Moral Injury in Critical Care


Published: 07 May 2020

As the reality of rationing intensive care resources takes hold, moral injury, a term once only used within the military, is now entering the nursing vocabulary.

The current COVID-19 pandemic is currently placing healthcare professionals across the world under extreme pressure. Decisions have to be made about how to allocate scarce resources, or who amongst equally needy patients receives priority treatment. Further pressures come when nurses are faced with balancing their own physical and mental healthcare needs with those of their patients, and over time this is leading many nurses to experience feelings of moral injury (Greenberg 2020).

What is Moral Injury?

Williamson, Murphy and Greenberg (2020) define moral injury as the profound psychological distress that results from actions, or the lack of them, which violate a person’s moral or ethical code.

Unlike post-traumatic stress disorder (PTSD), moral injury is not classified as a mental illness. Similarly, the term moral distress occurs when the practitioner knows the ethically correct action to take but feels powerless to take that action (Epstein and Delgado 2020).

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. It’s a concern that is beginning to surface for many critical care teams at this time.

Moral Injury in ICU Settings

Lack of specific resources such as ventilators along with potential shortages of skilled staff may mean that care needs to be rationed. As White and Lo (2020) suggest, in ideal circumstances an independent triage officer or team should make decisions about allocating or discontinuing the resources needed for life support.

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 (2020) theorise that moral distress often occurs when the nurse 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; or
  • Inadequate staffing or staff who are not adequately trained to provide the required care.

Williamson, Murphy and Greenberg (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 potentially morally injurious event occurs concurrently with exposure to other traumatic events.

Langley, Kisorio and Schmollgruber (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; and
  5. Lack of support.

Psychological Preparedness

Despite enormous efforts to ensure adequate staffing and resources during the current COVID-19 pandemic, many healthcare practitioners will likely encounter situations where they cannot 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, Murphy and Greenberg (2020) suggest that front-line staff should be made aware of the possibility of potentially morally injurious events 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, Murphy and Greenberg (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 potentially morally injurious events, facilitate effective team cohesion and make informal, as well as professional sources of support readily available to their staff.

moral injury hold hands

Moral Residue

A concept similar to that of moral distress and moral injury is that of 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 and 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, as we begin to reflect on the lessons of nursing in a pandemic, 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). Whatever the individual or collective solutions, one thing is certain: these are extraordinary times for critical care nurses and perhaps now more than ever, there is a need to ensure the demands of working in a high-pressure environment don’t cause lasting damage.

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

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