Background & Aims One of the factors that seems to influence the incidence of moral distress (MD) in nurses is resilience. This study aimed to investigate the relationship between resilience and MD in nurses working in emergency departments (EDs). Materials & Methods This is a descriptive-analytical study with a cross-sectional design that was conducted from April to June 2024 on 133 nurses from the EDs of hospitals in Urmia city, Iran, who were selected using a two-stage sampling method. They completed a sociodemographic form, the Connor Davidson Resilience scale, and Nash's moral injury events scale (MIES). Data analysis was performed using Pearson’s correlation test, multiple linear regression analysis, independent t-test, and one-way analysis of variance in SPSS software, version 23. Results The mean age of the participants was 32.7±45.5 years. The mean resilience score was 78.33±0.54, and the mean MIES score was 30.19±8.44. There was a significant negative relationship between resilience and MD among ED nurses (r=-0.45, P=0.001). Conclusion Given the relationship between resilience and MD in ED nurses, the increase in their resilience can reduce their MD level. Therefore, nursing managers should take measures such as organizational support and improving working conditions to promote the resilience of ED nurses and, thus, reduce their MD.

Police officers operate at the intersection of pervasive community trauma and persistent organizational stress, making them uniquely vulnerable to potentially psychologically traumatizing and morally injurious events. The impact of this chronic trauma exposure can be either mitigated or exacerbated by individual and organizational factors. Existing trauma-informed policing initiatives have largely centered on community-facing practices, while officer well-being and relevant organizational determinants of wellness are neglected. This paper advances enhanced trauma-informed policing (E-TIP), a novel conceptual, multi-level framework that integrates (a) meaning-making processes, (b) trauma exposure considerations (adverse childhood experiences, secondary/vicarious trauma, moral injury), (c) person-centered leadership, and (d) organizational justice, unified by emotional intelligence (EI) as a cross-cutting competency. Synthesizing neurocognitive, psychological, and organizational literature, we describe how trauma reshapes attention, appraisal, identity, and decision-making, and explicate the moderating roles of leadership, EI, and justice in redirecting trajectories from dysregulation and cynicism toward resilience and posttraumatic growth. We propose testable linkages between EI and adaptive meaning-making; leadership and relational safety; and organizational justice and ethical decision-making. The paper translates these mechanisms into practice through implementation targets: EI-embedded training for officers and supervisors; leader development in trauma-informed, person-centered behaviors; and organizational reforms that institutionalize procedural, distributive, interpersonal, and informational justice. We conclude with a research agenda to assess E-TIP's impact on officer health, decision quality, and community trust. E-TIP reframes trauma-informed policing as a bi-directional, evidence-informed approach designed to safeguard both communities and the officers who serve them.

Large scale combat operations (LSCO) are anticipated to expose service members to challenging, high-stakes scenarios with significant moral implications. Potentially morally injurious events and the psychological harms associated with moral injury among military personnel have been well-documented, but the possibility of positive experiences arising from morally charged experiences has been given less attention. In the present study, we explore a novel construct - the potentially morally elevating experience (PMEE) - that constitutes a positively-oriented parallel to the potentially morally injurious event. Previously deployed U.S. Army soldiers (n = 1,622) completed a cross-sectional survey that included assessment of three forms of PMEEs - morally elevating acts by the self, morally elevating acts by others, and moral elevation from experiencing the support of others. Associations between PMEEs and symptoms of depression, anxiety, posttraumatic stress, and problematic alcohol use were explored. PMEEs were found to be common, but not universal, among previously deployed soldiers. Moreover, PMEEs were negatively associated with symptoms of depression, anxiety, and posttraumatic stress. No associations were observed between PMEEs and problematic alcohol use. Building on these findings, we propose a unified model of military moral experience during deployment. Findings and implications are considered within the context of future conflicts involving LSCO.

Moral Injury is an emerging concept initially studied in the military context, capturing the profound psychological, emotional, and spiritual suffering experienced by individuals who perceive that they have transgressed their deeply held moral or ethical beliefs. In healthcare, Moral Injury occurs when systemic constraints, organizational policies, or professional commitments force healthcare workers (HCWs) to act in ways that dissent from their values. Our study aimed to explore qualitatively the phenomenon of Moral Injury among physicians in healthcare settings in Romania and the Republic of Moldova, focusing on how systemic and organizational factors contribute to their experiences. The study employed a qualitative research design. We collected and analysed 17 interviews with doctors from Romania and Republic of Moldova. We identified four central themes and subsequent sub-themes: Perception and Understanding of Moral Injury; Factors contributing to Moral Injury; Impact on Patient Safety and Quality of Care; Coping Strategies and Emotional Survival Mechanisms. Our findings suggest that Moral Injury is not the result of isolated events but rather the outcome of persistent exposure to systemic dysfunctions, including coercive hierarchies, politicized leadership, inadequate resources, and the prioritization of economic performance over patient welfare. Physicians described feelings of shame and betrayal when compelled to comply with orders that contradicted their professional ethics.

BackgroundMoral injury, first identified in military settings, is increasingly recognised in healthcare, yet little is known about its impact on psychiatric nurses, particularly in Japan. Japanese psychiatric care remains heavily institutionalised, with widespread use of involuntary treatment and mechanical restraint, raising ethical concerns.AimThis study explores the experiences and causes of moral injury among psychiatric nurses in Japan who resigned due to moral or ethical distress.Research designA qualitative descriptive design was adopted.Participants and research contextSemi-structured interviews were conducted with 12 former psychiatric nurses between May 2024 and February 2025. Participants were nurses who had worked in psychiatric settings and quit due to ethical problems. They were recruited through purposive and snowball sampling. Data were analysed thematically.Ethical considerationThe study was conducted after the research ethics committees had approved, written informed consent was obtained from the participants, and their privacy was carefully considered.ResultsIn this study, two of six main themes are reported: (1) causes of moral injury and (2) experiences of moral injury. Nurses reported morally injurious practices such as unjustified mechanical restraints, neglect of patients, long-term institutionalisation for profit, physical abuse, and coercive treatments. These actions often conflicted with their personal and professional values, leading to negative feelings including guilt, shame, anger, and isolation. Many attempted to resist or improve care but faced institutional backlash or apathy from colleagues. Cultural norms valuing conformity and professional hierarchies further hindered ethical action and reinforced silence.ConclusionMoral injury among psychiatric nurses in Japan is deeply tied to systemic and cultural factors that normalise unethical practices and discourage dissent. The findings underscore the need for structural reform in psychiatric care, greater ethical support for nurses, and recognition of resistance not as insubordination but as a vital expression of professional integrity.

Assessing students in competency-based medical education can be time-consuming and demanding for faculty, especially with large classes and complex topics. Traditional methods can lead to inconsistencies and a lack of targeted feedback. Innovative and accessible solutions to improve the efficiency, objectivity, and effectiveness of assessment in medical education are needed. From September 2024 to February 2025, the authors piloted the use of large language models (LLMs) with retrieval-augmented generation to assess students' understanding of moral injury. The authors selected and uploaded 6 seminal articles on moral injury within military and veteran populations to Google Gemini 1.5 Pro. They tasked the same LLM with creating a grading rubric based on these articles to assess 165 student responses in a military medical ethics course (Uniformed Services University of the Health Sciences). The authors uploaded both the generated rubric and the student responses to each of 3 LLMs (Google Gemini 1.5 Pro, Google Gemini 2.0 Flash, and OpenAI ChatGPT-4o) with a prompt to generate scores for the student responses. In the authors' expert opinion, an LLM (Google Gemini 1.5 Pro) successfully generated a grading rubric that captured the nuances of moral injury and its implications for military medical practice. The LLMs' scoring accuracy was compared against 2 experienced educators to generate validity evidence. The best-performing model, OpenAI ChatGPT-4o, demonstrated an interrater reliability of 0.77 and 0.68 for reviewers 1 and 2, respectively, indicating a higher level of agreement between the LLM and both individual reviewers than between the 2 reviewers (0.57). While this approach shows promise, faculty oversight is necessary to ensure ethical accountability and address potential biases. Further research is needed to optimize the integration of AI and human capabilities in assessment to ultimately enhance the quality of health care professional education and improve patient outcomes.

Exploring the relationship between Adverse Childhood Experiences, Moral Injury and Social Support in a Clinical Sample of UK Military Veterans

Moral injury and the myth of resilience: A qualitative exploration of cancer care provision in ontario throughout the COVID-19 pandemic

The true cost of the white coat: How academic medicine's definition of success silences authenticity and compounds trauma in medical training.

What we talk about when we talk about psychiatric mental health nurses' work-related distress: An umbrella review and concept mapping network analysis.

Integrating moral injury into forensic psychiatry.

BackgroundIn recent years, research has revealed the emotionally demanding side of research for researchers (in addition to research participants). This research provides useful guidance, especially for researchers who work with research participants facing difficult situations such as illness, forced displacement, and conflict. Yet, they tend to focus on research projects in the Global North. We explore emotionally demanding research and its impact on researcher wellbeing, and formal support systems and informal mitigation measures in a Global South context marked by conflict and violence and a complex international and interdisciplinary collaboration.MethodsWe interviewed thirteen researchers and one psychosocial staff support specialist involved in a UK Global Challenges Research Fund project on improving healthcare at the intersection of gender and protracted displacement amongst Somali and Congolese refugees and internally displaced people in Somalia, DR Congo, Kenya, and South Africa (2020–2024). The analysis explores the intersections of four recurrent themes: fieldwork conditions, researcher symptoms, support systems, and mitigation measures.ResultsResearching protracted displacement exposed the teams to multiple forms of emotionally demanding work, leading to distress, exhaustion, sleep disruption, guilt, and features of vicarious trauma and moral injury. These impacts were heightened by researchers’ own histories, socio-economic inequalities, COVID-19, and insecurity. Formal psychosocial support was provided, but uptake was low due to timing, online delivery, trust, and unfamiliarity; participants recommended compulsory, continuous, locally grounded, and one‑to‑one options. Informal measures – team debriefings, buddying, adaptive safety practices, and peer support – were widely used and valued. Ethical tensions around aid expectations coming from the research participants persisted.ConclusionsFirst, echoing calls for a feminist ethics of care, the article recognises emotional responses as an inherent part of ethical research practice. Second, it articulates the benefits of local wellbeing champions. Third, it highlights that researcher wellbeing support should be a multifaceted and ongoing process rather than a one size fits all once-off event. Fourth, it calls for structural change to recognise emotional challenges as part of research ethics and integrity processes (rather than solely the responsibility of individual researchers) and to budget for devolved and locally appropriate psychosocial support service provision for researchers.

Background Clinical practice is a necessary experience for nursing students to become qualified nurses. The impact of moral injury on nursing interns’ coping styles remains unclear. This study aimed to explore the correlation between moral injury and positive coping style among nursing interns in clinical practice and to examine the mediating roles of moral resilience and moral courage on this correlation. Methods A convenience sample of nursing interns ( n = 1,122) from 6 nursing schools in the Southwest China were recruited using social media platforms. The Chinese version of Moral Injury Symptom Scale: Healthcare Professionals Version, Simplified Coping Style Questionnaire, Rushton Moral Resilience Scale and Nurses’ Moral Courage Scale were used to collect data from February 1 to April 15, 2024. Regression-based mediation analysis was used to distinguish the direct effect of moral injury on positive coping style, and the indirect effect mediated by moral resilience and moral courage. Results Moral injury was negatively associated with moral resilience ( r = −0.463, P < 0.001), moral courage ( r = −0.226, P < 0.001) and positive coping scores ( r = −0.235, P < 0.001). Moral resilience was positively correlated to moral courage ( r = 0.184, P < 0.001) and positive coping scores ( r = 0.196, P < 0.001). Moral courage was positively associated with positive coping scores ( r = 0.515, P < 0.001). The mediation effect test indicates that moral injury can directly influence positive coping ( p < 0.01), with the direct effect accounting for 46.61% of the total effect. Additionally, moral injury can indirectly influence positive coping through the mediating effects of moral resilience and moral courage, as well as through the sequential mediation of both. The mediation effects account for 18.64%, 23.73% and 11.02% of the total effect, respectively. Conclusion Moral injury is negatively correlated with positive coping style of nursing interns in China, and moral resilience and moral courage may buffer the negative effects of moral injury and improve the coping strategies.

This scoping review maps peer-reviewed scholarship on military chaplaincy (2014–2024) indexed in Scopus and Web of Science. We asked how chaplains’ roles, delivery models, collaborations, and methodological approaches relate to moral injury, suicide care, religious and ethnic plurality, and readiness. Searches (14 March 2025) yielded 217 records and after analysis 58 met our criteria analysis. We classified studies as outcomes (n=3), implementation/provider-facing (n=37), and conceptual/historical/policy/evidence syntheses (n=18). The literature depicts a maturing discipline, moving from traditional ad hoc pastoral responses towards structured, reproducible approaches. Military Chaplain collaboration with behavioural health and command is the most developed thematic area, supported by learning collaboratives and crisis protocols. Moral-injury interventions cluster into chaplain-only, co-facilitated, and protocolised narrative-ritual models, with promising but limited outcome signals. Evidence-informed practice is growing via screening, shared language, and brief interventions; comparative work highlights diverse measurement approaches, ethics, and governance across countries. Samples are heavily weighted toward Christian chaplains, male service members, and the U.S. VA/DoD contexts. Gaps include rigorous trials, non-U.S. and minority-faith contexts, mechanism testing, and economic evaluation.

BackgroundMoral suffering is a growing concern in healthcare, especially in the nursing profession. It encompasses various forms, such as moral distress and moral injury, both of which impact nurses' professional integrity and mental and physical health. Despite extensive research, there is still no consensus on their definitions, distinctions, or causes, which impedes effective interventions. However, given their overlapping characteristics and consequences, joint consideration could offer critical insights to refine existing concepts.AimTo explore how nurses in clinical practice perceive moral suffering and analyze the essence of their experience of moral suffering.Research designData were collected through qualitative, semi-structured online interviews. The interview transcripts were analyzed using qualitative content analysis.Participants and research contextA total of 47 registered nurses from different clinical settings in German hospitals participated in the study.Ethical considerationsThe study protocol was approved by the Institutional Review Board at University Medicine Greifswald. All participants provided written informed consent.FindingsThe essence of moral suffering was determined in five main categories with corresponding subcategories: A trigger situation (1) in which a person in a specific moral disposition is present (2), whereupon they assess the situation as morally meaningful (3) and, accordingly, moral suffering is experienced in its three specific dimensions: (4) the characteristics (dynamic, context-dependence, temporality, fuzziness), dimensions of experience (rational and emotional integrity-related manifestation), and dimensions of action (handling, coping, prevention). This experience of moral suffering has consequences (5).ConclusionsThis study illuminates the complex nature of moral suffering among nurses, revealing its multidimensional essence and the interplay between personal and professional factors. The results underscore the need for a systemic approach to address moral suffering in nursing, emphasizing the importance of ethical leadership and workplace health promotion, and fostering shared values within healthcare teams.

Military chaplains (MCs) are trained to address aspects of health beyond the remit of mental health professionals, namely the spiritual/religious and existential dimensions of service members’ mental health, within the biopsychosocial-spiritual (BPSS) model. Models of military spiritual care differ, and in Sweden this is termed Military Soul Care (militär själavård), regulated through the ACCES framework (Advisory role; Commander and Crisis support; Ceremonies; Education; Soul care conversations in absolute secrecy). The study aimed to explore the contribution and meaning that MCs attribute to Military Soul Care in the Armed Forces. A qualitative questionnaire was employed, extending earlier Swedish research while reaching broader scope and depth. Fifty MCs participated. Using an inductive approach, three overarching themes emerged: Preserving the human character in an inhuman situation, Sustaining ethical and moral dimensions and reflections in a military context and, Framing cultural coherence to assist meaning-making in a military context. While these findings resonate with the Swedish Armed Forces’ understanding and purpose of Military Soul Care, they highlight additional emphases that deepen the comprehension of its role. Recent research from the war in Ukraine underscores how sustaining the moral character of military personnel is vital, as the relentless brutality of war erodes the moral frameworks underpinning civilian identities and contexts of peace. This aligns closely with the concept of moral injury. Accordingly, the contribution and meaning of Military Soul Care should be recognized as extending far beyond a spiritual/religious function, constituting a holistic approach to mental health within the BPSS model. The Swedish model is existential rather than spiritual or religious, and inclusive rather than exclusive. As it is culturally embedded within specific Swedish traditions, frameworks, and understandings, it does not satisfactorily align with concepts such as ‘spiritual’ and ‘religious’. Future research is especially encouraged on sustaining the human character and advancing a culturally sensitive approach to military chaplaincy.

To identify moral injury (MI) latent profiles, transitions in MI profile membership over time, and predictors of MI profile transitions. This study represents the first attempt to characterize transitions in MI latent profile membership and examine associated risk and protective factors. Latent transition analyses were conducted in a sample of 4,784 U.S. military veterans who responded to Waves 2 (W2) and 6 (W6) of the Veterans Metrics Initiative survey. The Moral Injury Events Scale and a variety of covariates were used in the analyses. Three MI profiles were identified, low exposure/distress (80.2% sample membership at W2 and 72.9% at W6), moderate exposure/distress (14.0% at W2 and 20.0% at W6), and high exposure/distress (5.8% at W2 and 7.1% at W6). Higher PTSD and ACEs scores were associated with greater odds of transitioning from the low to the high exposure/distress profile, while higher scores on social support and a sense of purpose were associated with lesser odds of transitioning from the low to the high exposure/distress profile. The use of person-centered analytic techniques, especially those that can accommodate longitudinal data, is important for advancing the study of MI, especially in terms of identifying risk and protective factors that can guide treatment efforts. The study's findings indicate the importance of considering malleable and nonmalleable risk and protective factors in understanding MI experiences and informing strategies to help those who are feeling MI-related distress. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

This study explores the experiences of direct care nurses with moral distress (MD) and moral injury (MI) during the COVID-19 pandemic. To understand how nurses experienced ethically challenging events that conflicted with their professional values and led to MD and MI. A phenomenologic design was used to examine lived experiences of direct care nurses in acute care settings. Participants were recruited via social media and professional organizations to complete an online survey. Qualitative content analysis was used to identify themes. Nurses described potentially morally injurious events, including ethical conflicts, clinical decisions beyond their control, inadequate leadership presence, and unsafe staffing. These experiences resulted in MD (feelings of guilt and emotional exhaustion) and MI, including betrayal by leadership, colleagues, and even loved ones. Many nurses described providing suboptimal care, witnessing patients die alone, and being asked to work beyond their expertise. Nurses encountered complex ethical challenges during the pandemic that contributed to MD and MI. These findings underscore the importance of ethical leadership, enhanced preparedness, and further education. Long-term strategies must extend beyond symbolic gestures to provide tangible, visible support and address the moral and psychological burdens that nurses face.

War-related stressors, such as economic loss, traumatic loss, and forced displacement, are well-documented risk factors for psychopathology. The mechanisms connecting war-related stressors to psychiatric symptoms remain unclear, particularly among civilians in conflict zones. Betrayal-related moral injury-feeling abandoned or let down by trusted leaders or institutions-can erode a sense of safety and justice and intensify distress. The present study examined whether such appraisals represent a psychological pathway linking war-related stressors to depression, posttraumatic stress disorder (PTSD), and anxiety. Civilians (N = 681, Mage = 31.3 years, SD = 5.6) exposed to conflict zones in southern and northern Israel following the October 7, 2023, events were recruited using an online platform. We conducted a longitudinal study with assessments in February, March, and May 2024 (Days 1, 30, and 90, respectively), evaluating participants' exposure to war-related stressors, betrayal-related moral injury (measured using the Moral Injury Events Scale), and depression, PTSD, and anxiety symptoms. We hypothesized that betrayal would mediate the relationships between war-related stressors and all symptom types. Economic loss directly influenced all three outcomes, whereas traumatic loss directly affected only PTSD. Betrayal mediated the associations between both economic and traumatic loss and psychopathology outcomes-depression, PTSD, and anxiety-but did not mediate the associations between displacement and these outcomes. The findings underscore the role that a sense of betrayal may play in the relationships between economic and traumatic loss and mental health outcomes. Targeted interventions addressing betrayal may help mitigate these symptoms in civilians exposed to trauma. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Balancing work and family responsibilities is challenging for working mothers, particularly those with caregiving duties. The present study investigates the relationship between work-family conflict (WFC) and moral injury, focusing on the potential moderating role of moral resilience. Italian working mothers (N = 285), either with preschool children or caring responsibilities for elderly parents and adolescent/young adult children, completed measures of WFC, moral injury, and moral resilience. Results indicated an association between work-family conflict (WFC) and moral injury, with moral resilience attenuating this relationship. Specifically, at higher levels of moral resilience, the relationship between WFC and moral injury was weaker. This protective mechanism was consistent across different caregiving groups. These findings enhance understanding of the complex psychological experiences of working mothers and emphasize the importance of interventions, such as flexible work policies and moral resilience training, to provide effective support. Practical implications, study limitations, and directions for future research are discussed.