Background:
Moral injury happens when individuals perpetrate, witness, or feel complicit in actions that breach their core moral values. While often explored in military contexts, it is increasingly recognised in high-risk civilian professions such as paramedicine. The existing literature emphasises traumatic exposures, but less attention is given to organisational systems that repeatedly place workers in ethically challenging situations. This study investigates how organisational rostering, shift demands, and staffing shortages contribute to moral distress and potential moral injury among Australian paramedics, particularly rural paramedics.
Methods:
Drawing from a larger study on sleep disruption and shiftwork in healthcare, this study focused on organisational contributors to fatigue among paramedics. Semi-structured interviews were conducted with 11 Australian paramedics using constructivist grounded theory methodology. Interviews were transcribed and analysed through open and axial coding to identify themes linking organisational practices to fatigue and moral strain.
Results:
Paramedics consistently expressed a strong moral duty to their communities and patients, often putting this before their own fatigue or safety. Even when aware of their fatigue, they felt compelled to “weigh up the options,” considering who else might respond, potential delays, and the possible cost to patient outcomes.
Organisational systems normalised excessive workloads, with participants reporting up to 10 consecutive shifts, 96-hour on-call periods, and overnight callouts followed by full shifts. On-call time—classified as “free time”—was described as psychologically exhausting due to continuous anticipatory vigilance. Although management technically discouraged unsafe workloads, systems permitted staff to self-approve excessive hours, effectively transferring responsibility to individuals.
Fatigue-related incidents, including clinical errors and vehicle accidents, were seen as individual failings rather than systemic risks. Paramedics felt guilty when declining shifts and feared community judgment if an adverse event happened while they were unavailable. Even when not actively responding, participants felt they were “never truly off” due to the constant state of anticipatory stress of on-call.
Conclusion:
Organisational structures that normalise fatigue, promote self-sacrifice, and externalise responsibility place paramedics in recurring moral conflict. Fatigue is not merely a physiological risk factor, but a moral stressor. Meaningful prevention requires shifting from individual resilience narratives toward organisational accountability and ethically informed staffing policies.