Compromised Conscience: A Scoping Review of Moral Injury Among Firefighters, Paramedics, and Police Officers
Open accessAbstract
Background: Public Safety Personnel (e.g., firefighters, paramedics, and police officers) are routinely exposed to human suffering and need to make quick, morally challenging decisions. Such decisions can affect their psychological wellbeing. Participating in or observing an event or situation that conflicts with personal values can potentially lead to the development of moral injury. Common stressors associated with moral injury include betrayal, inability to prevent death or harm, and ethical dilemmas. Potentially psychologically traumatic event exposures and post-traumatic stress disorder can be comorbid with moral injury; however, moral injury extends beyond fear to include spiritual, cognitive, emotional or existential struggles, which can produce feelings of severe shame, guilt, and anger. Objective: This scoping review was designed to identify the extant empirical research regarding the construct of moral injury, its associated constructs, and how it relates to moral distress in firefighters, paramedics, and police officers. Methods: A systematic literature search of peer-reviewed research was conducted using databases MEDLINE, EMBASE, APA PsychInfo, CINHAL PLUS, Web of Science, SCOPUS, and Google Scholar. Included studies were selected based on the inclusion criteria before being manually extracted and independently screened by two reviewers. Results: The initial database search returned 777 articles, 506 of which remained after removal of duplicates. Following review of titles, abstracts, and full texts, 32 studies were included in the current review. Participants in the articles were primarily police officers, with fewer articles focusing on paramedics and firefighters. There were two studies that included mixed populations (i.e., one study with police officers, firefighters, and other emergency service workers; one study with paramedic and firefighter incident commanders). Most studies were qualitative and focused on four topics: values, ethical decision-making, organizational betrayal, and spirituality. Conclusion: Public safety organizations appear to recognize the experience of moral distress or moral injury among public safety personnel that results from disconnects between personal core values, formal and informal organizational values, vocational duties, and expectations. Further research is needed to better understand moral distress or moral injury specific to public safety personnel and inform training and treatment in support of public safety personnel mental health.
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Inadequately fulfilling caring work according to their own ethical standards might also lead paramedics to develop moral distress.
“Inadequately fulfilling caring work according to their own ethical standards might also lead paramedics to develop moral distress, a phenomenon often occurring when healthcare professionals feel powerless to take the ethically correct action [17, 18].”
From Paramedics’ perceptions of job demands and resources in Finnish emergency medical services: a qualitative study (2022) · cites this paper as [17]
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BackgroundEthical Decision Making in Disaster and Emergency Management: A Systematic Review of the Literature
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Self-citationForgiveness: A Key Component of Healing From Moral Injury?
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Critical Care Providers’ Moral Distress: Frequency, Burden, and Potential Resources
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“Although moral injury occurs in other occupations (for a review see Lentz and colleagues [11]), combat situations (and especially insurgency warfare), often result in ambiguous, split-second decisions, in which the sanctioned course of action is not readily apparent or results”
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Große, G., Frick, E., & Schütte‐Nütgen, K. (2022) · Spiritual Care · doi:10.1515/spircare-2022-0018 · Cited by 1 · see citing works
Dangermond, K., Weewer, R., Duyndam, J., & Machielse, A. (2022) · International Journal of Emergency Management · doi:10.1504/ijem.2022.125166 · Cited by 1 · see citing works
Moral Injury, Compound Officer Trauma, and Officer Mental Health
MacLean, C. E., & Densley, J. A. (2023) · Springer eBooks · doi:10.1007/978-3-031-39082-1_3
(2023) · Australian Journal of Emergency Management · doi:10.47389/38.4
THE RELATIONSHIP BETWEEN LEVELS OF CONSCIENCE, PATIENCE, AND PSYCHOLOGICAL RESI
Karayaman, S. (2023) · International Journal Of Eurasia Social Sciences · doi:10.35826/ijoess.3371
Schröder‐Bäck, P. (2023) · Geschichte und Ethik der Polizei und öffentlichen Verwaltung · doi:10.1007/978-3-658-42899-0_6
Abrahamson, D. E. (2024) · Springer eBooks · doi:10.1007/978-3-031-67943-8_6
Moral Injury and Nursing Practice
Čartolovni, A., Stolt, M., Suhonen, R., & Scott, P. A. (2024) · Springer eBooks · doi:10.1007/978-3-031-54108-7_4
- Authors
- Lentz, L. M., Smith-MacDonald, L., Malloy, D., Carleton, R. N., & Brémault-Phillips, S.
- Affiliations
- Western University (CA)
- University of Regina (CA)
- Corresponding author
- Lentz, Liana M.
- Venue
- Frontiers in Psychology
- Publisher
- Frontiers Media SA
- Published
- 2021-03-31
- Volume
- 12
- Pages
- 639781-639781
- ISSN
- 1664-1078 (ISSN-L)
- PMC
- PMC8044342
- OpenAlex
- W3150699884
- Cited by
- 143
- References
- 116
- Citations by year
- 2026: 34 · 2025: 34 · 2024: 18 · 2023: 29 · 2022: 23 · 2021: 5
- FWCI
- 2.49
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Frontiers in Psychology (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- oURspace (University of Regina) (submittedVersion, cc-by)
- Funders
- Canadian Institutes of Health Research
- Topics
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Health Sciences › Health Professions › General Health Professions › Ethics in medical practice
- Health Sciences › Health Professions › Occupational Therapy › Occupational Health and Performance
- Keywords
- moral injury, moral distress, public safety personnel, firefighters, paramedics, police officers, ethical decision-making, personal values, spirituality, guilt and shame, workplace mental health, trauma exposure
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