Moral distress and moral injury among nurses in German acute inpatient care – a cross-sectional study

Abstract

Abstract Background Moral suffering in health care is increasingly a focus of research. The extent of and relationship between two distinct forms of moral suffering, namely, moral injury (MI) and moral distress (MD), has not yet been studied in nurses in acute inpatient care in Germany. Objectives This study aims to examine the severity of MI and MD in the context of organizational support, the correlation between the two constructs, and the variables associated with the extent of MD and MI. Methods We conducted a cross-sectional study including 1323 nurses employed in German hospitals. The data were collected in March and April 2023 in an online survey using the German version of the Moral Distress Scale (MDS), the German Moral Injury Symptom Scale for Health Professionals (G-MISS-HP), the Perceived Organizational Support Scale (POS-s) and an additional questionnaire on the individual perception of ethical and structural conditions in the institution. The data were analyzed descriptively. Partial credit Rasch models were fitted to the item-level responses of the G-MISS-HP and the MDS to obtain interval-level measures of moral injury and moral distress for subsequent analyses. Median regressions with backward variable selection were performed for MD- and MI-Rasch scores to identify variables associated with the level of moral distress/injury. The associations between the MD and MI-Rasch scores were tested using Spearman’s correlation test. Results A total of 68.6% ( n = 907; 95% CI: 66.1%–71.1%) of the respondents scored above the validated G-MISS-HP screening threshold (≥ 29), which has previously been associated with impairment in family, social, and occupational functioning. Spearman’s correlation analysis revealed statistically significant positive associations between the MD-Rasch score and the MI-Rasch subscores (guilt/shame subscore: r = 0.57, 95% CI [0.53; 0.61]; spiritual troubles subscore: r = 0.22, 95% CI [0.16; 0.27]; condemnation subscore: r = 0.39, 95% CI [0.34; 0.43], all p < 0.001). Median regression analyses revealed significant associations of both MD and MI with perceived organizational support (POS-s), satisfaction with the treatment team’s consideration of own perspective, responsibility for staff, and participation in interprofessional case discussions. Conclusions Manifestations of moral suffering are common. Our findings highlight the importance of measures to promote an ethical climate and to address the negative consequences of moral suffering, particularly at the management level. Registration German Clinical Trials Register ( https://www.drks.de/ ): DRKS00030785 (date: 06 February 2023).

The authors' abstract, as published at the source. BMC Nursing, 2026 · DOI ↗