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Understanding Nurses Experiencing Moral Injury


What was frequently confused as burnout in previous years has recently been accurately identified as moral injury for nurses. Burnout, an occupational phenomenon (not a medical condition), results from chronic workplace stress, is characterized by feelings of exhaustion, increased mental distancing from one's work or cynicism about work, and reduced professional efficacy. Moral injury, however, has been described as a deep soul wound that occurs when a person feels they must take actions, or witness actions, that violate their deeply held moral beliefs. The term describes the challenges of simultaneously knowing what care patients need but being unable to provide it due to constraints beyond a caregiver's control. As nurses navigate the dynamic policies and procedures of healthcare in an already high-stress environment, correctly recognizing their challenges and struggles is often difficult, yet extremely important. While we've long understood the physical toll a 12-hour shift can have on nurses, understanding emotional impacts and their effects on the nursing workforce has been less appreciated.

How nurses experience moral injury

Nurses enter the healthcare industry with an internal yearning to care for others. Having an in-depth knowledge about patient care and being unable to ensure that patients receive quality care creates a moral conflict. You may feel a distressing disconnection between the values that led you into your profession in the first place and the compromises you must make from day to day. This is only exacerbated as financial and regulatory imperatives and inadequate care models shift focus away from the vital patient-clinician relationship. Feelings associated with moral injury might include:

  • Shame
  • Inadequacy
  • Distress
  • Self-blame
  • Withdrawal
  • Guilt
  • Anxiety
  • Anger
  • Remorse

Moral injury during COVID-19

Understanding the difference between burnout and moral injury is important, as using different terminology reframes the problem and the solutions. Burnout is a series of events often characterized by physical symptoms of emotional exhaustion and chronic stress, depersonalization, and reduced personal accomplishment. Burnout has been discussed in the healthcare industry for many years. However, moral injury differs significantly and is more aligned with the post-traumatic stress disorder symptoms (PTSD) observed in soldiers following battle. Moral injury became more prevalent in nurses during the COVID-19 pandemic where nurses experienced extreme conditions that compromised the quality of patient care. While moral injury is not a new issue in healthcare, the COVID-19 pandemic increased challenges for nurses. During the peaks of the pandemic, nurses were faced with many situations that could prompt feelings of moral injury, such as:

  • Increased personal protective equipment (PPE) created an alarming sense of fear in patients, when helping them to remain calm is of the utmost importance.
  • Heightened restrictions prevented nurses from comforting patients through physical touch such as hand holding or even wiping away tears or sweat.
  • Additional equipment such as fans and ventilators made it difficult for nurses to be heard as they tried to offer kind words of comfort to patients.
  • New protocols limited patients' visitors, leaving nurses to communicate at an increased amount with patients' families -- often delivering unfortunate updates on their status.
  • Shortage in equipment forced nurses in many situations to reuse PPE as a last resort, despite the increased risk of infection associated with doing so (to both themselves and to patients).
  • Overcrowded facilities have been faced with the heart wrenching decision to turn patients away based on the predicted survivability rate.

Effects of moral injury on nurses

Intense feelings of moral injury can contribute to the development of mental health challenges, and the accumulating effect of moral injuries over time can have long-lasting effects on one's sense of self. Common effects of moral injury on caregivers might include:

  • Negative changes in behavior (both significant and ongoing)
  • Loss of motivation
  • Weakened sense of empathy or compassion
  • Compulsive behavior
  • Changes in sleep
  • Isolation

Additionally, when nurses find themselves in situations where they feel they cannot live up to their own values, or where their teams are not meeting high standards of care, they can experience distrust of colleagues or of the leaders of their organization. As COVID-19 infection rates become more manageable in most parts of the country, nurses and nursing leaders know all too well what the calm before the storm can feel like. With the rise of new COVID-19 strains and novel viruses, such as the monkeypox virus, which was recently declared a public health emergency, it's fair for nurses to expect that efforts will be focused on preventing moral injury and prioritizing their mental health.

Preventing nurses experiencing moral injury

Nurses and nursing leaders can make a conscious effort to help promote understanding and change the conversation around moral injury as critical first steps to addressing this growing challenge. Nursing leaders can ensure their teams have education, resources, and support on how to recognize and address moral injury. Providing timely communication and giving recognition to their nurses can help their teams feel valued and respected. While medicine is referred to as a team sport, it rings especially true in today's nursing workforce. As nurses work to improve cross-functional communication and performance, an inherent sense of teamwork and solidarity is also created -- particularly helpful during times of crisis. For those experiencing moral injury, having support from those also on the front lines can make all the difference. As Johns Hopkins Medicine advises, it's absolutely essential that nurses have and use a support system. Especially for those on the front lines during a pandemic or public health crisis, support from team members also experiencing distressing factors can reduce feelings of isolation and despair.

Take these courses to learn more about stress management:

From Distress to Destress With Stress Management
(1.0 contact hour)
A stress response causes specific biological changes, such as increased heart rate, bronchodilation, horripilation (goose bumps), increased blood pressure, increased sweat production, decreased immune response, decreased insulin, and increased blood glucose. The volume of research in this area is growing rapidly, and it is safe to conclude that immune modulations caused by psychosocial stressors or interventions directly affect health outcomes. In 2013, the American Nurses Association launched its health risk appraisal; it was taken by more than 14,000 nurses and nursing students. Topping the list of health and safety hazards is stress, with 82% of respondents listing stress as the primary health hazard in the work environment. A high level of workplace stress has negative effects for both individual nurses and the organizations that employ them. This module provides information to help healthcare professionals manage stress for both themselves and their patients. COVID-19: Managing Staff Mental Health During a Pandemic
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This course provides objective analysis of data to address healthcare provider mental health needs related to the COVID-19 pandemic.