Moral Injury Among Medical Personnel and First Responders Across Different Healthcare and Emergency Response Settings: A Narrative Review

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Abstract
Moral injury is increasingly recognized as a significant concern among medical personnel and first responders, particularly in high-stress healthcare and emergency settings. This review aims to synthesize current evidence on the prevalence, risk factors, and outcomes of moral injury among medical personnel and first responders across diverse healthcare and emergency response environments. We included peer-reviewed studies reporting on moral injury among medical personnel or first responders in any healthcare or emergency response setting, excluding studies that did not report original data or focused solely on military populations. We systematically searched PubMed, Google Scholar, and Central, up to April 2025. Risk of bias was assessed directly from the manuscripts. Data were synthesized narratively and, where possible, pooled using random-effects meta-analysis. A total of 41 studies involving 14,500 participants were included. The prevalence of moral injury ranged from 4.1% to 69.44% across settings. Key risk factors identified included exposure to traumatic events, organizational constraints, and lack of support. Meta-analysis indicated a significant association between moral injury and symptoms of PTSD. The evidence is limited by heterogeneity in measurement tools and study designs, as well as a moderate risk of bias in several included studies. In conclusion, moral injury is prevalent among medical personnel and first responders, with important implications for mental health interventions and organizational policy. This review was not funded externally, and is registered in PROSPERO (CRD420251019492).

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