An Introduction to Moral Injury

An Introduction to Moral Injury: What is it & Why should I care?

By Dr Lorraine Smith-MacDonald, Dr Liana Lentz  & Dr Suzette Brémault-Philips

The ever-evolving global COVID-19 pandemic has placed public safety personnel (PSP) and frontline healthcare providers in unprecedented situations not seen in decades, if ever before. Amidst feelings of pride and personal satisfaction when providing care, PSP may also experience increased stress and anxiety as they carry out work-related tasks, and heightened concern over their own welfare and that of their families, colleagues and the people and communities they serve. High stake COVID-19-related decisions needing to be made in the course of service provision may also weigh heavily and result in PSP feeling distressed or conflicted. Left unresolved, this distress could lead to Operational Stress Injuries (OSI), Posttraumatic Stress Injuries (PTSI), and/or Moral Injuries.1 

Specific to Moral Injury (MI) are a few considerations:

  • Decisions made by PSP are generally guided by strong personal and organizational values. During this pandemic, however, decisions made may clash with deeply held personal and organizational morals and values (e.g., determination of who does and does not receive medical interventions), and result in an MI.
  • Moral Injury is “...a particular trauma syndrome including psychological, existential, behavioral, and interpersonal issues that emerge following perceived violations of deep moral beliefs by oneself or trusted individuals.”2
  • MI can impact you personally, and have negative effects on your health and wellbeing (e.g., feelings such as guilt, shame, anger, anxiety, sadness; self-criticism and judgement; stress-related and mood disorders).3-4
  • MI can impact you professionally. Unresolved moral distress can have negative short and long-term consequences (e.g,decreased job satisfaction, capacity to work, or overall engagement in the profession)5-6

Moral injury and moral distress. While there currently is little evidence-based literature regarding MI specific to PSP, existing literature about moral distress among healthcare providers suggests that it can occur (1) when a caregiver feels an acute sense of responsibility for what happened or cannot act in a patient’s best interest; and (2) when organizational constraints interfere with best or ethically correct care.7 Potentially morally injurious experiences (MIEs) to which you may be exposed during the COVID-19 pandemic may be similar (e.g., being expected to perform duties with minimal training or direction, or insufficient personal protective gear, medical equipment, or staff; or witnessing suffering on a large scale). Equally, COVID-19-specific MIEs may be completely different from what is reported in the literature.

While MI may be less known than posttraumatic stress disorder (PTSD), it can have a significant impact on individuals, families and organizations. Addressing it in a timely manner is important for your health and wellbeing. If you suspect that you have experienced an MIE or have a MI, reach out to and seek help from family, friends, colleagues, leadership, and healthcare professionals.

A Guide to Moral Injury

  1. Canadian Institute for Public Safety Research and Treatment (CIPSRT). (2019). Glossary of terms: A shared understanding of the common terms used to describe psychological trauma (version 2.1). Regina, SK: Author.
  2. Jinkerson, J. D. (2016). Defining and assessing moral injury: A syndrome perspective. Traumatology, 22(2), 122–130.
  3. Frankfurt, S., & Frazier, P. (2019). A review of research on moral injury in combat veterans. Military Psychology, 28(5), 318–330.
  4. Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695–706.
  5. Severinsson, E. (2003). Moral stress and burnout: qualitative content analysis. Nursing and Health Sciences, 5, 59-66.https://org/10.1046/j.1442-2018.2003.00135.x
  6. Shoorideh, F.A., Ashktorab, T., Yaghmaei, F., & Majd, H.A.(2015). Relationship between ICU nurses’ moral distress with burnout and anticipated turnover. Nursing Ethics, 22(11), 64-76.http://dio: 10.1177/0969733014534874
  7. Corley, M.C., Elswick, R.K., Gorman, M., & Clor T. (2001). Development and evaluation of a moral distress scale. Journal of Advanced Nursing, 33(2), 250-256.