Moral injury: the suffering that is not burnout
Table of contents
The patient needed an intensive care bed that did not exist. The doctor did what she could, argued with the regulation service, called other hospitals, and the bed never came. Weeks later, she does not feel exhausted in the usual sense. She feels guilty, angry at the institution and with the sense of having betrayed what she believed her role to be. Resting does not fix it.
This kind of suffering has a name. Moral injury is the wound that arises when someone does, fails to prevent or witnesses something that goes against deep values, or when they feel betrayed by someone who had authority and should have acted well. The term came from military psychiatry, but it gained ground in health care, especially during the pandemic.
This text explains what moral injury is, how it differs from moral distress and burnout, what studies show in health professionals and what doctors and institutions can do to prevent and repair this harm.
Key points
- Moral injury is the wound caused by acts or omissions that violate deep values, or by betrayal by someone with authority.
- It shows up as guilt, shame, anger, loss of trust and withdrawal.
- Moral injury is not burnout, but it can lead to burnout if it is not recognized.
- In studies, moral injury is associated with anxiety, depression, post-traumatic stress and suicidal ideation.
- Working conditions and institutional culture weigh as much as individual factors.
- Prevention and repair require changes in the system, not just personal resilience.
What moral injury is
The concept began with the psychiatrist Jonathan Shay, who treated war veterans in the United States (Rosen et al., 2022). He noticed that part of these patients' suffering did not fit the diagnosis of post-traumatic stress disorder. While post-traumatic stress arises from a frightening or dangerous event, moral injury, for Shay, results from a betrayal of what is morally right, committed by someone with legitimate authority, in a high-risk situation.
Brett Litz broadened the definition to include the lasting psychological, biological, spiritual, behavioral and social impact of committing, failing to prevent or witnessing acts that violate deep moral beliefs (Rosen et al., 2022). In this view, the injury can come from actions as well as omissions, and the individual may be the one who committed the act. In all cases, moral injury shakes identity and can lead to guilt, shame and social withdrawal.
In health professionals, the definition most used in recent studies refers to psychological, behavioral, social and spiritual problems that arise from the perception of having transgressed internalized moral beliefs (Maguen and Griffin, 2022). These values are rooted in cultural, institutional and group norms. The central point is that the injury can occur even when the professional follows the recommended standard of care.
Where the wound comes from
The authors describe three main sources of potentially injurious events: taking part in an act that goes against one's own values, witnessing that act and feeling betrayed by leaders or institutions (Usset et al., 2024). In clinical practice, this can mean denying visits to a dying patient, restricting tests for lack of supplies or seeing colleagues work without adequate protection (Maguen and Griffin, 2022).
A scoping review gathered the few empirical studies on moral injury in health professionals available at the start of the pandemic (Čartolovni et al., 2021). The searches, done in April 2020, produced 2044 results, but only seven articles closely focused on the topic. In these studies, moral injury appeared under other names, such as conscience stress, regret in the face of ethical situations, moral distress and ethical distress.
The same review describes nurses who witnessed unnecessary patient suffering and felt they were not doing enough (Čartolovni et al., 2021). Some of these cases of moral distress, over time and in certain contexts, can leave a residue and end in moral injury. The authors point out that the line between one and the other still needs to be defined.
Moral injury, moral distress and burnout
The three terms often appear together, but they describe different experiences. A perspective piece proposes that they form a continuum (Rosen et al., 2022). Moral distress, if it persists, is a common cause of moral injury. Moral injury, if untreated, can lead to burnout. In practice, the progression is uneven, with ups and downs, and a single severe event can quickly lead to burnout.
Burnout is usually understood as the combination of emotional exhaustion, depersonalization or cynicism and a sense of low personal accomplishment (Rosen et al., 2022). Moral injury can contribute to these symptoms. The inability to practice medicine according to one's own values raises doubts about one's effectiveness and, above all, can lead to cynicism and disengagement.
But, as the same authors summarize, moral injury is not burnout (Rosen et al., 2022). The fact that so many physicians fear burnout suggests they are not yet emotionally numbed. Those who reach burnout no longer suffer from the violation of values, because they have stopped feeling. The distancing typical of burnout can be seen as the absence of moral investment.
The distinction has a practical consequence. Treating moral injury as tiredness leads to solutions that do not touch the problem, such as recommending rest or relaxation activities. Recognizing the moral wound opens space for other responses: naming what happened, discussing the decision with the team and correcting the condition that caused the violation.
| Aspect | Moral distress | Moral injury | Burnout |
|---|---|---|---|
| Origin | Knowing what is right and being prevented from acting | Committing, witnessing or suffering a betrayal that violates values | Chronic work stress |
| Typical emotions | Anguish, frustration | Guilt, shame, anger, loss of trust | Exhaustion, cynicism |
| Relationship with values | Values preserved and in conflict | Values wounded, identity shaken | Reduced moral investment |
| Response to rest | Eases if the cause leaves the scene | Rest alone does not repair | Rest helps, but is not enough |
| Focus of the response | Remove the cause | Recognition, repair and change in the system | Workload, resources and work organization |
The table simplifies a picture that, in real life, has overlaps. The same professional can experience the three states at different times, and the same event can cause moral distress in one colleague and moral injury in another (Rosen et al., 2022).
A scale to identify
Researchers in the United States developed a 10-item scale to identify symptoms of moral injury in health professionals (Mantri et al., 2020). A total of 181 professionals from a university health system took part, most of them physicians. The scale assesses betrayal, guilt, shame, moral concerns, religious conflict, loss of faith, loss of meaning, difficulty forgiving, loss of trust and self-condemnation, with scores from 10 to 100.
The scale had a strong correlation with burnout (0.57) and with another measure of moral injury (0.65), and a modest correlation with depression and anxiety (Mantri et al., 2020). A score of 36 or more had a sensitivity of 84 out of 100 and a specificity of 93 out of 100 for identifying symptoms that cause moderate to extreme problems in family, social life and work.
Tools like this help research and screening, but there is an important caveat. The authors of the perspective piece warn that measuring moral injury can lead to treating it as a disease (Rosen et al., 2022). Guilt and anger in the face of a moral violation are understandable responses. The problem lies in the circumstances that cause the violation, not in the injured professional.
What the studies show in health professionals
The pandemic multiplied studies on the topic. A scoping review gathered 19 studies published up to October 2021 on moral stressors, moral distress and moral injury in health professionals during covid-19 (Riedel et al., 2022). The authors concluded that a common theoretical model explaining the causes and consequences of these phenomena was missing.
A later systematic review included 18 articles, out of 248 found, published up to December 2022 (Thibodeau et al., 2023). The results indicated that moral injury is associated both with professional well-being factors and with mental health outcomes. The authors call for more theoretical development and evidence-based interventions.
Moral injury and mental health
The first meta-analysis on moral injury and mental health in health professionals gathered 33 studies from 13 countries, with 31,849 people (Coimbra et al., 2023). Moral injury had a positive association with every problem assessed: symptoms of post-traumatic stress, anxiety, depression, burnout and suicidal ideation. Correlations ranged from 0.30 to 0.41, which the authors classify as a moderate association.
The meta-analysis found details that deserve attention (Coimbra et al., 2023). Samples with more nurses showed a stronger relationship between moral injury and depressive and anxiety symptoms. Samples with more professionals in direct care of patients with covid-19 showed a smaller effect. The authors note that many scales used were not created for health professionals, which limits the conclusions.
A study in the United States followed 350 health professionals at three points in time, at the start and after 30 and 90 days, between September and December 2020 (Amsalem et al., 2021). At the start, 72 out of every 100 reported probable anxiety, depression or post-traumatic stress. That number was 62 out of every 100 on day 30 and 64 out of every 100 on day 90. High moral injury was associated with several symptoms, including suicidal ideation, especially among those who reported exposure to covid-19.
Another survey, with 595 respondents from a research network in the United States, found clinically significant moral injury in 32.4 out of every 100 (Rushton et al., 2022). Nurses reported the highest occurrence. More intense ethical concerns were associated with more symptoms, and having 20 years or more in the profession was also among the factors linked to moral injury.
What professionals report
A qualitative study interviewed 30 frontline professionals from the United Kingdom's public health service (Hegarty et al., 2022). They described routine exposure to ethical conflicts created by the worsening of long-standing problems in the system, such as staff and resource shortages. The reported symptoms were linked mainly to the perception of institutional betrayal and to the feeling of being unable to fulfill the duty of care toward patients.
The interviewees reported increased anxiety, depressive symptoms and sleep changes (Hegarty et al., 2022). Most believed that changes in the organization were needed to avoid excessive exposure to these events and to allow moral distress to be resolved. The authors advocate an organizational strategy with several fronts.
A commentary published early in the pandemic describes how professionals wear not only protective equipment but also an emotional barrier to keep working (Dean et al., 2020). Like soldiers, they postpone processing grief, trauma and betrayal, and the risk appears when the pace slows. The authors note that, for many doctors, saying they need help is still associated with shame, not courage.
Work environment and institutional culture
If moral injury arises from the gap between what professionals believe is right and what they are able to do, working conditions move to the center of the problem. A study at 21 veterans medical centers in the United States heard 2004 health professionals in high-risk sectors during the pandemic (Purcell et al., 2024).
Among the participants, 39 out of 100 were at risk of moral injury, 41 out of 100 of post-traumatic stress, 27 out of 100 of depression and 25 out of 100 of persistent burnout (Purcell et al., 2024). The factors that most predicted risk of moral injury were the perception of a lack of support from management for worker health and safety, supervisor support, colleague support and autonomy to make decisions at work. All are modifiable factors.
Among the factors linked to the pandemic, prolonged staff shortages, restricted visits from family members and intense conflict between work and family appeared (Purcell et al., 2024). In interviews with 46 participants, the protective themes were a collaborative work community, engaged leadership, autonomy to make changes and the opportunity to process difficult events.
Witnessing, taking part, feeling betrayed
A longitudinal study with 473 health professionals in the United States assessed each type of potentially harmful event in May 2020 and followed the participants until May 2021 (Usset et al., 2024). At the first point, 17.67 out of 100 reported having taken part in an event of this kind, 41.44 out of 100 reported having witnessed one and 76.61 out of 100 said they felt betrayed by health organizations.
The effects varied according to the type of exposure (Usset et al., 2024). Those who witnessed a harmful event had a higher risk of intending to leave their job one year later (relative risk 1.66, confidence interval 1.17 to 2.34). Those who took part had a higher risk of burnout (relative risk 1.38, confidence interval 1.03 to 1.85). The feeling of betrayal, despite being very frequent, was not associated with these outcomes in the full models.
These results suggest that asking whether the professional suffered moral injury is not enough (Usset et al., 2024). It matters to know what type of event it was, because the consequences and the most useful responses may differ. For those who manage teams, the loss of experienced professionals is a concrete cost of leaving moral injury unaddressed.
Prevention and repair
The authors of the perspective piece state that moral distress may be inevitable in health care, but moral injury and burnout are not (Rosen et al., 2022). To prevent and repair, leadership needs to recognize that the problem is not individual weakness, but systems and contexts that need to change. Cultivating moral resilience helps, but no professional, however resilient, can sustain an excessive workload with scarce resources indefinitely.
That is why isolated sessions of mindfulness or yoga do not solve moral injury (Rosen et al., 2022). A problem that arises from the context requires solutions in the context and in the community. This does not mean that caring for oneself is useless, but that individual care needs to come together with changes in the organization of work.
Prevention at three levels
A proposed research agenda organizes prevention at three levels (Maguen and Griffin, 2022). At the primary level, information about moral injury, encouragement of informal support and proactive contacts from leadership. At the secondary level, reducing stigma and training the team to recognize signs in colleagues. At the tertiary level, access to confidential, prompt and available mental health services.
Studies with health professionals consistently show that leadership support protects against moral injury (Maguen and Griffin, 2022). This support means being heard, having concerns answered, trust, empathy, feeling valued and having present and visible leaders. Adequate infrastructure and clear communication also appeared as central themes.
In the study of veterans centers, the recommendations included involving professionals in high-impact decisions that affect them and creating clear and consistent communication channels between management and team (Purcell et al., 2024). These are measures that are simple to describe and hard to maintain, but they directly address the feeling of institutional betrayal.
Treatment
There are specific treatments for moral injury developed for military personnel, focused on reducing guilt and shame and increasing self-compassion and the ability to forgive oneself (Maguen and Griffin, 2022). Some treatments for post-traumatic stress also seem to help. But most were designed for moral injury linked to war, and adaptation for health professionals is still under study.
Among health professionals, some interventions have shown preliminary acceptability and feasibility, such as an online group program based on acceptance and commitment therapy, which has not yet been tested in a clinical trial (Maguen and Griffin, 2022). The authors acknowledge that the research published so far is more descriptive than comparative.
In the survey with 595 respondents, moral resilience, defined as the ability to preserve or restore integrity, worked as a moderator between time in the profession and moral injury (Rushton and colleagues, 2022). The authors see it as a promising individual resource, but call for more research on how to cultivate it and on the system factors that prevent injury.
What to do in practice
For the physician, the first step is to name what you feel. Guilt, anger, shame and loss of confidence after a situation in which values were violated are not signs of weakness or incompetence. They are understandable responses to a moral violation, and recognizing them helps separate moral injury from ordinary tiredness (Rosen and colleagues, 2022).
The second step is to talk. Speaking with colleagues who have lived through similar situations, with a trusted supervisor or with a mental health professional reduces isolation. Peer support and the opportunity to process difficult events appear among the protective factors in the studies (Purcell and colleagues, 2024). The experience of second victim, when the physician suffers after an error, has points in common with moral injury and calls for the same kind of support.
The third step is to seek help when symptoms persist. Anxiety, depression, sleep changes and thoughts of death associated with moral injury call for professional assessment (Coimbra and colleagues, 2023; Amsalem and colleagues, 2021). The text on suicide risk shows what clinical assessment captures and why it is worth asking directly.
For those who lead teams, the list is different. Being present, listening, explaining difficult decisions, involving the team before high-impact changes and ensuring confidential access to mental health care are measures supported by the studies (Maguen and Griffin, 2022; Purcell and colleagues, 2024). A culture that treats error and ethical conflict as an opportunity to learn, as in a just culture, also reduces the sense of betrayal.
Mistakes that repeat
The first mistake is to call everything burnout. Moral injury has a different origin and response, and offering only rest or relaxation activities to someone who feels betrayed can deepen the sense of abandonment (Rosen and colleagues, 2022).
The second mistake is to treat moral injury as an individual problem. The studies show that support from management, supervisors and colleagues and autonomy at work are among the main modifiable risk factors (Purcell and colleagues, 2024).
The third mistake is to ignore those who witness. Witnessing a harmful event was associated with more intention to leave the job, even without direct participation (Usset and colleagues, 2024). Residents and students who observe difficult decisions also need space to talk, and burnout in medical school often starts there.
The fourth mistake is to think the crisis has passed. The pandemic gave visibility to the topic, but moral injury existed before it and continues to exist whenever resources, staff or space for decisions consistent with the values of care are lacking (Rosen and colleagues, 2022; Hegarty and colleagues, 2022).
How NEXO helps train this reasoning
In NEXO, the case of the day is fictional, with a real clinical presentation and up to six progressive clues, and you propose the diagnosis by looking for the code in ICD-10.
The limits on using the game are described on the Economy page of NEXO. If you research the teaching of clinical reasoning, the page for Researcher explains how to get in touch. Professionals who write or review cases find information on Curator and on Creators, and institutions can learn about the proposal on the partnerships page. Practicing differential diagnosis with clues and searching for the right ICD-10 code complete this training.
Frequently asked questions
What is moral injury?
It is the psychological, social and spiritual harm that arises when someone commits, fails to prevent or witnesses acts that violate deep values, or when they feel betrayed by someone in authority. Guilt, shame, anger and loss of trust are common manifestations.
Is moral injury the same as burnout?
It is not. Burnout involves exhaustion, cynicism and low accomplishment, with loss of moral investment. In moral injury, values remain alive and wounded. The two can be linked, because unrecognized moral injury can lead to burnout.
What is the difference between moral distress and moral injury?
In moral distress, the professional knows what is right and is prevented from acting. In moral injury, the violation has already happened and leaves a wound in identity. Sustained moral distress is one of the most common causes of moral injury.
Does moral injury affect mental health?
Yes. A meta-analysis with more than 31 thousand professionals found a moderate association between moral injury and symptoms of post-traumatic stress, anxiety, depression, burnout and suicidal ideation.
What can the institution do?
Ensure leadership support, clear communication, team participation in high-impact decisions, adequate staff and resources, and confidential and rapid access to mental health care.
Take-home messages
- Moral injury is the wound caused by violating or witnessing the violation of deep values, or by betrayal by someone in authority.
- It is distinct from moral distress and burnout, although the three can be linked.
- Moral injury is associated with anxiety, depression, post-traumatic stress and suicidal ideation.
- Support from management, supervisors and colleagues and autonomy at work are modifiable factors.
- Witnessing and taking part in harmful events have different consequences.
- Personal resilience helps, but prevention and repair depend on changes in the system.
References
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- Dean W, Jacobs B, Manfredi RA. Moral Injury: The Invisible Epidemic in COVID Health Care Workers. Ann Emerg Med. 2020. PMID 32586634.
- Hegarty S, Lamb D, Stevelink SAM, et al. 'It hurts your heart': frontline healthcare worker experiences of moral injury during the COVID-19 pandemic. Eur J Psychotraumatol. 2022. PMID 36276556.
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