Exploration of Nurses' Experiences Related to Moral Injury: A Reflexive Thematic Analysis of Nurse Interviews

ABSTRACT

Aim

To provide a description of nurses' experiences related to moral injury, including Potentially Morally Injurious Events and factors related to the impact of those events.

Design

Reflexive thematic analysis of nurse interviews.

Method

Nurses were recruited from an ongoing study within a large academic medical centre. Nurses who enrolled in the present study participated in semi‐structured individual interviews using an interview guide based on Litz's conceptualisation of moral injury. Themes were identified in the recorded and transcribed interviews.

Results

Interviews were conducted with 12 nurses in May and June 2023 and coded for themes within three broad categories: (a) Nursing Values, (b) Experiences of Potentially Morally Injurious Events and (c) Stressors and Supports. Within these categories, we pinpointed 8 themes and 3 subthemes, which highlight the nurses experience of potentially morally injurious events related to challenging care, strained relationships with physicians, and treatment inequity, which conflict with their nursing values. We identified team and organisational factors, including senior leadership behaviours, team dynamics and access to resources that appear to intensify or lessen the impact of these events.

Conclusion

Potentially Morally Injurious Events contribute to the occupational stress experienced by nurses, particularly when systemic organisational factors and demands prevent them from providing the value‐driven and ethically necessary healthcare. Limiting Potentially Morally Injurious Events and providing supportive environments following stressors requires organisational‐level changes within healthcare environments to prevent and alleviate nurses' occupational stress.

Impact

This research highlights the need for healthcare organisations to implement systemic interventions aimed both at reducing Potentially Morally Injurious Events and creating system and team‐level supports to lessen the impact of unavoidable events. These results pinpoint specific areas for prevention, intervention and support.

Patient or Public Contribution

No Patient or Public Contribution.

Summary.

• What is already known

  • ○
    Occupational hazards in health care, such as stress and burnout, have been linked to poor outcomes for healthcare professionals, patients and healthcare systems.
  • ○
    Moral injury is emerging as a significant hazard that is associated with burnout, decreased well‐being and impairment in healthcare professionals.
  • ○
    There is a need to develop frameworks for understanding moral injury in healthcare settings.
• What this paper adds

  • ○
    Nurses report exposure to potentially morally injurious events related to (1) involvement in challenging patient care, (2) nurse–doctor ruptures and (3) inequity in access to care.
  • ○
    These potentially morally injurious events can occur at a patient, team/interpersonal level and system level.
  • ○
    Following exposure to potentially morally injurious events, supportive structures may prevent the development of moral injury.
• Implications for practice and policy

  • ○
    Healthcare organisations should ensure their core values are identified and integrated into their mission, vision and daily operations.
  • ○
    Systemic reforms are needed to address the root causes of moral injury, which may include improving access to resources, staffing, working conditions and transparency.
  • ○
    Leadership training and development, as well as systemic support structures, are needed to influence positive changes in the clinical environment.

1. Introduction

Occupational stressors can have profound negative effects on healthcare professionals (HCPs), including increased mental health risks (Davis et al. 2021) and occupational burnout (Chirico et al. 2021). These occupational hazards are associated with poor outcomes for HCPs, patients and healthcare systems (Hall et al. 2016). Historically, well‐being degradations have been approached from an ‘individual deficit’ that places responsibility for wellness on the individual HCP; however, emerging science increasingly focuses on understanding and addressing systems‐level factors that drive these degradations (Shanafelt 2021). It has become clear that HCP functioning problems are not the result of a personal resilience deficits, but rather, systemic problems plaguing our national healthcare system (West et al. 2020).

In 2019, the National Academy of Medicine (NAM) published a call to action to better understand these occupational stressors, identify systems‐level interventions to prevent or reduce occupational stress, and how HCPs can be better supported (National Academies of Sciences and Medicine 2019). In addition to the more frequently discussed occupational hazards, NAM included a focus on moral injury in health care. Subsequently, NAM published a National Plan for Health Workforce Well‐being, which specifically called for a national research agenda on moral injury, among other causes of organisational, learning environment and health system factors impacting well‐being (National Academy of Medicine 2024). Although moral injury is a construct studied extensively in military populations, less is known about moral injury in other populations, such as HCPs (Griffin et al. 2019).

2. Background

2.1. Moral Injury

Litz et al. (2009) originally defined moral injury as resulting from exposure to potentially morally injurious events (PMIEs), which include “Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (700). Farnsworth et al. (2017) later described PMIEs as “a situation occurring in a high‐stakes environment where an individual perceives that an important moral value has been violated by the actions of self or others” (392) and Shay (2014) emphasised the role of betrayal by leaders in defining PMIEs. After experiencing a PMIE, unresolved dissonance can lead to moral injury, which is characterised by enduring emotional distress and profound changes in self‐perception and worldview (Litz et al. 2009).

Whereas moral injury has been largely studied and intervened upon in military contexts (Griffin et al. 2019), research in healthcare contexts has historically focused on moral distress. Moral distress occurs when an individual knows the morally correct action to take but, due to systemic barriers, is unable to take that action (Jameton 1984). Epstein and Hamric (2009) proposed a model of the ‘crescendo effect.’ In this model, moral distress can be caused by “presence of constraints, either internal (personal) or external (institutional) that prevent one from taking actions that one perceives to be morally right” (2). Persistent distress can lead to the accumulation of moral residue, or the unresolved feelings following a moral distressing event. This can result in a new baseline for moral distress and thus heightening susceptibility to future distress. Additionally, researchers suggest that these cumulative morally distressing events and residual effects can contribute to the development of moral injury (Čartolovni et al. 2021; Mewborn et al. 2023).

Challenges associated with moral injury emerged as a signature wound during the Covid‐19 pandemic, with studies indicating that up to 38% of HCPs (Rushton et al. 2022) and 57% of nurses (Callis et al. 2024) reported experiencing clinically significant moral injury. Daily stressors inherent to healthcare work appear to play a significant role in the development of moral injury (Demir et al. 2024). Norman et al. (2021) found that a substantial percentage, ranging from 53% to 88%, experienced moral distress related to concerns about their impact on family, fears of spreading illness and other work‐related issues. Researchers investigating types of PMIEs experienced by HCPs found that individuals who transgress their own values often also witness value breaches and feel betrayed by leaders (Weber et al. 2023).

Exposure of HCPs to PMIEs or the experience of moral injury is associated with impaired personal well‐being (Mewborn et al. 2023; Riedel et al. 2022). Researchers have identified relationships between moral injury and psychosocial or functional impairment (Mantri et al. 2021; Norman et al. 2021; Weber et al. 2023), post‐traumatic stress disorder (Amsalem et al. 2021; Norman et al. 2021), anxiety (Amsalem et al. 2021; Mantri et al. 2021), depression (Mantri et al. 2021) and suicidal ideation (Amsalem et al. 2021). Additionally, healthcare researchers have investigated the association between PMIEs, moral injury and professional well‐being. Several studies have identified a significant relationship between moral injury and burnout (Mantri et al. 2021; Norman et al. 2021). However, the causal relationship between functioning, mental health symptoms, burnout and moral injury remains unclear (Thibodeau et al. 2023). Studies examining individual factors such as age, experience, gender, education level and religiosity in relation to moral injury have produced mixed results or are limited (Mantri et al. 2021; Mũrage et al. 2024; Riedel et al. 2022; Rushton et al. 2022).

Despite the recognised need for a consistent framework and definition of moral injury, there remains a significant gap in understanding its context and impact on non‐military populations (Griffin et al. 2019; Maguen and Griffin 2022). Nurses, who constitute the majority of HCPs (World Health Organization 2020) and report the highest rates of PMIEs (Rushton et al. 2022), are particularly vulnerable to moral injury. Addressing moral injury among nurses is crucial, not only for their own well‐being, but also because they play a pivotal role in patient care delivery, and their well‐being directly influences healthcare quality and patient safety.

3. The Study

This qualitative study seeks to deepen our understanding of moral injury among nurses in healthcare settings through their accounts of PMIEs and experiences of moral injury. By exploring nurses' firsthand experiences, the study sheds light on the unique challenges they encounter and their implications for moral injury. Specifically, we examine how nurses within a United States Mountain West (U.S. Mountain West) healthcare system articulate the nature of PMIEs and factors related to the impact of moral injury.

4. Methods

4.1. Design

The authors employed a qualitative interview design in this study to allow for flexible, contextual, and rich understanding of the phenomenon of PMIEs and moral injury in nurses. Participants engaged in one 45‐ to 60‐min interview with a member of the research team. The nurses also had the option to participate in online surveys; however, the qualitative interviews are the focus of this paper. Interviews were analysed using reflexive thematic analysis (TA; Braun and Clarke 2021). The authors used this pattern‐based methodology to develop themes related to nurses' values and transgression of their moral beliefs given their unique and nuanced experiences. Standards for reporting qualitative research (O'Brien et al. 2014) were used to report these results.

4.2. Theoretical Framework

Use of reflexive TA allows for an exploratory, inductive and theoretically flexible approach (Braun and Clarke 2021). This approach involves delving into the data, uncovering, analysing and narrating patterns of significance within the dataset. Themes are identified through drawing from nuances in the data while addressing the core research query. An assumption of reflexive thematic analysis is that researchers enter with subjectivities, which are outrightly discussed within the research team. Thus, the method requires reflexivity—a self‐awareness on the part of the researcher.

Litz et al. (2009) conceptualization of moral injury was used in the development of the interview guide for this study, and as such, influenced the data collection. Beyond this initial structure, no frameworks or theories were used in interpreting the data. This decision was made due to the lack of established frameworks for understanding the experience of moral injury in healthcare (Thibodeau et al. 2023) and the exploratory nature of this study. This approach allowed the nurses' responses to drive the themes and answer the research questions.

4.3. Sampling, Recruitment and Inclusion Criteria

The nurses in this study were recruited from a larger study of HCP employed in a large academic healthcare system in the U.S. Mountain West (Smith et al. 2022). This health system includes multiple specialty hospitals and community clinics. All participants in the pool were recruited into the study in 2020 and participated in optional periodic surveys. In the Summer of 2023, the survey included an opt‐in question providing permission to be contacted with recruitment information for this study. Inclusionary criteria included that the HCP be a registered nurse from the participant pool. No other inclusion or exclusion criteria were used.

5. Data Collection

A semi‐structured interview guide was created by the authors and used in each of the interviews. The guide consisted of nine interview questions and additional prompting questions to facilitate gathering rich data. Interviews were conducted individually by three of the authors (M.J.V., E.E. and A.S.) in May– June 2023. All interviews were recorded via a video conferencing platform and transcribed verbatim using a confidential transcription service. Transcription accuracy checks were conducted by one author (E.E.).

5.1. Data Analysis

Data were analysed using reflexive TA (Braun and Clarke 2021). Reflexive TA allows for inductive analysis of data, where themes are identified in the codes, using explicit and latent meanings gleaned from the data. This method consists of six steps that may be reiterated throughout the analysis process, including (1) familiarisation with the data, (2) coding the data, (3) generation of initial themes, (4) reviewing and developing themes, (5) refining themes and (6) writing up the analysis. While following Braun and Clarke's (2021) six‐phase approach to reflexive thematic analysis, we approached these phases flexibly and iteratively. Table 1 provides an overview of how each phase was implemented, highlighting the collaborative and reflexive nature of our analysis process.

TABLE 1.

Reflexive thematic analysis phases and application.

Phases	Application in the study
Familiarisation with the data	Researchers immersed themselves in the data by repeatedly reading transcripts and listening to audio recordings. Initial observations and patterns were noted
2Coding the data	Two authors independently generated initial codes, focusing on both semantic and latent content relevant to nurses' experiences of moral injury. Codes were compared and refined through discussion involving coders and methodologist
3Generation of initial themes	Researchers collaboratively identified potential themes by clustering related codes and exploring relationships between them
4Reviewing and developing themes	Themes were reviewed against the coded extracts and entire dataset to ensure coherence and distinctiveness. Some themes were merged, split, or discarded based on their relevance
5Refining and defining themes	Themes were defined to capture the essence of the data. The research team engaged in iterative discussions to refine themes and subthemes to ensure accurate representation of nurses' experiences
6Writing up	During the write‐up, all authors engaged in discussion during which we further refined theme descriptions, identified gaps, and contextualised findings within existing MI literature

5.2. Ethical Considerations

This study was approved by the University of Utah's Institutional Review Board (IRB #00158703) on 2/1/2023. Due to the nature of the data, there was a risk of disclosing behaviour that meets mandatory reporting requirements related to serious risk to public health or safety, as well as the threat of harm to an individual, including oneself. To minimise risk, participants were provided information on reporting requirements, as well as informed that they could choose not to respond to any question or discontinue the interview at any time. Additionally, due to the potentially distressing nature of the content of the interviews, all participants were given crisis resources at the completion of the interview.

5.3. Rigour and Reflexivity

The six phases of the analysis were conducted by three authors (M.J.V., E.E., K.W.T.), with the exception of initial coding, which was completed by two authors (M.J.V. and E.E.). Due to the subjective nature of the Reflexive TA (Braun and Clarke 2021), initial codes were developed independently and then interpretations were compared. The two primary coders reviewed the codes and identified initial themes. The coders then checked and inter‐rated the themes with the methodologist (K.W.T.). This process was repeated over multiple meetings by reviewing the thematic groupings, naming and defining the themes, and revisiting the coded data to ensure that the defined themes aligned with the data.

6. Findings

Twelve nurses consented to take part in this study and participated in the individual interviews. These participants held diverse roles such as direct patient care, educators and managers, with experience in various practice settings, including ambulatory, emergency, inpatient and perioperative care. They represented a wide range of clinical areas, including emergency, gastroenterology, inpatient and outpatient float, neurology, oncology, orthopaedics, surgery/anaesthesia, telephone triage and women's and children's services. Additionally, the nurses had prior experience in other care settings and clinical areas, which were also reflected in their narratives. See Table 2 for participant demographics. In the text below, some identifying information, including gender and work units or specific roles, were altered to protect anonymity; all names are pseudonyms.

TABLE 2.

Participant demographics.

	n	%	M	SD
Gender
Female	9	75
Male	3	25
Race and ethnicity
White	12	100
Age			48.12	12.75
Years of experience			17.58	13.55
Setting
Ambulatory	3	25
Emergency	1	8.33
Inpatient	5	41.66
Perioperative	3	25

7. Themes

Using reflexive thematic analysis, we analysed interviews to understand the nurses' values, descriptions of PMIEs, and the layers of influence on the events the nurses identified as morally injurious. Below, we describe and provide representative quotes for 8 themes and 3 subthemes. Themes were placed under three broad categories (a) nursing values, (b) experiences of morally injurious events and (c) stressors and supports. Quotes were minorly edited for readability.

7.1. Nursing Values

To center interview conversation and provide context for the potentially morally injurious events (PMIEs), we first asked nurses to describe their values and philosophy of care. We identified two themes in the nurses' responses: Patient‐centered, humanising care is paramount for nurses, and nurses are driven by Benevolence.

7.1.1. Value Theme 1: Patient‐Centered Care

Multiple nurses described the paramount value of their work as providing patient‐centered, or humanised, care with empathy, compassion, and advocating for the well‐being and desires of patients. Sue concisely stated, ‘Well, when you look at a person, you see a person, that's the first thing’. Melissa described not losing focus of the individual amidst procedural requirements or simply viewing them as a medical problem to be solved. ‘For me, it's recognising each person as an individual, and they're very different and have different needs. There's a lot of processes and protocols around healthcare. We can't look past the individual. [We] guide what we do by the individual and their needs, their wants, their experiences, their values. So, to me it's just treating each person as an individual and making them feel… they're important. Have you ever been to a place where you go, you just walk up to a counter and people don't even acknowledge you? You're a burden for being there? For me it's the opposite of that. The patients are valued, I mean, we need them, they need us, we gotta work with them and, and see each person as an individual, but not as a disease process’.

In their expression of patient‐centered and humanising care, many nurses focused on compassion and empathy for their patients. They expressed constant awareness that they are seeing patients during stressful and scary moments in the patients', and family members', lives. When asked what values guide her work in healthcare, Mary said, ‘The patient first, that is always my number one thing. Our patients come to us on some of the hardest days of their life and dealing with a lot of, a lot of physical and emotional things. And our role is to help support them in whatever way we need—medically, physically, emotionally, those kinds of things. So that's what has always guided me’.

Many nurses conveyed patient‐centered care with a focus on their role as a patient advocate and educator. They provided examples of meeting patients where they are at, assessing patient healthcare knowledge, and providing education where needed. Stephanie said, ‘I do my best to be a patient advocate because I know sometimes other team members don't go through everything they should go through with patients. For example, like if I'm accessing a port and it's the first time somebody's port has been accessed, he'll tell me ‘what, like, what are you doing? I don't know anything about this object that's been surgically placed in my body.’ I'm like, ‘Okay, well let me tell you about your port and what it looks like and what it does and how we use it’.

7.1.2. Value Theme 2: Benevolence

The nurses described their work as nurses as guided by benevolence. They expressed a value in contributing, helping others, and being a part of something bigger than themselves. Chris captured this belief when he said, ‘we're always working towards the greater good and sometimes I have to sacrifice to help other people and if that's my time or my stress or something’. Della similarly expressed that she values contributing to the care of others, even when patients are not doing well, ‘It's not always rainbows and butterflies and sometimes it's very emotional, distressing and it's a privilege to be part of that for everybody. So whether it's a happy outcome or a sad outcome, I really enjoy being able to take care of people’.

7.2. Experiences of Potentially Morally Injurious Events (PMIEs)

We asked nurses to describe times they have been involved in PMIEs to provide understanding of the types of events experienced by healthcare workers. From their experiences, we identified three PMIE themes: Involvement in Challenging patient care, Nurse‐doctor ruptures and Inequity in access to care.

7.2.1. PMIE Theme 1: Involvement in Challenging Care

Nurses recounted instances where they were engaged in patient care that contradicted their moral beliefs, leading to significant distress. These included providing patient care they perceived as unhelpful or unneeded. Chris described being involved in what he perceived as futile care with a terminally ill patient during a blood shortage, ‘We had a patient that was very sick… They had a clotting disorder and the patient was bleeding to death and we knew that we couldn't really do anything to stop it … We had been receiving emails about this blood shortage and we knew this patient was gonna die and they just kept calling to get more blood and put more blood into the patient. And, a lot of us felt like that was very wasteful because this patient was not gonna survive and as much as you put the blood into the patient, the blood would just flow right out’.

The nurses also described care that infringed on patient autonomy. Sue recounted a situation where there was pressure to administer treatment that the patient did not want, ‘There was a woman who had… a terminal disease that if treated bought her another three to six months. She was an older woman with a traumatic childhood, but had very supportive children and their spouses, thank goodness. This doctor became insistent that she undertake this particular treatment and she said no, and she was laying in bed, and she curled up away from him. And he went and knelt down and got right in her face. And that was really wrong. … I mean this woman had come to terms with her death and her death was a relief to her’.

Finally, the nurses described distress in being involved in care where errors were made. Ray described involvement in care where the patient was a healthy female who underwent a routine surgery, ‘it was a botched surgery. And then the thing that was frustrating for us, and we had done all the things we were supposed to do, we did the incident reports, we reported them, we did everything that we saw was medically, ethical, and we got no support. And this was a long time ago at [a different hospital]… but some of my coworkers from years ago that I am still friends with, all of us that were involved in that can still remember, I mean, I close my eyes and see her… it just got so egregious that we just couldn't, you know, couldn't handle it anymore’.

7.2.2. PMIE Theme 2: Nurse‐Doctor Ruptures

The nurses shared experiences of PMIEs that involved distress as a result of strained relationships with physicians, including disrespect, hostility and tension. Chris identified the risk of voicing patient care concerns, saying, ‘We are in a situation where when you're in a room, a scrub tech or a nurse, and something is happening that is being done by a surgeon, you may not always feel comfortable to speak up or you may feel that there's retaliation’. Melissa, who manages a group of nurses, emphasised that nurses might avoid interacting with doctors to prevent conflicts, where this avoidance could compromise patient safety, ‘What I see happen, is interactions between doctors and nurses that are very unprofessional and actually, the way staff are treated, cause potential safety issues with patients. For example, as a nurse, I don't want to call a doctor just to give them something to do, to interrupt their day, to frustrate them. However, as a nurse, if I have something that needs to be addressed that I bring to the physician's attention and get treated as if [I'm] a burden, it creates the likelihood that I'm not gonna want to call them with a patient concern again’. Similarly, Ray, who also manages nurses, described this ongoing issue between nurses and physicians and highlighted a power imbalance in the relationship, saying,‘Um, the dilemma for nursing is there's some people that are afraid to call an attending because you'll get your head bit off. ‘Why are you calling me?’ Because [physicians] have minions to deal with everything. Some of [the physicians] are fine. And it's like anything else, you learn who is more approachable and who's not. There's a huge intimidation factor’.

The nurses identified that these ruptures impact the culture in the work environment. Ray said, ‘I think a lot of [moral injuries are] death by a thousand little cuts. [It is not about] the minor things, but over time, it's why people leave. It's the constant daily battle…’. Melissa spoke of how she and her colleagues use formal reporting mechanisms to report issues, ‘… you have no power, no authority to do anything about it other than report it…like with reporting a patient concern, but you feel like you're putting your neck out, waiting for the guillotine to come down. It's not a good feeling and it's not a great experience when you do that. But to the nurses' credit in our department, they're willing to speak up. But it causes a lot of turmoil, inner turmoil, frustration and concern’. She indicated that the poor treatment of nurses is persistent, saying, ‘There is a culture that still permits what is happening. I'll listen to nurses get off the phone. I'm like, man, [the physicians] sure are snappy and rude, and it's allowed. They see the nurses or the people who are lower on the hierarchy as something that's getting in their way… the overall issue still persists in that it's kind of permitted and administration will tell you, “no, it's not, that's not acceptable”…but the actions say otherwise where it's permitted. And, where it's permitted, it's promoted’. Melissa also noted that residents learn this and begin to act in the same fashion, perpetuating problematic interactions.

7.2.3. PMIE Theme 3: Inequity in Access to Care

The nurses indicated that PMIEs often involve being unable to provide patients with adequate or equitable care due to political, insurance, or organisational financial reasons. Mary summarised this sentiment, saying, ‘Sometimes it feels like the decisions that are being made are not being made with the idea of the patient and the whole reason that we exist. You know, we exist because of the patient and, are we making decisions based on that, or are we making decisions based on these other non‐patient focused reasons?’ A few nurses described being unable to provide desired treatment to uninsured or underinsured patients. Della, for example, expressed being unable to provide the desired patient care due to financial reasons and, as a Spanish‐speaking nurse, found herself in the dual‐role of negotiating care with patients. She said, ‘A lot of our patients who are self‐pay are Spanish‐speaking patients. I'm fluent in Spanish and so it becomes an awkward conversation for me. I'm taking care of you and I'm really involved in your care, but we need to talk about money now’.

Miriam spoke about changes during the Covid‐19 pandemic and that changes in federal support put her in the position where she could not provide the requested care. She said, ‘When the CARES act expired and we could no longer provide monoclonal antibodies to all the patients who needed them because of ability to pay, that was awful. Having to tell people that they couldn't get the medical treatment that they could have a week ago because people in power decided, no, we're just done with that. And that was hard. That was really hard because it was wrong. It violated my moral code and it violated best practices. It violated the research, it violated the science, it violated fiscal responsibility. There is no part of that decision that was wise or caring or followed the fact’.

Others found themselves in distressing situations with a lack of adequate continuum of care and social services for uninsured patients. Mitch described the stress of these situations, ‘When patients are brought in the hospital and come in through the emergency room, we give treatment. They have to be treated. A lot of times those people are put into rooms in the hospital, they're unfunded. We know that and that's part of our job as we still give them care. We do as much as we can for them. The problem that I have is when we discharge them or when we've completed the care. Well, these people were homeless coming in and it's hard for me to send somebody back into the same situation that they left and knowing that they can have the same injury happen again and again and again because of the environment they're in. You can't change it’.

7.3. Stressors and Solutions (S&S)

In addition to the PMIEs, we found the nurses often described stressors or supports (S&S) that contribute to their experience of moral injury. Three themes identified in this area included: Senior leadership behaviour, Team dynamics and Access to resources. Within access to resources, we found three sub‐themes: Staffing and resources, Pay and benefits and Formal supports.

7.3.1. S&S Theme 1: Senior Leader Behaviour

Nurses described leadership behaviour as an indicator of how they are valued, supported, and listened to within the organisation. Supportive leadership behaviours include that leaders are visible, engaged and aware of current issues, as well as fostering a responsive culture where concerns are heard and addressed. The nurses spoke highly of their immediate management team but indicated there were minimal demonstrations of support beyond that team. Mary spoke about how helpful it is to have management that takes the time to listen, ‘They're always willing to sit down and talk to you about what's going on. I think they're very conscientious about making sure that they have time with everyone, [such as] ‘Ok. What are the challenges?’ … Which, I think, makes a difference to the nurses in the room because then the managers have the resources they need to help support them’. Others highlighted that senior leadership is not accessible. Miriam said, ‘There are a lot of layers of leadership between the senior leadership and my direct manager that we don't hear from’.

When speaking of senior leadership, Mary said, ‘Yeah, I think it is very easy to become too far removed from the actual patient. It's very, it is easy to lose touch…because those are the people making the decisions. I feel like [they are] not understanding priorities, not understanding what's important’. Similarly, Chris said, ‘I would say my immediate leadership, my manager and my nursing director, are very in touch with what's going on. They're here every day, they're checking in with us, they're always talking about things. But [senior administration], I don't think [they have] any clue what people go through on a day‐to‐day basis. I think they're very disconnected from the reality of what occurs’. He added, ‘I think that any time a concern is brought to [senior leadership], it's kind of immediately dismissed. They view it as hyperbole or as us being dramatic’.

The nurses also brought up shifting priorities as leadership became removed from direct patient care. Jamie discussed being involved in a committee that was charged with ‘making the department better’ where she suggested a focus on patient readiness due to challenges she experienced in her day‐to‐day role including, ‘How can we get this process so that my job isn't as hard?’ However, she indicated her and her colleagues' feedback was dismissed and the outcome of the group was ‘the [employee break] area will be cleaned out on Friday night’. Della also identified issues with prioritising non‐patient or care issues, saying, ‘I overall really love my management team. I feel like, in some things, they are more worried about pleasing their bosses… And their priorities become more of budget and admin, boss pleasing, versus being in touch completely with the dilemmas that we have on our unit’.

7.3.2. S&S Theme 2: Team Dynamics

In the interviews, feeling isolated or having a supportive team culture was overwhelmingly apparent as a factor that could either be a stressor or buffer for emotional distress. The nurses identified a lack of collegiality as contributing to a challenging work environment, including feelings of isolation and a lack of compassion. Raquel, who works on various units, found she cannot easily develop peer supports, saying, ‘I'm in a different place every single day. I haven't formulated those kinds of relationships. Everything is on the surface’. Stephanie discussed leaving a role where the team and manager did not treat her well to return to her prior, supportive team. ‘I think it was a pretty slow decline. Um, but it started with things that my immediate leader in my group did… her dismissing me, or not talking to me, but talking to everybody else. Or if I said, well, here's an idea, and then she would [say] no… or that won't work’.

Inversely, the nurses expressed how shared experiences help create mutually supportive relationships. Danielle stated, ‘we've got a little family here, right? And I'm sure every unit feels that way, but I've worked places where it doesn't feel that way and there's not that camaraderie and people are not as patient and inclusive’. Melissa focused on colleagues as providing support in the form of validation, ‘Sometimes you get gas‐lit as a nurse. You're like, wait a minute, did I do something wrong? You start questioning yourself… and being able to share that with [other nurses] and be validated that yes, you did do the right thing. …So being able to share the experience, have a sounding board, be able to be validated’.

Raquel described how knowledge of shared experiences helps develop compassion for one another and fosters a willingness to step up for each other when needed, ‘We all have really sad and awful things that happened to us… Each person takes 15 patients a day, so everybody has a little bit of a sad story. You can count on those particular people’. Chris shared that, after one particularly difficult case, he felt closer to his colleagues, ‘I think the coworkers that experienced that together, we still have a good relationship and I think everybody was a little bit closer because of it’.

7.3.3. S&S Theme 3: Resources

Resources, the final S&S theme identified, encompassed three key subthemes: staffing and medical resources, pay and benefits and formal supports. This theme highlights the multifaceted challenges nurses face related to the availability and adequacy of essential resources necessary for their professional and personal well‐being. Each subtheme centres on specific aspects of resource‐related stressors and supports that significantly impact nurses' ability to perform their duties effectively and maintain their resilience in a demanding healthcare environment.

7.3.4. S&S Sub Theme 1: Resources—Staffing and Medical Resources

The nurses cited being understaffed and lacking access to necessary resources and equipment as contributing to stress and the inability to recover after PMIEs. Chris shared that there was a surge of operations after COVID‐19 restrictions were lifted to increase hospital revenue at the cost of burdening nurses. He said, ‘we're overworked, we're understaffed… We're one of the only areas of the hospital that actually makes money. People pay their bills when they have surgery and so that's one of the biggest revenue generators for a hospital system… There's just been an unrelenting push to just do more and more and more with less and less and less. So, if we have staffing challenges, they don't care, “[just] do surgeries”. If we have equipment or resource issues, they don't care, “do the surgeries”, because that's what's keeping us making money’. Sue also highlighted that staffing issues cause problems for nurses who then become too busy to manage their workload effectively, saying ‘one of the big stressors for nurses is there is so much to do. How do we do it all? Did we leave something out? … So that comes down again to staffing’. Jamie expressed that adequate nursing staff levels are not a financial priority, saying funds are prioritised in other areas and then ‘we only have enough money left to pay for six nurses.’ leaving units understaffed.

In addition to human resources, nurses also discussed difficulties with medical resources and equipment, which led to PMIEs and stress due to workflow inefficiencies. As discussed above, Chris recounted an incident where the need to ration blood caused distress, saying ‘If the physician was about to make a decision to [use] eight units of red blood cells, there should be something that they can log in and say, well, how many do we have left in the system?’ Jamie highlighted similar stressors with regard to finding needed equipment, saying ‘The process of getting a 20 gauge in this room so I don't have to search other rooms?’ She further stated, ‘If I had that unlimited resources, the first thing would just be a very nice, clean and organised, especially that organised [unit]. Everything is all over the place. That place needs to be sorted and organised… where we could do our job without needing to search for the bladder scanner’.

7.3.5. S&S Sub Theme 2: Resources—Pay and Benefits

Finally, the nurses raised concerns around pay and benefits. Sue said, ‘You know, taking the financial stress off of people goes a long way to helping with resiliency. And I think one of the reasons I'm resilient is I have additional sources of income, so I could afford to be a nurse’. Jamie discussed that nurses are at higher risk due to exposure to illnesses, but unlike other professions where occupational hazards are covered by employers, nurses often do not receive the same level of support, ‘I pay higher healthcare premiums…I pay more out of pocket’. Some of the nurses focused on pay when discussing inadequate staffing. Sue discussed concerns that there are not enough health care assistants (HCAs) to support nurses in routine care. She said, ‘Pay for HCAs needs to be higher. You know, you're competing in the whole marketplace, HCAs can do a lot of other things’.

7.3.6. S&S Sub Theme 3: Resources—Formal Support

The nurses recounted engaging formal support for coping with distress using workplace resources. These included formal debriefs following PMIEs, employee assistance plans (EAP) and mental health support provided through hospital services. Mary used therapy and FMLA with the support and encouragement of her supervisor, ‘I was very fortunate that my leader had also gone through a very [similar situation] because he was making those decisions with me. The buildup of all of that and a lot of other things that we witnessed, he had already gone through that himself and so he was very understanding. He had taken his own leave. I felt really lucky and supported in that ability to step away and say, I need to take a break and recover’. Still others highlighted that services need to be readily available, Danielle said, ‘I know there are a lot of resources out there. It's a matter of getting them utilised and getting them to the people… I know that there's peer support, there's the wellness center, and EAP, but making them approachable and accessible is the difficulty. And helping people to understand that they can actually be a useful thing…’.

8. Discussion

The field of healthcare is fast‐paced, high‐stress, and high‐stakes, exposing nurses to PMIEs and leaving them at risk of developing moral injury. Although significant research has been conducted within military settings, understanding and addressing moral injury within the healthcare system remains limited. We identified three themes in the nurses' descriptions of PMIEs they experienced: involvement in challenging patient care, nurse‐doctor ruptures, and inequity in access to care. Importantly, the nurses also described other factors that contribute to the experience of moral injury, which we identified as stressors and supports. Although these elements were not directly tied to the PMIEs, participants explained how senior leadership behaviour, team dynamics, and access to resources influence the daily experiences, recovery following PMIEs, and overall well‐being.

The themes identified findings fit within accepted organisational structures of moral stressors that indicate they occur at a patient‐care level, team or interpersonal relationship level and system level (Epstein et al. 2019). The first theme included PMIEs at the patient‐care level, such as providing futile care, care that violated patient autonomy, or when medical errors occur. PMIEs within this category appear to most directly conflict with nurses' core values of patient‐oriented and humanising care. The second PMIE theme, strained nurse and doctor relationships, occurs at an interpersonal or team level. These ruptures are not only daily stressors, but also cause dilemmas where nurses have to choose between prioritising their own well‐being, by avoidance of tense interactions, and providing optimal patient care. The PMIEs recounted in this study involved the nurses acting against their values, witnessing a moral transgression, or betrayal by an individual who is in a position of authority. Such violations of the moral code can result in cognitive dissonance and result in an altered view of self‐competency and the world as a just place (Riedel et al. 2022).

The final theme in the nurses' descriptions of PMIEs they have experienced was inequity in access to care. These moral stressors occur at an organisational and system level and challenge the nurses' deeply held value of benevolence—acting for the greater good. Nurses expressed profound distress when forced to deny patients care due to systemic constraints, including lack of insurance, inadequate coverage and policy alterations. Notably, while the nurses responded to a question about PMIEs, these narratives align closely with conventional descriptions of moral distress—that is, there was a morally clear action but the nurses were prevented from acting accordingly (Jameton 1984). Moral distress is viewed as situational, and associated negative cognitions and emotions are temporary or less severe than those of a PMIE and subsequent moral injury (Čartolovni et al. 2021). Nevertheless, the nurses' descriptions of repeated experiences support the hypothesis that morally distressing events can accumulate, build moral residue, and also result in moral injury (Epstein and Hamric 2009).

In the nurses' descriptions of their PMIEs, the nurses discussed other factors that contributed to their experience of distress. These factors align with the concept of organisational vulnerabilities, which have been identified in studies of moral injury in healthcare (Riedel et al. 2022). In the present study, these vulnerabilities included perceptions that senior leaders are not present or visible, unaware of current constraints in practice, and not taking complaints seriously. On a team level, this included a lack of supportive relationships and isolation. On a system level, there was poor access to resources that caused unnecessary work, overburdened staff, or a lack of access to formal support. The nurses also expressed that the absence of these reflected how the organisation values nurses and them as individuals. These factors appear to exacerbate or facilitate the experience of moral injury and moral distress.

When effectively implemented, however, these factors can be mechanisms of support and provide a buffering effect or protect against experiencing distress related to moral injury. This aligns with the job demands–resources theory of occupational stress and well‐being that posits the presence of job resources can moderate the impact of job demands (Bakker et al. 2023). As such, we offer these factors as solutions to prevent or mitigate an individual from experiencing the distress associated with moral injury. Positive leadership behaviours can facilitate trust, support and engagement at work (Mewborn et al. 2023). Collaborative team dynamics can be a source of support, foster effective communication and teamwork, and facilitate an environment where nurses feel heard, valued and empowered (Silverman et al. 2021). Novel systems‐level interventions can be designed and feasibly implemented at low cost to mitigate harms of inevitable PMIEs through building psychological safety, trust, and social support on nursing units (Usset et al. 2024). Finally, resources can free up nurses' cognitively and emotionally, allowing them to focus more on delivering high‐quality patient care and carefully navigate moral challenges (Bakker et al. 2023). Each of these solutions lies at a team or organisational level, which places the onus on leaders and systems to address the drivers (Shanafelt 2021), rather than further burdening individual HCPs.

8.1. Implications for Healthcare Systems

Based on participants' narratives, we offer several suggestions aimed to reduce the impact of moral injury or moral distress among nurses. First, given the value driven aspect of nursing, healthcare organisations would benefit from assessing how values are being operationalised within their systems. Many healthcare organisations invest time and effort identifying core values but stop short of integrating these values into their mission and vision statements or everyday operations. Intentional steps can be taken to communicate and reinforce values alignment between the healthcare organisation's stated intentions and actual practices (Dunning et al. 2021). This could range from articulating a clear ethical framework that emphasises core values and principles to facilitate decision making across all levels, to ensuring values congruence at the local level with staffing, communication, huddles, professional development, promotion and patient experience (Browne and Chun Tie 2024). Second, leadership training and development have the potential to develop confidence and self‐efficacy in leaders' ability to effect change (Bond et al. 2023). These crucial initiatives should emphasise positive and transformational leadership behaviours, including transparency and open communication, that bolster trust and engagement among all HCPs and are influential in creating positive changes across a variety of clinical environments. Although providers in leadership roles may strive to support their nursing teams, the root causes lie within the broader healthcare system. Further, as private equity has become increasingly present in healthcare, the incongruence between healthcare systems and healthcare workers has grown through the reduction of the quality of care that is provided and the increased cost burden for patients (Kannan et al. 2023). Healthcare workers sit at the crux of providing care for patients that runs the risk of being increasingly values‐discrepant, thus cultivating risk for ethical dilemmas and PMIEs (Pavlova et al. 2023). To effectively address nurse burnout and PMIEs, comprehensive systemic reforms are necessary to improve working conditions, provide adequate staffing, transparency about billing and staffing practices, transparency about medical decision making (for the benefit of patient or profit?), as well as effectively communicating change efforts to ensure that nurses feel appreciated and supported in their critical roles. Third, enhancing team dynamics through regular team building activities and conflict‐resolution training may promote better collaboration and communication. The stressful nature and likelihood of interpersonal ruptures within healthcare organisations are inevitable. However, repairing these ruptures through deliberate and intentional communication efforts is crucial to maintaining positive working relationships. Fourth, access to quality mental health support via professional counselling and peer support programmes can ameliorate the emotional toll of their work. Fifth, managing workloads by ensuring adequate staffing levels and offering flexible scheduling options further alleviates stress and prevents burnout. Finally, at the policy level, regulatory changes and professional standards can provide a broader framework for addressing moral injury and distress. Implementing regulations to limit excessive work hours, as well as advocating for mental health parity in insurance coverage, is a vital step.

8.2. Strengths and Limitations

Strengths of this study include diverse representation of nursing roles, work settings and clinical areas. The participants' extensive and varied clinical experience contributed to rich narratives, reflecting their deep familiarity with healthcare systems and extensive practice knowledge. The qualitative and semi‐structured interview approach enabled the investigators to capture nuanced and contextual examples of potentially morally injurious events. These detailed examples provide valuable insights that can directly inform and drive necessary system changes and mechanisms of support, demonstrating the practical impact of the study.

Although this study provides valuable insights, there are limitations inherent to the study design and analytic approach. For example, semi‐structured interviews allow for flexibility but can introduce variability in data collection. The authors addressed this by adding specific prompts following interview questions to support systematic data collection. Also, the interpretation of responses in Reflexive TA is subjective and may differ by coders. To address subjectivity, the researchers engaged in a self‐reflective reflexive process, coded individually, and then compared codes. This study is also limited by its focus on nurses' self‐reported experiences in one hospital system. The nurses involved were all experienced HCPs and white.

8.3. Future Research

Future research should explore moral injury across diverse healthcare settings and with diverse professionals, including age, race and experience level, as well as across various professional roles to enhance the applicability of these findings and support the development of comprehensive prevention and intervention strategies. Additionally, while we prompted individuals with a definition of a PMIEs during the interview, individual interpretation of what qualifies as a PMIE was left to the individual nurse. Though definitional differences exist, researchers should work to establish clear criteria with examples from healthcare settings and test whether events can be reliably categorised to distinguish between moral frustration, moral distress and potentially morally injurious events. This delineation would facilitate investigations into whether occupational and clinically meaningful distinctions exist. Future research should also explore whether organisational or team interventions on the factors identified in this study can be used to prevent the devastating impact of moral injury.

8.4. Conclusion

This study identified significant moral stressors and PMIEs for nurses, including challenging patient care, strained nurse‐doctor relationships and inequities in access to care. Awareness of these stressors enables healthcare systems to take action by pinpointing critical areas and scenarios requiring enhanced prevention, intervention and support strategies. Importantly, our findings also illuminate the role of stressors and support factors that can leave an individual vulnerable to or protect against moral injury following a PMIE or morally distressing event. While it may not be possible to completely ameliorate moral dilemmas in healthcare, interventions on leadership behaviours, team dynamics and resource availability may help mitigate their impact.

Author Contributions

All authors have agreed on the final version and meet at least one of the following criteria: (1) substantial contributions to conception and design, acquisition of data or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content.

Ethics Statement

This study was approved by the University of Utah's Institutional Review Board (IRB 00158703) on 2/1/2023. Due to the nature of the data, there was risk of disclosing behaviour that meets mandatory reporting requirements related to serious risk to public health or safety, as well as threat of harm to an individual, including oneself. To minimise risk, participants were provided information on reporting requirements, as well as informed that they could choose not to respond to any question or discontinue the interview at any time. Additionally, due to the potentially distressing nature of content of the interviews, all participants were given crisis resources at the completion of the interview.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Research data are not shared.