Moral Injury in Critical Care


Published: 03 May 2023

What is Moral Injury?

Moral injury is the severe psychological distress that occurs when a person performs actions that violate their moral or ethical code (or fail to take actions in a way that violates their moral or ethical code) (Williamson et al. 2020).

It’s a term that originated from the psychological, social and spiritual distress experienced by military personnel who were involved in events that betrayed their moral code while on depoloyment (Open Arms 2019).

More recently, however, the concept of moral injury in a healthcare context has started to be explored, especially in light of the COVID-19 pandemic (Sutherland 2022).

For healthcare teams working in overstretched critical care environments, potentially morally injurious events (PMIEs) can lead to negative thoughts as well as deep feelings of shame or guilt, which can, in turn, lead to more serious mental health problems.

While moral injury is not classified as a mental illness, it may be associated with post-traumatic stress disorder (PTSD) or depression (Open Arms 2019).

Symptoms of Moral Injury

A person experiencing moral injury might feel:

  • Guilty
  • Ashamed
  • Sad
  • Angry
  • Anxious
  • Disgusted
  • Bad
  • Damaged
  • Unworthy.

(Open Arms 2019; Norman & Maguen 2021)

They might also:

  • Feel they’ve lost faith in others or humanity
  • Avoid intimacy
  • Question their religious faith
  • Engage in self-sabotaging behaviours due to being unable to forigve themselves (e.g. sabotaging relationships because they don’t feel like they deserve them).

(Open Arms 2019; Norman & Maguen 2021)

Moral Injury in ICU Settings

Ideally, in critical care settings, an independent triage officer or team should make decisions about allocating or discontinuing the resources needed for life support (White & Lo 2020).

The belief is that by separating the triage role from the clinical role, objectivity can be maintained, conflicts of commitment can be avoided and moral distress of the clinical team providing care can be minimised.

However, when independent triage isn’t available and demand frequently outstrips the supply of essential resources, feelings of frustration and anger over having to deny or ration care can build up over time, leaving the practitioner with a legacy of negative feelings that can be difficult to process.

Under the surface, however, and more difficult to identify, are the feelings that can threaten the very foundation of moral integrity.

moral injury icu
'Coronavirus patients at the Imam Khomeini Hospital in Tehran, Iran' by Fars News Agency is licensed under CC BY 4.0

Potential Risk Factors for Moral Injury

Epstein and Delgado (2010) theorise that moral distress often occurs when the healthcare worker knows what is best for the patient, but that course of action conflicts with what is best for the organisation, other providers, other patients or society as a whole. For example, when there is:

  • Inadequate communication about end of life care between providers, patients and families
  • Inappropriate use of healthcare resources
  • Inadequate staffing, or staff who are not adequately trained to provide the required care.

Williamson et al. (2020) suggest that moral injury is more likely if staff feel unaware or unprepared for the emotional and psychological consequences of decisions, or if the PMIE occurs concurrently with exposure to other traumatic events.

Langley et al. (2015) suggest that sources of moral distress and injury occur within five broad categories of experience:

  1. Collegial incompetence or inexperience
  2. Resource constraints
  3. End-of-life issues
  4. Lack of consultation, communication and negotiation
  5. Lack of support.

Psychological Preparedness

Despite enormous efforts to ensure adequate staffing and resources during the COVID-19 pandemic, many healthcare practitioners likely encountered situations where they could not say to a grieving relative, ‘We did all we could’, but rather, ‘We did our best with the resources available, but it wasn’t enough’, and as (Greenberg et. al 2020) suggest, that is the seed of a moral injury.

Of course, not everyone will be affected to the same degree, but no one is invulnerable either, which raises the question of psychological preparedness. Williamson et al. (2020) suggest that front-line staff should be made aware of the possibility of PMIEs and the emotions, thoughts and behaviours that might be experienced as a result.

Discussing this topic in advance or taking a ‘nip it in the bud’ approach can help develop psychological preparedness and allow staff to understand some inevitable symptoms of distress. It also facilitates social support, which is known to be generally protective for mental health.

Williamson et al. (2020) also note that psychological screening approaches tend to be ineffective. Instead, they suggest it is imperative for employers to actively monitor staff exposed to PMIEs, facilitate effective team cohesion and make informal, as well as professional, sources of support readily available to their staff.

moral injury patient holding hands

Moral Residue

A concept similar to that of moral injury is moral residue. It’s a state of mind that arises from times when we have seriously compromised ourselves or allowed ourselves to be compromised by external events (Epstein & Delgado 2020).

In other words, moral wounding can easily occur when a person has to act against their values, often due to constraints beyond their control. The result is a long-lasting ‘moral residue’ that can be damaging to mental health, especially if morally distressing episodes are repeated over time.

Ethical conflicts have always occurred in critical care nursing and have long been associated with burnout and job dissatisfaction. Yet, today, perhaps more than ever, new questions about how to preserve good mental health will need to be asked.

Do nurses need to show more compassion, not just to their patients but also to each other? Furthermore, what more can team leaders or managers do to ensure the necessary level of mental preparedness to work in such challenging intensive care environments?

One answer could be to encourage practitioners to embrace nurturing practices such as meditation and other stress-relieving activities, whilst also acknowledging that self-care means something different to each person (Burger 2020).


There used to be a saying years ago: ‘If you can’t stand the heat, get out of the kitchen.’ Luckily, we have come a long way in our understanding of mental wellbeing since then. Perhaps, as Burger (2020) proposes, the term moral injury may well be on course to replace the much favoured term of ‘burnout’. Others go further by suggesting that moral injury is itself the root-cause of burnout and PTSD. Either way, this is a discussion that is only just beginning.

moral injury meditation


Test Your Knowledge

Question 1 of 2

True or false: Psychological screening approaches for staff are effective.


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Anne Watkins View profile
Anne is a freelance lecturer and medical writer at Mind Body Ink. She is a former midwife and nurse teacher with over 25 years’ experience working in the fields of healthcare, stress management and medical hypnosis. Her background includes working as a hospital midwife, Critical Care nurse, lecturer in Neonatal Intensive Care, and as a Clinical Nurse Specialist for a company making life support equipment. Anne has also studied many forms of complementary medicine and has extensive experience in the field of clinical hypnosis. She has a special interest in integrating complementary medicine into conventional healthcare settings and is currently an Associate Tutor, lecturing in Health Coaching and Medical Hypnosis at Exeter University in the UK. As a former Midwife, Anne has a natural passion for writing about fertility, pregnancy, birthing and baby care. Her recent publications include The Health Factor, Coach Yourself To Better Health and Positive Thinking For Kids. You can read more about her work at