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

BACKGROUND: 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. OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: Moral resilience and healthy work environment may reduce moral injury. Future research should explore supportive interventions targeting early-career ICU nurses.