From Moral Ambiguity to Moral Injury in Nursing Academia: An Autoethnographic Account of Moral Distress and Institutional Life.

Abstract

Moral distress has been documented in clinical nursing, but far less attention has been given to morally troubling experiences within academic healthcare settings. This study examines how conflicts between professional values and organizational culture may give rise to moral ambiguity, evolve into moral distress, and contribute to moral injury over time. Guided by a critical, transformative theoretical framework, this longitudinal autoethnography explores these experiences across a 45-year nursing career in academic settings. Data were generated through sustained self-observation and reflexive writing between 2013 and 2023, using thematic analysis, along with external documents for triangulation. The analysis identified three academic scenarios in which concerns related to student safety, tenure standards, and racism created ethically troubling situations. Across these scenarios, moral ambiguity emerged at the intersection of personal values, professional obligations, and institutional expectations. Moral distress developed when actions taken in response to these situations were unsupported, ineffective, institutionally silenced, or professionally costly. Moral injury became visible retrospectively through the enduring emotional, embodied, professional, and financial consequences of these unresolved moral events. Subthemes included faculty incivility and racism. Recognizing this progression changed how these experiences could be understood. What had long been interpreted as personal failure, poor coping, or professional inadequacy could instead be seen as part of a larger moral struggle shaped by organizational culture. This study suggests that moral ambiguity may be an early and often unnamed part of that struggle and that when it remains unresolved or unsupported, it can move into moral distress and, in some circumstances, moral injury. Bringing these experiences into view may help academic nursing better recognize and respond to the moral consequences of institutional life.