Moral Injury and the Nurse Manager

The concept of moral injury was originally defined outside of healthcare, a term emerging from a military occupation to describe the psychological and emotional distress experienced when individuals either encounter, refrain from challenging or take part in actions that may impact and impose upon personal moral beliefs (Koenig and Zaben 2021). Moral injury definitions have since been applied to many professions, including the nursing profession, where nurses frequently confront situations where they may not be able to provide the standard of care they believe is professionally and morally right due to organisational or structural resources (Williamson et al. 2020). For nursing managers, the concept of moral injury has a distinct form because the role covers not only patient care, but also employee care and day-to-day management of service resources. Frequent navigation of tension between providing safe, compassionate care and the reality of nursing workforce shortages, increasing patient acuity and persistent financial pressures within health services can cause nurse managers to experience moral distress and decision fatigue (British Medical Association 2025). No nursing manager begins their working day intent on making decisions that negatively affect patient care. However, the cumulative pressures of budget management, cost improvement programmes and service change initiatives risk placing nursing managers in situations that may threaten their moral integrity. Moral injury in nursing management typically begins subtly. Early signs emerge when managers recognise rising pressures yet feel unable to take appropriate action due to organisational constraints (Royal College of Nursing 2022). This early stage may involve feelings of discomfort, unease or frustration as nurse managers attempt to balance competing priorities. Moral injury becomes more pronounced when these priorities intensify to the point where nurse managers repeatedly engage in or enforce decisions that conflict with their personal and professional commitment to person-centred care. Some examples that may be familiar to the reader are enabling nursing staff to work with potentially unsafe nurse–patient ratios, an unintentional delay to essential patient services due to capacity limitations of the service or implementing nursing staff financial reductions that risk compromising patient quality and/or experience. As moral injury progresses, the consequences can be significant, moving towards a concept of moral distress that informs McCarthy and Gastmans (2014) and nurse managers may begin to experience feelings of internalised guilt, shame and perceived powerlessness in organisational hierarchies. These feelings can then contribute to behaviours such as withdrawal from management responsibilities or impairing service level decision making and risk weakening the culture of compassionate care and nursing staff support that nurse managers expect to uphold (Nash 2025). The ability to recognise moral injury in oneself is a sign of the continued commitment to the nursing profession. Although understandably distressing, the nurse manager still cares about patient safety and staff well-being, and having an awareness of early warning signs provides an opportunity for the nurse manager to seek support and guidance. Addressing moral injury requires support at both an individual and organisational levels. As described earlier, the organisational variables that may contribute to moral injury sit beyond the nurse manager's direct sphere of influence. Health services rarely have the capacity to rapidly increase financial flexibility, expand intake of students entering higher education to become the next nursing generation, or reduce the rising acuity and complexity of the patient population they serve (McCauley 2020). There are strategies that can help nurse managers remain grounded in their values and reduce the emotional toll of morally challenging organisational situations. Having access to both clinical and managerial supervisory support and connecting with other nurse managers who share similar challenges can reduce isolation and reinforce a sense of professional community. Employment or private-based counselling enables nurse managers to also reflect on their experiences of being nurses with service responsibility and organisational accountability whilst understanding and making sense of the individual experience of moral injury (Labrague et al. 2017). In conclusion addressing moral injury is both a personal and organisational responsibility. Through an ongoing development of practices that protect the wellbeing of patients and staff whilst upholding the organisation's responsibility to provide a safe and supportive working environment, nurse managers can continue to lead with compassion and with personal values intact, even in the face of organisational pressures. The author has nothing to report. The author declares no conflicts of interest. The author has nothing to report.