly pronounced when situations of conflict between patient interests and caregiver safety were present, practitioners witnessed inadequate care provision, there was unnecessary isolation of patients in relation to perceived impacts on their freedom and autonomy, and feelings of abandonment by colleagues in the wake of a personal infection (Riedel et al., 2022; Xue et al., 2022). Restrictions on visitation rights, the inability to show facial expressions due to masking, and the lack of finances, medical resources, time and empathy from supervisors, in addition to balancing personal needs with enhanced caseloads, while simultaneously managing obligations to family (including fear of infecting family members) are frequent in the moral hazard literature (Riedel et al., 2022) In terms of what is known to mitigate moral hazard, Currier et al., 2021 describe how scaling up responses to moral hazard across the health system can be achieved through the deployment of a public health perspective on the topic. This may include creating more supportive workplaces that reduce adverse emotional outcomes by lowering workplace stress (Hines et al., 2021), and bolstering the availability and suitable deployment of mental health services for HSWs (Ritter et al., 2023). Shale, 2020 provides perhaps the most specific path to achieve better outcomes in the delivery of those services, including providing health systems leaders and health and safety teams with tools and supports to: [1] acknowledge an injured party as a moral equal; [2] acknowledge the authority of shared norms in duty-to-care; [3] acknowledge injury; [4] acknowledge responsibility without blame; [5] acknowledge that remedy is due; [6] acknowledge righteous anger or other negative feelings as appropriate responses to extraordinary circumstances; and [7] acknowledge that in injuring another, we should experience sorrow and regret. Such a reflective orientation towards clinical practice and occupational safety—including the need for a scaling up of psychological first aid—has also been suggested by others (Latimer et al., 2023). Less is known about moral injury in the context of responding to other crises, such as those caused by fossil fuel-driven climate change, especially among HSWs. Some population-level analyses suggest that moral hazard may be particularly prominent among younger generations who see the Buse et al., 2025 Page 4 of 17 actions of an older generation as a threat to their values and safety ( Hickman, 2021). Such argumentation is consistent with explorations of moral hazard in the context of anti-microbial resistance. For example, drawing on interviews with practitioners, scientists and policy-makers in Australia and the UK, moral hazard is documented to arise from the need to provide immediate treatment to avoid harm, while still recognizing that the use of antimicrobials may risk the longer-term risks to anti-microbial resistance. This creates an entry point to attend to tensions between individual and population risk (Davis et al. 2024). Moreover, early examinations of the impacts of climate emergencies on HSWs often focus on impacts to the health system more generally, without attending to the needs of the people responsible for implementing programs and policies in their wake (Tsakonas et al., 2024). Studies that do highlight the physical and mental health risks suggest that psychological trauma and moral hazard experienced by HSWs requires more research (Tsakonas et al., 2025). METHODS This study is the extension of previously published research (Tsakonas et al., 2025), and employs trauma-informed semi-structured key informant interviews (Alessi & Kahn, 2022; Berger & Quiros, 2016) with participants (N=28) representing a diverse range of roles (i.e. nurses, physicians, paramedics, public health professionals, health facility and systems administrators, long-term care workers, psychologists and pharmacists) across British Columbia’s health system to examine both perceived and actual impacts of climate events on HSWs. Interviews sought to highlight emerging adaptations and future recommendations from a practitioner’s perspective. Purposeful and snowball sampling techniques were used to capture a broad spectrum of experiences across different geographies, administrative regions and professional roles within BC. Specifically, our team deployed a maximum variability sampling frame, aiming for a near even representation of participants across each of BC’s geographic health regions (i.e. Interior Health, Northern Health, Island Health, Vancouver Coastal Health and Fraser Health), but balanced these needs with the need to hear from multiple health system roles, including perspectives from provincial decision-makers. Recruitment bias was attended to via this approach, and through referral sampling methods to source nuanced perspectives. Eligibility criteria required participants to be at least 19 years of age, employed as an HSW in one of BC’s health regions since at least 2021, and to have experience working during one or more climate-related emergencies (e.g., extreme temperature events, floods, wildfires, droughts). Upon agreeing to participate, interviews were scheduled via Zoom at a time convenient for the participant. Participants were first asked questions about their role and responsibilities to contextualize their position. Then, our semi-structured process followed the following topical areas of inquiry, starting with practitioner experience working across multiple seasons of the year in relation to acute climate-related emergency events. Depending on practitioner experience, our team then asked about what it was like working under the conditions of specific emergency events, probed at impacts to patient populations as well as their own physical and mental health, how their organization or team adapted to meet those challenges, and encouraged to share recommendations to further address those impacts. When discussing occupational health risks, we included specific questions about mental health impacts of climate-related emergency events. This included a specific prompt about the notion of moral hazard related to COVID-19, which encouraged participants to reflect on its possible prevalence and/or their experience of it in relation to climate-related emergency response. In instances where moral hazard was not known, a brief description was provided, but most participants were familiar with the concept from their experience working during the pandemic. Buse et al., 2025 Page 5 of 17 Data collection occurred between July 2023 and January 2024, concluding once data saturation was reached. Saturation was determined when interviews from a specific geographic region no longer contributed novel regional insights or broader findings. Additionally, the study considered both code saturation—the identification of a range of issues across geographic regions and job roles—and meaning saturation, wherein interviews yielded diminishing new insights, to determine when to cease recruitment (Fusch & Ness, 2015; Hennink et al., 2017; Weller et al., 2018). All interviews were audiorecorded and transcribed verbatim. To promote co-creation of research data, participants were provided with transcripts of their interviews to validate accuracy, make clarifications, and offer additional details if necessary. Ethical approval for this study was granted by the Research Ethics Boards of Simon Fraser University and the Northern Health Region. A thematic analysis was conducted using both inductive and deductive approaches (Belotto, 2018; Fereday & Muir-Cochrane, 2006; Nowell et al., 2017). This analysis was informed by the World Health Organization’s Operational Framework for Building Climate-Resilient Health Systems (World Health Organization, 2015), as well as a published rapid evidence review on the effects of climate change on the health system workforce (Tsakonas et al., 2024), with a particular focus on nations within the Organization for Economic Co-operation and Development (OECD). An initial codebook was developed to illustrate how various components of the health system both support and expose HSWs to risks in the context of acute and long-term climate-related hazards (e.g., wildfires, floods, extreme heat). The coding process was iterative, allowing for the development of new codes reflective of the BC health system context (Vaughn & Turner, 2016). Identified themes were organized into broad categories, and all transcripts were coded to reflect participants’ health regions and professional roles to preserve contextual integrity. Two researchers systematically reviewed coded data, analyzing it within the context of each interview, the participant’s job role, and their health region, as well as in relation to the overall dataset. To ensure inter-coder reliability, team members engaged in multiple rounds of coding using an initial sample of the same five transcripts. Three researchers convened to review the coding approach for each transcript, fostering familiarity with the analytical framework. In cases of coding discrepancies, team discussions were held to reach consensus. Typically, consensus was achieved through discussion; however, in rare instances of disagreement, a two-thirds majority decision-making process was employed to support code application. This approach ensured clarity and consistency in coding methodologies, with any ambiguous text flagged for team deliberation. Finally, the researchers also considered their own positionality in relation to the co-construction of the data, and reflected on this in the form of memos in areas where their positionality may have clouded their ability to fully understand the respondent. Lead author CB approaches this work as a third generation, cisgender, able-bodied, white, male settler who has lived in communities across Canada and has over 15 years of research experience on health system staff dealing with the impacts of climate change; second author KT is an MSc candidate and an able-bodied, cisgendered woman of European and Gitxsan descent who views this work through three years of research experience on health system adaptation to climate change and health equity in disaster risk reduction for rural communities; third author SB is a Masters of Public Health candidate who is a cisgender, third generation settler of Punjabi heritage with interests in health equity and the emergency management discourse in BC; and senior author TT is a white settler and cis-physician-scientist who has been studying and testing interventions to improve environmental and occupational health for 30 years. Buse et al., 2025 Page 6 of 17 RESULTS Our analysis of 28 transcripts from various roles across BC’s health system including doctors, nurses, public health professionals, paramedics, pharmacists, long-term care workers and emergency response staff (see Table 1). Table 1. Distribution of Interviewees by Job Roles and Health Region Northern Health Interior Health Fraser Health Island Health Vancouver Coastal Health Province Total Doctor 1 3 1 3 8 Nurse 1 1 1 3 Paramedic 1 1 2 Long-term Care Worker 2 2 Emergency Response Staff 1 3 2 6 Pharmacist 1 1 Public Health Professional 1 1 3 5 Psychologist 1 1 Total 6 6 4 6 4 2 28 We identified three unique aspects of moral hazard: [1] HSWs who were often impacted themselves by climate events had to make trade-offs between caring for the populations that they serve and caring for themselves, their friends, neighbours and families; [2] HSWs were forced to make real-time ethical decisions around care provision and resource allocation for patients; and [3] organizational determinants of moral hazard created conditions that paralyzed workers in their ability to address population health outcomes. Each of these categories is described in greater detail below in relation to supporting evidence. Caring for themselves, their families, friends and neighbours conflict with professional responsibilities The first instance of moral hazard described by HSWs was perhaps the most straightforward. HSWs were typically members of the communities in which they worked, and often, climate-related emergencies would create cascading impacts on themselves and their families while simultaneously impacting people in their personal networks: “More recently with the with the fire out of [town omitted], where we have staff that are needed to and expected to respond… and help the organization. For example, evacuating a long-term care facility, which we did on the weekend. But they're also impacted by the actual event. So they're actually being evacuated themselves, or an evacuation alert, or people that are even staff that have lost their homes and fires, or physicians that have lost their homes in fires. And then they're also needed to come in, right, do their job or show up in the hospital for their shift. So that places a big strain on the workforce” (Interviewee 6, Public Health Professional, Interior Health). Many participants highlighted that the reality of working in the health system during times of emergency are accompanied by significant feelings of anxiety among HSWs, even as they met professional obligations. For example, Participant 10 empathized with evacuated patients and communities while under evacuation order, highlighting the highly personal nature and emotional toll of living under those conditions, particularly when imagining risks to family members: Buse et al., 2025 Page 7 of 17 “But you know, it's just, it's just chaos, right and then, in the middle of trying to make sure all of the vulnerable populations are safe and whatnot, you're also trying to make sure you're okay and your family's okay, so that you can continue taking care of others than you're also just dealing with logistics around, yes, transferring patients and long term care and people such like that you have plans for them to be somewhere safe, you got to deal with all the medication issues” (Interviewee 10, Public Health, Northern Health). This was a common consideration among HSWs, and often led to “mental health impacts and the distress [of] people trying to care for their own families and being concerned about their personal circumstances” (Interviewee 27, Emergency Response Staff, Fraser Health). Evacuation was often the most significant personal impact referenced by HSWs, outside of other occupational health risks described in previous reporting from this work. Here, HSWs often raised the difficulty that HSWs experience in balancing and managing exceptional circumstances and risks to their families, homes and neighbourhoods. This resulted in experiences of isolation in the workplace, but also delays in the day-to-day work that their teams are advancing to improve population health across the region, and in turn, reinforced a wider sense of ‘eco-grief’ for future impacts of climate across their regions: “Many of the leaders and senior executives were impacted and like key people for me and my work were. All the peers that I do all my work with. They happen to all live pretty much in the same neighborhoods… And so all of a sudden, like my support in the work, they’re all like dealing with all this stuff in their personal life. And like, in a moment, I'm on evacuation. Now I have to go! I have to pack up! I have to go! And we were actually supposed to be launching [an important document] that week. And so it was just this like feeling of like, oh, this is so real. So, we obviously delayed the launch… So yeah, that was a lot to juggle, and then I was, but I was totally fine. Like, I was totally fine. But oh my gosh, I'm feeling so much anxiety and panic around it, but I'm actually okay. But when will it be me in that position? Just also holding eco grief in general, or like, your personal anxieties about actually having to evacuate yourself or actually not being able to leave your house because of air quality” (Interviewee 9, Public Health Staff, Interior Health). These findings reinforce the notion that as community members themselves, HSWs are often doubly impacted by climate emergencies. They face dual responsibilities of caring for themselves, their families, friends and neighbours, all while juggling the professional responsibility of caring for patients and communities. Resource/staffing limitations and ethical trade-offs in the provision of care as root causes of moral hazard when responding to climate-related emergencies While many participants highlighted personal versus professional trade-offs in relation to climaterelated emergencies, moral hazard was most pronounced among HSWs during periods of response, particularly when the health system was experiencing stress. Many participants highlighted the interface of the extreme events of 2021 in relation to COVID-19 protocols, and how an already exhausted workforce now had to once again rise to the occasion of other emergency events demanding resources and staff. These cascading climate events were found to worsen moral hazard as they “contribute to people's job satisfaction and quality of life, because if they leave their shift knowing that there's a whole bunch of things that they didn't get to, like, that doesn't feel good, but we're only human ourselves, so we just do the best we can” (Interviewee 17, Paramedic, Island Health). Indeed, the backdrop to many of the 2021 climate emergency events was a health system that was already Buse et al., 2025 Page 8 of 17 nearing its breaking point and experiencing staff departures as a result of strenuous and stressful work environments during the pandemic. As two respondents put it: “And then when the climate events started to happen, it just felt like, oh you can't even imagine that there could be more right now. Like more…a new problem, bigger than, almost is its own epidemic on top of a pandemic… It's like, okay, well COVID is taking a backseat and people are not getting as good of care now. But are they needing oxygen? Or are they going home and hope for the best? Because people were dying of heat as well. And yeah, you definitely feel the quality of care drop more and more. It becomes really just a matter of like life and death” (Interviewee 15, Doctor, Interior Health). “I was terrified and then to add I'm already isolating from friends and family and the only way we could really see people was to go outside. And then to have smoke hit was just like, okay this is one more thing to add to like the already building pressure of, of life and then you know,… isolate people for COVID if they have a cough, the symptoms. So they come in with like, a exacerbation from the smoke and then we have to isolate them and follow our contact procedures when it's got nothing to do with COVID at all, and it's totally to do with their disease process. But then they become even more isolated because they have to be in a private room and they can't be moving around. And so it's not great for patient quality and you don't care for people as a nurse as well as you do if they're not on precautions. So it's detrimental to the patient themselves. And then we're also getting you know, patients are getting-who don't have COVID are getting COVID exposures in the hospital. So then they're getting at risk. It's just all compounding in that that person who comes in with a COPD exacerbation might also… not have been previously hospitalized if there wasn't smoke comes into the hospital and then is that risk of getting COVID. So it just builds on each other” (Interviewee 2, Nurse, Interior Health). In terms of the provision of care, moral hazard was highlighted in instances of staffing and resource constraints. Many participants flagged the need to do more with less in emergency settings, and that moral hazard stemmed from providing whatever care was possible “and recognizing that their best wasn’t good enough in their words, and people were dying” (Interviewee 1, Doctor, Vancouver Coastal Health). Respondents highlighted that this not only created moral hazard, but also impacted feelings of self-worth and a diminished sense of professional contribution to solving a health crisis. In terms of resource deployment, participants were quick to point out limitations of the system in terms of ambulances, helicopters and beds, many of which were unavailable during the high call volumes of the heat dome, as demonstrated by the following two HSWs: “And so what would happen is because we only had so much capacity to send ambulances, we were only responding to those higher acuity, you know, the oranges and the reds and purples at the peak of the heat dome. So then you also have paramedics suffering moral distress, because, you know, they, they finally get to whatever address and the person has been... So you know, the patient would say I called for an ambulance, four hours ago, I called yesterday. And now my grandma's much worse, or whatever the case is. So those frontline paramedics, and those dispatchers and those call takers are also receiving, you know, that that distress of an overwhelmed system” (Interviewee 22, Emergency Response Staff, BC Emergency Health Services). “The 911 Call Center in that they had so many people calling in during the heat that were in great despair, and their ability to send ambulances out was very minimal in some instances, and the psychological impact of that on the on both EMTs as well as people on the 911 call center has, is profound and has created incidents of not only as you would expect trauma and depression, you have to look at the impact of moral injury of people being faced with not being able to perform the job in the way that they felt they always could and should do and having to Buse et al., 2025 Page 9 of 17 make choices about where and how to direct services and how and when to respond” (Interviewee 3, Psychologist, Interior Health). In a health system that was already stretched from COVID-19, staffing constraints also played a role. Participants highlighted that lower staffing levels meant longer shifts, and often an inability to provide quality care. A pharmacist working on a complex care team during a major flood event that limited staff ability to be on site shared: “the one that stands out the most is the atmospheric river. And I just had to be nimble and work with my fellow pharmacy leadership colleagues to figure out okay, who's actually on site, where/how are we going to cover these different clinical areas, probably going to have to go down to more troubleshooting mode as opposed to like full clinical pharmacy coverage. So that means, you know, lower quality patient care, because if we're, if we have fewer staff on site, we can’t like dig into drug therapy problems” (Interviewee 5, Pharmacist, Interior Health). However, resource and staffing constraints were particularly pronounced among practitioners working in rural and remote places that already had limited capacity relative to more densely populated urban areas. For example, a paramedic on Vancouver Island shared that: “We typically don't have a doctor available outside of like a Monday to Friday nine to five sort of situation. So in addition to the unfortunate illness for the patient, that's also really hard on paramedics who, you know, need a functioning system in order to deliver the care they deliver. We don't, we don't really have a lot of tools that we can really help people with, in most cases, we stabilize with transport. So yeah, being stuck with somebody where we can't help them. That'spretty hard” (Interviewee 17, Paramedic, Island Health). Perhaps more importantly, participants also shared stories of needing to make real-time ethical trade-offs in the provision of care that created conditions for moral hazard to arise. In certain cases, respondents needed to consider shelter in place guidelines from wildfires and heat with competing infection control measures for COVID-19. In others, participants raised the challenges of evacuation in long-term and acute care settings: “we've got our hospital system, you know, we're going to accommodate five acute patients into our medical ward. But we have 100 Long Term Care residents who might evacuate. How do you prioritize that?” (Interview 26, Emergency Response Staff, Fraser Health). These instances were most pronounced during the heat dome, where health regions and service providers were already struggling with short-staffing and burnout: “BCEHS leadership was under such intense pressure… Consequently the leaders were going off on stress leave, frontline staff were booking off on stress leave, and the staff in the dispatch area at BCEHS 30% of the staff actually quit or went on stress leave after the heat dome. Staff were leaving, because of the extreme psychological, emotional trauma on them with people phoning and screaming at them that they needed help. The staff in dispatch were overwhelmed as the 911 phone calls were beyond what the staff could cope with. When I came to BCEHS we had to do several debriefing sessions with the staff that did not leave after the heat dome as the 911 phone calls were overwhelmed. They were completely backed up, the system was failing, there wasn't enough ambulances” (Interviewee 22, Emergency Response Staff, BC Emergency Health Services). This participant went on to indicate that not only was the sheer volume of calls creating psychologicaloverwhelm for respondents, but in many cases, paramedics were arriving on scene to deal with Buse, C. G., Poland, B., Wong, J., & Haluza-Delay, R. (2019). ‘We’re all brave pioneers on this road’: A Bourdieusian analysis of field creation for public health adaptation to climate change in Ontario, Canada. Critical Public Health, 1–11. https://doi.org/10.1080/09581596.2019.1682123 Caroline Hickman. (2021). Climate anxiety in children and young people and their beliefs about government responses to climate change: A global survey. Lancet Planetary Health, 5. https://www.thelancet.com/action/showPdf?pii=S2 542-5196%2821%2900278-3 Čartolovni, A., Stolt, M., Scott, P. A., & Suhonen, R. (2021). Moral injury in healthcare professionals: A scoping review and discussion. Nursing Ethics, 28(5), 590–602. https://doi.org/10.1177/0969733020966776 Currier, J. M., Drescher, K. D., & Nieuwsma, J. (2021). Future directions for addressing moral injury in clinical practice: Concluding comments. In J. M. Currier, K. D. Drescher, & J. Nieuwsma (Eds.), Addressing moral injury in clinical practice. (pp. 261–271). American Psychological Association. https://doi.org/10.1037/0000204-015 Fereday, J., & Muir-Cochrane, E. (2006). Demonstrating Rigor Using Thematic Analysis: A Hybrid Approach of Inductive and Deductive Coding and Theme Development. International Journal of Qualitative Methods, 5(1), 80–92. https://doi.org/10.1177/160940690600500107 French, L., Hanna, P., & Huckle, C. (2022). “If I die, they do not care”: U.K. National Health Service staff experiences of betrayal-based moral injury during COVID-19. Psychological Trauma: Theory, Research, Practice, and Policy, 14(3), 516–521. https://doi.org/10.1037/tra0001134 Fusch, P., & Ness, L. (2015). Are We There Yet? Data Saturation in Qualitative Research. Walden Faculty and Staff Publications, 20(9). https://scholarworks.waldenu.edu/facpubs/455 Gillett, N. P., Cannon, A. J., Malinina, E., Schnorbus, M., Anslow, F., Sun, Q., Kirchmeier-Young, M., Zwiers, F., Seiler, C., Zhang, X., Flato, G., Wan, H., Li, G., & Castellan, A. (2022). Human influence on the 2021 British Columbia floods. Weather and Climate Extremes, 36, 100441. https://doi.org/10.1016/j.wace.2022.100441 Hennink, M. M., Kaiser, B. N., & Marconi, V. C. (2017). Code Saturation Versus Meaning Saturation: How Many Interviews Are Enough? Qualitative Health Research, 27(4), 591–608. https://doi.org/10.1177/1049732316665344 Henritze, E., Goldman, S., Simon, S., & Brown, A. D. (2023). Moral injury as an inclusive mental health framework for addressing climate change distress and promoting justice-oriented care. The Lancet Planetary Health, 7(3), e238–e241. https://doi.org/10.1016/S2542-5196(22)00335-7 Hines, S. E., Chin, K. H., Glick, D. R., & Wickwire, E. M. (2021). Trends in Moral Injury, Distress, and Resilience Factors among Healthcare Workers at the Beginning of the COVID-19 Pandemic. International Journal of Environmental Research and Public Health, 18(2), 488. https://doi.org/10.3390/ijerph18020488 Jinkerson, J. D. (2016). Defining and assessing moral injury: A syndrome perspective. Traumatology, 22(2), 122–130. https://doi.org/10.1037/trm0000069 Kherbache, A., Mertens, E., & Denier, Y. (2022). Moral distress in medicine: An ethical analysis. Journal of Health Psychology, 27(8), 1971–1990. https://doi.org/10.1177/13591053211014586 Latimer, A. L., Otis, M. D., MuddMartin, G., & Moser, D. K. (2023). Moral distress during COVID-19: The importance of perceived organizational support for hospital nurses. Journal of Health Psychology, 28(3), 279–292. https://doi.org/10.1177/13591053221111850 Low, M. P., & Loh, Y. X. (2024). Influence of employee-centred CSR for a better workplace. In R. Shrivastava & K. Jain (Eds.), Humanizing Businesses for a Better World of Work (1st ed, pp. 87–107). Emerald Publishing Limited. Maftei, A., & Holman, A.-C. (2021). The prevalence of exposure to potentially morally injurious events among physicians during the COVID-19 pandemic. European Journal of Psychotraumatology, 12(1), 1898791. https://doi.org/10.1080/20008198.2021.1898791 Mantri, S., Song, Y. K., Lawson, J. M., Berger, E. J., & Koenig, H. G. (2021). Moral Injury and Burnout in Health Care Professionals During the COVID-19 Pandemic. Journal of Nervous & Mental Disease, 209(10), 720–726. https://doi.org/10.1097/NMD.0000000000001367 Nowell, L. S., Norris, J. M., White, D. E., & Moules, N. J. (2017). Thematic Analysis: Striving to Meet the Trustworthiness Criteria. International Journal of Qualitative Methods, 16(1), 160940691773384. https://doi.org/10.1177/1609406917733847 Oelhafen, S., Monteverde, S., & Trachsel, M. (2024). Overestimating prevalence? Rethinking boundaries and confounders of moral distress. Journal of Health Psychology, 13591053241253233. https://doi.org/10.1177/13591053241253233 Redvers, N., Celidwen, Y., Schultz, C., Horn, O., Githaiga, C., Vera, M., Perdrisat, M., Mad Plume, L., Kobei, D., Kain, M. C., Poelina, A., Rojas, J. N., & Blondin, B. (2022). The determinants of planetary health: An Indigenous consensus perspective. The Lancet Planetary Health, 6(2), e156–e163. https://doi.org/10.1016/S2542-5196(21)00354-5 Riedel, P.-L., Kreh, A., Kulcar, V., Lieber, A., & Juen, B. (2022). A Scoping Review of Moral Stressors, Moral Distress and Moral Injury in Healthcare Workers during COVID-19. International Journal of Environmental Research and Public Health, 19(3), 1666. https://doi.org/10.3390/ijerph19031666 Ritter, M., Vance, M., & Iskander, J. (2023). Moral Injury Among US Public Health Service First Responders During the COVID-19 Pandemic. Public Health Reports, 138(5), 732–735. https://doi.org/10.1177/00333549231176294 Rushton, S. (2011). Global Health Security: Security for whom? Security from what? Political Studies, 59(4), 779–796. https://doi.org/10.1111/j.14679248.2011.00919.x Shale, S. (2020). Moral injury and the COVID-19 pandemic: Reframing what it is, who it affects and how care leaders can manage it. BMJ Leader, 4(4), 224–227. https://doi.org/10.1136/leader-2020000295 Smith, J., Tiwana, M. H., Murage, A., Samji, H., Morgan, R., & Delgado-Ron, J. A. (2024). Moral distress related to paid and unpaid care among healthcare workers during the COVID-19 pandemic. PLOS ONE, 19(9), e0310132. https://doi.org/10.1371/journal.pone.0310132 Steiner, C. I. (2023). A wound has no voice: Silence, emotions and community resilience in the wake of collective SARS-Cov-2 Trauma. NextGen Scientific Review - Annual Perspectives on Next Generation Science, 1, 1–9. Tsakonas, K., Badyal, S., Takaro, T., & Buse, C. (2025). Occupational health impacts of climate-related emergency events on health system workers in British Columbia. International Journal of Disaster Risk Reduction, 118, 105227. https://doi.org/10.1016/j.ijdrr.2025.105227 Tsakonas, K., Badyal, S., Takaro, T., & Buse, C. G. (2024). Rapid review of the impacts of climate change on the health system workforce and implications for action. The Journal of Climate Change and Health, 19, 100337. https://doi.org/10.1016/j.joclim.2024.100337 Vaughn, P., & Turner, C. (2016). Decoding via Coding: Analyzing Qualitative Text Data Through Thematic Coding and Survey Methodologies. Journal of Library Administration, 56(1), 41–51. https://doi.org/10.1080/01930826.2015.1105035 Weintrobe, S. (2021). Psychological roots of the climate crisis: Neoliberal exceptionalism and the culture of uncare. Bloomsbury Academic. Weller, S. C., Vickers, B., Bernard, H. R., Blackburn, A. M., Borgatti, S., Gravlee, C. C., & Johnson, J. C. (2018). Open-ended interview questions and saturation. PLOS ONE, 13(6), e0198606. https://doi.org/10.1371/journal.pone.0198606 Williamson, V., Murphy, D., & Greenberg, N. (2020). COVID-19 and experiences of moral injury in frontline key workers. Occupational Medicine, 70(5), 317–319. https://doi.org/10.1093/occmed/kqaa052 World Health Organization. (2015). Operational framework for building climate resilient health systems. World Health Organization. https://apps.who.int/iris/handle/10665/189951 Xue, Y., Lopes, J., Ritchie, K., D’Alessandro, A. M., Banfield, L., McCabe, R. E., Heber, A., Lanius, R. A., & McKinnon, M. C. (2022). Potential Circumstances Associated With Moral Injury and Moral Distress in Healthcare Workers and Public Safety Personnel Across the Globe During COVID-19: A Scoping Review. Frontiers in Psychiatry, 13, 863232. https://doi.org/10.3389/fpsyt.2022.8632