Moral Injury Among Intensive Care Unit Nurses: Roles of Moral Resilience and a Healthy Work Environment

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.