Moral injury in nurses during COVID-19: A systematic review and meta-analysis

BackgroundThe COVID-19 pandemic has posed unprecedented challenges for nurses, including resource shortages, heavier workloads, and ethical decision-making pressures, putting them at high risk for moral injury. This threatens their physical and mental health, job stability, and the quality of care.AimThe aim was to systematically assess the level of moral injury among nurses during the COVID-19 pandemic.MethodsA comprehensive search was conducted on 12 databases (PubMed, Web of Science, MEDLINE, ProQuest, Embase, CINAHL, Scopus, PsycINFO, CBM, CNKI, VIP, WanFang Data) for cross-sectional studies published up to 20 July 2025, that reported the level of moral injury among nurses using the Moral Injury Symptoms Scale-Health Professionals Version. A systematic review and meta-analysis were conducted. Two researchers independently screened the literature, extracted data, and assessed methodological quality. The pooled mean score was calculated using random-effects or fixed-effects models, with subgroup analysis to explore heterogeneity.Ethical considerationsEthical approval was not required as the review synthesized publicly available data.ResultsThis study included 16 articles, involving 5824 participants. The meta-analysis showed that the pooled mean total MISS-HP score for nurses was 42.12 (95% CI: 40.70-43.53). Among the dimensions, the pooled mean score for Loss of religion/spiritual faith was the highest at 5.68 (95% CI: 4.61-6.74), while the pooled mean score for religious struggles was the lowest at 2.26 (95% CI: 1.13-3.40). Subgroup analysis results indicated significant differences in moral injury levels among nurses based on Survey year and department (p < .001).ConclusionsUnder the context of the COVID-19 pandemic, nurses experienced moderate to high levels of moral injury, particularly during the early stages of the pandemic in 2020, with emergency department nurses being most affected. To support nurses' well-being and mental health, healthcare institutions should strengthen ethical support systems, improve management, and consider the role of religion/spiritual faith in alleviating moral injury.