Authors: Chloe J Brennan; Carl Roberts; Jon C Cole · Research

How Common Are Moral Injury and Post-Traumatic Embitterment Among Workers?

A comprehensive analysis reveals high rates of moral distress and embitterment in healthcare, military, and other professions

Source: Brennan, C. J., Roberts, C., & Cole, J. C. (2024). Prevalence of occupational moral injury and post-traumatic embitterment disorder: a systematic review and meta-analysis. BMJ Open, 14(2), e071776.

What you need to know

  • Moral injury and post-traumatic embitterment disorder (PTED) are common reactions to deeply unfair or ethically troubling events at work
  • About 67% of workers experience potentially morally injurious events, with 45% of healthcare workers showing clinical signs of moral injury
  • Civilian workers like teachers and healthcare staff face even higher rates of moral injury than military personnel
  • These conditions are linked to depression, anxiety, burnout and difficulty staying in jobs

Understanding Moral Injury and PTED

When people experience deeply unfair or ethically troubling situations at work, they can develop two types of psychological reactions: moral injury and post-traumatic embitterment disorder (PTED).

Moral injury happens when someone experiences events that violate their core moral beliefs and values. This could include being forced to make impossible ethical decisions, witnessing others act unethically, or feeling betrayed by leaders or institutions they trusted. For example, a nurse might develop moral injury if forced to ration care during a crisis, or a teacher might experience it after being unable to help a struggling student due to system constraints.

PTED develops when someone experiences a deeply unfair event that leaves them feeling bitter and unable to move forward. Unlike depression or anxiety, the core emotion is a profound sense of injustice and violation of basic values. A worker might develop PTED after being unfairly fired, passed over for promotion, or forced to implement policies they believe harm others.

How Common Are These Problems?

This research combined data from 88 different studies to understand how widespread moral injury and PTED are among workers. The findings are concerning:

  • 67% of workers across different jobs reported experiencing at least one potentially morally injurious event
  • 45% of healthcare workers showed clinical signs of moral injury
  • 26% of workers showed clinically significant levels of PTED
  • 48% witnessed others acting unethically at work
  • 46% experienced betrayal by leaders or institutions
  • 31% reported doing things themselves that violated their values

Surprisingly, civilian workers like teachers, healthcare staff, and child protection workers reported even higher rates of moral injury than military personnel. This challenges the common belief that moral injury mainly affects combat veterans.

Who Is Most at Risk?

The research found that certain occupations face higher risks:

Healthcare Workers:

  • 71% experienced potentially morally injurious events
  • 45% showed clinical signs of moral injury
  • Frequently faced impossible ethical decisions, especially during health crises

Educators:

  • 88% experienced potentially morally injurious events
  • Reported high rates of institutional betrayal
  • Often struggled with system constraints preventing them from helping students

Child Protection Workers:

  • 92% witnessed others acting unethically
  • Faced frequent ethical challenges in protecting vulnerable children
  • Reported high rates of institutional constraints

Military Personnel:

  • Actually showed lower rates of moral injury than civilian workers
  • May be better prepared through training
  • Still faced significant challenges, especially related to combat exposure

Impact on Mental Health and Work

Both moral injury and PTED are linked to serious consequences:

Mental Health Effects:

  • Depression
  • Anxiety
  • Post-traumatic stress
  • Burnout
  • Substance use problems

Work-Related Impact:

  • Difficulty staying in jobs
  • Increased sick leave
  • Problems with work relationships
  • Reduced job satisfaction
  • Risk of leaving the profession entirely

What Helps Protect Workers?

The research identified several factors that might help prevent or reduce the impact of moral injury and PTED:

Protective Factors:

  • Strong sense of justice and fairness at work
  • Clear ethical guidelines and support
  • Good leadership and institutional trust
  • Ability to speak up about concerns
  • Support from colleagues
  • Training in ethical decision-making

Risk Factors:

  • Lack of institutional support
  • Poor leadership
  • Limited resources to do the job properly
  • Isolation from colleagues
  • Pressure to act against values
  • Repeated exposure to ethical challenges

Conclusions

  • Moral injury and PTED are much more common in workplace settings than previously recognized
  • Civilian workers, especially in helping professions, face particularly high risks
  • Organizations need better systems to prevent and address these problems
  • More research is needed on effective treatments and prevention strategies
  • The impact on workers and organizations is significant and deserves more attention
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