Moral distress and moral injury in healthcare: A review and instrument analysis

Abstract

Human and veterinary healthcare workers experience poor mental health, including burnout. However, some argue that burnout cannot fully explain their experiences. Moral distress (MD) and moral injury (MI) are gaining research attention, but there is limited consensus on their definitions and associated symptoms within healthcare. We explored how MD and MI are defined and measured in healthcare using the structure of a scoping review. Next, we conducted an item-by-item analysis to examine the instruments measuring these constructs. Our results revealed that MD focuses on antecedents, while MI emphasizes symptoms. A key gap across these instruments is the absence of a timeframe or a severity scale for distress. We also identified moral mindfulness and sensitivity to morally demanding situations as a potential third element. Finally, the potential overlap between MI and burnout’s emotional exhaustion and cynicism symptoms creates ambiguity in distinguishing whether an individual is experiencing MI, burnout, or both.