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california; plcmmc; covid-19; nurse; moral injury



Moral Injury (MI) was defined by Jonathan Shay in 1994 as committing acts that betray one’s moral compass in high-stakes situations, while under the authority of another, that severely affect one’s well-being. MI was measured solely in the military prior to the COVID pandemic.


1.Explore the relationship between moral injury (MI) and perceived work performance in hospital nurses following the pandemic surges. 2. Determine relationships between MI and select participant demographics and between work performance and select demographics.


A convenience sample of 191 nurses from seven Southern California Hospitals participated in the study from March to June 2022. The mean years of experience of participants was 15, 84% worked full-time, 53% were Caucasian, and 97% cared for COVID-19 patients.


Cross-sectional multi-site survey.

Variables and Instruments

The DV was MI. The IVs were work performance and nurse demographics. The Moral Injury Symptom Scale was revised for use with Health Professionals (MISS-HP) and used in this study. Perceived work performance was measured using the Nurse Performance Index (NPI).

Data Analysis

Descriptive analysis was used to calculate scale scores and demographics. Correlational and linear regression analysis were used to examine relationships between dependent and independent variables and specifically to determine if MISS-HP scores were a predictor of NPI scores.


Increased levels of moral injury were a significant predictor of decreased levels of perceived work performance. Younger and less experienced nurses had greater levels of moral injury. Levels of MI due to the traumatic situations that nurses experienced during the pandemic negatively affected self-reported work performance. Nurses reported at times having to modify their standards to get their work done.


Nurse well-being programs and improved working conditions for nurses are needful to avoid compromising quality nursing care and patient safety. In-hospital care programs for nurses that include sacred spaces like Tea for the Soul, serenity lounges, and provision for consistent break times with adequate staffing, are imperative in optimizing nurse performance and thus optimizing patient care outcomes as well as organizational outcomes.

Clinical Institute

Mental Health




Infectious Diseases


Behavioral Health


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