Mediating Role of Self-Compassion in the Relationship Between Morally Injurious Events and General Mental Health Among South Korean Youth

Invisible Moral Wounds of the COVID-19 Pandemic: Are We Experiencing Moral Injury?

Moral injury (MI) results from perpetration of or exposure to distressing events, known as morally injurious events (MIEs), that challenge moral beliefs and values. Due to the type of involvement in recent military conflicts, many veterans report MIEs that may cause dissonance and, in turn, MI. Although two existing measures assess MIEs, neither currently assesses the defining characteristics of MI (i.e., guilt, shame, difficulty forgiving self and others, and withdrawal). The present study reports the initial psychometric test of a modified version (Robbins, Kelley, Hamrick, Bravo, & White, 2017) of the Moral Injury Questionnaire - Military version (MIQ-M; Currier, Holland, Drescher, & Foy, 2015) in a sample of 328 military personnel (e.g., veterans, National Guard/reservists, active duty members). The MIQ-M was modified to assess both MIEs and the defining characteristics of MI. Exploratory factor analyses suggested a three-factor model of MIEs consisting of Atrocities of war, Psychological consequences of war, and Leadership failure or betrayal. The modified MIQ-M factors were correlated with defining characteristics of MI. In addition, each MIE factor and associated defining characteristics of MI were positively correlated with symptoms of posttraumatic stress disorder, depression, and anxiety, as well as substance use. The modified MIQ-M is a reliable measure of MI that is comprised of three subscales that are associated with, but distinct from, mental health outcomes. Although findings are promising, further research evaluating the applicability of the modified MIQ-M in clinical settings is required to establish construct validity of the defining characteristics and secondary manifestations of MI.

Multinational intensive care unit nurses' moral courage, resilience, neutralisation, injury, and distress: A cross-sectional and mediation analysis study.

BackgroundHealthcare workers (HCWs) can face situations that conflict with their moral beliefs, leading to moral injury, an adverse psychological consequence that was more frequent during the COVID-19 pandemic. Self-compassion is a potential coping mechanism for moral injury by encouraging acceptance of human limitations and suffering.ObjectivesThis study aimed to examine the associations between self-compassion components and moral injury prevalence among HCWs in Quebec, Canada, during the COVID-19 pandemic.Research designA cross-sectional study design was employed. Participants: and research context: The sample of this study consisted of HCWs and leaders from the Quebec province. Participants completed validated self-administered questionnaires assessing both positive and negative self-compassion components (self-kindness vs self-judgment; common humanity vs isolation; and mindfulness vs overidentification) and moral injury dimensions (self-oriented and other-oriented). Prevalence ratios (PRs) and 95% confidence intervals (CIs) for the associations between self-compassion components and moral injury dimensions were modeled using Poison robust regressions. The models were adjusted for various covariates, including sex, age, gender, and socio-demographic and lifestyle factors.Ethical considerationsEthical approval for this study was obtained from the ethics committee of the Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale in Quebec, Canada. All participants provided written informed consent prior to participating in the study. Additionally, permission was sought and obtained from the original authors of the tools used in this study, including the self-compassion and moral injury scales.ResultsThe study involved 572 HCWs (60.5% nurses) and leaders. Around half of the participants (50.70%) exhibited moderate levels of self-compassion, while the prevalence of low levels of self-compassion ranged from 21.68% to 48.08% for the positive subscales and from 23.78% to 44.41% for the negative subscales. Regarding moral injury, 10.14% of participants reported moderate to high self-oriented moral injury, 29.19% reported moderate to high other-oriented moral injury, and 13.81% demonstrated moderate to high total moral injury. Higher self-compassion levels were associated with lower moral injury prevalence. HCWs with high self-compassion had a 93% lower likelihood of experiencing moral injury (PR: 0.07, 95% CI: 0.03-0.19). Self-kindness demonstrated the strongest association with reduced moral injury (PR: 0.24, 95% CI: 0.11-0.52), followed by mindfulness (PR: 0.37, 95% CI: 0.18-0.75). However, common humanity did not show a statistically significant association with moral injury prevalence.ConclusionThese findings suggest a potential association between self-compassion and reduced prevalence of moral injury among HCWs, highlighting promising interventions to manage moral injury during crises. Such initiatives could promote the mental wellbeing of HCWs and preventing the negative consequences of moral injury, including anxiety, depression, and burnout.

The Psychiatric Ramifications of Moral Injury Among Veterans

Given high rates of poor mental health among humanitarian aid workers, there has been a strong push for more research identifying risk and protective factors tied to poor mental health among this at-risk population. The present study examined moral injury (i.e., psychological, ethical, and/or spiritual conflict experienced when an individual’s basic sense of humanity is violated) as a new form of trauma that may place humanitarian aid workers at higher risk for poor mental health outcomes. Further, we tested a model examining rumination as a mechanism linking moral injury to mental health outcomes within this population. A total of 124 (67.2% cisgender women; 59.7% White; Mean age = 38.66, SD = 13.66) humanitarian aid personnel participated in a cross-sectional online survey study examining humanitarian aid experiences, moral injury, rumination, and mental health outcomes. Our preliminary findings suggest that humanitarian aid workers are susceptible to experiencing moral injury and that higher reports of moral injury were significantly associated with poorer mental health outcomes (e.g., depression, anxiety, suicidal ideation, sleep problems, memory issues). Furthermore, we found that ruminative thinking (particularly problem-focused thoughts and repetitive thoughts) indirectly linked moral injury to negative mental health outcomes among this population. Our preliminary study established the presence of at least moderate correlations between moral injury, rumination, and adverse mental health outcomes among humanitarian aid personnel. Considering complex humanitarian emergencies are becoming more commonplace, future longitudinal studies are most certainly needed in order to further understand and legitimize the threat that moral injury poses to humanitarian aid workers.

Background: Sexual and gender minorities (SGMs) are at an increased risk for developing mental health disorders due to their socially stigmatized identities. Minority stress (i.e. discrimination, identity nondisclosure, internalized stigma) has been shown to impact mental health outcomes among SGMs. Both distal and proximal minority stressors may serve as potentially morally injurious events (PMIEs), which may lead to moral injury and trauma/stressor-related symptoms. Critically, minority stress-related moral injury among SGMs has never before been explored using a mixed-methods approach. Methods: Thirty-seven SGM participants with diverse minority identities participated in the study. Using a convergent parallel mixed-methods design, we conducted semi-structured qualitative interviews, performed clinical assessments, and administered a comprehensive battery of quantitative measures. Here, we modified the Moral Injury Event Scale (MIES) for use with SGMs. Qualitative themes were extracted and then converged with MIES scores to investigate differential thematic presentations based on the quantitative intensity of SGM-related PMIEs. Results: Data analysis indicated four core themes related to moral injury among SGMs: shame (internalizing stigma), guilt, betrayal/loss of trust, and attachment injuries (rejection, altered sense-of-self, and social cognition). The qualitative presentation of these themes differed depending on MIES severity. Attachment injuries emerged as a unique core feature of moral injury among SGMs, whereby the remaining core themes align with previous moral injury research. Furthermore, quantitative analyses revealed that the level of exposure to and intensity of minority stress-related PMIEs was positively associated with hazardous alcohol use and trauma-related symptoms. Conclusions: This is the first mixed-methods study to investigate minority stressors as PMIEs, highlighting how these experiences may contribute to symptoms of moral injury among SGMs. Moral injury may serve as a valuable framework for better understanding trauma-related symptoms and mental health disparities among SGMs. These findings have the potential to inform novel treatment interventions aimed at addressing mental health burdens among SGMs.

Noteworthy advancements with respect to moral injury (MI) have occurred during the past five years. MI has now been sufficiently recognized and officially noted within the DSM-5-TR Updates under 'Religious, Spiritual and Moral Problem' Z code ("Section of Other Conditions that May Be a Focus of Clinical Attention"). Here we summarize the changes in the DSM related to MI and discuss the possibility of its future inclusion in other diagnostic nomenclature (e.g., WHO-ICD). With regard to classifying MI as a distinct diagnostic entity, criteria for MI as a disorder are reviewed based on scales assessing the severity of MI symptoms and the functional impairment that these symptoms create. We discuss problems with conceptualizing MI as a distinct diagnostic entity based on the concerns commonly encountered when categorizing mental health conditions as discrete disorders. Moral distress and injury are also discussed in terms of a dimensional or spectrum approach. This paper argues that moral injury is best conceptualized as a dimensional construct within a broader spectrum of moral trauma, with categorical diagnosis reserved for severe and persistent cases. The spectrums discussed range from 'moral dilemma/moral challenge' to 'moral distress' to 'moral injury' to 'moral injury disorder'. Finally, concerns raised by clergy and chaplains about inclusion of MI in the DSM or other diagnostic nomenclature systems are noted. MI has been increasingly recognized as a significant syndrome requiring future research to define its boundaries, identify the best treatment approaches, and determine those appropriate to be involved in the treatment of MI.

Moral injury: the effect on mental health and implications for treatment

Background: Moral injury is defined as the strong emotional and cognitive reactions following events which clash with someone’s moral code, values or expectations. During the COVID-19 pandemic, increased exposure to Potentially Morally Injurious Events (PMIEs) has placed healthcare workers (HCWs) at risk of moral injury. Yet little is known about the lived experience of cumulative PMIE exposure and how NHS staff respond to this. Objective: We sought to rectify this knowledge gap by qualitatively exploring the lived experiences and perspectives of clinical frontline NHS staff who responded to COVID-19. Methods: We recruited a diverse sample of 30 clinical frontline HCWs from the NHS CHECK study cohort, for single time point qualitative interviews. All participants endorsed at least one item on the 9-item Moral Injury Events Scale (MIES) [Nash et al., 2013. Psychometric evaluation of the moral injury events scale. Military Medicine, 178(6), 646–652] at six month follow up. Interviews followed a semi-structured guide and were analysed using reflexive thematic analysis. Results: HCWs described being routinely exposed to ethical conflicts, created by exacerbations of pre-existing systemic issues including inadequate staffing and resourcing. We found that HCWs experienced a range of mental health symptoms primarily related to perceptions of institutional betrayal as well as feeling unable to fulfil their duty of care towards patients. Conclusion: These results suggest that a multi-facetted organisational strategy is warranted to prepare for PMIE exposure, promote opportunities for resolution of symptoms associated with moral injury and prevent organisational disengagement. HIGHLIGHTS Clinical frontline healthcare workers (HCWs) have been exposed to an accumulation of potentially morally injurious events (PMIEs) throughout the COVID-19 pandemic, including feeling betrayed by both government and NHS leaders as well as feeling unable to provide duty of care to patients. HCWs described the significant adverse impact of this exposure on their mental health, including increased anxiety and depression symptoms and sleep disturbance. Most HCWs interviewed believed that organisational change within the NHS was necessary to prevent excess PMIE exposure and promote resolution of moral distress.

Management and leadership of intensive care units for the future.

IntroductionAbout 20% of police calls involve a person experiencing a behavioral health crisis. To better address these community member’s needs and reduce risk of harm, jurisdictions are developing programs that shift calls for crises related to homelessness, addiction, and mental health to non-law enforcement alternatives. In responding to these calls, first responders working in these alternative response programs are exposed to a different set of moral dilemmas and pressures, increasing their risk of developing moral injury.MethodsThe Alternative Response Program Moral Injury and Burnout Model highlights causes of exposure to potentially morally injurious events and the interplay between moral distress, moral injury, and burnout among first responders working in alternative response programs. The conceptual model was developed through a multi-year participatory action research (PAR) study with members of a large urban alternative response program. The article draws on a highly diverse set of data sources that contributed to the development and refinement of the model, including focus group discussions, analysis of call logs, assessment of moral injury, and reflective conversations with members and leaders of the alternative response program. Through our collaboration, we identified contributory factors that can produce moral injury and opportunities for interventions to mitigate moral injury. We piloted several interventions collaboratively developed with team members and hypothesized to reduce moral distress and injury based on this model.ResultsOur model explains sources of moral dilemmas and how these can lead to moral distress, moral injury, and burnout. The model also points to intervention pathways to reduce or prevent these outcomes. We provide illustrations of how moral injury arises, using data from the program members, describe six pathways, and share examples for how moral injury may be mitigated.DiscussionDespite scarce research in first responders, moral injury and burnout are growing concerns in alternative response programs. Our goal was to amplify participants’ voices to highlight both their struggles as well as proposed interventions fostering resilience. Through close collaboration, we developed a moral injury model that resonates for these first responders and can guide a better understanding of issues and pathways for interventions among high-risk occupational groups.

The present study used mediation analysis to examine the associations among morally injurious events (MIEs), moral injury, and suicidality in a sample of 285 Operation Enduring Freedom and Operation Iraqi Freedom veterans. Additionally, moderated mediation analysis was used to examine rumination and mindfulness as potential moderators of the MIE, moral injury, suicidality associations. Participants were largely male (n = 174, 61.1%), White (n = 197, 69.1%), and reported a mean age of 32.01 years (SD = 6.90 years). The most represented branch of the military was the Army (n = 136, 47.7%), followed by the Navy (n = 87, 30.5%) and participants on average reported completing 3.05 (SD = 1.38) deployments in support of OIF and 3.15 (SD = 1.42) deployments in support of OEF. Moral injury mediated the association between MIEs and suicidality, such that higher levels of exposure to potential MIEs were associated with higher levels of moral injury; which in turn was associated with higher suicidality. Our moderated mediation models revealed that this indirect effect was attenuated among individuals with higher mindfulness (i.e., the nonjudging of experience and acting with awareness dimensions of mindfulness) and strengthened among those who reported higher rumination. Results point to the potential utility of mindfulness-based therapies among service members who serve in combat and who report moral injury.

Shame on the brain: Neural correlates of moral injury event recall in posttraumatic stress disorder.

Despite a burgeoning of research on moral injury in the past decade, existing reviews have not explored the breadth of consequences and the multitude of pathways through which moral injury and potentially morally injurious experiences (PMIEs) influence mental and behavioural health outcomes. This study aimed to identify associations between moral injury on mental and behavioural health. Literature searches of psychological and medical databases were conducted through April 2020. Eligible studies measured moral injury or PMIEs, and health outcomes (e.g., depression, substance use and suicidality). Fifty-seven publications representing 49 separate samples were included. Studies examined the impact of moral injury on post-traumatic stress disorder (PTSD) (n = 43); depression (n = 32); anxiety (n = 15); suicide (n = 15); substance use (n = 14); and 'other' health outcomes, including pain, burnout, sleep disturbance and treatment-seeking behaviours (n = 11). The majority of studies found significant positive associations between moral injury-related constructs, mental health and behavioural health outcomes; however, the majority were also cross-sectional and focused on military samples. Proposed mediators included lack of social support, negative cognitions and meaning-making. Moderators included self-compassion, pre-deployment mental health education and mindfulness. Moral injury is associated with a variety of negative health outcomes. Research is needed to determine the mechanisms by which moral injury may influence these outcomes over time.