Moral injury among psychiatric nurses: Experiences and contributing factors

Abstract

Background

Moral 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.

Aim

This study explores the experiences and causes of moral injury among psychiatric nurses in Japan who resigned due to moral or ethical distress.

Research design

A qualitative descriptive design was adopted.

Participants and research context

Semi-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 consideration

The study was conducted after the research ethics committees had approved, written informed consent was obtained from the participants, and their privacy was carefully considered.

Results

In 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.

Conclusion

Moral 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.