Working in emergency medicine can be tough. We all know that. But beyond the obvious stresses of shift work, difficult decisions, and witnessing human suffering, there’s something else that can fundamentally change us as healthcare professionals. It’s called moral injury, and it might be more common than we think.
When I spotted this paper in the European Journal of Psychotraumatology, it immediately caught my attention. Not just because it’s UK-based research (always a bonus), but because it tackles something many of us have probably experienced but struggle to name. That gnawing feeling when you’re forced to act against your values, when you witness something that violates your moral code, or when the system you work within betrays the very principles that brought you to emergency medicine in the first place.
Here is the abstract, but as always we encourage you to read the whole paper, especially as this one is available open access:
Abstract
Background: Moral injury describes the impact of witnessing or being part of events that violate one’s values. Initially described in relation to conflict and war, recent work shows that moral injury is a relevant concept for professionals working in emergency situations. Emergency responders work in contexts of human suffering and make complex decisions in time-pressured, high-stakes situations, but emergency responders’ viewpoints regarding moral injury and how strongly they align with different viewpoints is currently not well understood.
Objective: We sought to investigate how moral injury is conceptualised and how emergency responders in the United Kingdom (UK) relate to experiences of moral injury.
Method: In this Q-methodology (mixed-methods) study, seven experts co-created a set of 45 opinion statements (Q-set) capturing different facets of moral injury in the context of emergency responding. Subsequently, N = 21 emergency responders (police, fire service, emergency medicine, ambulance, and community first-response staff) completed an online Q-sort task, sorting statements according to how much they identified with them.
Results: A by-person factor analysis yielded a three-factor solution mapping onto theoretical positions of moral injury, including loss of trust in others (Factor 1), loss of trust in oneself (Factor 2), and loss of trust in authority (Factor 3).
Conclusions: Our findings support the assumption that moral injury is not a unitary concept but instead comprises different facets that people may identify with to a greater or lesser extent, depending on their role. Our results suggest differences between police vs. hospital ward workers and length of time in the profession. Future research into tailored relational and systemic interventions may be required to address the variety of experiences of moral injury in emergency responders.
What kind of paper is this?
This is a mixed-methods study using something called Q-methodology. If you haven’t come across Q-methodology before, don’t worry, I hadn’t either until recently. It’s essentially a way of exploring different viewpoints on a topic by getting people to sort statements according to how much they agree with them, then using statistical analysis to find patterns in those responses.
The researchers first worked with seven experts to create 45 statements about moral injury in emergency responding. Then they got 21 emergency responders to sort these statements from “most unlike me” to “most like me” and provide qualitative feedback about their choices.
Tell me about the participants
The 21 participants were a mixed bunch of UK emergency responders: police officers (8), fire service (5), emergency medicine doctors (2), ambulance staff (3), and community first responders (3). About half had been working in emergency services for 10 years or less, whilst the other half had been at it for 11 years or more.
This is a fairly small sample, but that’s typical for Q-methodology studies. The goal isn’t to make generalisable statements about all emergency responders, but rather to explore the range of viewpoints that exist about moral injury in this population.
What were the interventions?
There weren’t really “interventions” in the traditional sense. Participants completed an online Q-sort task where they arranged the 45 statements about moral injury into a grid ranging from “most unlike me” to “most like me”. They also provided qualitative comments about the statements they found most and least applicable to their experiences.
What did they find?
The researchers identified three distinct “factors” or viewpoints about moral injury, each representing different ways that emergency responders experience and conceptualise moral injury:
Factor 1: “Trying to Help while Feeling Hated, Misunderstood, and Undervalued” This viewpoint was characterised by feeling disconnected and experiencing a loss of trust from the public. Participants loading onto this factor felt that the general public had lost faith in their organisation and experienced an “us vs them” dynamic. They felt confident about their own values but disconnected from morally injurious events. Interestingly, this factor was most strongly associated with police officers.
Factor 2: “Eaten Away by the Job” This represented people who felt fundamentally changed by their work, particularly by exposure to death. Unlike Factor 1, these participants didn’t feel numb or disconnected. Instead, they were “eaten up” by doubts about whether they’d done their best, felt guilty about failing to save lives, and questioned their faith. This factor was most associated with people who had worked in emergency services the longest.
Factor 3: “It’s All On Me: Personal Responsibility and Personal Protection” This viewpoint emphasised personal responsibility and self-protection. These participants felt suspicious about sharing information at work, were angry about having to choose between duty of care and personal wellbeing, and used humour as a coping mechanism. They showed loyalty to colleagues but had lost trust in authority and wider organisations. This factor was most associated with newer workers and those in hospital settings.
What does this mean?
This research provides some fascinating insights into how moral injury manifests differently across emergency responders.
The key finding that moral injury involves different types of trust erosion (in others, in oneself, and in authority) aligns with existing theory whilst adding nuance to our understanding.
From a clinical perspective, this has several implications for those of us working in emergency departments:
Recognition: The three factors help us recognise that moral injury isn’t a one-size-fits-all experience. A newly qualified doctor struggling with institutional failures might experience Factor 3-type moral injury, whilst a consultant who’s been seeing too much death might align more with Factor 2.
Intervention: The authors argue (and I agree) that purely individual approaches to addressing moral injury may be insufficient. If the problem is systemic and relational, then solutions need to address power imbalances and rebuild trust at organisational levels, not just help individuals cope better.
Professional differences: The finding that police officers were more likely to experience Factor 1 (feeling hated by the public) whilst hospital workers aligned more with Factor 3 (loss of trust in authority) suggests that different emergency services face different moral injury challenges.
Critical appraisal points
There are some important limitations to consider:
- Survivor bias: The researchers only captured views from people still working in emergency services. Those who left due to moral injury might have different perspectives that we’re missing entirely.
- Sample size and generalisability: Whilst appropriate for Q-methodology, 21 participants is small. The findings give us insights into possible viewpoints but can’t tell us how common each type of moral injury is in the broader population.
- Timing: Data collection occurred during COVID-19 (December 2021 to February 2022), which the authors acknowledge may have created a “perfect storm” for moral injury. Whether these findings hold in “normal” times is unclear.
- Professional representation: Only two emergency medicine doctors participated, limiting our ability to understand how these findings specifically apply to ED staff.
Clinical bottom line
Moral injury appears to be a multifaceted problem that goes beyond individual resilience. The three types identified here (loss of trust in others, self, and authority) provide a useful framework for understanding different manifestations of moral injury in emergency responders.
For those of us working in emergency departments, this research suggests we need to think beyond individual support strategies. Whilst resilience training and psychological support remain important, addressing moral injury effectively requires tackling systemic issues: rebuilding public trust, improving organisational support, and creating cultures where staff feel valued and protected.
The authors suggest group interventions like Schwartz Rounds, which provide structured spaces for healthcare workers to reflect on the emotional impact of their work. In Virchester, we’ve been discussing implementing something similar – this research provides additional impetus for that conversation.
Perhaps most importantly, this paper validates what many of us have felt but struggled to articulate: that sometimes the hardest part of our job isn’t the clinical challenges, but the moral conflicts that arise when the system we work within doesn’t align with our values. Recognising this as a legitimate occupational hazard, rather than a personal failing, is an important first step.
References
- Bell V, Murray E, Muñoz L, Krahé C. In harm’s way: moral injury and the erosion of trust for emergency responders in the United Kingdom. Eur J Psychotraumatol. 2025;16(1):2513107. doi:10.1080/20008066.2025.2513107
-  Iain Beardsell, “Podcast – Moral Injury with Caroline Leech at Tactical Trauma 24,” in St.Emlyn’s, February 19, 2025, https://www.stemlynsblog.org/moral-injury/.
- Esther Murray, “Moral Injury during COVID-19. St Emlyn’s,” in St.Emlyn’s, January 3, 2021, https://www.stemlynsblog.org/moral-injury-during-covid-19-st-emlyns/.
- Simon Carley, “Podcast – Moral Injury in Emergency and Pre-hospital care with Esther Murray,” in St.Emlyn’s, August 30, 2018, https://www.stemlynsblog.org/moral-injury-in-emergency-and-pre-hospital-care-esther-murray-on-st-emlyns-podcast/.
