Reflections on Ethical Leadership: Organizational Ethics and Moral Injury

Structural Justice Ethics in Health Care

Multinational intensive care unit nurses' moral courage, resilience, neutralisation, injury, and distress: A cross-sectional and mediation analysis study.

The mediating roles of moral courage and moral resilience between nurses’ moral distress and moral injury: An online cross-sectional study

During a public health crisis, such as the COVID-19 pandemic, nurse leaders coordinate timely high-quality care, maintain profit margins, and ensure regulatory compliance while supporting the health and wellbeing of the nursing workforce. In a rapidly changing environment where resources may be scarce, nurse leaders are vulnerable to moral injury; however, organizational effectiveness may help to buffer moral challenges in healthcare leadership, thereby fostering greater moral resilience and reducing turnover intention. To understand mechanisms by which perceived organizational effectiveness contributes to nurse leaders' moral wellness (i.e., moral injury and moral resilience) and thereby effects work outcomes (i.e., engagement, burnout, and turnover intention). A cross-sectional survey of nurse leaders (N = 817) from across the United States was conducted using a snowball methodology, independent t-tests, and structural equation modeling to examine theoretical relationships among moral injury, moral resilience, and organizational effectiveness. Higher ratings on every facet of perceived organizational effectiveness were significantly related to greater moral resilience (p < 0.001 for all t-tests) and lower moral injury (p < 0.001 for all t-tests) among nurse leaders. Structural equation models indicated both moral resilience and moral injury were significant mediators of the relationship between organizational effectiveness and work outcomes. Moral resilience and moral injury significantly mediated the effect of organizational effectiveness on burnout. Moral resilience was also a significant mediator of the relationship between organizational effectiveness and moral injury. Dismantling organizational patterns and processes in healthcare organizations that contribute to moral injury and lower moral resilience may be important levers for increasing engagement, decreasing burnout, and reducing turnover of nurse leaders.

Moral injury, which is caused by actions that violate moral beliefs, gained recognition during the COVID-19 pandemic and still affects intensive care unit (ICU) nurses. Moral resilience and a healthy work environment may be protective by promoting ethical practice and self-stewardship. To measure the prevalence of moral injury in ICU nurses; examine relationships among moral injury, moral resilience, and healthy work environment; and assess differences in moral injury by demographic characteristics. A cross-sectional survey was conducted June to July 2023 across 22 hospitals in a large US health system. Instruments were the Moral Injury Symptom Scale-Health Professionals, the Rushton Moral Resilience Scale-16, and the Healthy Work Environment Assessment Tool. Correlation analyses, multiple regression, and analysis of variance were used to test relationships and group differences. Of 304 ICU nurses, 169 (55.6%) met criteria for moderate to severe moral injury symptoms. Moral resilience (r = -0.58) and healthy work environment (r = -0.40) were significantly inversely associated with moral injury (P < .001). The regression model (F2,292 = 91.75; P < .001) explained 38% of variance in moral injury scores. Moral injury scores were lowest in older nurses and those with daily chaplain interactions (P < .001). Ethics consultation participation did not affect moral injury but significantly affected moral resilience; nurses who did not know how to request support had the lowest moral resilience scores. Moral resilience and healthy work environment may reduce moral injury. Future research should explore supportive interventions targeting early-career ICU nurses.

Background:The 2019 coronavirus (COVID-19) pandemic placed unprecedented strains on the U.S. health care system, putting health care workers (HCWs) at increased risk for experiencing moral injury (MI). Moral resilience (MR), the ability to preserve or restore integrity, has been proposed as a resource to mitigate the detrimental effects of MI among HCWs.Objectives:The objectives of this study were to investigate the prevalence of MI among HCWs, to identify the relationship among factors that predict MI, and to determine whether MR can act as buffer against it.Design:Web-based exploratory survey.Setting/Subjects:HCWs from a research network in the U.S. mid-Atlantic region.Measurements:Survey items included: our outcome, Moral Injury Symptoms Scale–Health Professional (MISS-HP), and predictors including demographics, items derived from the Rushton Moral Resilience Scale (RMRS), and ethical concerns index (ECI).Results:Sixty-five percent of 595 respondents provided COVID-19 care. The overall prevalence of clinically significant MI in HCWs was 32.4%; nurses reporting the highest occurrence. Higher scores on each of the ECI items were significantly positively associated with higher MI symptoms (p < 0.05). MI among HCWs was significantly related to the following: MR score, ECI score, religious affiliation, and having ≥20 years in their profession. MR was a moderator of the effect of years of experience on MI.Conclusions:HCWs are experiencing MI during the pandemic. MR offers a promising individual resource to buffer the detrimental impact of MI. Further research is needed to understand how to cultivate MR, reduce ECI, and understand other systems level factors to prevent MI symptoms in U.S. HCWs.

Purpose: This study aimed to identify research trends in moral resilience in healthcare through text network analysis and topic modeling of abstracts published in domestic and international journals and to propose future research directions.Methods: A quantitative content analysis was conducted on English abstracts of studies related to moral or ethical resilience in healthcare published through May 2025. Sixty-three papers were selected after removing duplicates, and screening was conducted using eight databases: KISS, RISS, DBpia, KCI, CINAHL, Embase, PubMed, and Web of Science. Texts were analyzed using NetMiner 4.5.1 for keyword co-occurrence network construction and Latent Dirichlet Allocation topic modeling. Core keywords were identified using degree and centrality indices, and topics were named through researcher consensus.Results: Research on moral resilience in healthcare began in 2013 and has increased rapidly after 2023, particularly after the coronavirus disease 2019 pandemic. Among 230 extracted keywords, “moral resilience,” “moral distress,” and “care” showed the highest centrality. Five major topics were identified: (1) moral resilience and burnout in practice, (2) moral resilience among nursing students, (3) moral competence and fatigue in practice, (4) moral resilience assessment, and (5) moral injury and secondary traumatic stress among healthcare workers.Conclusion: Moral resilience reflects the ethical strength that enables healthcare professionals to sustain integrity amid moral adversity. Although the number of international studies has increased, domestic research remains limited. Further work should clarify this concept, develop training programs, and explore organizational strategies to strengthen moral resilience.

BackgroundEmergency nurses frequently experience moral injury (MI) arising from high-risk ethical conflicts, heavy workloads, and exposure to traumatic events, which can contribute to health-related productivity loss (HRPL). However, the underlying mechanisms remain unclear. Crucially, perceived social support and moral resilience may mediate this relationship by mitigating negative effects. Clarifying the mediating roles of perceived social support and moral resilience is essential to evaluate their influence on the relationship between MI and productivity loss, and to establish a model that explains this mechanism, thereby contributing to protecting nurses’ well-being and safeguarding patient care quality.ObjectiveThis study aims to explore the relationship between MI and HRPL, and to examine the mediating roles of social support and moral resilience. These insights are of great significance for enhancing the physical and mental well-being of emergency nurses and improving the overall quality of medical care.MethodsA prospective cross-sectional survey was conducted among 483 emergency nurses from five tertiary hospitals across three provinces in mainland China between January and May 2025. The survey instruments included the General demographic questionnaire, Moral Injury Symptoms Scale-Health Professionals Version (MISS-HP), Rushton Moral Resilience Scale (RMRS), Perceived Social Support Scale (PSSS) and Stanford presenteeism scale-6 (SPS-6). Descriptive analysis and Pearson correlation analysis were performed using SPSS 29.0. The structural equation model was constructed with AMOS 29.0 software, and Bootstrap testing was conducted.ResultsThe results showed that moral injury directly affected Health-related productivity loss (β = 0.282, 95% CI [0.183, 0.382]). Perceived social support and moral resilience both played mediating roles in the relationship between MI and HRPL (β = 0.042, 95%CI [0.008, 0.076]) (β = 0.079, 95%CI [0.046, 0.117]). Perceived social support and moral resilience play chain mediating roles between MI and HRPL (β = 0.020, 95%CI [0.010, 0.034]). The structural model demonstrated good fit indices (CFI = 0.947, RMSEA = 0.045), indicating the robustness of the proposed model.ConclusionPerceived social support and moral resilience jointly buffer the impact of MI on nurses’ health-related productivity. Interventions should therefore strengthen both support and resilience. For example, hospitals could implement peer-support groups or resilience workshops, and nurses could practice mindfulness or seek mentorship to bolster coping skills. These strategies may mitigate the negative effects of moral injury and improve productivity. However, as a cross-sectional survey relying on self-reported measures, this study may be subject to response bias, highlighting the need for future longitudinal research.

While nurse leaders have a voice in some organizational decisions, their moral resilience and moral injury can be affected by organizational structures and processes during a public health emergency such as the COVID-19 pandemic. The purpose of this exploratory descriptive analysis was to characterize the differences and commonalities between types of nurse leaders and their experiences of perceived organizational effectiveness, moral injury, and moral resilience during the COVID-19 pandemic. This was a quantitative study conducted via an online, national, cross-sectional survey. The survey included sociodemographic and professional practice questions, validated instruments measuring organizational effectiveness, moral injury, and moral resilience. Open-ended questions allowed participants to expand on topics of particular interest. Quantitative data were analyzed using ANCOVA models, qualitative data accompanies the quantitative results for descriptive elaboration. In total, 763 nurse leaders were included in the analysis. Executives scored higher on overall organizational effectiveness than other leaders but not nurse managers. Examining the differences in specific facets of organizational effectiveness revealed that nurse managers rated several aspects of staffing lower than executives. One-third of respondents met the threshold for clinically significant levels of moral injury (score ≥ 36). No significant differences were found between nurse leader roles on moral injury. ANCOVAs indicated that nurse executives had higher total moral resilience than either nurse managers (p = 0.030) or other leaders (p < 0.001). In the open-ended questions, nurse leaders discussed two additional facets of organizational effectiveness that affected moral injury and moral resilience: (1) inequity between healthcare workers in different roles, and (2) an imbalance between organizational finances and patient safety. Organizations can promote retention and moral resilience among nurse leaders by cultivating trustworthy behaviors. This may be achieved through authentic communication and transparency, and by promoting the values reflected in the nursing code of ethics. Not applicable.

Background: The relationship between moral resilience, moral distress, and moral injury among nurses during the COVID-19 pandemic has been widely investigated; however, the literature in the post-COVID-19 era is scarce. Research aim: To examine the impact of moral resilience on moral distress and moral injury among nurses after the COVID-19 pandemic.Research design: Cross-sectional study.Participants and research context: We obtained a convenience sample of 1118 nurses in Greece. We collected demographic data (gender, age) and work-related data (understaffed wards, shift work, clinical experience). We measured moral resilience with the revised "Rushton Moral Resilience Scale", moral distress with the "Moral Distress Thermometer", and moral injury with the "Moral Injury Symptom Scale-Healthcare Professionals" version. We adjusted all multivariable models for demographic variables.Ethical considerations: The Ethics Committee of the Faculty of Nursing, National and Kapodistrian University of Athens approved our study protocol (approval number; 474, approved: November 2023). Our study followed the Declaration of Helsinki.Findings/results: Multivariable linear regression analysis showed that moral resilience reduced moral distress and moral injury. In particular, we found that increased response to moral adversity was associated with decreased moral distress (adjusted coefficient beta = -1.81, 95% confidence interval [CI] = -2.07 to -1.54). Moreover, we found that increased response to moral adversity (adjusted coefficient beta = -8.24, 95% CI = -9.37 to -7.10) and increased moral efficacy (adjusted coefficient beta = -3.24, 95% CI = -5.03 to -1.45) were associated with reduced moral injury.Conclusions: Moral resilience can reduce the level of moral distress and moral injury among nurses. However, the persistence of moderate moral resilience among Greek nurses does not guarantee its sustainability. To ensure that this resilience is maintained and potentially enhanced, it is imperative for nurse leaders and policymakers to strategically design interventions to address issues at the organizational, team, and individual levels.

This study investigated the relationship between adherence to organizational ethics and employee performance, with three main objectives: This study will aim at (i) establishing the level of the relationship between organizational ethics and employee performance, (ii) determining which ethical principles have the most significant impact on employee performance, and (iii) establishing ways for enhancing the levels of organizational ethics. Primary and secondary data were collected using literature reviews, and only reliable information was used. This study established a positive correlation between ethics and organizational success—specifically, integrity, fairness, accountability, organizational transparency, and ethical leadership with trust, job satisfaction, motivation, and idea generation. Ethical leadership was relevant to promoting responsibility and respect and improving organizational performance. Also, the study stressed the interconnectedness of ethical values by illustrating that one's lack – in this case, transparency – can erode others – here, fairness and accountability. The measures proposed were the adoption of strong ethical standards, endorsement of the ethical conduct of leaders, utilization of reporting channels, and encouragement of discussion of ethics to improve compliance. Thus, the research provided benefits to theoretical knowledge by associating ethical governance with performance results while providing practical prescriptions for the practice. Nevertheless, the study was not without its weaknesses, noting methodological limitations, including the use of secondary data. However, the authors suggested that further studies should be conducted on ethical issues across organizations from different industries and cultures of practice. Keywords: Organizational Ethics, Employee Performance, Ethical Leadership, Accountability, Transparency

Investigations about moral resilience and moral courage as mediators between moral distress and moral injury remain underreported among nurses during the COVID-19 pandemic. Nurses (n = 412) from the Philippines were conveniently recruited via social media platforms and completed four self-report scales. The mediation model depicts that moral distress negatively impacts moral resilience and moral courage while positively affecting moral injury. Moral resilience and moral courage negatively impact moral injury, whereas moral resilience directly impacts moral courage. Finally, moral resilience and moral courage demonstrated a mediating effect between moral distress and moral injury. Findings indicate that healthcare organizations and nurse managers should nurture morally resilient and courageous therapeutic practices among frontline healthcare professionals to mitigate the negative effects of moral distress and moral injury.

With the gradual formation of the global economic integration,more and more enterprises are facing the dilemmas to balance the economic benefits and social benefits,or the pursuit of corporate profits and complying with morals and ethics. Ethical issues in organizations have been regarded as one of the core elements which can obtain competitive edges. Consequently,issue of business ethic have emerged under such circumstances and received more and more attention in the global literature. Business ethic is composed of two aspects:organizational ethic and work ethic. Organizational ethic refers to the rules of conduct and the ethical norms which should be followed when organizations engaged in commercial activities and dealt with the relationship between inside and outside organizations. Work ethic,as an aspect of organizational ethic,is a series of ethic norms which the employees comply with when they perform their job,interact with others and treat environment in the workplace. Since Weber proposed that the Protestant work ethic was the origin of the Spirit of Capitalism,the study on the work ethic of employees has yielded some achievement in the field of the western organizational behavior. Moreover,it has become one of the critical issues in the fields of organizational behavior and human resource management. However,limited data are available in China regarding the importance of work ethic in human resource management and organizational behavior. Therefore,the current study was designed to development a measure of work ethic among Chinese employees (eg.,The Work Ethic Questionnaire) to test and cross-validate the construct of the work ethic. The methods used in this study involved literature review,interview,pilot-testing and survey. Based on the literature review,interview and pilot-testing,items for the Work Ethic Questionnaire were developed. The survey data were from 955 employees of 21 different enterprises and from various districts in China,508 undergraduates of six universities and 461 soldiers from two military units. The survey data were mainly analyzed using exploratory factor analysis (EFA),confirmatory factor analysis (CFA) and cross-validation test. The result showed that work ethic of Chinese employees was a multi-dimension construct which included occupational integrity,work meaning,diligence,enterprising and interpersonal harmony. The Work Ethic Questionnaire had high validity and reliability. That's to say,a five-dimension model could reflect the Chinese employees' work ethic construct,which was different from the results of those researches in the West. At the same time,the five-dimension model was tested by using the cross-validation among college student sample and soldier sample and showed similar goodness-of-fit. The construct,content,and connotation of work ethic dimension and their differences compared to western results were discussed. Finally,further research needs were discussed. These needs include the examination of the impact of the work ethic,and the exploration of the factors that may influence work ethic.

Invisible Moral Wounds of the COVID-19 Pandemic: Are We Experiencing Moral Injury?

Traumatic stress and moral injury may contribute to burnout, but their relationship to institutional betrayal and moral resilience is poorly understood, leaving risk and protective factors understudied. To examine traumatic stress symptoms, moral injury symptoms, moral resilience, and institutional betrayal experienced by critical care nurses and examine how moral injury and traumatic stress symptoms relate to moral resilience, institutional betrayal, and patient-related burnout. This cross-sectional study included 121 critical care nurses and used an online survey. Validated instruments were used to measure key variables. Descriptive statistics, regression analyses, and group t tests were used to examine relationships among variables. Of participating nurses, 71.5% reported significant moral injury symptoms and/or traumatic stress. Both moral injury symptoms and traumatic stress were associated with burnout. Regression models showed that institutional betrayal was associated with increased likelihood of traumatic stress and moral injury. Increases in scores on Response to Moral Adversity subscale of moral resilience were associated with a lower likelihood of traumatic stress and moral injury symptoms. Moral resilience, especially response to difficult circumstances, may be protective in critical care environments, but system factors (eg, institutional betrayal) must also be addressed systemically rather than relying on individual-level interventions to address nurses' needs.