Reckoning with Moral Injury In Correctional Healthcare: Using Participatory Action Research to Develop a Moral Injury Response Toolkit

Background and Purpose: Correctional healthcare workers face the challenge of providing high-acuity clients with care in environments shaped by punishment, control, and institutional violence. In these settings, they may be unable to act in accordance with professional ethics, clinical judgment, and commitment to humane care, creating risk for moral injury (Dean & Talbot, 2023; Shay, 2014). Although correctional institutions are critical sites of public health and social welfare, limited research has examined moral injury among correctional healthcare workers, and even less has translated to actionable interventions (Blinded, 2024). This study addresses that gap in the literature by using participatory action research (PAR) to develop a workforce-informed Moral Injury Response Toolkit for correctional healthcare settings.

Methods: This study used a PAR design guided by the principle “nothing about us without us.” Toolkit development built on findings from the researchers’ prior (2024) phenomenological mixed methods study (n=124) identifying moral injury as a pervasive occupational hazard in correctional healthcare. In this PAR phase, the researcher conducted a series of focus groups with diverse correctional healthcare professionals (n=15) representing multiple disciplines, correctional settings, regions, and more than 120 cumulative years of experience. Focus groups elicited participants’ descriptions of morally injurious experiences, perceived impacts, and recommendations for intervention strategies. Data were analyzed using interpretative phenomenological analysis. Iterative coding and theme development were used to identify shared meaning, recurring structural conditions, and priority domains for toolkit construction. Findings directly informed co-development of recently published and accessible toolkit content.

Results: Across five focus groups, participants affirmed moral injury as a pervasive and recurring feature of correctional healthcare. Participants identified consistent contributors, including conflict between custody and treatment obligations, resource scarcity, exposure to violence, and organizational cultures that normalize ethical compromise. These conditions were described as undermining moral agency, straining professional identity, and contributing to emotional distress. Participants identified five priorities for intervention: 1- defining and educating workers about moral injury; 2 - delineating the “harms of helping” within correctional settings; 3 - naming “stealth mode” or subversive survival strategies; 4 - developing concrete tools such as scripts, videos, and train-the-trainer resources; and 5 - focusing on organizational/systems-level causes and responses (Blinded, 2025). These findings informed development of the interdisciplinary Moral Injury Response Toolkit.

Conclusions and Implications: This study advances social work research by translating empirical findings into a practice-informed interventions for a workforce serving structurally marginalized populations. Findings support framing moral injury as a systemic workforce issue shaped by organizational conditions rather than an individual problem. This study reflects research in service of democracy and the common good by elevating worker voice, promoting ethical/equitable care, and strengthening accountability within institutions that shape health, freedom, and dignity. Implications include the need for organizational investment in moral injury prevention and response, greater attention to correctional healthcare as a social work research priority, and future research examining implementation and outcomes of toolkit-informed interventions. More broadly, it demonstrates how participatory, practice-engaged social work research can strengthen institutions, and advance justice within systems that profoundly shape health, dignity, and democratic belonging.