The process of moral injury among psychiatric nurses: From before experiencing moral injury to recovery

Abstract

Background

Repeated exposure to ethically challenging situations may lead to moral injury (MI). Though MI among healthcare professionals has attracted increasing attention, studies on the process of MI are limited.

Aim

To elucidate the entire process that psychiatric nurses in Japan undergo from before experiencing MI to their subsequent recovery. Core values in psychiatric nursing, what mitigate MI, and what is important to prevent MI are discussed.

Research design

A descriptive, qualitative design was adopted.

Participants and research context

Twelve nurses were interviewed between May 2024 and February 2025. Participants were nurses who had worked in psychiatric settings and had resigned because of witnessing or conducting unethical practices. Purposive snowball sampling, semi-structured interviews, and thematic data analysis were conducted.

Ethical consideration

Ethical approval was obtained from institutional IRBs.

Results

Before starting work, the nurses had professional values in psychiatric nursing, and they expected to practice nursing based on these values. On entering the wards, they encountered various events that conflicted with their values. At first, participants doubted whether the practices they observed were appropriate, which gradually intensified and developed into persistent internal conflict. Repeated failure to improve the quality of care led to MI. Participants felt a strong responsibility, which mitigated MI and kept them working. As morally injurious events accumulated, participants developed increasingly negative feelings, ultimately leading to resignation. Their recovery after resignation involved positive and negative emotions. Eventually, they recovered sufficiently to move forward.

Conclusion

Core values in psychiatric nursing include commitment to patients and respect for their rights. One effective way to mitigate MI is to establish psychologically safe spaces in which shared experiences and values are acknowledged and validated. Moral resilience and courage are important in preventing MI. Both concepts should not be considered personal traits but rather a shared capacity in a group.