Moral injury in nursing: An evolutionary concept analysis

BackgroundMoral injury is an important ethical and psychological concern in nursing, but its conceptual boundaries remain ambiguous due to overlapping with related constructs such as moral distress, burnout, compassion fatigue, and post-traumatic stress disorder. Lack of conceptual clarity hinders its consistent measurement and devising interventional strategies.ObjectiveTo clarify the concept of moral injury in nursing.DesignConcept analysis based on the Rodgers' evolutionary method.SearchA structured literature search of PubMed, Scopus, Web of Science, CINAHL, and Embase was conducted to support Rodgers' evolutionary concept analysis. The retrieved literature was analyzed to identify surrogate terms, related concepts, antecedents, attributes, consequences, and empirical referents of moral injury.ResultsThirty-five studies (12 qualitative, 22 quantitative, and one mixed-method) were included, indicating that moral injury in nursing has reached relative conceptual maturity. Moral injury is conceptualized as a multidimensional moral-psychological phenomenon characterized by three defining attributes: "ethical integrity violation," "identity disruption," and "persistent moral suffering." Antecedents are identified across individual, professional, organizational, and societal/system levels, encompassing personal moral characteristics, ethically challenging clinical situations, organizational constraints, and broader healthcare system conditions. Consequences similarly extend across individual, professional, organizational, and patient-care levels, including enduring psychological suffering, impaired professional functioning, reduced organizational effectiveness, workforce instability, and compromised quality of care. Existing empirical referents incompletely capture the multidimensional nature of the concept, particularly the disruption of professional identity. A conceptual framework that integrates the key conceptual elements has been developed.ConclusionsThis concept analysis establishes clearer conceptual boundaries for moral injury in nursing and distinguishes it from related constructs. The proposed conceptual framework provides a foundation for future measurement refinement, empirical research, and intervention development while highlighting the importance of organizational strategies that preserve nurses' moral integrity and support ethical professional practice.