• To learn about the concept of moral injury and how it can be applied in the healthcare sector
• To enhance your knowledge of the manifestations and risk factors associated with moral injury
• To enable you to consider the strategies that could be implemented in your area of practice to mitigate and/or prevent moral injury
Moral injury may be experienced when a person perpetrates, witnesses or fails to prevent an act that conflicts with their moral values and beliefs. The concept of moral injury has its origins in the context of military personnel encountering ethically challenging decisions during armed conflict. The term has been applied to healthcare and moral injury is increasingly acknowledged to be a challenge for healthcare professionals. Nurses across all specialties and settings are frequently required to make or witness ethically challenging decisions about patient care. The coronavirus disease 2019 (COVID-19) pandemic has increased nurses’ risk of sustaining moral injury. This article discusses the manifestations of moral injury and its associated risk factors, including the effects of the COVID-19 pandemic. It also outlines various strategies that can be used to mitigate and/or prevent moral injury in nurses.
Nursing Standard. doi: 10.7748/ns.2021.e11703Peer review
This article has been subject to external double-blind peer review and checked for plagiarism using automated software
Rowlands SL (2021) Understanding and mitigating moral injury in nurses. Nursing Standard. doi: 10.7748/ns.2021.e11703
Published online: 22 July 2021
Moral distress may occur when a person is aware of the ethical action to take in a situation but feels prevented from taking that action, either because of external constraints such as limited resources, or because of internal issues such as self-doubt, fear of conflict or lack of confidence (Moss et al 2016, Rushton et al 2017). A morally distressing event can become a potentially morally injurious event and may eventually cause moral injury, although there is no official threshold or criteria for determining when an event can be classified as a moral injury (Jones 2020). Moral injury can result from a single morally distressing event (Hossain and Clatty 2020) or an accumulation of morally distressing events (Stovall et al 2020).
The term ‘moral injury’ was coined in the 1990s by Jonathan Shay to describe the moral suffering potentially experienced by military personnel when encountering ethically challenging decisions, such as leaving behind a wounded comrade or shooting a sniper who is using a civilian as a human shield (Shay 2014). Moral injury may be experienced when a person perpetrates, witnesses or fails to prevent an act that conflicts with their moral values and beliefs (Larsson et al 2018, Dean et al 2019). According to Shay (2014), moral injury is within an individual’s control to some extent, but only if they receive expert leadership that is supportive and ethical.
In the past few years, the term ‘moral injury’ has been applied to the healthcare sector (Pattison et al 2019), implying that healthcare staff are susceptible to moral dilemmas that are similar to those that might be experienced by military personnel. It is interesting that the language used to describe the provision of direct patient care often mirrors that used to describe a war zone, with terms such as ‘trenches’ and ‘the front line’ (Stovall et al 2020).
Healthcare staff are likely to be regularly exposed to morally distressing events, such as a patient death that may have been preventable. Nurses across all specialties and settings are frequently required to make ethically challenging decisions about patient care; for example, prioritising certain aspects of care over others where there are staff shortages, or implementing invasive treatments for a patient at the end of life in the absence of an advance care plan or support from relatives in decision-making (Rushton et al 2017). Moral injury is a consequence of the moral dilemmas that continually arise in healthcare. Healthcare staff may feel, for example, that delivering the most appropriate care to a patient is compromised because the systems that are in place are inadequate (Ford 2019). However, while moral dilemmas are unavoidable in healthcare, moral injury can be mitigated or possibly prevented. Box 1 provides a summary of the terms moral distress, potentially morally injurious event and moral injury.
• Moral distress – this may occur when a person is aware of the ethical action to take in a situation but feels prevented from taking that action, because of external constraints or internal issues
• Potentially morally injurious event – this is a morally distressing event that may lead to moral injury. The risk of a morally distressing event becoming a potentially morally injurious event, and of a potentially morally injurious event causing moral injury, is exacerbated by factors such as a rapidly changing environment, high pressure environments where decisions, for example, can be the difference between life and death, and limited resources
• Moral injury – this may be experienced when a person perpetrates, witnesses or fails to prevent an act that conflicts with their moral values and beliefs. It can result from a single morally distressing event or an accumulation of morally distressing events
There is a lack of understanding regarding moral injury in healthcare professionals (Mantri et al 2020). Some researchers believe that what is labelled as ‘burnout’ in healthcare professionals may in fact be moral injury (Ford 2019, Kopacz et al 2019). In one survey, only 1% of NHS trust leaders in England reported that they were not concerned at all about the level of burnout in the workforce (NHS Providers 2020). However, it may be that moral injury, rather than burnout, is the underlying issue. Dean et al (2019) asserted that this difference in terminology is important, since burnout ‘suggests that the issue resides within the individual, who is in some way deficient’, while moral injury ‘describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control’.
This article discusses the manifestations of moral injury in nurses, its associated risk factors, the effects of the coronavirus disease 2019 (COVID-19) pandemic on nurses’ risk of moral injury, and the strategies that healthcare organisations, nurse managers and nurses can use to mitigate and/or prevent its occurrence.
• Moral injury may be experienced when a person perpetrates, witnesses or fails to prevent an act that conflicts with their moral values and beliefs
• Some researchers believe that what is labelled as ‘burnout’ in healthcare professionals may often be moral injury
• Feelings that may arise in a person when they sustain moral injury include shame, guilt, self-blame and disgust
• Whether an individual sustains moral injury is likely to be influenced by the support they receive before, during and after a morally distressing event or potentially morally injurious event
Feelings that may arise in a person when they sustain moral injury include shame, guilt, self-blame and disgust (Greenberg et al 2020, Hossain and Clatty 2020, Lesley 2020, Stovall et al 2020). While moral injury is not in itself a mental health issue (Greenberg et al 2020), it has been suggested that it places the person at risk of developing burnout, post-traumatic stress disorder (PTSD), anxiety and depression (Stovall et al 2020).
The most immediate risk of moral injury is that nurses cease to verbalise the dilemmas they are experiencing and disengage from discussions about ethically challenging decisions or actions in practice because they feel powerless to reconcile the moral conflict. This feeling of powerlessness can result in an inability to fulfil their professional duties, leading to compromised patient care and suboptimal patient outcomes (Welborn 2019). People who have sustained moral injury may also experience an altered sense of self and a loss of trust (Lesley 2020, Stovall et al 2020).
Secondary manifestations of moral injury include depression and anxiety, PTSD, feelings of inferiority, anger, self-harming behaviours, social issues and a change in world view or profession (Williamson et al 2018, Lesley 2020, Stovall et al 2020). Moral injury can lead to compassion fatigue (Alharbi et al 2020), causing anger, apathy and a reduced attention span (Ledoux 2015), which can be detrimental to patient care and to the emotional well-being of the nurse (Dasan et al 2015, Pattison et al 2019, Hofmeyer and Taylor 2020). Moral injury can also lead to emotional distance and avoidance (Larsson et al 2018).
These various manifestations of moral injury increase the risk of nurses taking prolonged absences from work or leaving the profession, which in turn potentially compounds the ongoing crisis in nurse recruitment and retention in the NHS (The King’s Fund 2020a).
There are various factors that increase the likelihood of morally distressing events becoming potentially morally injurious events and potentially morally injurious events causing moral injury. Risk factors for moral injury include working in a rapidly changing environment where patient safety and lives are at risk and resources are limited (Taifoori and Valiee 2015, Mantri et al 2020). Feeling inadequately prepared for the moral challenges that one encounters can cause or contribute to moral injury (Lesley 2020).
Insufficient staffing levels have been identified as a factor that can contribute to moral injury (Taifoori and Valiee 2015, Pattison et al 2019, Stovall et al 2020). In England, the nursing vacancy rate in the NHS was 9.7% in December 2020 (NHS Digital 2021). If these vacancies remain unfilled, nurses will become increasingly vulnerable to moral injury.
Nurses understand that patient safety often relies on their care and professionalism, so many strive to achieve perfection in their practice, but this may not be possible within the constraints of the healthcare system and striving to achieve unrealistic standards of care can contribute to moral injury (Stovall et al 2020). Another risk factor for moral injury in nurses may be the length of time they have been working in the profession. One UK study found that there appears to be an association between the length of time healthcare professionals have been qualified and their levels of emotional exhaustion, with emotional exhaustion increasing with time, which is itself associated with moral injury (Pattison et al 2019). No one is immune to moral injury, but according to Lesley (2020), individuals with well-developed ego functions may be less prone to it, possibly because they tend not to question themselves too harshly and are better able to maintain their self-esteem than those with less developed ego functions.
The COVID-19 pandemic has exacerbated the factors that can lead to moral injury and put nurses at increased risk of sustaining it. During the pandemic, moral dilemmas have become increasingly frequent and acute, with nurses having to make decisions that conflict with best practice standards and can be morally questionable (Lesley 2020). For example, during the first wave of the pandemic in 2020, a significant increase in the number of patients requiring hospital care forced healthcare professionals to make challenging decisions about the allocation of resources to maximise the benefits of treatment across the population, since demand exceeded supply (Alharbi et al 2020, Greenberg et al 2020, White and Lo 2020). Examples of this included in some cases having to withhold mechanical ventilation from patients who would have received it under normal circumstances or removing ventilatory support sooner than normal. Making or witnessing such decisions and actions has the potential to cause moral injury.
During the first wave of the pandemic, treatment was based largely on ‘trial and error’ because healthcare professionals were caring for a large number of patients with a new condition. A shortage of critical care beds meant that patients who would normally have been transferred to a critical care unit were cared for on general hospital wards. Additionally, in some cases nurses had to resort to using defective and/or obsolete equipment, while many nurses were redeployed to critical care settings with minimal preparation or training (Lesley 2020). Such circumstances and the decisions involved in them have the potential to cause moral injury.
The COVID-19 pandemic has also increased the risks incurred by healthcare professionals at work and has therefore generated a fear of the potential consequences of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) for themselves and their families, thereby negatively affecting their psychological well-being (de Wit et al 2020). During times of crisis, healthcare professionals often feel a sense of duty and a strong desire to remain at work despite the threats to their personal safety (Markwell et al 2020), but they need to feel able to reconcile their duty to care for patients with their desire to protect their families (Greenberg et al 2020, Hossain 2020). If this is not the case, there is a risk of moral injury (Greenberg et al 2020).
In the first few weeks and months of the pandemic, there was an international shortage of personal protective equipment (PPE) (Burki 2020, World Health Organization 2020). At times, this placed healthcare professionals in an untenable position: continue to care for their patients and expose themselves to the risk of infection or protect themselves and their families by ceasing to care for patients (Hossain 2020).
While it is generally accepted that nurses have a duty to care for patients with an infectious disease, this duty is not absolute, since nurses equally have a duty to protect themselves (Solano et al 2015). To protect themselves from infection with SARS-CoV-2, nurses are required to wear appropriate PPE when entering the room of a patient with diagnosed or suspected COVID-19, even if that patient requires emergency resuscitation (Public Health England 2021). This requirement can cause a delay in providing resuscitation that can subsequently reduce the likelihood of the intervention being successful. However, failure to comply with this requirement puts nurses’ health at risk, along with the health of their families, other patients and colleagues (Lesley 2020). Furthermore, nurses may fear losing the approval of colleagues if they refuse to care for a patient, even if their refusal is justified (Lesley 2020). Such moral dilemmas, fears and feelings of shame or guilt are further potential sources of moral injury.
Whether an individual sustains moral injury is likely to be influenced by the support they receive before, during and after a morally distressing event or potentially morally injurious event (Greenberg et al 2020). Therefore, understanding how moral integrity can be maintained can assist in protecting the well-being of staff working in high-stress environments (Moss et al 2016). Nurses, nurse managers and healthcare organisations can implement various strategies to mitigate moral injury (Hofmeyer and Taylor 2020).
Given that feeling inadequately prepared for the moral challenges encountered in practice is a risk factor for moral injury (Lesley 2020), nurse managers can mitigate moral injury by honestly and openly preparing their staff for the moral dilemmas they are likely to encounter. It is important that they avoid offering false reassurance, since this can fuel feelings of anger in the future (Greenberg et al 2020, The King’s Fund 2020b). Nurse educators also have a role in this preparation, since they can support nursing students to understand the moral dilemmas that they are likely to encounter in practice.
Healthcare professionals need to feel supported to make ethically challenging decisions about patient care – such as decisions to not treat a patient or to not escalate treatment to increasingly invasive options – through clear and rigorous policies and guidance from their organisations (Solano et al 2015). They should also be empowered to advocate for themselves and for their patients (Dzau et al 2020) and to report any concerns they may have about unethical care without fear of reprisal.
Nurses should be given the opportunity to discuss, in a safe environment, the challenges they experience in clinical practice (Dzau et al 2020, Greenberg et al 2020, The King’s Fund 2020b). One method adopted by many UK healthcare organisations to enable staff to discuss challenging experiences is to implement Schwartz Center Rounds (Robert et al 2017), which provide a structured forum where healthcare staff can discuss the emotional aspects of their work. They have been shown to support staff to recognise the usefulness of expressing their emotions and help them feel valued (Smith et al 2020). Schwartz Center Rounds should be facilitated by an experienced person, such as a team leader, and can be conducted remotely if necessary (Greenberg et al 2020). Clinical supervision, which encourages the healthcare professional to reflect on their practice, has a role in making nurses feel supported and better able to manage the challenges they experience (Davenport 2013).
One way in which nurses may respond to moral injury is by developing emotional distance from the distressing event they have experienced. While accepting events rather than dwelling on them excessively can be a useful coping mechanism, it is important that this emotional distance does not become avoidance (Larsson et al 2018). Nurses who develop avoidant behaviours – for example, not talking about their feelings of shame and guilt – need to be identified and supported (Greenberg et al 2020), as should any staff member who may be particularly vulnerable to moral injury (The King’s Fund 2020b).
Being able to identify the manifestations of moral injury can support nurse managers to prevent potentially morally injurious events from causing moral injury (Stovall et al 2020). Even the most experienced or seemingly resilient team members may sustain moral injury and require support. Routine support processes, such as clinical supervision and appraisals, should include information on moral injury (Greenberg et al 2020). Managers themselves also need to be monitored for signs of emotional distress, with senior managers monitoring junior managers (Greenberg et al 2020).
Resilience is the ability to ‘recover or healthfully adapt to challenges, stress, adversity or trauma’ (Rushton 2016), while moral resilience is having the confidence to address a morally distressing situation guided by one’s beliefs (Hossain and Clatty 2020). Pattison et al (2019) asserted that since healthcare professionals increasingly care for patients with complex health needs, they require greater access to support, particularly resilience training.
Developing moral resilience can enable nurses to maintain a sense of perspective and accept that some circumstances are outside of their control, supporting them to respond to moral dilemmas in a healthy and constructive manner (Hossain and Clatty 2020). However, some authors have suggested that focusing on resilience places the onus of responsibility onto nurses themselves, by making them responsible for how they cope with moral injury rather than holding healthcare organisations accountable for the circumstances that have given rise to it (Traynor 2018). Furthermore, it is unclear whether resilience training actually results in higher levels of resilience (Kunzler et al 2020).
Pattison et al (2019) found that healthcare professionals consider it important to manage their emotional well-being and want to be supported to do so through strategies such as mindfulness, meditation or massage. Mindfulness interventions aim to foster greater attention to and awareness of the present moment, and can support people to release strong negative emotions, thus reducing feelings of stress, anxiety, fear and helplessness (Rushton 2016, Hossain and Clatty 2020). Self-care has also been suggested as a strategy for nurses to avoid or mitigate moral injury (Hofmeyer and Taylor 2020, Hossain and Clatty 2020). Self-care may include self-awareness, self-compassion, debriefing with colleagues, accepting support from family and friends, and seeking professional health from a therapist, for example. Dean et al (2019) emphasised that healthcare organisations must make the well-being of their staff a priority and allocate sufficient resources to this.
In the context of the COVID-19 pandemic, it is likely that at least some healthcare professionals, including nurses, will experience harmful long-term effects of moral challenges on their emotional well-being (Greenberg et al 2020). Dzau et al (2020) suggested that there should be a national programme to measure the well-being of healthcare professionals and monitor the outcomes of interventions. They called for previous well-being programmes to be sustained and supplemented throughout the pandemic, and for national funding to be made available for healthcare professionals who experience adverse mental health effects from the pandemic. Box 2 summarises the strategies that can be used to mitigate or prevent moral injury in nurses.
Strategies for healthcare organisations
• Make the mental and moral well-being of staff a priority, including in terms of funding
• Provide nurses with a safe forum to discuss emotional challenges, such as Schwartz Center Rounds and clinical supervision
• Provide nurses with resilience training
Strategies for nurse managers
• Be familiar with the manifestations of moral injury to be able to identify them and support team members
• Honestly and openly prepare nurses for the moral challenges they are likely to encounter and avoid offering false reassurance
• Offer access to interventions for improving the mental health and well-being of nurses such as mindfulness, meditation or massage
• Ensure nurses feel able to advocate for themselves and their patients without fear of reprisal
Strategies for nurses
• Make self-care a priority
• Use the support mechanisms that are available in their healthcare organisation, such as Schwartz Center Rounds, resilience training and mindfulness
(Davenport 2013, Rushton 2016, Robert et al 2017, Dean et al 2019, Pattison et al 2019, Dzau et al 2020, Greenberg et al 2020, Hofmeyer and Taylor 2020, Hossain and Clatty 2020, The King’s Fund 2020a)
Nurses are inevitably exposed to moral dilemmas in their practice, and the COVID-19 pandemic has increased the risk of them experiencing moral injury. Moral injury can have various adverse effects on nurses and consequently on the quality of patient care they provide. It may also compound the nurse recruitment and retention crisis in the NHS. Therefore, it is crucial to mitigate, and attempt to prevent, moral injury in nurses. Healthcare organisations and nurse managers have a central role in this by demonstrating empathy and honesty, encouraging their staff to talk about the challenges they encounter, promoting self-care, and ensuring that their staff feel supported in making challenging decisions. It is also crucial that supporting the emotional well-being of nurses is made a priority and it is appropriately resourced.
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