A Theoretical and Empirical Investigation of Moral Injury Among Healthcare Workers in Nigerian Teaching Hospitals

Moral injury, the damage to fundamental beliefs about right and wrong caused by perpetrating, failing to prevent, or witnessing events that transgress one's moral code, is an emerging construct with significant implications for healthcare worker psychological wellbeing, and its theoretical character and empirical prevalence in Nigerian healthcare settings have not been investigated. This study conducted an original theoretical and empirical investigation of moral injury among healthcare workers in Nigerian teaching hospitals. A mixed-methods design employing both quantitative survey and grounded theory qualitative research was adopted, with data collected at Lagos University Teaching Hospital, University of Nigeria Teaching Hospital, and Bayero University Teaching Hospital. Phase one administered the Moral Injury Symptom Scale-Healthcare Professionals version to 350 healthcare workers, supplemented by the PHQ-9 and MBI. Phase two conducted in-depth interviews with 36 participants purposively sampled across moral injury severity levels and professional roles. Phase one results showed clinically significant moral injury in 41.4 percent of respondents, significantly higher than international benchmarks from similar hospital settings. Moral injury was significantly associated with depression (r = 0.58, p < 0.001) and burnout (r = 0.54, p < 0.001) above and beyond job stress. Resource inadequacy-driven moral injury (being unable to provide adequate care due to system failures) was the dominant moral injury type identified in phase two. The original Nigerian Healthcare Moral Injury Model proposes resource adequacy as a primary structural driver absent from international moral injury frameworks. Expert review confirmed the theoretical advance. Keywords: moral injury, healthcare workers, teaching hospitals, Nigeria, occupational counselling