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Cited by 454Ethics in medical practiceEthics and bioethics in healthcareEthics in Business and Education

Moral injury in healthcare professionals: A scoping review and discussion

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Čartolovni, Anto, Stolt, Minna, Scott, P Anne, Suhonen, Riitta·2021·Nursing Ethics
DOI 10.1177/0969733020966776PMC PMC8366182
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Abstract

Moral injury emerged in the healthcare discussion quite recently because of the difficulties and challenges healthcare workers and healthcare systems face in the context of the COVID-19 pandemic. Moral injury involves a deep emotional wound and is unique to those who bear witness to intense human suffering and cruelty. This article aims to synthesise the very limited evidence from empirical studies on moral injury and to discuss a better understanding of the concept of moral injury, its importance in the healthcare context and its relation to the well-known concept of moral distress. A scoping literature review design was used to support the discussion. Systematic literature searches conducted in April 2020 in two electronic databases, PubMed/Medline and PsychInfo, produced 2044 hits but only a handful of empirical papers, from which seven well-focused articles were identified. The concept of moral injury was considered under other concepts as well such as stress of conscience, regrets for ethical situation, moral distress and ethical suffering, guilt without fault, and existential suffering with inflicting pain. Nurses had witnessed these difficult ethical situations when faced with unnecessary patient suffering and a feeling of not doing enough. Some cases of moral distress may turn into moral residue and end in moral injury with time, and in certain circumstances and contexts. The association between these concepts needs further investigation and confirmation through empirical studies; in particular, where to draw the line as to when moral distress turns into moral injury, leading to severe consequences. Given the very limited research on moral injury, discussion of moral injury in the context of the duty to care, for example, in this pandemic settings and similar situations warrants some consideration.

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  • When a tool perceived as clinically useful is withdrawn for reasons unrelated to performance, some staff may experience this as the loss of a valuable component of their daily work (moral distress or moral injury), stemming from dissonance between sense of purpose and actual practice.

    “When a tool perceived as clinically useful is withdrawn for reasons unrelated to performance, some staff may experience this as the loss of a valuable component of their daily work (sometimes referred to in the literature as 'moral distress or moral injury' 13 , stemming from the dissonance between sense of purpose and actual practice).”

    From Radiology staff perspectives after decommissioning an artificial intelligence (AI) tool for expedited lung cancer triage (2026) · cites this paper as [13]

    The Discussion and concept contextualization section supports moral distress as a response to impeded professional goals or thwarted moral action, which fits the cited explanation of dissonance between purpose and practice. It does not address withdrawal of a clinically useful tool, and it distinguishes moral injury from distress by linking injury to potentially morally injurious events and more lasting consequences. Thus, the source supports the conceptual analogy, but not the specific tool-withdrawal scenario or its characterization as moral injury. (LLM, conf=0.85)

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Authors
Čartolovni, A., Stolt, M., Scott, P. A., & Suhonen, R.
Affiliations
  • University of Hull (GB)
  • University of Turku (FI)
  • Ollscoil na Gaillimhe – University of Galway (IE)
Corresponding author
Čartolovni, Anto
ORCID
Venue
Nursing Ethics
Publisher
SAGE Publications
Published
2021-01-11
Volume
28
Issue
5
Pages
590-602
ISSN
  • 0969-7330 (ISSN-L)
  • 1477-0989
DOI
10.1177/0969733020966776
PMC
PMC8366182
OpenAlex
W3119083154
Cited by
454
References
5
Citations by year
2026: 128 · 2025: 91 · 2024: 88 · 2023: 71 · 2022: 55 · 2021: 21
FWCI
11.87
Type
journal article
Language
en
Open access
Licence
Locations
  • Nursing Ethics (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • Repository@Hull (Worktribe) (University of Hull) (submittedVersion, cc-by-nc)
  • UTUPub (University of Turku) (submittedVersion)
Funders
  • Hrvatska Zaklada za Znanost (UIP-2019-04-3212)
  • European Cooperation in Science and Technology (CA15208)
Topics
  • Health Sciences › Health Professions › General Health Professions › Ethics in medical practice
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
  • Social Sciences › Decision Sciences › Information Systems and Management › Ethics in Business and Education
Keywords
moral injury, moral distress, moral residue, stress of conscience, existential suffering, nurses, healthcare workers, COVID-19 pandemic, duty to care, ethical suffering, patient suffering
MeSH terms
COVID-19, Health Personnel, Humans, Morals, Stress Disorders, Post-Traumatic, Pandemics

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