Introduction: Moral injury involves the adverse psychological, biological, spiritual, behavioural, and social consequences of actions that violate moral values. It can lead to anxiety, depression, burnout, and post-traumatic stress disorder. Nurses, who often face ethical dilemmas, are particularly vulnerable. Despite its significance, the relationship between moral injury and mental health outcomes in nurses remains underexplored. Aim: This systematic review aimed to describe the associations among moral injury, anxiety, depression, and quality of life in nurses. Methods: The review was registered in PROSPERO (CRD42023438731) and was conducted following the PRISMA guidelines. A literature search was performed in December 2023 across PubMed, CINAHL, Scopus, and Web of Science. Peer-reviewed primary research involving nurses, published in English or Italian, without time restrictions, was considered eligible. The risk of bias and the quality of evidence were assessed using the Joanna Briggs Institute checklist and the GRADE approach. Results: Out of 4730 articles identified, eight met the inclusion criteria. The analysis revealed significant positive associations between moral injury, anxiety, and depression, along with a significant negative association with quality of life. Conclusion: These findings highlight the need for healthcare systems to implement strategies that mitigate moral injury among nurses. Future research should prioritize longitudinal studies to explore causal relationships and develop targeted interventions. Additionally, standardizing the concept and measurements of moral injury is crucial for enhancing the comparability and understanding of this phenomenon.
GriffinBJPurcellNBurkmanK, et al.Moral injury: an integrative review. J Trauma Stress2019; 32: 350–362. DOI: 10.1002/jts.22362.
2.
KoenigHGYoussefNAPearceM. Assessment of moral injury in veterans and active duty military personnel with PTSD: a review. Front Psychiatr2019; 10: 443. DOI: 10.3389/fpsyt.2019.00443.
3.
HegartySLambDStevelinkSAM, et al.‘It hurts your heart’: frontline healthcare worker experiences of moral injury during the COVID-19 pandemic. Eur J Psychotraumatol2022; 13: 2128028. DOI: 10.1080/20008066.2022.2128028.
4.
GibbonsSWShaferMHicklingEJ, et al.How do deployed health care providers experience moral injury?Narrat Inq Bioeth2013; 3: 247–259. DOI: 10.1353/nib.2013.0055.
5.
WilliamsonVMurphyDCastroC, et al.Moral injury and the need to carry out ethically responsible research. Research Ethics2021; 17: 135–142.
6.
ČartolovniAStoltMScottPA, et al.Moral injury in healthcare professionals: a scoping review and discussion. Nurs Ethics2021; 28: 590–602. DOI: 10.1177/0969733020966776.
7.
LambDGnanapragasamSGreenbergN, et al.Psychosocial impact of the COVID-19 pandemic on 4378 UK healthcare workers and ancillary staff: initial baseline data from a cohort study collected during the first wave of the pandemic. Occup Environ Med2021; 78: 801–808. DOI: 10.1136/oemed-2020-107276.
8.
CurrierJMMcCormickWDrescherKD. How do morally injurious events occur? A qualitative analysis of perspectives of veterans with PTSD. Traumatology2015; 21: 106–116. DOI: 10.1037/trm0000027.
9.
WilliamsonVStevelinkSAMGreenbergN. Occupational moral injury and mental health: systematic review and meta-analysis. Br J Psychiatry2018; 212: 339–346. DOI: 10.1192/bjp.2018.55.
10.
MantriSSongYKLawsonJM, et al.Moral injury and burnout in health care professionals during the COVID-19 pandemic. J Nerv Ment Dis2021; 209: 720–726. DOI: 10.1097/nmd.0000000000001367.
11.
MewbornEKFingerhoodMLJohansonL, et al.Examining moral injury in clinical practice: a narrative literature review. Nurs Ethics2023; 30: 960–974. DOI: 10.1177/09697330231164762.
12.
StovallMHansenLvan RynM. A critical review: moral injury in nurses in the aftermath of a patient safety incident. J Nurs Scholarsh2020; 52: 320–328. DOI: 10.1111/jnu.12551.
13.
RushtonCHNelsonKEAntonsdottirI, et al.Perceived organizational effectiveness, moral injury, and moral resilience among nurses during the COVID-19 pandemic: secondary analysis. Nurs Manag2022; 53: 12–22. DOI: 10.1097/01.NUMA.0000834524.01865.cc.
14.
RushtonCHThomasTAAntonsdottirIM, et al.Moral injury and moral resilience in health care workers during COVID-19 pandemic. J Palliat Med2022; 25: 712–719. DOI: 10.1089/jpm.2021.0076.
15.
WangZAl ZabenFKoenigHG, et al.Spirituality, moral injury and mental health among Chinese health professionals. BJPsych Open2021; 7: e135. DOI: 10.1192/bjo.2021.972.
16.
RiedelPLKrehAKulcarV, et al.A scoping review of moral stressors, moral distress and moral injury in healthcare workers during COVID-19. Int J Environ Res Publ Health2022; 19: 19031666. DOI: 10.3390/ijerph19031666.
17.
RowlandsSL. Understanding and mitigating moral injury in nurses. Nurs Stand2021; 36: 40–44. DOI: 10.7748/ns.2021.e11703.
18.
ShayJ. Achilles in Vietnam: combat trauma and the undoing of character. New York, NY: Simon & Schuster, 1995.
LitzBTSteinNDelaneyE, et al.Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev2009; 29: 695–706. DOI: 10.1016/j.cpr.2009.07.003.
21.
FrankfurtSFrazierP. A review of research on moral injury in combat veterans. Mil Psychol2016; 28: 318–330. DOI: 10.1037/mil0000132.
22.
NormanSBNichterBMaguenS, et al.Moral injury among U.S. combat veterans with and without PTSD and depression. J Psychiatr Res2022; 154: 190–197. DOI: 10.1016/j.jpsychires.2022.07.033.
23.
RichardsonNMLamsonALSmithM, et al.Defining moral injury among military populations: a systematic review. J Trauma Stress2020; 33: 575–586. DOI: 10.1002/jts.22553.
24.
BryanCJMorrowCEEtienneN, et al.Guilt, shame, and suicidal ideation in a military outpatient clinical sample. Depress Anxiety2013; 30: 55–60. DOI: 10.1002/da.22002.
25.
KoenigHGAmesDYoussefNA, et al.The moral injury symptom scale-military version. J Relig Health2018; 57: 249–265. DOI: 10.1007/s10943-017-0531-9.
26.
KoenigHGAmesDYoussefNA, et al.Screening for moral injury: the moral injury symptom scale - military version short form. Mil Med2018; 183: e659–e665. DOI: 10.1093/milmed/usy017.
27.
NashWPMarino CarperTLMillsMA, et al.Psychometric evaluation of the moral injury events scale. Mil Med2013; 178: 646–652. DOI: 10.7205/milmed-d-13-00017.
28.
PapazoglouKBlumbergDMChiongbianVB, et al.The role of moral injury in PTSD among law enforcement officers: a brief report. Front Psychol2020; 11: 310. DOI: 10.3389/fpsyg.2020.00310.
29.
LentzLMSmith-MacDonaldLMalloyD, et al.Compromised conscience: a scoping review of moral injury among firefighters, paramedics, and police officers. Front Psychol2021; 12: 639781. DOI: 10.3389/fpsyg.2021.639781.
30.
FeinsteinAPavisianBStormH. Journalists covering the refugee and migration crisis are affected by moral injury not PTSD. JRSM Open2018; 9: 2054270418759010. DOI: 10.1177/2054270418759010.
31.
SugrueEP. Moral injury among professionals in K–12 education. Am Educ Res J2020; 57: 43–68. DOI: 10.3102/0002831219848690.
32.
GaitensJCondonMFernandesE, et al.COVID-19 and essential workers: a narrative review of health outcomes and moral injury. Int J Environ Res Publ Health2021; 18: 1446.
33.
NickersonASchnyderUBryantRA, et al.Moral injury in traumatized refugees. Psychother Psychosom2015; 84: 122–123. DOI: 10.1159/000369353.
34.
TemoneyKE. The war came alive inside of them. J Relig Ethics2021; 49: 479–494. DOI: 10.1111/jore.12366.
35.
CarletonTCSnodgrassJL. Moral injury after abortion: exploring the psychospiritual impact on Catholic women. London, UK: Routledge, 2022.
36.
DeanWTalbotSDeanA. Reframing clinician distress: moral injury not burnout. Fed Pract2019; 36: 400–402.
37.
HodgsonTJCareyLB. Moral injury and definitional clarity: betrayal, spirituality and the role of chaplains. J Relig Health2017; 56: 1212–1228. DOI: 10.1007/s10943-017-0407-z.
38.
LindertJ. Moral injury and moral distress. Eur J Publ Health2021; 31: 454. DOI: 10.1093/eurpub/ckab164.454.
39.
MantriSLawsonJMWangZ, et al.Identifying moral injury in healthcare professionals: the moral injury symptom scale-HP. J Relig Health2020; 59: 2323–2340. DOI: 10.1007/s10943-020-01065-w.
40.
KopaczMSAmesDKoenigHG. It’s time to talk about physician burnout and moral injury. Lancet Psychiatr2019; 6: e28. DOI: 10.1016/s2215-0366(19)30385-2.
41.
RosenACahillJMDugdaleLS. Moral injury in health care: identification and repair in the COVID-19 era. J Gen Intern Med2022; 37: 3739–3743. DOI: 10.1007/s11606-022-07761-5.
42.
EpsteinEGHamricAB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics2009; 20: 330–342.
43.
LinzerMPoplauS. Eliminating burnout and moral injury: bolder steps required. EClinical Med2021; 39: 101090. DOI: 10.1016/j.eclinm.2021.101090.
44.
DzengEWachterRM. Ethics in conflict: moral distress as a root cause of burnout. J Gen Intern Med2020; 35: 409–411. DOI: 10.1007/s11606-019-05505-6.
45.
RamosAMBarlemELDBarlemJGT, et al.Cross-cultural adaptation and validation of the moral distress scale-revised for nurses. Rev Bras Enferm2017; 70: 1011–1017. DOI: 10.1590/0034-7167-2016-0518.
46.
KoenigHGAl ZabenF. Moral injury: an increasingly recognized and widespread syndrome. J Relig Health2021; 60: 2989–3011. DOI: 10.1007/s10943-021-01328-0.
47.
MaslachCLeiterMP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatr2016; 15: 103–111. DOI: 10.1002/wps.20311.
48.
KirkpatrickHAHellerGM. Post-traumatic stress disorder: theory and treatment update. Int J Psychiatr Med2014; 47: 337–346. DOI: 10.2190/PM.47.4.h.
49.
BartzakPJ. Moral injury is the wound: PTSD is the manifestation. Medsurg Nurs2015; 24(3): 10–11.
50.
DeanWJacobsBManfrediRA. Moral injury: the invisible epidemic in COVID health care workers. Ann Emerg Med2020; 76: 385–386. DOI: 10.1016/j.annemergmed.2020.05.023.
51.
HinesSEChinKHGlickDR, et al.Trends in moral injury, distress, and resilience factors among healthcare workers at the beginning of the COVID-19 pandemic. Int J Environ Res Publ Health2021; 18: 18020488. DOI: 10.3390/ijerph18020488.
52.
MantriSLawsonJMWangZ, et al.Prevalence and predictors of moral injury symptoms in health care professionals. J Nerv Ment Dis2021; 209: 174–180. DOI: 10.1097/nmd.0000000000001277.
53.
BeckCT. Secondary qualitative analysis of moral injury in obstetric and neonatal nurses. J Obstet Gynecol Neonatal Nurs2022; 51: 166–176. DOI: 10.1016/j.jogn.2021.12.003.
54.
NagdeeNManuel de AndradeV. I don’t really know where I stand because I don’t know if I took something away from her’: moral injury in South African speech-language therapists and audiologists due to patient death and dying. Int J Lang Commun Disord2023; 58: 28–38. DOI: 10.1111/1460-6984.12765.
55.
AdeyemoOOTuSFalakoS, et al.Stressors on frontline healthcare workers during the COVID-19 pandemic: a focus on moral injury and implications for the future. Int Arch Occup Environ Health2022; 95: 1755–1762. DOI: 10.1007/s00420-022-01867-3.
56.
AkhtarMFaizeFAMalikRZ, et al.Moral injury and psychological resilience among healthcare professionals amid COVID-19 pandemic. Pakistan J Med Sci2022; 38: 1338–1342. DOI: 10.12669/pjms.38.5.5122.
57.
MackelCEAltermanRLBussMK, et al.Moral distress and moral injury among attending neurosurgeons: a national survey. Neurosurgery2022; 91: 59–65. DOI: 10.1227/neu.0000000000001921.
58.
WoernerAJGreenbergCHChickJFB, et al.Moral injury among interventional radiologists. Acad Radiol2024; 31: 1122–1129. DOI: 10.1016/j.acra.2023.09.015.
59.
WilliamsonVMurphyDGreenbergN. Experiences and impact of moral injury in U.K. veterinary professional wellbeing. Eur J Psychotraumatol2022; 13: 2051351. DOI: 10.1080/20008198.2022.2051351.
60.
BorgesLMHollidayRBarnesSM, et al.A longitudinal analysis of the role of potentially morally injurious events on COVID-19-related psychosocial functioning among healthcare providers. PLoS One2021; 16: e0260033. DOI: 10.1371/journal.pone.0260033.
61.
UlrichCMTaylorCSoekenK, et al.Everyday ethics: ethical issues and stress in nursing practice. J Adv Nurs2010; 66: 2510–2519. DOI: 10.1111/j.1365-2648.2010.05425.x.
62.
HinesSEChinKHLevineAR, et al.Initiation of a survey of healthcare worker distress and moral injury at the onset of the COVID-19 surge. Am J Ind Med2020; 63: 830–833. DOI: 10.1002/ajim.23157.
63.
DaleLPCuffeSPSambucoN, et al.Morally distressing experiences, moral injury, and burnout in Florida healthcare providers during the COVID-19 pandemic. Int J Environ Res Publ Health2021; 18: 182312319. DOI: 10.3390/ijerph182312319.
64.
SafdarCAQayyumR. Moral injury, emotional labor and burnout: an unbearable burden for health professionals. Pakistan J Med Sci2021; 37: 1256–1258. DOI: 10.12669/pjms.37.5.4794.
65.
KingstonAM. Break the silence: physician suicide in the time of COVID-19. Mo Med2020; 117: 426–429.
66.
RosenbaumL. Facing covid-19 in Italy - ethics, logistics, and therapeutics on the epidemic’s front line. N Engl J Med2020; 382: 1873–1875. DOI: 10.1056/NEJMp2005492.
67.
LitamSDABalkinRS. Moral injury in health-care workers during COVID-19 pandemic. Traumatology2021; 27: 14–19. DOI: 10.1037/trm0000290.
68.
GreenbergNDochertyMGnanapragasamS, et al.Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ2020; 368: m1211. DOI: 10.1136/bmj.m1211.
69.
SilvermanHJKheirbekREMoscou-JacksonG, et al.Moral distress in nurses caring for patients with Covid-19. Nurs Ethics2021; 28: 1137–1164. DOI: 10.1177/09697330211003217.
70.
FauciAJLatinaRIacorossiL, et al.Allocation of scarce critical care resources during public health emergencies: which ethical principles support decision making. Clin Ter2022; 173: 384–395. DOI: 10.7417/ct.2022.2450.
71.
RodríguezEAAgüero-FloresMLanda-BlancoM, et al.Moral injury and light triad traits: anxiety and depression in health-care personnel during the coronavirus-2019 pandemic in honduras. Hisp Health Care Int2021; 19: 230–238. DOI: 10.1177/15404153211042371.
72.
ShimizuKLinL. Defamation against healthcare workers during COVID-19 pandemic. Int J Health Pol Manag2022; 11: 720–721. DOI: 10.34172/ijhpm.2020.184.
73.
WeissingerGMSwavelyDHoltzH, et al.Critical care nurses’ moral resilience, moral injury, institutional betrayal, and traumatic stress after COVID-19. Am J Crit Care2024; 33: 105–114. DOI: 10.4037/ajcc2024481.
74.
PageMJMcKenzieJEBossuytPM, et al.The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ2021; 372: n71. DOI: 10.1136/bmj.n71.
75.
PageMJMoherDBossuytPM, et al.PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ2021; 372: n160. DOI: 10.1136/bmj.n160.
76.
RichardsonWSWilsonMCNishikawaJ, et al.The well-built clinical question: a key to evidence-based decisions. ACP J Club1995; 123: A12–A13.
77.
OuzzaniMHammadyHFedorowiczZ, et al.Rayyan—a web and mobile app for systematic reviews. Syst Rev2016; 5: 210. DOI: 10.1186/s13643-016-0384-4.
78.
HigginsJPTTJChandlerJCumpstonM, et al.Cochrane handbook for systematic reviews of interventions version 6.4. London, UK: Cochrane, 2023.
79.
McKenzieJEBrennanSERyanRE, et al.Summarizing study characteristics and preparing for synthesis. In: Cochrane handbook for systematic reviews of interventions. London, UK: Cochrane, 2019, 229–240.
80.
MoolaSMZSearsKSfetcuR, et al.Chapter 7: systematic reviews of etiology and risk. In: AromatarisEMZ (ed) JBI manual for evidence synthesis. Adelaide, SA: JBI, 2020.
81.
CampbellMMcKenzieJESowdenA, et al.Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline. BMJ2020; 368: l6890. DOI: 10.1136/bmj.l6890.
82.
OgilvieDFayterDPetticrewM, et al.The harvest plot: a method for synthesising evidence about the differential effects of interventions. BMC Med Res Methodol2008; 8: 8. DOI: 10.1186/1471-2288-8-8.
83.
MoolaSMunnZTufanaruC, et al.Chapter 7: systematic reviews of etiology and risk. Joanna Briggs Institute Reviewer’s Manual The Joanna Briggs Institute2017; 5: 217–269.
84.
SchünemannHJOxmanADBrozekJ, et al.Grading quality of evidence and strength of recommendations for diagnostic tests and strategies. BMJ2008; 336: 1106–1110. DOI: 10.1136/bmj.39500.677199.AE.
85.
AmsalemDLazarovAMarkowitzJC, et al.Psychiatric symptoms and moral injury among US healthcare workers in the COVID-19 era. BMC Psychiatr2021; 21: 546. DOI: 10.1186/s12888-021-03565-9.
86.
ZerachGLevi-BelzY. Moral injury and mental health outcomes among Israeli health and social care workers during the COVID-19 pandemic: a latent class analysis approach. Eur J Psychotraumatol2021; 12: 1945749. DOI: 10.1080/20008198.2021.1945749.
87.
BenatovJZerachGLevi-BelzY. Moral injury, depression, and anxiety symptoms among health and social care workers during the COVID-19 pandemic: the moderating role of belongingness. Int J Soc Psychiatr2022; 68: 1026–1035. DOI: 10.1177/00207640221099421.
88.
NieuwsmaJAO’BrienECXuH, et al.Patterns of potential moral injury in post-9/11 combat veterans and COVID-19 healthcare workers. J Gen Intern Med2022; 37: 2033–2040. DOI: 10.1007/s11606-022-07487-4.
89.
WangZKoenigHGTongY, et al.Moral injury in Chinese health professionals during the COVID-19 pandemic. Psychol Trauma2022; 14: 250–257. DOI: 10.1037/tra0001026.
90.
SpitzerRLKroenkeKWilliamsJB, et al.A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med2006; 166: 1092–1097. DOI: 10.1001/archinte.166.10.1092.
91.
KroenkeKSpitzerRLWilliamsJB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med2001; 16: 606–613. DOI: 10.1046/j.1525-1497.2001.016009606.x.
92.
HaysRDBjornerJBRevickiDA, et al.Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items. Qual Life Res2009; 18: 873–880. DOI: 10.1007/s11136-009-9496-9.
93.
CoimbraBMZylberstajnCvan ZuidenM, et al.Moral injury and mental health among health-care workers during the COVID-19 pandemic: meta-analysis. Eur J Psychotraumatol2023; 15: 2299659. DOI: 10.1080/20008066.2023.2299659.
94.
LeiQHeZKoenigHG, et al.Light personality style and moral injury among Chinese health professionals. J Relig Health2023; 62: 3942–3956. DOI: 10.1007/s10943-023-01921-5.
95.
WilliamsonVLambDHotopfM, et al.Moral injury and psychological wellbeing in UK healthcare staff. J Ment Health2023; 32: 890–898. DOI: 10.1080/09638237.2023.2182414.
96.
CecereLde NovellisSGravanteA, et al.Quality of life of critical care nurses and impact on anxiety, depression, stress, burnout and sleep quality: a cross-sectional study. Intensive Crit Care Nurs2023; 79: 103494. DOI: 10.1016/j.iccn.2023.103494.
97.
GravanteFToscanoGCecereL, et al.Quality of life, Stress, and Burnout of Italian nurses during the outbreak of COVID-19: a cross-sectional study. Prof Inferm2023; 75: 28–38. DOI: 10.7429/pi.2022.751028.
98.
TestoniIBrondoloERonconiL, et al.Burnout following moral injury and dehumanization: a study of distress among Italian medical staff during the first COVID-19 pandemic period. Psychol Trauma2022: 1346. DOI: 10.1037/tra0001346.
99.
LarssonGNilssonSHyllengrenP, et al.Stress reactions following acute situations involving moral challenges among health care professionals. Scand J Psychol2018; 59: 177–185. DOI: 10.1111/sjop.12425.
100.
FitzpatrickJJPignatielloGKimM, et al.Moral injury, nurse well-being, and resilience among nurses practicing during the COVID-19 pandemic. J Nurs Adm2022; 52: 392–398. DOI: 10.1097/nna.0000000000001171.
101.
LiangTKaka MirzaHMalakoutikhahA, et al.Moral injury and its correlates among Iranian nurses in the second year of the COVID-19 pandemic: a multicenter cross-sectional study. J Relig Health2023; 62: 3979–3994. DOI: 10.1007/s10943-023-01938-w.
102.
JovarauskaiteLMurphyDTruskauskaite-KunevicieneI, et al.Associations between moral injury and ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD among help-seeking nurses: a cross-sectional study. BMJ Open2022; 12: e056289. DOI: 10.1136/bmjopen-2021-056289.
103.
ShenYZhanYZhengH, et al.Anxiety and its association with perceived stress and insomnia among nurses fighting against COVID-19 in Wuhan: a cross-sectional survey. J Clin Nurs2021; 30: 2654–2664. DOI: 10.1111/jocn.15678.
104.
CheungTYipPSF. Depression, anxiety and symptoms of stress among Hong Kong nurses: a cross-sectional study. Int J Environ Res Publ Health2015; 12: 11072–11100.
105.
Abou ElallaEAwaadMElhabibyM, et al.Substance abuse among nursing staff: prevalence and sociodemographic and clinical characteristics. Addict Disord Their Treat2020; 19: 99–107. DOI: 10.1097/adt.0000000000000191.
106.
JunqueiraMABSantosMAAraújoLB, et al.Depressive symptoms and drug use among nursing staff professionals. Escola Anna Nery2018; 22: 129.
107.
FoliKJZhangLReddickB. Predictors of substance use in registered nurses: the role of psychological trauma. West J Nurs Res2021; 43: 1023–1033. DOI: 10.1177/0193945920987123.
108.
CheungTYipPSF. Self-harm in nurses: prevalence and correlates. J Adv Nurs2016; 72: 2124–2137. DOI: 10.1111/jan.12987.
109.
Silva DdosSTavaresNVAlexandreAR, et al.[Depression and suicide risk among nursing professionals: an integrative review]. Rev Esc Enferm USP2015; 49: 1027–1036. DOI: 10.1590/s0080-623420150000600020.
110.
CheungTLeePHYipPS. Suicidality among Hong Kong nurses: prevalence and correlates. J Adv Nurs2016; 72: 836–848. DOI: 10.1111/jan.12869.
111.
KousloglouSMouzasOBonotisK, et al.Insomnia and burnout in Greek nurses. Hippokratia2014; 18: 150–155.
112.
Membrive-JiménezMJGómez-UrquizaJLSuleiman-MartosN, et al.Relation between burnout and sleep problems in nurses: a systematic review with meta-analysis. Healthcare2022; 10: 954.
113.
FoliKJForsterAChengC, et al.Voices from the COVID-19 frontline: nurses’ trauma and coping. J Adv Nurs2021; 77: 3853–3866. DOI: 10.1111/jan.14988.
114.
MealerMBurnhamELGoodeCJ, et al.The prevalence and impact of post traumatic stress disorder and burnout syndrome in nurses. Depress Anxiety2009; 26: 1118–1126. DOI: 10.1002/da.20631.
115.
ChinWSChenYCHoJJ, et al.Psychological work environment and suicidal ideation among nurses in taiwan. J Nurs Scholarsh2019; 51: 106–113. DOI: 10.1111/jnu.12441.
116.
KabirHChowdhurySRRoyAK, et al.Association of workplace bullying and burnout with nurses’ suicidal ideation in Bangladesh. Sci Rep2023; 13: 14641. DOI: 10.1038/s41598-023-41594-4.
117.
StanojevićSČartolovniA. Moral distress and moral injury and their interplay as a challenge for leadership and management: the case of Croatia. J Nurs Manag2022; 30: 2335–2345. DOI: 10.1111/jonm.13835.
118.
CallisABSaulTBindlerRJ. The impact of moral injury on self-reported work performance in hospital nurses following the global pandemic surge. J Nurs Adm2024; 54: 177–183. DOI: 10.1097/nna.0000000000001404.
119.
TengYDehghanMHossini RafsanjanipoorSM, et al.Is nurses’ clinical competence associated with their moral identity and injury?Nurs Ethics2023; 2023: 9697330231209284. DOI: 10.1177/09697330231209284.
120.
PolatŞKutluLAyF, et al.Decision-making styles, anxiety levels, and critical thinking levels of nurses. Jpn J Nurs Sci2019; 16: 309–321. DOI: 10.1111/jjns.12240.
121.
BetsiouSPitsiouGPanagiotidouE, et al.Nursing errors in intensive care unit and their association with burnout, anxiety, insomnia and working environment: a cross-sectional study. Hippokratia2022; 26: 110–117.
122.
MelnykBMTanAHsiehAP, et al.Critical care nurses’ physical and mental health, worksite wellness support, and medical errors. Am J Crit Care2021; 30: 176–184. DOI: 10.4037/ajcc2021301.
123.
ModaresnezhadMAndrewsMCMesmer-MagnusJ, et al.Anxiety, job satisfaction, supervisor support and turnover intentions of mid-career nurses: a structural equation model analysis. J Nurs Manag2021; 29: 931–942. DOI: 10.1111/jonm.13229.
124.
TaburAElkefiSEmhanA, et al.Anxiety, burnout and depression, psychological well-being as predictor of healthcare professionals’ turnover during the COVID-19 pandemic: study in a pandemic hospital. Healthcare2022; 10: 10030525. DOI: 10.3390/healthcare10030525.
BerdidaDJEGrandeRAN. Moral distress, moral resilience, moral courage, and moral injury among nurses in the Philippines during the COVID-19 pandemic: a mediation analysis. J Relig Health2023; 62: 3957–3978. DOI: 10.1007/s10943-023-01873-w.
127.
RabinSKikaNLambD, et al.Moral injuries in healthcare workers: what causes them and what to do about them?J Healthc Leader2023; 15: 153–160. DOI: 10.2147/jhl.S396659.
128.
XueYLopesJRitchieK, et al.Potential circumstances associated with moral injury and moral distress in healthcare workers and public safety personnel across the globe during COVID-19: a scoping review. Front Psychiatr2022; 13: 863232. DOI: 10.3389/fpsyt.2022.863232.
129.
JohnstoneREdwardsP. Supporting nurse leaders to recognise and mitigate the effects of moral injury. Nurs Manag. 2022; e2067. DOI: 10.7748/nm.2022.e2067.
130.
KrehABrancaleoniRMagaliniSC, et al.Ethical and psychosocial considerations for hospital personnel in the Covid-19 crisis: moral injury and resilience. PLoS One2021; 16: e0249609. DOI: 10.1371/journal.pone.0249609.
131.
SolanoTGilbertGLKerridgeIH, et al.Ethical considerations in the management of Ebola virus disease. Med J Aust2015; 203: 193–195. DOI: 10.5694/mja15.00168.
132.
NelsonKEHansonGCBoyceD, et al.Organizational impact on healthcare workers’ moral injury during COVID-19: a mixed-methods analysis. J Nurs Adm2022; 52: 57–66. DOI: 10.1097/nna.0000000000001103.
133.
AustinCLSaylorRFinleyPJ. Moral distress in physicians and nurses: impact on professional quality of life and turnover. Psychol Trauma2017; 9: 399–406. DOI: 10.1037/tra0000201.
134.
Gilbert-OuimetMZahiriharsiniABironC, et al.Predict, prevent and manage moral injuries in Canadian frontline healthcare workers and leaders facing the COVID-19 pandemic: protocol of a mixed methods study. SSM Ment Health2022; 2: 100124. DOI: 10.1016/j.ssmmh.2022.100124.
135.
GravanteFLombardiACecereL, et al.[Emergency nurses and workplace violence: a cross-sectional study in Campania, South Italy]. Prof Inferm2020; 73: 89–97. DOI: 10.7429/pi.2020.732089.
136.
AnastasiGBambiS. Utilization and effects of security technologies in mental health: a scoping review. Int J Ment Health Nurs2023; 32: 1561–1582. DOI: 10.1111/inm.13193.
137.
SharmaMECousinsR. Understanding moral injury in frontline health care professionals 2 years after the onset of COVID-19. J Nerv Ment Dis2023; 211: 934–939. DOI: 10.1097/nmd.0000000000001665.
138.
Levi-BelzYZerachG. “How can they treat it if they can’t identify it?”: mental health professionals’ knowledge and perspectives of moral injury. Psychol Trauma2023; 15: S436–s445. DOI: 10.1037/tra0001206.
139.
HossainFClattyA. Self-care strategies in response to nurses’ moral injury during COVID-19 pandemic. Nurs Ethics2021; 28: 23–32. DOI: 10.1177/0969733020961825.
140.
KelleyMLStrowgerMChentsovaVO, et al.Mindfulness to manage moral injury: rationale and development of a live online 7-week group intervention for veterans with moral injury. Contemp Clin Trials Commun2022; 30: 101011. DOI: 10.1016/j.conctc.2022.101011.
141.
WilliamsonVLobbanJMurphyD. Moral injury and the potential utility of art therapy in treatment. BMJ Mil Health2023; 169: e6–e8. DOI: 10.1136/bmjmilitary-2021-001947.
142.
BorgesLMBarnesSMFarnsworthJK, et al.Cultivating psychological flexibility to address religious and spiritual suffering in moral injury. J Health Care Chaplain2022; 28: S32–S41. DOI: 10.1080/08854726.2022.2031467.
143.
HanleyMACoppaDShieldsD. A practice-based theory of healing through therapeutic touch: advancing holistic nursing practice. J Holist Nurs2017; 35: 369–381. DOI: 10.1177/0898010117721827.
144.
EmmerichSJ. Contemplative practice, acceptance, and healing in moral injury. J Health Care Chaplain2022; 28: S25–S31. DOI: 10.1080/08854726.2022.2032977.
145.
AmesDEricksonZGeiseC, et al.Treatment of moral injury in U.S. veterans with PTSD using a structured chaplain intervention. J Relig Health2021; 60: 3052–3060. DOI: 10.1007/s10943-021-01312-8.
146.
TalbotSGDeanW. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. Stat2018; 7: 18.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
