The Weight of the Night Shift
The emergency room was a cacophony of beeping monitors, frantic voices, and the relentless hum of overhead lights. Sarah, an experienced ER nurse, navigated the chaos with efficiency, her eyes betraying the exhaustion that had settled deep within her.
Her last patient was a young mother, critically injured in a car accident. The ER had been swamped that night, with patients arriving in waves and limited resources stretched thin. Institutional pressures included management’s expectations to handle an ever-increasing caseload with fewer staff, constant directives to expedite care, and the unspoken yet clear demand to maintain performance and avoid mistakes despite mounting stress. Sarah felt the weight of these pressures pressing on her shoulders. Despite her best efforts and those of her colleagues, they were unable to provide the level of care that would have been ideal. The mother did not survive, and the sorrowful cries of the family left Sarah feeling a profound sense of failure.
In the quiet moments between patients, Sarah’s mind was haunted by the night’s events. She wondered how much her exhaustion had impacted her decision-making. She considered how she might have advocated more effectively for the patient and other choices she made in the face of overwhelming demands. The thought that her fatigue might have influenced her ability to provide the best care—leading to this tragic outcome—gnawed at her conscience. The nagging guilt she felt that she had failed the patient, compounded by frustration and anger she felt regarding institutional pressures weighed heavily on her.
This wasn’t the first time Sarah had grappled with such distressing thoughts, but the cumulative impact of these experiences was beginning to take a significant toll on her well-being. Her ongoing struggle is a poignant example of moral injury. Unlike the immediate and visible trauma of physical injury, moral injury manifests in more subtle, profound ways. Sarah began to experience symptoms including guilt, shame, anger, and emotional numbness. She felt herself withdrawing from her colleagues and loved ones. Sarah’s situation highlights the complex interplay between personal values, professional demands, and mental health challenges that occur in cases of moral injury.
What is Moral Injury?
Moral injury refers to the psychological distress that arises when an individual feels they have acted—or failed to act—against their deeply held moral values. Often linked with professions facing high ethical demands, such as healthcare workers, military personnel, first responders, and social workers, moral injury can result from committing, witnessing, or learning about events that violate one’s sense of what is right and just.
In healthcare, for example, clinicians may feel morally injured when institutional systems (e.g., insurance policies and limited resources) prevent them from providing care aligned with their ethical commitments. Members of the military may experience moral injury when they follow a direct command but later realise that their actions were inconsistent with their moral ideals (Shepherd, 2021). Jonathan Shay (1994) first used the term "moral injury" in his book Achilles in Vietnam, describing how soldiers are traumatised not just by external events but also by the guilt and shame of carrying out orders that conflict with their morality.
The consequences of moral injury are severe and varied, ranging from social isolation and suicidal thoughts (He et al., 2023) to occupational impairment, substance abuse, and disintegration of one's core self (Jin et al., 2022). While not yet classified as a mental disorder in the DSM-5, growing research indicates that moral injury may contribute to conditions like PTSD, depression, and burnout (Jin et al., 2022). Understanding and addressing moral injury is essential for supporting those facing ethical and emotional turmoil in their professional and personal lives.
How Moral Injury Contributes to Burnout
Moral Injury is a less-discussed factor contributing to burnout in professionals. Originally defined by Maslach and Jackson (1981), burnout is often marked by emotional exhaustion, depersonalisation, and a lack of personal accomplishment. While typically caused by chronic stress, burnout becomes particularly prevalent in professions that are emotionally and physically demanding (Van Droogenbroeck, Spruyt, & Vanroelen, 2014). However, for individuals in high-stress professions—whether healthcare workers, teachers, or military personnel—the emotional toll of moral injury can also lead to or exacerbate burnout. The chronic stress of working in environments where one’s ethics are regularly challenged, paired with a lack of adequate support or resources, can result in deep emotional exhaustion. Over time, this moral conflict diminishes personal accomplishment and leads to depersonalisation, a hallmark of burnout. Hence, Moral Injury may be a key factor contributing to occupational functional impairment for those in professions that lead to situations that compromise their ethical and moral ideology (Sert-Ozen & Kalaycioglu, 2022).
Moral Injury and PTSD
Moral injury should not be confused with post-traumatic stress disorder (PTSD), although the two can co-occur. PTSD often results from traumatic, life-threatening events that provoke fear, horror, or helplessness, leading to physiological symptoms like hypervigilance, flashbacks, and avoidance. In contrast, moral injury stems from actions or experiences that conflict with one’s deeply held moral beliefs (He et al., 2023). It involves a sense of guilt, shame, and regret—an internal conflict that can erode one's moral integrity and sense of self. These conditions can co-occur, as individuals may simultaneously face the physiological impacts of a traumatic, life-threatening event and struggle with the profound moral conflicts stemming from their actions that contradict their deeply held beliefs.
Moral injury often involves a feeling of betrayal—by leaders, institutions, or even oneself—and the consequences can result in PTSD symptoms. People may withdraw from their community or loved ones, experience intrusive thoughts, emotional numbness, or turn to harmful behaviors such as substance abuse or reckless decision-making (Shepherd, 2021).
The Role of a Strong Moral Compass in Vulnerability and Resilience
Individuals with a strong moral sense may be particularly susceptible to moral injury due to their heightened sensitivity to ethical violations and conflicts (Liebert, 2019). Their deeply ingrained values and principles make them more acutely aware of when these values are compromised, leading to a more intense experience of moral injury. However, this same strong moral foundation can also serve as a source of resilience.
Pathways to Recovery from Moral Injury
Recognising moral injury as an honorable experience rather than a stigmatising one may encourage individuals to seek help, reducing long-term psychological harm and leading to healthier outcomes (Herman, 2015). By viewing moral injury as a reflection of a person’s moral integrity and commitment rather than a personal failing, individuals can develop greater self-compassion. When moral injury is seen as a legitimate and honorable struggle, individuals may feel more comfortable and less fearful about seeking professional help. They are more likely to view therapy or support as a means of addressing a respected and understandable challenge rather than something to be ashamed of.
Professional psychological and medical support plays a crucial role in addressing moral injury and its associated mental health difficulties. Therapy provides a structured and empathetic space where individuals can explore and process the deep-seated emotions of guilt, shame, and regret that often accompany moral injury. Through therapeutic interventions, individuals can reconstruct their trauma narratives, gain insights into their moral conflicts, and develop healthier coping strategies (Herman, 2015). Additionally, therapy helps validate their experiences, reduce feelings of isolation, and foster a sense of hope and resilience. By addressing the complex interplay between moral injury and mental health challenges, professional support may help individuals reclaim their sense of self and restore their overall well-being.
For those with religious and spiritual affiliations, recovery from moral injury can benefit from an interdisciplinary approach that addresses not only psychological but also spiritual wounds. This holistic care may involve chaplains or religious leaders, as addressing the spiritual dimension can facilitate healing (Jin et al., 2022). These professionals may help to restore connections between individuals and their communities (Herman, 2015). Fostering resilience and engaging in spiritual practices such as meditation, prayer, or compassionate community involvement can also play a pivotal role in healing.
As moral injury and its impact on mental health become increasingly recognised, it is clear that addressing these hidden wounds is crucial for promoting long-term well-being in emotionally demanding professions. For Sarah, understanding her experiences as moral injury rather than personal failure is a critical step toward healing. By recognising the complex factors that contributed to her distress—such as institutional pressures, exhaustion, and moral conflict—Sarah can begin to address the underlying issues and seek the support needed to reclaim her sense of self and restore her well-being.
Kylie Walls is a registered psychologist who aims to guide her clients as they curate the pieces of their past to create a story of hope for the future. See www.curatedmind.com.au to learn more about the supports available.
References:
Stress, burnout, and moral injury: The state of the healthcare workforce. Journal of Healthcare Management. 2019;64(3):125-127. https://www.proquest.com/scholarly-journals/stress-burnout-moral-injury-state-healthcare/docview/2242091521/se-2.
Herman, J. (2015). Trauma and recovery: The aftermath of violence, from domestic abuse to political terror. New York: Basic Books. (Originally published in 1992)
He, Z., Lei, Q., Hu, X., Xiong, M., Liu, J., Wen, J., Shi, X., & Wang, Z. (2023). Moral injury and suicidal ideation among health professionals: The role of mental health. Journal of Affective Disorders, 333, 58–64. https://doi.org/10.1016/j.jad.2023.04.033
Jin, J., Weiman, K., Bremault-Phillips, S., & Vermetten, E. (2022). Moral Injury and Recovery in Uniformed Professionals: Lessons From Conversations Among International Students and Experts. Frontiers in Psychiatry, 13, 880442–880442. https://doi.org/10.3389/fpsyt.2022.880442
Liebert, E. A. (2019). Accessible Spiritual Practices to Aid in Recovery from Moral Injury. Pastoral Psychology, 68(1), 41–57. https://doi.org/10.1007/s11089-018-0825-1
Maslach, C., & Jackson, S. (1981). The measurement of experienced burnout. Journal of Organizational Behavior, 2, 99-113. doi:10.1002/job.4030020205
Norris, D. M., & Primm, A. (2024). Burnout and Moral Injury Among Black Psychiatrists and Other Black Mental Health Professionals. Psychiatric Services (Washington, D.C.), 75(1), 83–86. https://doi.org/10.1176/appi.ps.20220522
Sert-Ozen, A., Kalaycioglu, O., 2022. The effect of occupational moral injury on career abandonment intention among physicians in the context of the COVID-19 pandemic. Saf. Health Work. https://doi.org/10.1016/j.shaw.2022.12.002.
Shepherd, A. P. (2021). Loyalty, Betrayal, and Atonement: A Philosophy of Moral Injury. Transactions of the Charles S. Peirce Society, 57(4), 511–533. https://doi.org/10.2979/trancharpeirsoc.57.4.05
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