2026; 9(3): 15-25

DOI: 10.32114/CCI.2026.9.3.15.25
Published online: 2026-09-30 (first online 2026-09-23)

Moral injury in intensive care: conceptual boundaries, burden, prevention, and organizational moral repair - a narrative review.

Nirosha Rathnakumari [1] .

[1] Department of Nursing, Faculty of Nursing, KIU, Sri Lanka.

    Abstract:

Abstract [EN]   - Moral injury describes persistent moral, psychological, social, behavioral, or spiritual harm after events appraised as violating deeply held values or involving betrayal by a trusted authority. Intensive care is a high-risk environment because clinicians repeatedly encounter treatment limitation, nonbeneficial care, death, scarcity, hierarchical constraint, and institutional failure. This narrative review integrates conceptual, epidemiological, psychometric, and intervention evidence while separating ICU-specific findings from broader healthcare-worker data. Reported moral injury prevalence across healthcare and first-responder studies ranges from 4.1% to 69.4%, reflecting substantial differences in instruments, thresholds, professions, pandemic phase, and sampling. In a meta-analysis of 33 studies involving 31,849 healthcare workers, moral injury showed moderate associations with posttraumatic stress, depression, anxiety, burnout, and suicidal ideation (r=.30-.41). ICU-specific evidence remains thinner and often measures moral distress rather than moral injury, preventing a precise ICU prevalence estimate. Current models plausibly connect potentially morally injurious events to persistent impairment through appraisals of agency, responsibility, harm, betrayal, and failed repair, but prospective ICU tests are scarce. The most actionable correlates are organizational: ethical climate, staffing and resource adequacy, participation in decisions, psychological safety, leadership support, and institutional trust. Intensive care cannot eliminate tragic choices, but preventable exposure and progression to persistent impairment may be reduced through transparent allocation, shared decision making, rapid ethics support, protected escalation, early voluntary support, and accountable organizational moral repair. The decisive evidence gap is the absence of adequately powered ICU trials using moral injury as a primary outcome.

Streszczenie [PL]   - Uraz moralny opisuje uporczywą krzywdę moralną, psychologiczną, społeczną, behawioralną lub duchową po zdarzeniach ocenionych jako naruszające głęboko zakorzenione wartości lub obejmujące zdradę ze strony zaufanego autorytetu. Oddział intensywnej terapii jest środowiskiem wysokiego ryzyka, ponieważ lekarze wielokrotnie spotykają się z ograniczeniami w leczeniu, niekorzystną opieką, śmiercią, niedoborem, ograniczeniami hierarchicznymi i niepowodzeniami instytucjonalnymi. Niniejszy przegląd narracyjny integruje dowody koncepcyjne, epidemiologiczne, psychometryczne i interwencyjne, jednocześnie oddzielając ustalenia specyficzne dla oddziałów intensywnej terapii od szerszych danych dotyczących pracowników służby zdrowia. Zgłaszana częstość występowania urazów moralnych w badaniach dotyczących opieki zdrowotnej i ratowników medycznych waha się od 4,1% do 69,4%, odzwierciedlając istotne różnice w zakresie instrumentów, progów, zawodów, fazy pandemii i doboru próby. W metaanalizie 33 badań z udziałem 31 849 pracowników służby zdrowia, uraz moralny wykazał umiarkowany związek z zespołem stresu pourazowego, depresją, lękiem, wypaleniem zawodowym i myślami samobójczymi (r = 0,30–0,41). Dowody dotyczące oddziałów intensywnej terapii (OIT) są wciąż słabsze i często mierzą cierpienie moralne, a nie uraz moralny, co uniemożliwia precyzyjne oszacowanie częstości występowania OIT. Obecne modele wiarygodnie łączą potencjalnie szkodliwe moralnie zdarzenia z trwałym upośledzeniem poprzez ocenę sprawczości, odpowiedzialności, krzywdy, zdrady i nieudanej naprawy, ale prospektywne testy OIT są skąpe. Najbardziej istotnymi korelacjami są: klimat etyczny, adekwatność personelu i zasobów, uczestnictwo w podejmowaniu decyzji, bezpieczeństwo psychologiczne, wsparcie kierownictwa i zaufanie do instytucji. Intensywna terapia nie może wyeliminować tragicznych wyborów, ale można zapobiec narażeniu na ryzyko i progresji do trwałego upośledzenia poprzez transparentną alokację, wspólne podejmowanie decyzji, szybkie wsparcie etyczne, chronioną eskalację, wczesne dobrowolne wsparcie i rozliczalną naprawę moralną w organizacji. Decydującą luką w dowodach jest brak odpowiednio wiarygodnych badań na OIT, w których uraz moralny był głównym celem.

    Citation:

VANCOUVER FORMAT

Rathnakumari N. Moral injury in intensive care: conceptual boundaries, burden, prevention, and organizational moral repair - a narrative review. Crit Care Innov. 2026; 9(3): 15-25.
DOI: 10.32114/CCI.2026.9.3.15.25

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