Moral Injury Beyond Burnout: A Scientometric Review of Clinician Distress and Its Blind Spots in Critical Care.

BACKGROUND

Moral injury is increasingly used to describe clinician distress after perceived moral transgression, forced complicity, or institutional betrayal. Its distinction from burnout and its empirical organisation in healthcare remain insufficiently defined.

METHODS

We combined a conceptual review with a document co-citation analysis of moral-injury literature indexed in the Web of Science Core Collection from 1961 to 2026 (20 April 2026). The network comprised 1573 cited references and 5497 co-citation links and was clustered in CiteSpace.

RESULTS

The network contained ten communities and showed strong structure (modularity Q = 0.73; mean silhouette S = 0.74). Four findings were most relevant to clinical and occupational mental health: the definitional core remains unsettled; healthcare and veteran literatures have developed as partially parallel traditions; measurement and operationalisation papers occupy disproportionately prominent positions in the citation-burst and sigma rankings; and the healthcare instrument that the network identifies as structurally prominent, the Moral Injury Symptom Scale for Healthcare Professionals, retains religious or spiritual elements that require calibration in secular and confessionally heterogeneous settings. Anaesthesiology and intensive care medicine are present in the empirical literature, but as of the search date no specialty-specific work had become an organising reference for the field; citation lag accounts for part of this.

CONCLUSIONS

Moral injury should not be treated as a synonym for burnout or as a deficit of individual resilience. Future research should specify definitions, validate instruments cross-culturally, stratify by clinical role and specialty and empirically test interventions directed at the moral architecture of work.