The Marginalization of Spiritual Dimensions in Nursing Moral Injury Research: A Bibliometric Analysis, 2018-2025

Nursing moral injury research has expanded rapidly since 2020, yet the conceptual foundations and intellectual trajectories of this growth remain unexamined. This bibliometric study analyzed 179 publications retrieved from the Web of Science Core Collection (2018-2025) to map the conceptual evolution and intellectual foundations of nursing moral injury research, addressing two research questions: how have core concepts and thematic clusters evolved over time, and how has the co-citation knowledge base shifted across the study period? Keyword co-occurrence analysis with temporal overlay was performed via VOSviewer, and co-citation network analysis stratified across three pandemic-aligned periods was conducted via CiteSpace. The publication output increased fivefold between 2020 and 2021, which coincided with the COVID-19 pandemic, and it remained stable during the postpandemic period. Conceptual analysis revealed three concept strata distinguishable by the average year of publication: from contextual scaffolding around trauma, ethics, stress, and pandemic through pandemic-driven empirical research on psychological symptomatology and occupational outcomes to an individualized framework centered on moral resilience, compassion fatigue, and moral courage, with spirituality entering the middle stratum but not persisting into the recent vocabulary and with institutional betrayal entirely absent from the network. Co-citation analysis revealed a knowledge base shifting from the dominance of military psychology to nursing-specific specialization. However, the bio-psycho-social-spiritual framework of Carey and Hodgson (2018) never became an established part of the nursing moral injury knowledge base: it surfaced only briefly and peripherally within the military moral injury cluster of 2020-2022, and was absent from the nursing moral injury literature networks thereafter. Taken together, these findings reveal a field that has grown in volume and scope without consolidating around a stable theoretical anchor. Future research may benefit from adopting the bio-psycho-social-spiritual framework as an organizing structure for nursing-specific conceptualization, measurement, and intervention design, building toward a theoretically grounded and disciplinarily coherent nursing moral injury research agenda.