The RONA Compass

Spring 2026 – Issue 2

Link: https://mailchi.mp/4e212e4127ec/e-newsletter-the-rona-compass-spring-13898707

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Feature Article:

Moral Injury: A Recent Addition to the DSM-5-TR and Its Implications for the Nursing Profession

By Scott Jahner PMH-ARNP-BC

“Within nursing, MoraI Injury is increasingly prevalent due to systemic factors such as chronic staffing shortages, resource rationing, and perceived institutional betrayal.”

Moral injury is the profound psychological, social and spiritual distress resulting from actions – or inaction- that violate deeply held moral beliefs. The American Psychiatric Association now includes “moral problems” in the latest DSM-5-TR, acknowledging it as a significant issue for clinical attention.

Summary

Moral injury (MI) represents a profound psychological syndrome resulting from actions or events that transgress an individual’s deeply held moral beliefs. The formal recognition of MI in the September 2025 Diagnostic and Statistical Manual Disorders (5th e., Text Revised) update under Z-code Z65.8 marks a critical shift in validating these psychological sequelae as a legitimate focus of clinical attention (Wortham & VanderWeele, 2025; U.S. Department of Veteran Affairs, 2025). Within nursing, MI is increasingly prevalent due to systemic factors such as chronic staffing shortages, resource rationing, and perceived institutional betrayal. These drivers lead to significant occupational hazards, including a heightened risk of suicide. Distinguishing MI from related constructs like burnout (Z73.0) and PTSD (F43.1) is essential for effective intervention (De Hert, 2020; Egan, 2025). Recovery necessitates a systemic approach, utilizing validated screening tools like the Moral Injury and Distress Scale (MIDS) and organizational support strategies such as Schwartz Rounds—which have demonstrated a 35.5% reduction in reported moral distress among nurses—to protect the moral integrity of the workforce (The Schwartz Center, 2024).

Evolution of Clinical Recognition in the DSM-5-TR

In September 2025, the updated Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) officially recognized Moral Injury (MI). The American Psychiatric Association (APA) expanded the diagnostic category for “Religious or Spiritual Problem” to “Moral, Religious, or Spiritual Problem,” assigned as ICD-10 Z-code Z65.8 (Wortham & VanderWeele, 2025). This taxonomic shift validates that moral suffering—experiences that disrupt an individual’s understanding of right and wrong, or their sense of goodness regarding themselves, others, or institutions—is a legitimate focus of clinical attention (Wortham & VanderWeele, 2025; U.S. Department of Veteran Affairs, 2025).

Conceptual Genesis: The Moral Trauma Spectrum

Initial conceptualizations of MI focused on the experiences of military soldiers tasked with situations that created moral dilemmas with “no right answer,” similar to Philippa Foot’s “Trolley Problem” (Wortham & VanderWeele, 2025). During the COVID-19 pandemic, a global lack of preparedness forced healthcare workers, most notably nurses, to face choices that carried these same agonizing moral dilemmas (Wortham & VanderWeele, 2025).
Moral injury is best understood not as a binary state but as a dimensional construct residing on a “moral trauma spectrum”. This spectrum accounts for the variations in persistence and severity of the distress, ranging from the transient “moral dilemma” or “moral challenge” to the more enduring “moral distress,” and finally to “moral injury” or “moral injury disorder” A moral dilemma involves a situation where no option feels entirely right, yet the individual must choose; moral distress arises when the individual knows the correct path but is constrained from taking it; and moral injury occurs when the subsequent psychological, emotional, and spiritual damage becomes a persistent feature of the individual’s identity. (Koenig, 2026)

A decade of research led by the Human Flourishing Program at Harvard University sought to understand these experiences to ensure leaders in “high-stakes roles” possess the tools necessary to identify injury and promote recovery (Wortham & VanderWeele, 2025). This work, in partnership with the APA, facilitated the addition of “moral problems” and a specific Z-code for MI into the DSM taxonomy (Wortham & VanderWeele, 2025; Norman & Maguen, 2025). This framework locates Moral Injury on a “moral trauma spectrum,” acknowledging it as an enduring psychological impact resulting from exposure to Potentially Morally Injurious Events (PMIEs).

Distinguishing Moral Injury from Related Constructs

Nurses encounter MI when their action or inaction goes against their beliefs, or when they witness behaviors that violate their values, causing psychological, behavioral, social, and spiritual distress (Norman & Maguen, 2025). It is clinically distinct from related constructs:

• Moral Injury (Z65.8): Characterized by profound guilt, shame, and a sense of betrayal. Unlike burnout, which implies an individual’s inability to cope, MI indicates a failure of the organizational moral climate driven by structural issues such as unsafe staffing and misaligned institutional priorities (Norman & Maguen, 2025).
• Burnout (Z73.0): An occupational stress syndrome caused by chronic exposure to job stress that manifests as emotional exhaustion, cynicism and depersonalization, reduced professional efficacy, and personal accomplishment (De Hert, 2020).
• Posttraumatic stress disorder (PTSD) (F43.1): A psychiatric condition presenting in individuals who experience or witness a traumatic, emotionally or physically harmful or life-threatening event or series of traumatic events. Symptoms include nightmares, flashbacks, severe anxiety, dissociation, and uncontrollable thoughts about the event or events (Egan, 2025).

Prevalence and the Critical Association with Suicide Risk

Evidence indicates that MI is a significant systemic challenge with prevalence rates varying by clinical setting. ICU and Critical Care nurses report the highest burden (40–55%), followed by Emergency Departments (35–50%) and Long-Term Care (30–45%) (Moral injury prevalence and triggers in nursing post-pandemic, 2025).

A concerning factor associated with these psychological sequelae is the high risk of suicide. In a population-based study of 1,232 participants, individuals screening positive for probable MI had significantly higher odds of current suicidal ideation (66%) and lifetime suicide attempts (41%) compared to those without the injury (Griffin et al., 2025). This data underscores the urgent need for healthcare leadership to maintain vigilant awareness following adverse or sentinel events to prevent potentially fatal outcomes (Griffin et al., 2025).

Evidence-Based Screening and Recovery Strategies

Due to the potential urgency associated with unrecognized moral injury, identification becomes critical as well as nurturing the development of moral resilience. Organizations can transition from reactive support to proactive stewardship by working towards a multilevel approach to address the drivers of MI, such as chronic staffing shortages and resource limitations (Moral injury prevalence and triggers in nursing post-pandemic, 2025).

A multilevel strategy for mitigation, focusing on individual, organizational, and policy interventions. Individual solutions such as self-reflection, emotional management, and mindfulness activities. Organizational support such as Schwartz Rounds, the Concentrate, Unrush, Reflect, and Act (CURA) reflection tool, Moral Case Deliberation (MCD), and ethical awareness can cultivate strong team cohesion and reduce moral injury. Policies to protect whistleblowers, uphold ethical standards, and mandate ethics consultation services critically safeguard health care worker’s moral agency to limit moral distress. Policy reforms that address structural barriers like staffing ratios are ways to help nursing staff to avoid institutionally created “Trolley Problems” from being a prominent experience. (Masdar et al, 2025).

Cultivating moral resilience allows nurses to remain undiminished by centering their values in the midst of adversity (AACN standards for establishing and sustaining healthy work environments, 2024). Moral Resilience is defined as the capacity to restore integrity in the face of moral adversity through self-awareness, moral efficacy, and relational integrity. (Masdar et al, 2025). Schwartz Rounds have been shown to reduce reported moral distress by 35.5% specifically among nurses by providing a structured forum for sharing the emotional dimensions of care (The Schwartz Center, 2024).

Once potential MI is identified, utilizing validated self-screening tools to identify MI among staff can be a helpful way of helping health workers to visualize and identify needs for further support. Some peer reviewed and validated self-screening tools include:
• Moral Injury and Distress Scale (MIDS): An 18-item tool assessing exposure to PMIEs and functional impact; a score of 27 or higher indicates clinically meaningful MI (U.S. Department of Veteran Affairs, 2025).
• Moral Injury Events Scale-Civilian (MIES-C): A 9-item scale that measures violations of beliefs across dimensions of self-transgression, transgression by others, and betrayal (Thomas et al., 2024).
• Expressions of Moral Injury Scale-Civilian (EMIS-C): A 17-item tool used to measure behavioral and spiritual sequelae of MI over time (Thomas et al., 2024).

Fostering a culture of ethical stewardship and team-based reflection is crucial for transitioning from reactive distress to proactive ethical empowerment in healthcare settings. (Masdar et al, 2025). By implementing these systemic strategies, nursing leadership can protect the moral integrity and mental health of the profession.

References:
American Association of Critical-Care Nurses. (2024). AACN standards for establishing and sustaining healthy work environments. https://www.aacn.org/nursing-excellence/standards/aacn-standards-for-establishing-and-sustaining-healthy-work-environments

De Hert, S. (2020). Burnout in healthcare workers: Prevalence, impact and preventative strategies. Local and Regional Anesthesia, 13, 171–183. ((https://doi.org/10.2147/LRA.S240564))

Egan, D., M.D. (2025, March). What is Posttraumatic Stress Disorder (PTSD)? Retrieved March 28, 2026, from https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd

Griffin, B. J., Maguen, S., McCue, M. L., Pietrzak, R. H., McLean, C. P., Hamblen, J. L., Jendro, A. M., &

Norman, S. B. (2025). Moral injury is independently associated with suicidal ideation and suicide attempt in high-stress, service-oriented occupations. npj Mental Health Research, 4(1), Article 32. https://doi.org/10.1038/s44184-025-00151-9

Healthcare. (2025). Moral injury prevalence and triggers in nursing post-pandemic. Healthcare, 13. https://pmc.ncbi.nlm.nih.gov/articles/PMC12610207/

Koenig HG, Carey LB, Wortham JS. Moral Injury in the DSM-5-TR: Syndrome Spectrum vs. Categorical Disorder. J Relig Health. 2026 Mar 23. doi: 10.1007/s10943-026-02632-3. Epub ahead of print. PMID: 41872581.

Masdar M, Lusmilasari L, Sholikhah EN, Effendy C. Facing Moral Distress: Why We Need to Enhance Moral Resilience in Palliative Care Nursing. Indian J Palliat Care. 2025 Oct-Dec;31(4):405-409. doi: 10.25259/IJPC_196_2025. Epub 2025 Aug 29. PMID: 41342017; PMCID: PMC12670416.

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President’s Message

This month our President elect Gordy West will begin his term as president. I am confident that he will bring his own brand of color, optimism and hope to RONA, just like Spring replaces Winter.

My departing request is to encourage you to participate in RONA activities. There really is something for everyone.  Hanging out with nurses never disappoints.  I’ll see you there!

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Tami Green – WSNA Hall of Fame Inductee

Rainier Olympic Nurses Association is proud to celebrate Tami Green, BA, RN, PMH-BC as a Washington State Nurses Association all of Fame inductee!

Induction into the Washington State Nurses Hall of Fame is WSNA’s highest honor, given to nurses who have made significant contributions to the profession of nursing. This is where we recognize the pioneers, the groundbreakers, and the heroes of nursing in Washington state.

Tami has been a passionate advocate for her patients, her fellow nurses, and the communities she serves. Her name had been well known among RONA members in Pierce County when, as a nurse, she ran for and was elected as a Washington State House of Representatives. For 10 years, Tami fought for nursing practice, mental healthcare, developmental disability services, as well as nursing practice and education.

Tami first came to RONA in 2017 as a write in candidate for president elect. She served one year as president elect and became president in 2018 and has served 4 terms as president while balancing work and family and continuing to serve as an advocate for patients and nurses as well as leading RONA through the COVID pandemic. Under her leadership, RONA grew from a district of one county to a region of seven counties, increasing the voice and power of nurses.

Tami currently serves as a member pro tem of the Washington State Board of Nursing, where her deep experience in mental health has proven invaluable on the Substance Abuse Disorder Review Panel and the Case Disposition Panel for Discipline. She continues to care for patients at Community Healthcare Clinic in Pierce County while launching a coaching business to help others achieve their goals.

Tami is an exemplar of service, commitment, and community. Her work has improved Washington state healthcare policy, nursing practice, and the lives of countless patients. Like her hero, Florence Nightingale, Tami works humbly and diligently to promote the nursing profession.

Congratulations Tami!