Healthcare is both heartwarming and heartbreaking – something every nurse expects when entering the profession. However, when heartbreaking moments conflict with your moral, ethical, or spiritual beliefs, the emotional toll can be profound. Repeated exposure to ethically distressing situations can lead to moral injury, a deep emotional and psychological strain that affects both personal wellbeing and professional performance.
Unlike burnout, which stems from exhaustion, moral injury arises from feeling powerless or complicit in actions that contradict one’s values. Though not a diagnosable condition, its impact can be severe. This guide explores moral injury in nursing, its signs and consequences, and strategies for prevention and recovery.
What is Moral Injury?
Moral injury occurs when nurses witness, perform, or are complicit in actions that conflict with their core values. In healthcare, this often involves situations where patient care is compromised due to systemic constraints, workplace policies, or leadership failures. The distress can also stem from concerns about potential harm to oneself or loved ones, such as exposure to contagious diseases.
When experiencing moral injury, nurses may struggle to reconcile their actions – or inaction – with their ethical beliefs, leading to longterm emotional distress.
Signs and Symptoms of Moral Injury
Moral injury can manifest in emotional, behavioral, and psychological ways. While it shares some symptoms with post-traumatic stress disorder (PTSD), it is distinct in that it is primarily rooted in guilt and shame rather than fear.
As The Moral Injury Project puts it, “Moral injury can take the life of those suffering from it, both metaphorically and literally. Moral injury debilitates people, preventing them from living full and healthy lives.”
Behavioral Signs
- Withdrawing from social interactions and loved ones.
- Engaging in reckless behavior or substance abuse.
- Avoiding reminders of distressing events.
Emotional Signs
- Persistent guilt, shame, or self-loathing.
- Emotional numbness, making compassionate care feel difficult.
- Feelings of helplessness or depression.
Psychological Signs
- Recurrent thoughts about distressing experiences.
- Loss of trust in leadership, coleagues, or the healthcare system.
- Increased risk of suicidal ideation.
Impact on Nurses and the Healthcare System
Healthcare workers, and nurses especially, are susceptible to experiencing moral injury. This can become even more true during times of high stress, like natural disasters, pandemics, or critical incidents, which can be full of split-second decisions and a feeling that you can’t possibly help everyone around you. When a nurse is experiencing moral injury, everyone around them may be affected by the resulting symptoms.
Effects on Personal Well-Being
Nurses may struggle to reconcile their desire to help their patients and being restricted in what they can offer. If this difficulty turns into moral injury, they may experience symptoms hindering their ability to continue a routine or maintain a high quality of life. The depression it causes may allow things like laundry, hygiene, nutrition, and even socializing to fall by the wayside.
Professional Consequences
Job dissatisfaction skyrockets when nurses are experiencing moral injury, burnout, or compassion fatigue. When someone isn’t happy in their workplace, they may become less effective, and their employers could notice and issue consequences. Consequences can also be self-imposed. Some nurses take drastic approaches, like leaving the profession altogether. Others may seek calmer settings with fewer reminders of the morally injurious events, like an outpatient primary care office rather than higher-stakes inpatient or hospital units.
Broader Implications for the Healthcare System
Nurses have been raising the alarm that moral injury – even if they don’t use that exact phrase – is a significant cause of the nursing shortage. The US Chamber of Congress compiled the results of several studies that back this up.
For instance, according to a study of over 50,000 nurses:
- 56.4% reported feeling depleted multiple times a week.
- 50.8% experienced emotional exhaustion.
- 45.1%: reported burnout
When nurses leave the profession, workloads increase, patient care suffers, and healthcare institutions struggle to maintain quality services.
Strategies for Addressing and Preventing Moral Injury
While it may be impossible to prevent all situations that could lead to moral injury, you and those around you can take steps to prevent or recover from moral injury.
1. Prioritize Mental Health Care
Mental health care plays a significant role in handling moral injury. You can take care of your mental health by having a strong, ongoing relationship with a mental health provider. However, that’s not the only way. If you have access to on-demand support – an increasingly common workplace benefit – consider using that in the more challenging times. You can also find a workplace buddy with whom you can check in regularly and ensure you’re both doing okay.
2. Strengthen Personal and Professional Relationships
Your friends, family, and community are crucial resources to maintain connection. With the Surgeon General’s advisory on loneliness and isolation, we can’t ignore the effects of disconnection and the value of relationships.
It may not always be easy to communicate with those around you – after all, moral injury can result in self-isolation and difficulty enjoying things. However, you don’t need to spend all day, every day, with people to foster those connections. You can make small decisions that can help build and maintain your relationships.
For instance, take some time away from social media, as those platforms can make people feel more disconnected. Avoiding distractions (e.g., your phone) when talking to someone in person can also make a huge difference. Doing something nice for someone else can boost your mood and improve that relationship.
3. Advocate for Change
Unless you’re in a leadership role, you may feel powerless to change things – and some experts think changes to moral injury rates start at the top.
Learn about how to advocate for yourself strategically in the workplace. A big part of this is being fully aware of what you want to change and thinking of a few solutions before bringing it up to those with authority. Finding allies – both at your level and above – makes a difference, so take some time to get to know those around you and figure out how they feel about different issues.
You may experience pushback, so having alternate people to speak with can be wise.
4. Practice Self Care
Self-care doesn’t look the same for everyone, so figure out what works for you. What brings you joy outside of work? Keep a list of small, medium, and large self-care activities you can turn to when feeling overwhelmed – whether it’s reading a book, taking a short walk, or planning a weekend getaway.
You and your wellbeing will always be more important than anything else, so take your personal days and sick leave when needed. Your team may have to cover for you, and when you are in a better place, you will return the favor in kind.
5. Recognize When It’s Time to Move On
Do you feel you get the support you need? Is the organization making positive steps toward caring for their nursing staff or rectifying the issues that caused your moral injury? Are the people who you observed making bad decisions continuing to do so?
If your workplace consistently contributes to moral injury and leadership fails to address concerns, consider seeking a new role within nursing that aligns better with your values.
