The role of organizations and leadership in repairing the damage and building supportive workplaces
- Moral injury in nursing occurs when systemic constraints force ethical compromise, causing guilt, shame, and betrayal.
- Unlike burnout or moral distress, moral injury deeply impacts moral integrity and identity.
- Addressing moral injury requires leadership support, systemic reform, and strong mental health resources.
THE SILENT CRISIS of moral injury continues to reshape the landscape of nursing, leaving many to question how they can continue in roles that compel them to compromise their deepest values. Moral injury in healthcare occurs when healthcare professionals, including nurses, feel obligated to act against their deeply held ethical beliefs due to systemic constraints and institutional demands, a concept first brought to national attention by Talbot and Dean in their work on clinician distress. According to Dean and colleagues, moral injury manifests as an insidious form of psychological distress, marked by intense feelings of guilt, shame, and betrayal that can significantly affect a nurse’s mental health and their ability to provide compassionate care. (See Moral injury: Definition and examples.)
Moral injury: Definition and examples
Griffin and colleagues note the initial identification of moral injury in military contexts, where soldiers experienced profound guilt and shame from actions taken during combat. In nursing, moral injury occurs when nurses engage in or witness actions that contradict their moral or ethical values.
As described by Rushton and colleagues, this can happen as a result of resource limitations, policy constraints, internal pressures such as personal ethical conflicts, and directives that prioritize efficiency over patient care. Nursing leaders also face moral injury when their actions, driven by systemic constraints, conflict with their professional and ethical values, leading to feelings of guilt and helplessness.
Actions that can lead to moral injury
- A nurse, due to an overly burdensome workload, must ration limited resources and adjust the level of care, knowing that some patients may receive suboptimal treatment as a result.
- A nurse receives orders to discharge a patient prematurely due to bed shortages, despite the patient’s need for continued inpatient care.
- A chief nursing officer feels obligated to implement budget cuts that result in reduced staffing levels, knowing this will increase the burden on frontline nurses and potentially compromise patient care.
Each of these situations creates inner conflict and emotional distress, leading to feelings of betrayal by the system meant to support patient care and staff well-being.
As healthcare professionals grapple with increasing pressures, such as resource shortages, overwhelming patient demands, and ethical dilemmas, understanding and addressing moral injury has become crucial to sustaining a healthy and effective nursing workforce, as described by Čartolovni and colleagues.
Burnout, moral distress, moral injury
Although a connection exists among burnout, moral distress, and moral injury, they’re distinct concepts.
Burnout
Freudenberger first described burnout in the 1970s, defining it as a state of physical, emotional, and mental exhaustion caused by prolonged stress. Contemporary literature continues to define burnout as a work-related syndrome characterized by exhaustion, cynicism, and reduced professional efficacy. As explained by Montgomery and colleagues, nurses experiencing burnout may feel overwhelmed by their workload, struggle with reduced professional accomplishment, and exhibit a growing sense of detachment from their patients and colleagues.
Moral distress
On the other hand, moral distress (a term introduced by Jameton in 1984) arises when nurses know the ethically appropriate action to take but are prevented from doing so by external constraints, such as institutional policies, legal limitations, and resource shortages. Moral distress can lead to frustration, powerlessness, and a sense of professional impotence. As described by Rushton and colleagues, repeated or unresolved experiences of moral distress may contribute to broader moral suffering and, over time, increase vulnerability to moral injury among healthcare clinicians.
Moral injury
Moral injury, a term first introduced in the 1990s, was more fully conceptualized in 2009 and has since been extended to clinical practice. As described by Talbot and Dean, it involves a deep ethical conflict and a sense of having betrayed one’s values. Nurses experiencing moral injury may report intense feelings of guilt, shame, and a loss of trust in the system.
Distinguishing moral injury from burnout and moral distress matters. The latter two primarily reflect responses to stress and ethical barriers in the work environment, whereas moral injury represents a deeper and more enduring threat to a nurse’s ethical integrity and professional identity. According to Dean and colleagues, nurses suffering from moral injury may experience internal conflict, questioning their role in the healthcare system and their ability to continue in their profession without compromising their ethical standards.
Causes of moral injury in nursing
Several factors contribute to moral injury in nursing, stemming from both individual vulnerabilities and systemic issues within healthcare. Mewborn and colleagues describe personal risk factors that may increase the likelihood of developing moral injury. They include age under 45, fewer years of healthcare work experience, lack of religious affiliation, history of anxiety or depression, job dissatisfaction, and existing burnout symptoms. These risk factors may increase a nurse’s susceptibility to psychological distress, making them more vulnerable to moral injury when they encounter ethically challenging situations in practice. In the context of high-demand, ethically complex work environments, these vulnerabilities can accelerate the development of moral injury.
Systemic issues related to moral injury include organizational and structural barriers that prevent nurses from delivering what they consider ethically and professionally appropriate care. As described by Rushton and colleagues, moral injury in healthcare frequently arises when system-level factors limit a clinician’s ability to act in accordance with their values. Common examples include inadequate staffing, lack of necessary medical supplies, and insufficient time to provide comprehensive care. These constraints may force nurses to deliver care that falls short of their professional standards.
Policies that place cost savings above patient care, such as early discharges or restricted treatment access, can heighten moral injury among nurses. In these scenarios, nurses may find themselves fighting to meet patient needs within a system that seems indifferent to the individuals they serve.
Ethical dilemmas become recurring sources of strain as nurses encounter directives that conflict with their professional values and the standards set by the American Nurses Association Code of Ethics for Nurses (Code). According to Rushton and colleagues, workplace cultures that discourage speaking up about ethical concerns or normalize compromised standards of care can compound moral injury, leaving nurses isolated and struggling within roles that should ideally uphold compassion and ethical responsibility.
Moral injury fallout
The consequences of moral injury are profound, affecting both personal and professional aspects of a nurse’s life. Research from Fitzpatrick and colleagues indicates a significant emotional and psychological toll, with chronic feelings of guilt, shame, and helplessness that lead to anxiety, depression, and even post-traumatic stress disorder. Nurses may struggle with overwhelming emotions that impact their mental health, making it difficult to find joy and fulfillment in their work and personal lives.
As described by Weissinger and colleagues, professional dissatisfaction serves as another consequence, as disillusionment with the healthcare system can lead to decreased job satisfaction and a desire to leave the profession. Nurses who experience moral injury may feel disconnected from their initial motivations for entering the field, questioning whether they can continue working in an environment that conflicts with their ethical values.
Interpersonal relationships also suffer as a result of moral injury. As described by Fitzpatrick and colleagues, the emotional burden can strain relationships with colleagues, friends, and family. Nurses may find it challenging to communicate their distress or seek support, leading to feelings of isolation and loneliness.
The chronic stress and emotional burden associated with moral injury may contribute to declines in physical well-being, as described by Fitzpatrick and colleagues. The ongoing physical strain can further diminish their overall well-being, creating a vicious cycle of stress and health problems.
How to address moral injury
Overcoming moral injury requires a multifaceted approach involving both individual support and systemic change, recognizing that both leaders and frontline staff face ethical challenges that contribute to moral injury.
Leadership
Engaged leadership is essential to fostering mutual understanding and collaboration between management and staff. As described by Kohnen and colleagues, leaders who actively listen to the struggles faced by nurses and are vulnerable in acknowledging their own challenges create a culture of empathy and shared responsibility. Regular forums for dialogue can enable meaningful discussions on systemic issues, promoting collaborative problem-solving and continuous improvement in ethical practice. However, without decreasing burdensome tasks and workloads, these efforts are merely a bandage on a deeper wound.
Leaders must go further by creating a work environment with increased resources and reduced demands whenever possible. By addressing the root causes of moral injury rather than just the symptoms, leaders promote a supportive work environment that bridges the gap between frontline staff and administrative decision-makers, facilitates meaningful change, and enhances organizational resilience.
Sexton and Frankel suggest that leaders consider implementing check-ins that allow them to establish a direct and supportive connection between themselves and staff. These brief and regular meetings help foster a positive organizational culture by showing concern and addressing issues, thus strengthening team cohesion and alignment. Through these check-ins, frontline nurses feel acknowledged and valued, which supports their psychological well-being and alleviates emotional exhaustion.
This approach can address fundamental psychological needs such as relatedness, competence, and autonomy, which can prove challenging during difficult periods. Sexton and Frankel note that although leader check-ins are relatively low-cost, they can significantly enhance trust, engagement, and resilience among nurses, offering a practical and immediate way to alleviate the impact of moral injury.
Support systems
Although members of the leadership team play a critical role in combating moral injury, they can’t work in silos. Moral injury mitigation requires support systems. As described by Melnyk and colleagues, robust support structures—including counseling services, peer support groups, and mental health resources—provide nurses with the tools to cope with emotional and psychological stress. These resources offer a safe space for both leaders and nurses to share experiences and seek guidance, fostering a sense of camaraderie and mutual support.
However, employee assistance programs and other resources depend on employees recognizing their experience of moral injury and reaching out for support. This reactive approach means that many cases of moral injury may go unaddressed until significant harm has occurred.
Melnyk and colleagues recommend implementing proactive support systems that integrate regular check-ins and mental health screenings into the culture and norms of the workplace to help identify and address issues early. Encouraging a culture of openness and reducing the stigma associated with seeking help can prove crucial to ensuring that nurses feel empowered to use these support systems before distress escalates to moral injury.
Ethical training
Ethical training can equip nurses with the knowledge to distinguish between ethical dilemmas and moral distress. Ethical dilemmas in healthcare involve situations where two or more ethically justifiable actions exist without a clear solution. Moral distress, as first described by Jameton, may overlap with ethical dilemmas and occurs when providers know the ethical action to take but feel powerless to do so. However, recent research from Rushton and colleagues indicates that moral distress can stem not only from constraints but also from ethical conflicts, uncertainty, and confusion within morally distressing situations.
Ongoing education on ethical decision-making and coping strategies equips nurses and leaders with the skills to navigate these complex issues effectively. Consulting the hospital’s ethics team when faced with ethical dilemmas can provide additional support and guidance, ensuring that decisions are made with a comprehensive understanding of the ethical implications. Ethical trainings offer a practical approach to resolving ethical conflicts while upholding professional integrity and patient-centered care, and also helping to prevent moral distress from escalating into moral injury.
Nurses and leaders can access ethical decision-making education through established professional and evidence-based resources. The Code provides a foundational framework to guide ethical practice and professional accountability. In addition, applying principles of evidence-based practice and improvement science can help clinicians systematically address ethical challenges within complex healthcare systems. Programs at The Ohio State University’s Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare offer accessible training in these approaches, equipping nurses and leaders with practical tools to navigate ethical dilemmas and strengthen moral resilience.
System-level policies
Organizational policies and system-level conditions shape the ethical environment for nursing practice. Evidence from Rushton and colleagues’ studies of moral injury in healthcare demonstrate that structural constraints contribute to ethically compromising situations and increase vulnerability to moral injury.
To counter those conditions, nurses and leadership can advocate for policies that prioritize patient care and ethical practice over financial considerations to help alleviate systemic constraints that contribute to moral injury. This could involve revisiting staffing policies, ensuring adequate resources, and promoting a culture of ethical responsibility. By addressing system-level contributors rather than placing responsibility solely on individual nurses, organizations can reduce conditions that give rise to moral injury.
Ultimately, addressing moral injury requires collaboration and mutual respect among leaders and employees. By working together to address systemic problems, healthcare organizations can cultivate a culture of ethical practice, professional satisfaction, and compassionate patient care.
Additionally, more research into moral injury will increase understanding of its causes, consequences, and effective interventions. Investments in research can lead to the development of evidence-based strategies to support nurses and improve the overall healthcare environment.
Shared responsibility
Addressing moral injury in nursing requires deliberate, sustained action at individual and organizational levels. This insidious phenomenon, distinct from burnout and moral distress, profoundly impacts nurses’ emotional well-being and undermines their ability to deliver patient-centered care with integrity. For frontline nurses, support is most effective when it’s practical and embedded into everyday work. Opportunities for reflection, peer connection, ethical dialogue, and education focused on navigating morally challenging situations may help nurses process difficult experiences and reduce isolation. Encouraging nurses to raise ethical concerns through established channels and shared governance structures also can support professional integrity and foster collective problem solving.
Equally important, healthcare leaders play a central role in mitigating moral injury by acknowledging ethical challenges, listening to frontline perspectives, and working collaboratively to address system-level constraints. Efforts to reduce unnecessary workload burdens, improve resource availability, and align organizational priorities with professional nursing values can help create environments that support ethical practice.
Ultimately, addressing moral injury depends on shared responsibility across all levels of the organization. When leadership practices and organizational policies reflect the realities of nursing work, healthcare systems are better positioned to support nurses’ well-being, ethical integrity, and ability to deliver high-quality care.
Joseph R. Travis is a nursing professional development specialist at the University of Alabama at Birmingham. Dana Morson is an assistant professor at the University of Alabama at Birmingham School of Nursing.
American Nurse Journal. 2026; 21(5). Doi: 10.51256/ANJ052638
References
American Nurses Association. Code of Ethics for Nurses. Silver Spring, MD: American Nurses Association; 2025. codeofethics.ana.org/provisions
Bianchi R, Schonfeld IS. Examining the evidence base for burnout. Bull World Health Organ. 2023;101(11):743-5. doi:10.2471/BLT.23.289996
Čartolovni A, Stolt M, Scott PA, Suhonen R. Moral injury in healthcare professionals: A scoping review and discussion. Nurs Ethics. 2021;28(5):590-602. doi:10.1177/0969733020966776
Dean W, Jacobs B, Manfredi RA. Moral injury: The invisible epidemic in COVID health care workers. Ann Emerg Med. 2020;76(4):385-6. doi:10.1016/j.annemergmed.2020.05.023
Dean W, Talbot S, Dean A. Reframing clinician distress: Moral injury not burnout. Fed Pract. 2019;36(9):400-2.
Fitzpatrick JJ, Pignatiello GA, Kim M, et al. Moral injury, nurse well-being, and resilience among nurses practicing during the COVID-19 pandemic. J Nurs Adm. 2022;52(7-8):392-8. doi:10.1097/NNA.0000000000001171
Freudenberger HJ. Staff burn-out. J Soc Issues. 1974;30(1):159-65. doi:10.1111/j.1540-4560.1974.tb00706.x
Griffin BJ, Purcell N, Burkman K, et al. Moral injury: An integrative review. J Trauma Stress. 2019;32(3):350-62. doi:10.1002/jts.22362
Jameton A. Nursing Practice, the Ethical Issues. Englewood Cliffs, NJ: Prentice-Hall; 1984.
Kohnen D, De Witte H, Schaufeli WB, Dello S, Bruyneel L, Sermeus W. Engaging leadership and nurse well-being: The role of the work environment and work motivation—A cross-sectional study. Hum Resour Health. 2024;22(1):8. doi:10.1186/s12960-023-00886-6
Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695-706. doi:10.1016/j.cpr.2009.07.003
Melnyk BM, Kelly SA, Stephens J, et al. Interventions to improve mental health, well-being, physical health, and lifestyle behaviors in physicians and nurses: A systematic review. Am J Health Promot. 2020;34(8):929-41. doi:10.1177/0890117120920451
Mewborn EK, Fingerhood ML, Johanson L, Hughes V. Examining moral injury in clinical practice: A narrative literature review. Nurs Ethics. 2023;30(7-8):960-74. doi:10.1177/09697330231164762
Montgomery AP, Patrician PA, Azuero A. Nurse burnout syndrome and work environment impact patient safety grade. J Nurs Care Qual. 2022;37(1):87-93. doi:10.1097/NCQ.0000000000000574
The Ohio State University College of Nursing. Helene Fuld Health Trust National Institute for Evidence-Based Practice in Nursing and Healthcare. fuld.nursing.osu.edu/
Rushton CH, Hanson GC, Boyce D, et al. Reliability and validity of the revised Rushton Moral Resilience Scale for healthcare workers. J Adv Nurs. 2024;80(3):1177-87. doi:10.1111/jan.15873
Rushton CH, Thomas TA, Antonsdottir IM, et al. Moral injury and moral resilience in health care workers during COVID-19 pandemic. J Palliat Med. 2022;25(5):712-9. doi:10.1089/jpm.2021.0076
Sexton JB, Frankel A. Leaders that listen meet essential psychological needs of the workforce. Mayo Clin Proc. 2023;98(6):823-5. doi:10.1016/j.mayocp.2023.04.015
Talbot SG, Dean W. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. STAT. July 26, 2018. statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury
Weissinger GM, Swavely D, Holtz H, et al. Critical care nurses’ moral resilience, moral injury, institutional betrayal, and traumatic stress after COVID-19. Am J Crit Care. 2024;33(2):105-14. doi:10.4037/ajcc2024481
Key words: moral injury, integrity, nurse identity, ethical compromise, systemic constraints, systemic reform
