Moral injury in healthcare

The American Association of Critical-Care Nurses describes moral distress as being unable to do the right thing because of limits in the institution. It often happens in the moment, like when there are not enough staff or beds.

A 2024 review of healthcare workers describes moral injury as long-term emotional and psychological pain with inner conflict, which can follow repeated or serious moral distress.

Moral injury is often triggered by leadership or system failures, so healing needs the organization to take responsibility and make repairs, not just the individual.

Burnout builds up over time when the demands of work clash with your values and the pressure of the system. Like moral injury, it cannot be solved by personal coping alone.

Having to decide who gets care first, or seeing a patient wait too long, can go against everything you were trained to do.

It might sound like

• “I had to choose, and someone lost out.”
• “We had the knowledge, just not the people.”

Patients’ care options and responsibility for advocating for patients and families were among the most common triggers in the 2024 review. Many staff describe distress at continuing treatment that seems to cause more suffering than good, or at sending patients home before they feel ready.

Hierarchy was one of the organizational triggers named in the 2024 review. Speaking up and being overruled, or not feeling safe to speak up at all, can leave a lasting mark.

Regulations and organizational values that clash with your own were linked to harm to staff wellbeing and retention in the 2024 review.

Moral injury can involve feeling betrayed by leaders or systems, not only by your own actions. It can also come from witnessing something wrong that you could not stop.

The VA names believing a patient’s death could have been prevented as one healthcare example of moral injury.

In a global survey of health professionals, being a nurse predicted higher moral injury scores.

A 2025 review found that moral injury in nurses was linked to more anxiety and depression and lower quality of life.

Younger age predicted higher moral injury in the global survey.

In a 2022 study of over 1,000 women physician trainees across 26 institutions, about 76% of those who completed the measure had moral injury. It was strongly linked to burnout, feeling like an impostor and low self-compassion.

Staff who cared directly for COVID-19 patients had higher odds of having their daily life affected by moral injury.

Doctors often feel caught between what patients need and what systems allow. See “Doctors’ mental health” for more.

Leaders may have to carry out decisions they disagree with, then face their teams. They can experience moral injury too, and are also key to preventing it for others.

• “I am not the nurse I thought I was.”
• “I can’t trust the people in charge anymore.”
• “I should have fought harder for that patient.”
• “What is the point if I can’t do this right?”

Moral injury and PTSD can both start with a hard event and both involve guilt, shame and loss of trust. Feeling constantly on high alert is more typical of PTSD. When both happen together, symptoms may be more severe.

1. Write down what happened, in plain words.
2. Name the value it went against, like fairness, honesty or protecting patients.
3. Sort what was in your control from what came from the system.
4. Notice what you would say to a colleague in the same place.

In women physician trainees, moral injury was strongly linked to low self-compassion. Learning to treat yourself with the same kindness you give others is an important part of healing.

AACN encourages leaning on coworkers, friends and family, and telling them when you are struggling. A trusted mentor can also help.

Ideas

• Join a committee working on the problem that hurt you
• Mentor a new colleague
• Push for change with others who share your concern
• Spend time on the parts of care that still feel meaningful

The VA notes that trauma-focused therapies still work when moral injury is present, and newer therapies focused on moral injury are being studied. A mental health provider or chaplain can help assess what you are facing.

You might call them when

• A patient’s wishes are unclear or being overridden
• Care seems to be causing more suffering than benefit
• Resources are being shared in a way that feels unfair
• The team strongly disagrees about what is right

AACN encourages nurses to raise concerns about how resources are shared, and to ask for open, transparent decisions.

Tips

• Bring a concrete example and a suggested change
• Focus on patient impact
• Go with colleagues who share your concern
• Use formal channels, and keep your own notes

AACN encourages nurses to notice when their inner voice conflicts with what they are asked to do. Paying attention early can help you act before distress deepens.

In a study of healthcare providers in Florida during the pandemic, leadership support was linked to both moral injury and burnout. The authors urged leaders to recognize how much their support matters.

The 2024 review found that rapid, top-down policy changes were a key trigger. It urged decision makers to be mindful of the impact on staff.

Better ways to make changes

• Admit when a decision is hard
• Ask frontline staff before deciding where possible
• Explain the reasons openly
• Follow up on how it is affecting people

Schwartz Rounds give clinical and non-clinical staff regular time to talk about the emotional side of their work. More than 700 healthcare organizations worldwide run them.

A study of how Rounds work found they offer a safe space to tell stories, show vulnerability and reflect, which can help staff reconnect with their values.

Try this

1. Notice and name it gently: “That case seemed to stay with you.”
2. Listen without judging or rushing to reassure.
3. Say what you see: “You cared about doing right by that patient.”
4. Share where support is, like an ethics consult or peer program.
5. Check in again later.

Try to avoid

• “It wasn’t your fault, just move on.”
• “That’s just how it is here.”
• “You need to toughen up.”

Ideas that help

• Ask if they want to talk, or just want company
• Gently encourage support if it lasts for weeks
• Notice if they are pulling away from people or things they love
• Remind them of who they are outside of work

Ideas

• Faith communities or chaplains who can talk about meaning and forgiveness
• Peer groups where staff can speak openly
• Professional associations that push for safer conditions
• Remembrance events for patients who died