Moral Distress, Moral Injury, and Ethical Burden among Helping Professionals: A Narrative Review

Introduction

In helping professions, work performance is closely connected to moral decision-making. Workers in healthcare, psychology, or social services often operate in environments with significant constraints. Their actions are shaped by organizational rules, lack of resources, and hierarchical structures. The discrepancy between perceived correctness of action and the real possibilities for implementation is not a rare phenomenon. Current research confirms it as one of the key sources of psychological burden (Beadle et al., 2024; Orgambídez et al., 2025). This state has a direct impact on staff mental health and the quality of care provided.

Interest in this topic in the professional literature increased sharply after 2000. The COVID-19 pandemic accelerated this trend. Extreme pressure on the system and emergency protocols placed professionals before demanding ethical choices. Many of these situations would never have arisen under normal conditions. Experiences from the crisis period showed that ethical burden is not just an abstract concept. It is daily reality that fundamentally affects professional identity and outcomes in work with clients.

The central concept in this area remains moral distress. Jameton (1984) defined it as a state in which an individual knows the correct solution, but institutional barriers prevent action. Although this definition opened the way for extensive research, it still raises discussion in professional circles. Morley et al. (2019) note that there is still no clear consensus on its precise delimitation. Despite this, the consequences of moral distress are well known. They are associated with anxiety, depression, and burnout syndrome (Oh & Gastmans, 2015). Current research findings confirm a strong relationship between this phenomenon and emotional exhaustion (Orgambídez et al., 2025).

In the last decades, the term moral injury has also become a prominent concept. It was originally studied in war veterans (Litz et al., 2009). It denotes deep damage to moral integrity resulting from serious violations of one’s own values. Moral distress and moral injury alone do not cover the full scope of the problem. The former focuses on external constraints and the latter on consequences of critical events. Both concepts often overlook the cumulative nature of burden. This is why the term ethical burden appears in the literature. Vinckers and Landeweer (2025) propose it as a broader framework for capturing the systemic nature of these processes.

The purpose of this review is to analyze and compare the concepts of moral distress, moral injury, and ethical burden. The article focuses on three fundamental question clusters. The first is analysis of definitions and relationships among these phenomena. The second examines individual and organizational factors that contribute to the burden. The final objective is to explore possibilities of integrating these into a unified theoretical framework. The analysis draws from literature published between 1984 and 2026. Particular attention is paid to healthcare, social, and psychological professions.

Methodology

This work is a narrative review. Its main aim is synthesis and comparison of scientific knowledge about moral distress, moral injury, and ethical burden in helping professions. A narrative synthesis was deliberately chosen. It allows capturing the terminological diversity of the investigated phenomena in a way that strict quantitative approaches might overlook. At the same time, it creates necessary space for critical comparison of theoretical frameworks across disciplines (Morley et al., 2019). In moral distress research, this approach is established. The reason is primarily the missing consensus in definitions and the substantial variability in instruments used. The narrative approach was also chosen given the conceptual fragmentation of the studied field, which still does not allow fully systematic comparison of findings.

Literature search was conducted in three electronic databases: PubMed, ScienceDirect, and Google Scholar. These sources cover relevant areas of medicine, nursing, psychology, and social work. The search focused on the period 1984 to 2026. Since 2010, a marked increase in scholarly interest and attempts to map the current state of knowledge has been observed. Earlier foundational works were included selectively as conceptual starting points (Jameton, 1984; Litz et al., 2009). A total of 46 sources were included in the final analysis, representing empirical studies, reviews, and theoretical articles.

The search used English key terms, specifically moral distress, moral injury, ethical burden, ethical stress, and helping professions. These terms were combined both individually and with Boolean operators AND and OR. The process was supplemented by a snowball method. Manual screening of reference lists in relevant studies allowed identification of additional important sources not found in the original database results.

Source selection was iterative and flexible. It was not a linear selection process but a gradual narrowing of the literature according to thematic relevance. The selection proceeded in several steps: (1) identification of sources based on keywords, (2) abstract screening, (3) in-depth analysis of full texts and their thematic relevance. The primary criterion was a direct link to the concepts under study as the main subject of analysis. Works in which these concepts appeared only marginally were excluded. Methodological quality also played an important role. Priority was given to peer-reviewed studies and reviews with a clearly described procedure, or theoretical texts with coherent argumentation. Inclusion criteria included thematic relevance, scientific character of publication, and links to helping professions, while exclusion criteria included marginal mentions of the concepts and methodologically insufficiently grounded studies. Source selection ended when conceptual saturation was reached, meaning additional studies no longer provided new significant theoretical insights.

The analysis included both quantitative and qualitative empirical studies. It also includes various types of reviews and theoretical articles. This deliberate typological breadth reflects the need to combine knowledge from multiple approaches given the complexity of the phenomena. In addition to English-language literature, selected studies from Slovak and Czech contexts were used as supplementary material.

Source analysis was carried out on three interrelated levels. The first was conceptual analysis focused on definitions of individual concepts and their relationships. The second level tracked individual and organizational factors contributing to burden. The final part was integrative synthesis. It evaluated possibilities for creating a unified theoretical framework for describing ethically demanding work. At the same time, it pointed to gaps that persist in current research.

Given the narrative character of the study, the goal is not to provide a list of all available sources. The paper instead focuses on analytically grounded synthesis of key concepts and their interconnections. This approach enables better understanding of the dynamics of moral burden in everyday helping practice. The author is also aware of potential source selection bias inherent in narrative reviews and sought to minimize it by including different study types and interdisciplinary approaches. The goal is not quantification of effects or meta-analytic generalization, but conceptual integration and critical reflection on existing approaches.

Theory

Moral Distress

Moral distress is currently a key concept in analyzing ethically demanding situations in helping professions. Jameton defined it in 1984 as a state in which an individual clearly knows what action is ethically right, but external barriers prevent its implementation. Such barriers include especially rigid organizational rules, resource shortages, and workplace hierarchical relations. Although this concept originally emerged in nursing, it gradually expanded into other disciplines. It has become an important framework for studying ethical burden among professionals across the helping professions. Despite its substantial spread, scholarly literature still does not offer a unified definition. Different approaches emphasize different aspects of this phenomenon, from cognitive judgment to psychological responses (Morley et al., 2019). Fourie (2015) warns in this context about the risk of confusing moral distress with related phenomena such as moral conflict or moral dilemma. The author notes that narrowing this term too much can lead to overlooking more complex problems in practice.

Efforts to better understand this dynamic led to the identification of core components of moral distress. Review studies suggest it is not a static moment, but a multi-layered process. It includes the presence of an ethically relevant situation, a clear belief in the correct course of action, and the existence of concrete barriers. The result is psychological suffering (Morley et al., 2019; Fourie, 2015). In many cases, a sense of moral failure also appears, directly affecting individual integrity.

A crucial role in the emergence of this tension is played by the nature of constraints. Research indicates that barriers may be individual, such as lack of assertiveness or fear of consequences. In practice, however, organizational and interpersonal factors dominate (Whitehead et al., 2015). Individual barriers can be partly corrected through competence development. Systemic factors such as staffing shortages or time pressure, however, remain largely unchangeable for the worker. These limitations are repeatedly identified in the literature as a main source of burden.

Long-term exposure to such factors has negative consequences for professionals’ mental and physical health. Analyses confirm a direct link to anxiety, depression, and burnout syndrome (Oh & Gastmans, 2015). These states lead to lower job satisfaction and frequent thoughts about changing occupation. Empirical findings further show strong connections with emotional exhaustion. This can be interpreted as the logical outcome of a mismatch between ethical demands and realistically available resources (Lamiani et al., 2017).

The cumulative nature of the whole phenomenon should not be overlooked. Repeated ethical conflicts leave professionals with so-called moral residue. These manifest as persistent feelings of guilt and helplessness. The mechanism known as the crescendo effect means that each additional demanding situation hits already weakened integrity (Epstein & Hamric, 2009). As a result, the intensity of distress progressively increases over time. Unlike ordinary work stress, these feelings do not disappear after rest but form lasting patterns in worker identity.

Despite its value, the concept of moral distress has several limitations. Its major weakness is the assumption that an optimal solution is always clearly known in advance. This overlooks complex moral dilemmas in which two legitimate values are in conflict (Morley et al., 2019). At the same time, this approach primarily focuses on individual experience, which can divert attention from deeper systemic roots of ethical burden. These limitations indicate the need for more comprehensive theoretical frameworks.

Another layer of critique concerns terminological ambiguity. Aljabery et al. (2024) note that attempts to expand the definition have led to ambiguous boundaries. Distress can then sometimes be difficult to distinguish from burnout, compassion fatigue, or moral injury. Morley et al. (2019) state that without a consistent foundation, empirical studies on this phenomenon are hard to compare. A further issue is measurement tools that capture distress more as a static state. Its cumulative and progressive nature is therefore only partially captured (Aljabery et al., 2024; Epstein & Hamric, 2009).

Beadle et al. (2024) also point to the lack of data on the impact of cultural differences. Most studies did not record participants’ ethnic background, which prevents reliable conclusions. Cultural conditioning of the phenomenon therefore remains one of the least examined areas. All these findings confirm that moral distress needs to be complemented by additional concepts. As a significant complement, moral injury appears especially useful, allowing better understanding of long-term consequences of demanding practice.

Moral Injury

The concept of moral injury has developed in scientific discussion along two main lines. These approaches mainly differ in what they consider the primary source of damage to integrity. Shay (2014) represents one line. Based on work with veterans, the author defines moral injury as betrayal by a trusted authority. This betrayal occurs in severe morally demanding situations in which what the individual sees as right is disrupted. It concerns not only the event itself, but also the fact that the person is placed in it or remains in it without support from the system or superiors. This approach emphasizes especially the relational dimension of the whole experience, namely the disruption of trust, and notes that effects reach deeply into internal experience. The result is often marked difficulty in regulating one’s own emotions.

The second and currently most cited model was formulated by Litz et al. (2009). Moral injury is understood as a set of lasting psychological, biological, and social consequences. These consequences are triggered by actions that are in direct contradiction to deep personal beliefs. Its definition includes not only direct commission but also omission or bearing witness to transgression. At the core of the process is cognitive dissonance associated with intense guilt and shame. The whole mechanism can be seen as a sequence of events: morally challenging experience, then negative emotions, then global disruption of worker identity.

Current theoretical debate subjects these models to criticism. Acampora et al. (2024) point to differences between humanistic and clinically oriented lines of research. They criticize especially efforts to reduce this phenomenon to an intrapsychic problem. In this way, its important social and relational dimension is often neglected. Hoyt (2023) also notes more than twelve different definitions and warns against excessive broadening of the concept, which can reduce precision. Carey and Hodgson (2018) made an attempt at integration. Their definition links perpetration with betrayal by authority and distinguishes between core and secondary symptoms.

VanderWeele et al. (2025) propose viewing this issue as a spectrum of moral trauma. In this model, moral injury is a middle-level form between distress and a more severe disorder. Moon and Keefe-Perry (2026) further expand this perspective by proposing moral disorientation, that is, loss of coherence in the value and meaning system. They also warn that current measurement tools have limits in capturing chronic forms of this state.

When transferred to helping professions, the specific character of this concept becomes apparent. Unlike in the military, this is not a matter of isolated critical events. In healthcare and social services, it is more cumulative burden (Rabin et al., 2023). Everyday ethically demanding situations lead to gradual erosion of integrity through so-called moral residue. Griffin et al. (2023) in their model point to interaction between individual and organizational factors. In this context, institutional betrayal is considered a particularly key risk (French et al., 2022).

In specific areas such as psychiatry, moral injury appears as a role conflict. The practitioner stands between the need to treat and the need to control the patient (Webb et al., 2023). The same is true in long-term care settings, where systemic constraints and lack of resources are central (Vinckers & Landeweer, 2025). The COVID-19 pandemic intensified these processes. Many healthcare workers experienced deep moral suffering that was not always clearly named (Jack & Kotronoulas, 2023). Empirical studies confirm these states are closely linked with anxiety and depression (Anastasi et al., 2024).

Research also reveals differences in individual vulnerability, conditioned by age, length of practice, or religious beliefs (Vlčková et al., 2025). Moral injury differs from post-traumatic stress disorder mainly by the dominance of guilt and shame. In PTSD, fear is central (Jovarauskaite et al., 2022). This phenomenon is also strongly linked to emotional exhaustion and burnout (Orgambídez et al., 2025). Unlike moral distress, which is tied to constrained action, moral injury affects moral integrity more deeply.

All these findings emphasize the need for new forms of support. Interventions should not focus only on the individual, but also on the organizational and ethical context of work. Moral injury helps to understand the long-term effects of difficult experiences. However, it still insufficiently captures the everyday and systemic nature of ethical demands. This limitation creates space for a broader framework of ethical burden, which allows a more comprehensive account of reality in helping professions.

Ethical Burden

The term “ethical burden” is a concept without a fixed definition and is used more loosely in scholarly literature. Yet, because it captures an experiential dimension that relatively narrower concepts like moral distress or moral injury cannot adequately capture, it proves analytically useful. It is daily and often almost invisible burden borne by a helping professional in the course of a profession with pronounced moral load. It appears especially where values, resources, and systemic conditions are not aligned. Ethical burden is not currently standardized terminologically. In this work, it is therefore used as a heuristic concept that captures the cumulative and systemic dimension of moral tension insufficiently covered by moral distress and moral injury. Its goal is not to replace existing concepts but to complement them with a chronic burden perspective arising over time.

At the same time, we understand ethical burden as a layered concept performing three functions: it represents the context in which moral tension arises, the process of its accumulation over time, and the resulting chronic state that emerges from this process.

In the broadest sense, ethical burden can be understood as the cumulative consequence of repeated exposure to challenging situations. These situations need not always be dramatic. This everyday character distinguishes it from moral distress, which is usually tied to a specific episodic event accompanied by helplessness (Buchbinder et al., 2024; Jameton, 1984). While moral distress is linked to a specific moment, ethical burden gradually forms as the result of repeated experiences and broader everyday tensions. Cribb (2011) captures this as routine moral load, which is part of professional role rather than an exceptional experience.

Hansen et al. (2025) interpret ethical burden in the context of value changes in healthcare. Processes of economization, bureaucratization, and digitization reshape institutional values that increasingly diverge from professionals’ value worlds. The tension between system demands and a worker’s convictions thus becomes a source of burden. This does not appear as a sudden moral rupture, but rather as long-term frustration, loss of meaning, and gradual erosion of professional integrity.

A similar line can be observed in the concept of moral stress. Cribb (2011) distinguishes it from moral distress by noting that it is not necessarily accompanied by helplessness and is not tied to a specific care event. It arises more from day-to-day functioning in a systemically strained environment (Buchbinder et al., 2024). Ethical burden is close to this concept but has broader scope. It includes not only systemic pressures but also subjective psychological response, which can accumulate especially through repeated experiences of moral distress over time.

Oelhafen et al. (2024) point to methodological limits of the research, noting that most studies on moral distress do not account for other load factors such as time pressure, staffing shortages, or hierarchical pressure. The result is overestimation of moral distress in a narrow sense and overlooking broader working conditions. Ethical burden as an integrative concept captures these dimensions and shows that moral distress is only one of its components, which may accumulate over time.

Empirical findings from Central European contexts supplement this picture. Studies on Slovak nurses report burden associated with patient deaths and excessive workload (Sováriová Soósová et al., 2013; Budayová et al., 2023). Although these studies do not work directly with the term ethical burden, they describe situations where the worker cannot meet their own professional standards, leading to burnout and declining quality of care. In the Czech context, Mareš (2016) notes that the term moral distress entered discourse relatively late, while workers may have experienced burden without being able to name it precisely. Ethical burden can thus function as an umbrella concept for these experiences.

Psychologists require particular attention, as ethical burden has a specific character there. Mareš (2017) points to pressure from superiors to prioritize institutional interests over client interests, representing repeated pressure to act against professional values. Exactly such recurring situations can lead to long-term experiences of moral distress that progressively accumulate into broader ethical burden. Similarly, Praško et al. (2024) point to daily dilemmas related to confidentiality and boundaries, whose accumulation can lead to moral fatigue and disorientation. Nissen-Lie et al. (2021) also show that personal burdens affect therapeutic work, deepening ethical burden further. For this study, therefore, we propose a working delineation with heuristic character. Ethical burden is the cumulative psychological, moral, and systemic consequence of long-term exposure to demanding working conditions, in which tension arises between the professional’s value world and institutional reality. It is not identical to moral distress, but it can significantly develop from it. Repeated experiences of moral distress accumulate over time and contribute to the formation of ethical burden as a chronic state.

This phenomenon appears in different domains. At the psychological level it means fatigue, loss of motivation, and frustration, while long-term accumulation of experiences leads to what is described as the crescendo effect (Epstein & Hamric, 2009). At the moral level, ethical burden threatens integrity because repeated situations in which one cannot act according to one’s values weaken congruence between conviction and action. At the systemic level, it is a result of institutional conditions such as low autonomy or hierarchical pressure (Hansen et al., 2025; Oelhafen et al., 2024).

Results of Literature Synthesis

The included studies show several findings but also indicate persistent inconsistency in disciplinary terminology. Even though the number of studies in this area is growing, the relationships between moral distress, moral injury, and ethical burden are interpreted in different ways. This condition confirms the need for a more systematic treatment of these in scholarly discussion.

Moral distress is most often understood in the literature as a situational phenomenon. It arises when a worker cannot act in accordance with their values due to external constraints, such as rigid organizational rules, hierarchical structures, or shortages of resources. This delimitation remains relatively stable, yet disagreement persists over which conditions are necessary for its emergence and how to distinguish it precisely from moral dilemmas or ordinary work stress. This ambiguity complicates both theoretical understanding and empirical research and comparability of results.

Moral injury, by contrast, represents deeper and qualitatively different intrusion into moral integrity. It has a long-term character and is connected with experience of severe moral transgression, whether through one’s own action, witnessing, or enduring betrayal by legitimate authority. Literature emphasizes that this is a phenomenon that exceeds immediate emotional reactions and touches identity, one’s relation to oneself, and the social environment.

Ethical burden appears in the analyzed studies as a broader and less strictly defined concept that makes it possible to capture the cumulative and temporally developing nature of moral tension in helping professions. Unlike single episodes of moral distress, it reflects everyday, often less obvious, but repeating situations in which misalignment occurs between professional values and real working conditions. This repetition suggests that ethical burden can be substantially shaped by cumulative moral distress over time, while also including broader systemic and contextual pressures.

Thus, the literature synthesis suggests dynamic links among these three concepts. Ethical burden can be understood as a broader context and simultaneously a process that develops over time. This context increases the likelihood of moral distress by creating an environment of repeated conflicts between values and possible action. At the same time, repeated and unresolved episodes of moral distress can accumulate and then feed back into deepening ethical burden as a chronic state. In long-term persistence and intensification of such experiences, moral integrity can be disrupted, increasing risk of moral injury development.

These findings indicate that the concepts should not be understood as strictly separate categories, but rather as interconnected phenomena within one continuum of moral suffering in helping professions, differing mainly in intensity, temporal course, and depth of impact on the individual.

Comparison and Conceptual Integration

Understanding moral suffering in helping professions requires precise delineation of three key concepts: moral distress, moral injury, and ethical burden. These terms are often conflated in both literature and practice, and their differentiation is not merely academic but a necessary prerequisite for adequately understanding problems and designing effective interventions. Each concept captures a different layer of experience, differing particularly in temporal dynamics, origin, and the level at which it emerges.

Moral distress is the historically oldest concept. Jameton (1984) defined it as a state of psychological disequilibrium arising in a situation where the professional knows the ethically correct solution, but external barriers prevent implementation. It is mainly an acute phenomenon tied to specific situations, with an identifiable trigger and manifesting as frustration, helplessness, or feelings of compromised personal integrity. Morley et al. (2019) state that its emergence presupposes the presence of a moral event, psychological strain, and a causal relation between them. At the same time, literature warns that moral distress cannot be reduced to isolated episodes. Epstein and Hamric (2009) describe the crescendo effect, in which unresolved situations lead to the accumulation of moral residue—that is, persistent feelings of guilt, failure, and compromise of values. This process increases sensitivity to further ethical conflicts and suggests that repeated moral distress can gradually transform into a more long-term form of burden (Fischer Grönlund et al., 2024; Sirilla et al., 2017).

Moral injury represents a deeper and qualitatively distinct phenomenon. Litz et al. (2009) define it as enduring psychological, biological, and social consequences of actions that fundamentally violate inner moral beliefs. Unlike distress, it leads to lasting change in one’s relation to oneself and to the moral order of the world. Its onset may be delayed and can intensify with later processing of experiences (VanderWeele et al., 2025). The source is moral transgression, which may take the form of one’s own action, witnessing, or enduring betrayal by authority (Shay, 2014). Shame, alienation, and loss of meaning dominate the response (Campbell et al., 2023). Griffin et al. (2026) show that moral injury can exist without the presence of depression or post-traumatic stress disorder, while Acampora et al. (2024) emphasize its relational and social character.

Ethical burden represents the broadest and least terminologically stabilized of the three concepts. Hansen et al. (2025) and Buchbinder et al. (2024) describe it as a chronic consequence of long-term work under demanding conditions where persistent tension arises between professional values and institutional reality. Unlike one-time distress episodes, it is a process shaped over time and rooted in everyday functioning within the system. Cribb (2011) describes this as routine moral burden. Ethical burden therefore links individual experience with systemic conditions and also provides a framework in which repeated distress experiences may accumulate and assume a chronic character. Studies also highlight the importance of organizational factors such as ethical climate and organizational justice, which significantly influence this burden (Zhang et al., 2026; Poeira & Nunes, 2025).

Relations among these concepts are dynamic and partially hierarchically organized. Moral distress can be understood as an acute response to a specific situation, while ethical burden is a broader context and also a process shaped over time. This process is largely formed precisely through repeated experience of moral distress and accumulation of moral residue (Epstein & Hamric, 2009; Aljabery et al., 2024). Ethical burden is therefore not only an environment but also the long-term result of these experiences. If persistent and intensified, these experiences can disrupt moral integrity and increase the risk of developing moral injury. VanderWeele et al. (2025) place distress and injury on a spectrum of moral trauma, while ethical burden extends this spectrum by including structural conditions of its emergence.

Research in this area has several limitations. There is often excessive focus on individual psyche (Jameton, 1984; Litz et al., 2009), leading to interventions oriented primarily to the individual while systemic factors remain secondary. Acampora et al. (2024) warn that moral experience is always relational and contextually rooted. Another issue is that measurement focuses on isolated critical events (Koenig et al., 2018), which leads to overlooking chronic forms of suffering (Griffin et al., 2025). Terminological ambiguity and insufficient capture of systemic causes also persist (Oelhafen et al., 2024; Hoyt, 2023).

On the basis of these findings, an integrative framework can be formulated as a three-layer model. Ethical burden forms its chronic and systemic foundation, determining conditions of work and framing everyday functioning. On this background, moral distress emerges as an acute reaction to the concrete impossibility of acting in line with values. If these situations repeat and remain unprocessed, they accumulate, deepening ethical burden and increasing risk of moral injury. This already represents a qualitative change in identity and moral self-understanding (Litz et al., 2009; Acampora et al., 2024). Moon and Keefe-Perry (2026) describe this state as moral disorientation, pointing to its existential dimension. The relationships between layers are reciprocal. Ethical burden increases the likelihood of moral distress, while repeated experiences of distress in turn contribute to its further deepening. Interventions targeting only one level are therefore insufficient. Individual coping strategies have limited effects unless accompanied by organizational-level changes (Kohútová et al., 2022; Merlo & Podbregar, 2026). This integrative framework thus allows moving beyond reductionist understanding and offers a more comprehensive understanding of moral suffering as a phenomenon arising at the intersection of individual and systemic processes, which is crucial for the long-term sustainability of helping professions.

Discussion

The aim of this review was to analyze and compare the concepts of moral distress, moral injury, and ethical burden. Although these terms often overlap in professional literature, this is not only terminological ambiguity but also a factor causing fragmentation of research and imprecise targeting of interventions. The presented analysis shows that each of these concepts captures a different dimension of moral suffering. The main contribution of the paper is therefore the proposal of an integrative theoretical framework that links these dimensions and makes it possible to understand moral suffering as a dynamic process occurring at the intersection of individual experience and the structural conditions of professional practice.

Findings suggest that moral suffering in helping professions cannot be reduced to isolated events or understood as a static state, but rather as a process with temporal dynamics and cumulative character. Moral distress appears in this process as an acute response to a specific ethical conflict, while ethical burden represents the chronic background and result of the long-term operation of these experiences. Repeated and unresolved episodes of moral distress may accumulate over time and contribute to the formation of ethical burden as a persistent state. This distinction is crucial for practice, since current interventions often focus on managing individual episodes of distress while overlooking long-term accumulation of burden and its systemic grounding.

A significant shift from traditional approaches is also a critical reassessment of individualistic interpretations of moral injury. Classical models mainly emphasize intrapsychic processes and experiences of guilt or shame. Based on current literature (Acampora et al., 2024; Moon & Keefe-Perry, 2026), however, this view can be considered reductionist because it neglects the relational and systemic dimension of the problem. Moral injury thus appears not only as the consequence of individual failure but also as a result of disruption of the moral order within which the professional operates. This shift has significant implications for prevention and intervention. Dominant emphasis on individual resilience proves insufficient if organizations continue to create situations in which acting in line with professional values is not possible. The proposed integrative model therefore shifts part of responsibility to organizational and broader structural levels. The model presented here also overcomes fragmentation of existing approaches by linking temporal dimensions (acute vs. chronic processes), levels of analysis (individual vs. system-level), and the qualitative depth of the phenomenon (distress vs. injury). It thus enables better understanding of how repeated episodes of moral distress may be one mechanism leading to the deepening of ethical burden and, under certain conditions, to disruption of moral integrity. Without such a framework, each phenomenon risks being studied in isolation, which limits possibilities for effective prevention and intervention.

Despite these contributions, the study has limits. Because of the narrative nature of the review, the same degree of reproducibility as systematic reviews is not possible. Source selection aimed to capture conceptual diversity, which may have led to selectivity. Thus results cannot be understood as an exhaustive synthesis, but rather as an analytically oriented literature selection. Terminological inconsistency in this field continues and remains a significant barrier to cumulative knowledge development. Another limitation is geographic and cultural imbalance in available data. Most studies come from the Anglophone context, and transferring these findings to Central Europe is not self-evident. Differences in organizational structures, hierarchy, and cultural norms may significantly affect how ethical burden is experienced and regulated. Although Slovak and Czech studies were included in the analysis, their limited number does not allow full comparison.

Research has also long focused mainly on healthcare professions, while psychologists and social workers remain relatively neglected. Yet these professions are characterized by complex ethical dilemmas and recurring situations that can lead to long-term experiencing of moral distress and its accumulation. The lack of empirical studies in this area therefore represents a significant research gap. Future research should focus on empirical validation of the proposed model, ideally through combined qualitative and longitudinal approaches. Qualitative studies can contribute to deeper understanding of how professionals interpret the transition between moral distress and moral injury, while longitudinal designs would enable capturing cumulative nature of ethical burden over time. Special attention is also needed for organizational factors such as ethical climate, autonomy, and decision-making transparency, which can function as protective or risk mechanisms. It can therefore be stated that moral suffering in helping professions is a complex, multi-level phenomenon that cannot be adequately explained or addressed at the individual level isolated from the work context. If support for professionals is to be effective, it must reflect not only their individual coping resources but also the conditions under which they are forced to act. Without this shift, helping professions will continue to operate over the long term at the cost of the gradual erosion of moral integrity of those who perform them.

Conclusion

This study shows that moral distress, moral injury, and ethical burden are not different explanations of the same phenomenon, but interconnected layers of one process. The proposed framework indicates that ethical burden is not merely a backdrop, but a dynamic process arising from the long-term operation of systemic conditions and repeated experience of moral distress. Precisely as its accumulated and persistent form, it contributes to deepening burden and, under certain conditions, to the development of more sustained disruption of moral integrity. From this perspective, ethical burden does not only show how individuals act in coping with demanding situations, but rather under what conditions they are repeatedly forced to act. If care for others is to remain sustainable over time, attention should not focus only on individual adaptation, but also on critical re-evaluation of the environment that systematically generates these situations.

Author: Mgr. Sabrina LUŠČÍKOVÁ

List of Bibliographic References

Acampora, C. D., Munch-Jurisic, D., Culbreth, A., Denne, S., & Smith, J. (2024). Critique of the standard model of moral injury. New Ideas in Psychology, 75, 101107. https://doi.org/10.1016/j.newideapsych.2024.101107

Aljabery, M., Coetzee-Prinsloo, I., Van der Wath, A., & Al-Hmaimat, N. (2024). Characteristics of moral distress from nurses' perspectives: An integrative review. International Journal of Nursing Sciences, 11(4), 578–585. https://doi.org/10.1016/j.ijnss.2024.10.005

Anastasi, G., Gravante, F., Barbato, P., Bambi, S., Stievano, A., & Latina, R. (2024). Moral injury and mental health outcomes in nurses: A systematic review. Nursing Ethics. Advance online publication. https://doi.org/10.1177/09697330241281376

Beadle, E. S., Walecka, A., Sangam, A. V., Moorhouse, J., Winter, M., Munro Wild, H., Trivedi, D., & Casarin, A. (2024). Triggers and factors associated with moral distress and moral injury in health and social care workers: A systematic review of qualitative studies. PLOS ONE, 19(6), e0303013. https://doi.org/10.1371/journal.pone.0303013

Buchbinder, M., et al. (2024). Moral stress and moral distress: Confronting challenges in healthcare systems under pressure. The American Journal of Bioethics, 24(12), 8–22. https://doi.org/10.1080/15265161.2023.2224270

Budayová, Z., Ludvigh Cintulová, L., & Mrosková, L. (2023). Analysis of risk of burnout at workers in the field of social services and health care. Journal of Education Culture and Society, 13(1), 365–380. https://doi.org/10.15503/jecs2023.1.365.380

Campbell, G. M., Biscoe, N., Bonson, A., & Murphy, D. (2026). Association of potential morally injurious events, moral injury and somatic symptoms of health in UK military veterans: A cross-sectional study. BMC Psychology, 14, 56. https://doi.org/10.1186/s40359-025-03788-5

Carey, L. B., & Hodgson, T. J. (2018). Chaplaincy, spiritual care and moral injury: Considerations regarding screening and treatment. Frontiers in Psychiatry, 9, Article 619. https://doi.org/10.3389/fpsyt.2018.00619

Cribb A. (2011). Integrity at work: managing routine moral stress in professional roles. Nursing philosophy : an international journal for healthcare professionals, 12(2), 119–127. https://doi.org/10.1111/j.1466-769X.2011.00484.x

Epstein, E. G., & Hamric, A. B. (2009). Moral distress, moral residue, and the crescendo effect. Journal of Clinical Ethics, 20(4), 330–342. https://doi.org/10.1086/JCE200920406

Fischer Grönlund, C., Isaksson, U., & Brännström, M. (2024). Moral distress thermometer: Swedish translation, cultural adaptation and validation. Nursing Ethics, 31(4), 461–471. https://doi.org/10.1177/09697330231197707

Fourie, C. (2015). Moral distress and moral conflict in clinical ethics. Bioethics, 29(2), 91–97. https://doi.org/10.1111/bioe.12064

French, L., Hanna, P., & Huckle, C. (2022). “If I die, they do not care”: U.K. National Health Service staff experiences of betrayal-based moral injury during COVID-19. Psychological Trauma: Theory, Research, Practice, and Policy, 14(3), 516–521. https://doi.org/10.1037/tra0001134

Griffin, B. J., Weber, M. C., Hinkson, K. D., Jendro, A. M., Pyne, J. M., Smith, A. J., Usset, T., Cucciare, M. A., Norman, S. B., Khan, A., Purcell, N., & Maguen, S. (2023). Toward a dimensional contextual model of moral injury: A scoping review on healthcare workers. Current Treatment Options in Psychiatry, 10(3), 199–216. https://doi.org/10.1007/s40501-023-00296-4

Griffin, B. J., Price, L. R., Jenkins, Z., Childs, A., Tong, L., Raciborski, R. A., Weber, M. C., Pyne, J. M., Maguen, S., Norman, S. B., & Vogt, D. (2025). A systematic review and meta-analysis of moral injury outcome measures. Current Treatment Options in Psychiatry, 12, 7. https://doi.org/10.1007/s40501-024-00342-9

Griffin, B. J., Warner, E. A., McCue, M. L., Pietrzak, R. H., McLean, C. P., Norman, S. B., & Maguen, S. (2026). The role of measurement in moral injury care: Latent profiles on the moral injury and distress scale. Frontiers in Psychiatry, 16, Article 1691018. https://doi.org/10.3389/fpsyt.2025.1691018

Hansen, D., Aleksandrova-Yankulovska, S., & Steger, F. (2025). Ethical analysis of the change of values in healthcare. Nursing ethics, 32(6), 1926–1939. https://doi.org/10.1177/09697330251319374

Hoyt, T. (2023). Moral injury: Wrestling with definitions and conceptual drift. Æther: A Journal of Strategic Airpower & Spacepower, 60–70.

Jack, F. J. G., & Kotronoulas, G. (2023). The perceptions of healthcare staff regarding moral injury and the impact on staff life and work during COVID-19: A scoping review of international evidence. Journal of Religion and Health, 62, 2836–2860. https://doi.org/10.1007/s10943-023-01803-w

Jameton, A. (1984). Nursing practice: The ethical issues. Prentice-Hall.

Jovarauskaite, L., Murphy, D., Truskauskaite-Kuneviciene, I., Dumarkaite, A., Andersson, G., & Kazlauskas, E. (2022). Associations between moral injury and ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD among help-seeking nurses: A cross-sectional study. BMJ Open, 12(5), e056289. https://doi.org/10.1136/bmjopen-2021-056289

Koenig, H. G. (2018). Measuring symptoms of moral injury in veterans and active duty military with PTSD. Religions, 9(3), 86. https://doi.org/10.3390/rel9030086

Kohútová, K., Štefáková, L., & Gerec, F. (2022). Impact of mindfulness and coping strategies on the well-being of hospice workers in Slovakia during the COVID-19 pandemic. Kontakt, 24(4), 331–338. https://doi.org/10.32725/kont.2022.040

Lamiani, G., Borghi, L., & Argentero, P. (2017). When healthcare professionals cannot do the right thing: A systematic review of moral distress and its correlates. Journal of Health Psychology, 22(1), 51–67. https://doi.org/10.1177/1359105315595120

Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695–706. https://doi.org/10.1016/j.cpr.2009.07.003

Mareš, J. (2016). Morální distres: Terminologie, teorie a modely. Kontakt, 18(3), e137–e144. https://doi.org/10.1016/j.kontakt.2016.07.001

Mareš, J. (2017). Morální distres školních psychologů. Pedagogická orientace, 27(2), 308–343. https://doi.org/10.5817/PedOr2017-2-308

Merlo, S., & Podbregar, I. (2026). Workplace stress and well-being in nursing: Insights from a Slovenian cross-sectional study. Healthcare, 14(6), Article 760. https://doi.org/10.3390/healthcare14060760

Moon, Z., & Keefe-Perry, L. C. (2026). Moral orienting systems: Reconceptualizing moral injury as moral disorientation. Frontiers in Psychiatry, 17, 1733645. https://doi.org/10.3389/fpsyt.2026.1733645

Morley, G., Ives, J., Bradbury-Jones, C., & Irvine, F. (2019). What is “moral distress”? A narrative synthesis of the literature. Nursing Ethics, 26(3), 646–662. https://doi.org/10.1177/0969733017724354

Nissen-Lie, H. A., Orlinsky, D. E., & Rønnestad, M. H. (2021). The emotionally burdened psychotherapist: Personal and situational risk factors. Professional Psychology: Research and Practice, 52(5), 429–438. https://doi.org/10.1037/pro0000387

Oelhafen, S., Monteverde, S., & Trachsel, M. (2024). Overestimating prevalence? Rethinking boundaries and confounders of moral distress. Journal of Health Psychology. Advance online publication. https://doi.org/10.1177/13591053241253233

Oh, Y., & Gastmans, C. (2015). Moral distress experienced by nurses: A quantitative literature review. Nursing Ethics, 22(1), 15–31. https://doi.org/10.1177/0969733013502803

Orgambídez, A., Borrego, Y., Alcalde, F. J., & Durán, A. (2025). Moral distress and emotional exhaustion in healthcare professionals: A systematic review and meta-analysis. Healthcare, 13(4), 393. https://doi.org/10.3390/healthcare13040393

Poeira, A., & Nunes, L. (2025). Retaining those who care: Ethical climate, leadership, and workforce sustainability in healthcare. Healthcare, 13(23), Article 3014. https://doi.org/10.3390/healthcare13233014

Praško, J., Ociskova, M., Krone, I., Gecaite-Stonciene, J., Abeltina, M., Liska, R., Slepecky, M., & Juskiene, A. (2024). Practical viewpoints on ethical questions and dilemmas in schema therapy. Neuroendocrinology Letters, 45(4), 294–306.

Rabin, S., Kika, N., Lamb, D., Murphy, D., Stevelink, S. A. M., Williamson, V., Wessely, S., & Greenberg, N. (2023). Moral injuries in healthcare workers: What causes them and what to do about them? Journal of Healthcare Leadership, 15, 153–160. https://doi.org/10.2147/JHL.S396659

Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182–191. https://doi.org/10.1037/a0036090

Sirilla, J., Thompson, K., Yamokoski, T., Risser, M. D., & Chipps, E. (2017). Moral distress in nurses providing direct patient care at an academic medical center. Worldviews on Evidence-Based Nursing, 14(2), 128–135. https://doi.org/10.1111/wvn.12213

Sováriová Soósová, M., Sušinková, J., & Cenknerová, M. (2013). Stres v práci sestier v paliatívnej ošetrovateľskej starostlivosti. Ošetřovatelství a porodní asistence, 4(3), 622–627.

VanderWeele, T. J., Wortham, J. S., Carey, L. B., Case, B. W., Cowden, R. G., Duffee, C., Jackson-Meyer, K., Lu, F., Mattson, S. A., Padgett, R. N., Peteet, J. R., Rutledge, J., Symons, X., & Koenig, H. G. (2025). Moral trauma, moral distress, moral injury, and moral injury disorder: Definitions and assessments. Frontiers in Psychology, 16, 1422441. https://doi.org/10.3389/fpsyg.2025.1422441

Vinckers, F., & Landweer, E. (2025). Moral distress among healthcare professionals in long-term care settings: A scoping review. Philosophy, Ethics, and Humanities in Medicine, 20, Article 8. https://doi.org/10.1186/s13010-025-00171-5

Vlčková, K., Janoušková, M., & Bankovská-Motlová, L. (2025). Psychometric properties of the Czech moral injury symptom scale. Scientific Reports, 15, 12965. https://doi.org/10.1038/s41598-025-97530-1

Webb, E. L., Ireland, J. L., Lewis, M., & Morris, D. (2023). Potential sources of moral injury for healthcare workers in forensic and psychiatric settings: A systematic review and meta-ethnography. Trauma, Violence, & Abuse. Advance online publication. https://doi.org/10.1177/15248380231167390

Whitehead, P. B., Herbertson, R. K., Hamric, A. B., Epstein, E. G., & Fisher, J. M. (2015). Moral distress among healthcare professionals: Report of an institution-wide survey. Journal of Nursing Scholarship, 47(2), 117–125. https://doi.org/10.1111/jnu.12115

Zhang, W., Zhang, J., Wang, J., Zhang, Q., & Wu, X. (2026). The mediation effects of moral resilience on the relationship between hospital ethical climate and work engagement among nurses: A cross-sectional study. BMC Nursing, 25, Article 46. https://doi.org/10.1186/s12912-025-04216-0