Keywords
Nurses
Trauma
Occupational health
Influencing factors
Submitted : 2025-07-03
Accepted : 2025-07-18
Published : 2025-08-02
Abstract
Nurses often face moral dilemmas in their work, and the resulting moral injury has become an important factor affecting the stability of the nursing workforce and nurses' professional health. This article reviews the concept of moral injury, the measurement tools, the influencing factors of moral injury such as demographic factors, psychological factors, and the adverse outcomes, to provide reference for the promotion of nurses' physical and mental health and the enhancement of the quality of nursing services, and the development of effective interventions for nurses’ moral injury, through the systematic summary of the knowledge related to moral injury.
References
Parsa-Parsi RW, 2022, The International Code of Medical Ethics of the World Medical Association. JAMA, 328(20): 2018–2021. DOI:10.1001/jama.2022.19697.
Xue B, Wang S, Chen D, et al., 2024, Moral Distress, Psychological Capital, and Burnout in Registered Nurses. Nursing Ethics, 31(2–3): 388–400. DOI:10.1177/09697330231202233.
Currier JM, McCormick W, Drescher KD, 2015, How Do Morally Injurious Events Occur? A Qualitative Analysis of Perspectives of Veterans with PTSD. Traumatology, 21(2): 106. DOI:10.1037/trm0000027.
Williamson V, Murphy D, Phelps A, et al., 2021, Moral Injury: The Effect on Mental Health and Implications for Treatment. The Lancet Psychiatry, 8(6): 453–455. DOI:10.1016/S2215-0366(21)00113-9.
Williamson V, Stevelink SAM, Greenberg N, 2018, Occupational Moral Injury and Mental Health: Systematic Review and Meta-Analysis. The British Journal of Psychiatry, 212(6): 339–346. DOI:10.1192/bjp.2018.55.
Wang Z, Koenig HG, Tong Y, et al., 2022, Moral Injury in Chinese Health Professionals During the COVID-19 Pandemic. Psychological Trauma: Theory, Research, Practice, and Policy, 14(2): 250.
Rodríguez EA, Agüero-Flores M, Landa-Blanco M, et al., 2021, Moral Injury and Light Triad Traits: Anxiety and Depression in Health-Care Personnel During the Coronavirus-2019 Pandemic in Honduras. Hispanic Health Care International, 19(4): 230–238. DOI:10.1177/15404153211042371.
Jovarauskaite L, Murphy D, Truskauskaite-Kuneviciene I, et al., 2022, Associations Between Moral Injury and ICD-11 Post-Traumatic Stress Disorder (PTSD) and Complex PTSD Among Help-Seeking Nurses: A Cross-Sectional Study. BMJ Open, 12(5): e056289. DOI:10.1136/bmjopen-2021-056289.
Shay J, 2003, Odysseus in America: Combat Trauma and the Trials of Homecoming. Simon and Schuster. Scribner, 1–352.
Litz BT, Stein N, Delaney E, et al., 2009, Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy. Clinical Psychology Review, 29(8): 695–706. DOI:10.1016/j.cpr.2009.07.003.
Dean W, Talbot S, Dean A, 2019, Reframing Clinician Distress: Moral Injury Not Burnout. Federal Practitioner, 36(9): 400.
Jinkerson JD, 2016, Defining and Assessing Moral Injury: A Syndrome Perspective. Traumatology, 22(2): 122. DOI:10.1037/trm0000069.
Mantri S, Lawson JM, Wang ZZ, et al., 2020, Identifying Moral Injury in Healthcare Professionals: The Moral Injury Symptom Scale-HP. Journal of Religion and Health, 59(5): 2323–2340.
Currier JM, Farnsworth JK, Drescher KD, et al., 2018, Development and Evaluation of the Expressions of Moral Injury Scale—Military Version. Clinical Psychology & Psychotherapy, 25(3): 474–488. DOI:10.1002/cpp.2170.
Zhizhong W, Koenig HG, Yan T, et al., 2020, Psychometric Properties of the Moral Injury Symptom Scale Among Chinese Health Professionals During the COVID-19 Pandemic. BMC Psychiatry, 20: 1–10. DOI:10.1186/s12888-020-02954-w.
Nash WP, Marino Carper TL, Mills MA, et al., 2013, Psychometric Evaluation of the Moral Injury Events Scale. Military Medicine, 178(6): 646–652. DOI:10.7205/MILMED-D-13-00017.
Morris DJ, Webb EL, Trundle G, et al., 2022, Moral Injury in Secure Mental Healthcare: Part I: Exploratory and Confirmatory Factor Analysis of the Moral Injury Events Scale. The Journal of Forensic Psychiatry & Psychology, 33(5): 708–725. DOI:10.1080/14789949.2022.2111318.
Fino E, Daniels JK, Micheli G, et al., 2023, Moral Injury in a Global Health Emergency: A Validation Study of the Italian Version of the Moral Injury Events Scale Adjusted to the Healthcare Setting. European Journal of Psychotraumatology, 14(2): 2263316. DOI:10.1080/20008066.2023.2263316.
Litz BT, Plouffe RA, Nazarov A, et al., 2022, Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium. Frontiers in Psychiatry, 13: 923928. DOI:10.3389/fpsyt.2022.923928.
Tao H, Nieuwsma JA, Meador KG, et al., 2023, Validation of the Moral Injury Outcome Scale in Acute Care Nurses. Frontiers in Psychiatry, 14: 1279255. DOI:10.3389/fpsyt.2023.1279255.
Akhtar M, Faize FA, Malik RZ, et al., 2022, Moral Injury and Psychological Resilience Among Healthcare Professionals Amid COVID-19 Pandemic. Pakistan Journal of Medical Sciences, 38(5): 1338. DOI:10.12669/pjms.38.5.5122.
Idrees S, Faize FA, Akhtar M, 2017, Psychological Reactions, Social Support, and Coping Styles in Pakistani Female Burn Survivors. Journal of Burn Care & Research, 38(6): e934–e943. DOI:10.1097/BCR.0000000000000525.
Liang T, Kaka Mirza H, Malakoutikhah A, et al., 2023, Moral Injury and Its Correlates Among Iranian Nurses in the Second Year of the COVID-19 Pandemic: A Multicenter Cross-Sectional Study. Journal of Religion and Health, 62(6): 3979–3994. DOI:10.1007/s10943-023-01938-w.
Rushton CH, Thomas TA, Antonsdottir IM, et al., 2022, Moral Injury and Moral Resilience in Health Care Workers During COVID-19 Pandemic. Journal of Palliative Medicine, 25(5): 712–719. DOI:10.1089/jpm.2021.0076.
Chen X, Wang L, Wang L, 2020, Study on the Status and Correlation of Moral Trauma Among Medical Interns. Chinese Medical Ethics, 33(11): 1335–1340.
Dai H, Li Y, Wu H, 2023, Relationship Between Moral Courage and Moral Distress Among Nurses. Journal of Nursing Science, 37(21): 53–57.
Fitzpatrick JJ, Pignatiello G, Kim M, et al., 2022, Moral Injury, Nurse Well-Being, and Resilience Among Nurses Practicing During the COVID-19 Pandemic. JONA: The Journal of Nursing Administration, 52(7/8): 392–398. DOI:10.1097/NNA.0000000000001171.
Zahiriharsini A, Gilbert-Ouimet M, Langlois L, et al, 2022, Associations Between Psychosocial Stressors at Work and Moral Injury in Frontline Healthcare Workers and Leaders Facing the COVID-19 Pandemic in Quebec, Canada: A Cross-Sectional Study. Journal of Psychiatric Research, 155: 269–278. DOI:10.1016/j.jpsychires.2022.09.006.
Riedel PL, Kreh A, Kulcar V, et al., 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. DOI:10.3390/ijerph19031666.
Ahmadi MH, Heidarzadeh M, Fathiazar A, et al., 2025, Investigating the Relationship Between Compassion Fatigue and Moral Injury in Nurses. Nursing Ethics, 32(1): 201–211. DOI:10.1177/09697330241247323.
Wang Z, Koenig HG, Tong Y, et al., 2022, Moral Injury in Chinese Health Professionals During the COVID-19 Pandemic. Psychological Trauma: Theory, Research, Practice, and Policy, 14(2): 250. DOI:10.1037/tra0001026.
Wang Z, Al Zaben F, Koenig HG, et al., 2021, Spirituality, Moral Injury and Mental Health Among Chinese Health Professionals. BJPsych Open, 7(4): e135. DOI:10.1192/bjo.2021.972.
Beadle ES, Walecka A, Sangam AV, et al., 2024, Triggers and Factors Associated With Moral Distress and Moral Injury in Health and Social Care Workers: A Systematic Review of Qualitative Studies. PLoS One, 19(6): e0303013.
Litz BT, Kerig PK, 2019, Introduction to the Special Issue on Moral Injury: Conceptual Challenges, Methodological Issues, and Clinical Applications. Journal of Traumatic Stress, 32(3): 341–349.
Rushton CH, Turner K, Brock RN, et al., 2025, Invisible Moral Wounds of the COVID-19 Pandemic: Are We Experiencing Moral Injury? AACN Advanced Critical Care, 36(1): 37–43.
Oser FK, Reichenbach R, 2005, Moral Resilience – The Unhappy Moralist. In W. Edelstein & G. Nunner-Winkler (Eds.), Morality in Context, 204–224.
Numminen O, Katajisto J, Leino-Kilpi H, 2019, Development and Validation of Nurses’ Moral Courage Scale. Nursing Ethics, 26(7–8): 2438–2455.
Berdida DJE, Grande RAN, 2023, Moral Distress, Moral Resilience, Moral Courage, and Moral Injury Among Nurses in the Philippines During the COVID-19 Pandemic: A Mediation Analysis. Journal of Religion and Health, 62(6): 3957–3978. DOI:10.1007/s10943-023-01873-w.
Shao R, Wang Y, 2024, Reflections on the Moral Injury and Coping of Medical Staff From the Perspective of Caring Ethics. Chinese Medical Ethics, 37(11): 1378–1386.
Rushton CH, Nelson KE, Antonsdottir I, et al., 2022, Perceived Organizational Effectiveness, Moral Injury, and Moral Resilience Among Nurses During the COVID-19 Pandemic: Secondary Analysis. Nursing Management, 53(7): 12–22. DOI:10.1097/01.NUMA.0000834524.01865.cc.
Rabin S, Kika N, Lamb D, et al., 2023, Moral Injuries in Healthcare Workers: What Causes Them and What to Do About Them? Journal of Healthcare Leadership, 2023: 153–160. DOI:10.2147/JHL.S396659.
Mantri S, Song YK, Lawson JM, et al., 2021, Moral Injury and Burnout in Health Care Professionals During the COVID-19 Pandemic. The Journal of Nervous and Mental Disease, 209(10): 720–726. DOI:10.1097/NMD.0000000000001367.
Williamson V, Lamb D, Hotopf M, et al., 2023, Moral Injury and Psychological Wellbeing in UK Healthcare Staff. Journal of Mental Health, 32(5): 890–898. DOI:10.1080/09638237.2023.2182414.
Coimbra BM, Zylberstajn C, van Zuiden M, et al., 2024, Moral Injury and Mental Health Among Health-Care Workers During the COVID-19 Pandemic: Meta-Analysis. European Journal of Psychotraumatology, 15(1): 2299659. DOI:10.1080/20008066.2023.2299659.
Stovall M, Hansen L, van Ryn M, 2020, A Critical Review: Moral Injury in Nurses in the Aftermath of a Patient Safety Incident. Journal of Nursing Scholarship, 52(3): 320–328. DOI:10.1111/jnu.12551.
Dale LP, Cuffe SP, Sambuco N, et al., 2021, Morally Distressing Experiences, Moral Injury, and Burnout in Florida Healthcare Providers During the COVID-19 Pandemic. International Journal of Environmental Research and Public Health, 18(23): 12319. DOI:10.3390/ijerph182312319.
Whitehead PB, Haisch CE, Hankey MS, et al., 2024, Studying Moral Distress and Moral Injury Among Inpatient and Outpatient Healthcare Professionals During the COVID-19 Pandemic. The International Journal of Psychiatry in Medicine, 59(4): 469–486. DOI:10.1177/00912174231205660.
Hines SE, Chin KH, Glick DR, et al., 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. DOI:10.3390/ijerph18020488.
de Veer AJE, Francke AL, Struijs A, et al., 2013, Determinants of Moral Distress in Daily Nursing Practice: A Cross Sectional Correlational Questionnaire Survey. International Journal of Nursing Studies, 50(1): 100–108. DOI:10.1016/j.ijnurstu.2012.08.017.
Cerit B, Dinç L, 2013, Ethical Decision-Making and Professional Behaviour Among Nurses: A Correlational Study. Nursing Ethics, 20(2): 200–212. DOI:10.1177/0969733012455562.
Baysal E, Sari D, Erdem H, 2019, Ethical Decision-Making Levels of Oncology Nurses. Nursing Ethics, 26(7–8): 2204–2212. DOI:10.1177/0969733018803662.
Kamisli S, Yuce D, Karakilic B, et al., 2017, Cancer Patients and Oncology Nursing: Perspectives of Oncology Nurses in Turkey. Nigerian Journal of Clinical Practice, 20(9): 1065–1073.
Dudzinski DM, 2016, Navigating Moral Distress Using the Moral Distress Map. Journal of Medical Ethics, 42(5): 321–324. DOI:10.1136/medethics-2015-103156.
Henrich NJ, Dodek PM, Gladstone E, et al., 2017, Consequences of Moral Distress in the Intensive Care Unit: A Qualitative Study. American Journal of Critical Care, 26(4): e48–e57.
Drenkard K, Swartwout E, 2005, Effectiveness of a Clinical Ladder Program. JONA: The Journal of Nursing Administration, 35(11): 502–506.
Parker S, Dark F, Newman E, et al., 2016, Longitudinal Comparative Evaluation of the Equivalence of an Integrated Peer-Support and Clinical Staffing Model for Residential Mental Health Rehabilitation: A Mixed Methods Protocol Incorporating Multiple Stakeholder Perspectives. BMC Psychiatry, 16: 1–21.
Dennis CL, 2003, Peer Support Within a Health Care Context: A Concept Analysis. International Journal of Nursing Studies, 40(3): 321–332.
Xiao P, Xhu M, 2023, Effect of Solution-Focused Model Combined With Mindfulness-Based Stress Reduction Therapy on Resilience and Quality of Life of Nurses in Disinfection Supply Center. China Journal of Health Psychology, 31(6): 882–886. DOI:10.13342/j.cnki.cjhp.2023.06.017.
Chen S, Chang YL, Yang F, 2017, Research Progress of Treatment and Prevention of Moral Injury in Foreign Army. Medicine & Philosophy (A), 38(10): 34–38.
Motamed-Jahromi M, Fereidouni Z, Dehghan A, 2017, Effectiveness of Positive Thinking Training Program on Nurses’ Quality of Work Life Through Smartphone Applications. International Scholarly Research Notices, 2017(1): 4965816.