Moral Injury: An Employee’s Guide to Understanding and Coping

Moral injury is the damage done to one’s conscience or moral compass, and can cause lasting psychological, biological, spiritual, behavioural, and social impacts. If the moral conflict relates to personal moral transgressions, moral injury can result in feelings of guilt, shame, and embarrassment, while feelings of anger, contempt, and disgust can result if the conflict relates to unethical behaviour of others. For first responders—who are often in high-stakes situations requiring split-second decisions—moral injury can arise from events such as being unable to save a life, making difficult ethical choices, or witnessing leadership failures.

Concept of Moral Injury

The concept of moral injury originated with Military Veterans and First Responders and was first defined by psychiatrist Dr. Jonathan Shay as the psychological, social and physiological results of a betrayal of ‘what’s right’. Moral injury extends to healthcare and frontline workers who are obligated to make critical decisions in high-pressure environments.

Moral injury can impact the perception of authority figures, especially if an authority figure was involved in the event related to the potentially morally injurious events (PMIEs). PMIEs are events where values or deeply held moral beliefs are violated, or when an individual experiences conflict about the immoral or unethical behaviour of others. Both result in moral pain (the negative emotions that occur in response to the event). Moral injury can also impact the capacity to trust others, cause people to be in more distant relationships and impact the way people see themselves, care for themselves and even plan for their future.

Risk factors for moral injury include events such as loss of life of vulnerable people, perceived lack of support from leadership, being unprepared psychologically to the possibility of encountering PMIEs, being exposed to other forms of trauma, and lacking social support following the PMIE.

Effects of Moral Injury

The effects of moral injury can be long lasting and devastating. The effects may include feelings of guilt, shame, embarrassment, having a spiritual crisis (loss of meaning, questioning morality, a shift/change in world view), and difficulty with trust.

As a result of moral injury, one may experience the following:

• avoidance

• depression

• re-experiencing the event

• anxiety

• self-harm and suicidal thoughts

• substance use

• feeling disconnected and alienated from others

• withdrawing and isolating from friends and family

• betrayal (feelings of helplessness, confusion, loss for pride in work, low morale, anger, disappointment, burnout)

Managing Moral Injury

Treatment approaches for moral injury aim to challenge and change patterns of thinking and behaviour to improve mood, functioning and well-being and are specific to address the guilt and shame associated with moral injury.

A number of strategies are considered when treating people presenting with moral injury. Because betrayal occurs when a person experiences conflict about the immoral or unethical behaviour of others, forgiveness can be a potential goal. Forgiveness means to stop feeling resentment, and occurs over time. Forgiveness is not about forgetting or excusing the betrayal, but is a deliberate process that allows one to let go of negative emotions that block the healing process.

A number of other research-based strategies may also be used including resilience-based interventions, mindfulness and gratitude practices, focusing on personal well-being, and developing a support network.

Some self-care practices you can try include:

• Quiet time alone to check-in with yourself.

• Have at least one meaningful conversation every day.

• Maintain your social connections.

• Support others and show kindness.

• Get a reality check from someone you trust.

• Get enough sleep, rest and downtime.

• Avoid self-medicating.

• Identify what’s important to you.

• Consult a counsellor or therapist via your health benefits or employee and family assistance program to help you learn techniques to manage your feelings.

Moral Injury and Relationships

Often people with moral injury have a hard time separating their work and personal life. Relationships can also can be affected by shift work and the time-sensitive duties that are so often required in the at-risk professions.

Individuals experiencing moral injury may have a two-fold challenge when opening up to their partner or friends about PMIEs:

1. They may wish to shield their partner, family, and friends from the realities of what they’ve experienced to protect them from the distress, or they may fear that they’ll be judged for their actions or inactions.

2. They may also feel that “civilians can’t relate” or understand what their experiences are like.

The Role of Connection in Healing Moral Injury

It’s important to recognize that healing from moral injury is largely supported by the people around us. A focus on disclosing the emotional impact of their work and the events, rather than the details of the traumatic events themselves, can help. It’s helpful to lean on trusted individuals—whether they are colleagues, friends, or family—who can provide a listening ear and help with the emotional burden. Connecting with those who understand and care can help restore trust and support the healing process.

References

1. Bryan, C.J., Bryan, A.O., Roberge, E., Leifker, F.R., & Rozek, D.C. (2018). “Moral injury, posttraumatic stress disorder, and suicidal behavior among National Guard personnel.” Psychological Trauma: Theory, Research, Practice, and Policy, 10(1):36-45. Accessed 4 March 2025.

2. Homewood Health. (2020). “First responder, military and veterans programming treatment manual.” Accessed 4 March 2025.

3. Shay, J. (2012). “Moral Injury.” Intertexts, 16(1):57-66. Accessed 4 March 2025.

4. Williamson, V., Stevelink, S.A.M., & Greenberg, N. (2018). “Occupational moral injury and mental health: Systematic review and meta-analysis.” The British Journal of Psychiatry, 212(6):339–346. Accessed 4 March 2025.