Moral injury in neurointerventional practice: multinational survey

BACKGROUND: Neurointerventional practice involves making time-critical decisions and facing potentially devastating complications and clinical outcomes. Clinician distress in this field has traditionally been framed through the call burden, burnout, or the 'second victim' phenomenon, but these constructs may not fully capture ethical and identity-based distress. Moral injury offers a complementary framework, yet remains largely unexplored among neurointerventionalists. METHODS: We conducted an anonymous, multinational, cross-sectional survey of practicing neurointerventionalists and trainees. The survey assessed exposure to ethically distressing situations, organizational culture, institutional support, and professional consequences consistent with moral injury constructs. Analyses were descriptive, with exploratory comparisons evaluating associations between moral injury-related experiences and consideration of reducing or transitioning away from neurointerventional practice. RESULTS: A total of 212 neurointerventionalists completed the survey. Moral injury was considered relevant or highly relevant by 88% of respondents. Frequent emotional exhaustion was reported by 46%. Recurrent exposure to ethically distressing situations, including pressure to treat patients with low expected benefit, was common. Lack of structured institutional support after major complications was reported by 64%, and 58% described an absence of psychological safety within their departments. Overall, 51% reported negative impacts on professional functioning, and 42% had considered reducing or transitioning away from neurointerventional duties; 18% had already modified their clinical practice. The probability of professional disengagement increased progressively with cumulative moral injury burden. Domain-specific differences were observed across emotional, ethical, and organizational stressors. CONCLUSIONS: Moral injury is prevalent among neurointerventionalists and is closely linked to organizational and systemic factors. It provides a clinically relevant framework to understand professional disengagement and workforce vulnerability in neurointerventional practice, underscoring the need for institution-level accountability, peer-support programs, and structural interventions and cultural change.