Moral Injury Among College Teachers: Prevalence, Types, and Negative Effects

In 2023, a collaborative research project was designed to explore a purposive sample of new graduate mental health nurses’ experiences of moral injury. The project aimed to examine the participants’ experiences of moral injury, identify the types of moral injury experienced and to use findings to enhance the content on professional resiliency in a postgraduate nursing programme. A qualitative research design was employed, with two focus groups and an individual interview conducted. Due to limited understandings of the term moral injury, the research team initially decided the study had failed to meet the aims and objectives. Nevertheless, after detailed comments from a conscientious reviewer, we revisited our results and realised that the participants had discussed moral distress and injury in their workplaces. This article explores a sample of new to mental health practice nurses’ experiences of moral injury, while also exploring the researchers’ evolving understandings of the term over the course of the project. Ideally documenting our experiences may help others who are relatively new to studying moral injury in nursing cohorts, particularly those in mental health.

Background Veterinary professionals (VPs) are often exposed to distressing and ethically challenging events in their line of work, yet little is known about whether they may experience moral injury and the impact potentially morally injurious events (PMIEs) may have on their wellbeing. This cross-sectional study aimed to examine the association between PMIEs and the mental health outcomes of U.K. VPs. Method Assessments of PMIE exposure and self-report measures of common mental disorders were administered using an anonymous online questionnaire to 90 U.K. VPs between December 2020 and May 2021. Results Exposure to PMIEs was reported by almost all VPs (89.0%), with acts of omission most frequently reported. Experiences of PMIEs were significantly associated with symptoms of PTSD (p < 0.01) and experiencing a betrayal event was significantly associated with PTSD symptoms (p<0.05). However, there was no significant association found between PMIE exposure and alcohol misuse or CMD (p > 0.05). Conclusions This study provides some of the first evidence that experiences of moral injury are significantly associated with adverse mental health outcomes in U.K. VPs. Future work is needed to design effective pathways for prevention and intervention for VPs exposed to highly challenging events. HIGHLIGHTS U.K. veterinary professionals were found to experience moral injury. Experiences of moral injury were significantly associated with symptoms of PTSD.

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

Background: Moral injury has been found to adversely affect US veteran mental health, and the mental health difficulties resulting from moral injury can be particularly challenging to treat. Yet little is known about the impact of moral injury on the well-being of UK armed forces (AF) veterans and how moral injury is currently addressed in treatment. Objective: The aim of this study was to examine UK AF veterans’ experiences of moral injury, and the perceptions and challenges faced by clinicians in treating moral injury-related mental health difficulties. Method: Six veterans who reported moral injury exposure and four clinicians who had treated veterans with moral injury were recruited from Combat Stress. Semi-structured qualitative interviews were conducted and data were analysed using thematic analysis. Results: Moral injury was perceived by clinicians to be common in UK AF veterans and, where present, had a considerable negative impact on mental health. Clinicians reported a lack of a manualized approach for treating cases of moral injury and, instead, used a combination of several non-post-traumatic stress disorder (PTSD)-specific therapies. Providing treatment for morally injured veterans could be challenging given the limited number of sessions that clinicians were able to provide. Moreover, moral injury was thought to be poorly understood among UK AF veteran clinical care teams. Conclusion: This study provides some of the first insight into the impact of moral injury on UK AF veteran well-being as well as clinician views of delivering psychological care following moral injury. These findings highlight that moral injury is experienced by UK AF veterans, and further examination of the prevalence of moral injury and whether current treatment approaches are appropriate and efficacious is needed.

Military personnel can be exposed to events such as killing or human suffering that can breach or violate their core moral frameworks. The breaching or violation of one’s core moral framework can create moral trauma—often termed “moral injury.” Moral injury has gained increased attention during the last decade due to its links to military suicide. The core characteristics of moral injury have not yet reached a universal consensus but can include deep feelings of shame, guilt, distrust, anger, and self-condemnation. Few studies have focused on moral injury in Australia. This paper is one of several published from a larger PhD study. The purpose of this paper is to understand participants’ experiences of moral injury. Analysis of the data revealed the overarching theme—walking forwards with moral injury—describing participants’ experiences of living with a moral injury and how they navigated and made meaning of their experience. From this overarching theme, three sub-themes emerged: (a) meaning-making and moral injury, (b) narratives of transformation, and (c) leading the charge. The study found that to continue “walking forwards” a transformation of identity was needed. The transformation happened when an understanding of the meaning underpinning identity occurred, and when validation and reconciliation of the experience were achieved. These findings enhance knowledge of the mechanisms needed to better support veterans living with moral injury in Australia. Outcomes from this work may assist clinicians or those working with military veterans in providing more appropriate care to those experiencing moral injury.

The Psychiatric Ramifications of Moral Injury Among Veterans

Background Moral stress refers to emotional and psychological feelings that occur due to an inability to do what one considers morally right while moral injury refers to the psychological distress that may result from action, inaction or witness to actions that violates an individual’s ethical code. Although these experiences have been reported among military and healthcare workers in humanitarian settings, research on the subject is limited. This study aimed to explore the experience of moral stress and injury amongst professionals in humanitarian settings. Materials and Methods Literature review and post presentation survey were completed by humanitarian workers. Results Out of the 33 participants who completed the survey, 94% reported to have experienced moral stress while 39% reported an experience of moral injury. None of the participants reported any workplace treatment or support from following their experience. Over half of the respondents said that the experience of moral stress/injury was the same for all workers (57%), followed by humanitarian workers (14%), military (11%), paramedics (8%), and nurses and doctors (5%) each. There was limited knowledge on appropriate response to their experiences of moral stress and injury and the majority only disclosed their experience to family and friends. Conclusion Moral stress and injury are common amongst humanitarian workers and indeed most workers. However, knowledge and workplace support for workers is limited. It is essential that employers prioritize workplace sensitization and support for workers to limit the impact. Multilevel intervention including research is essential to support workers especially those in humanitarian settings.

How does moral injury affect Muslim military personnel (MMP) serving in the United States longest war, Operations Enduring Freedom and Iraqi Freedom? Moral injury in MMP has often been triggered by stressors such as harassment, embarrassment, marginalization, prejudice, and being associated with a co-religionist enemy. MMP are perceived as a threat to the safety and security of the United States, which exacerbates their emotional state of mind because they do not feel included as valuable assets within their units. Little is known about this population’s mental state of mind and how they cope when their religion is ridiculed and distorted, causing it to become a stressor and exacerbating the effects of moral stress and injury experienced by individual MMP—including the author—as they serve their country today and in the recent past. Recommendations include (1) more in-depth studies on the experience of moral injury and how it manifests with this population, (2) studies on the incidence and prevalence of moral injury among MMP, and (3) more Muslim chaplains in the U.S. military.

Moral injury is defined as lasting distress due to perpetrating, failing to prevent, or witnessing acts that transgress or deeply violate one's moral or ethical code. Previous research has demonstrated that during the COVID-19 pandemic, healthcare workers were at increased risk of moral injury. However, there is a lack of studies that explore how physician social identity may affect experiences of moral injury. To identify the main sources of moral injury during the COVID-19 pandemic in a physician cohort, and how moral injury may be experienced differently based on physician social identity. Participants were 13 physicians who reported caring for COVID-19 patients at a major metropolitan university hospital system during the COVID-19 pandemic (March 2020-May 2023). Physicians were asked about experiences of moral injury and how their social identities affected their experience of caring for COVID-19 patients. Rapid thematic qualitative analysis was used to evaluate interview data. Four main sources of moral injury were identified in interview analysis, including (1) insufficient resources, (2) conflict between patient autonomy and institutional constraints, (3) balancing patient care and personal/family safety, and (4) witnessing inequality. One prominent theme emerged regarding social identity, with physicians with marginalized identities expressing that self-identification with marginalized patients contributed to their experience of moral injury. In our sample, physicians who cared for COVID-19 patients during the pandemic experienced various sources of moral injury. Identification of these sources, and the role of social identity, can assist with greater targeted individual and systemic support of physicians.

Exposures to potentially morally injurious events (PMIEs) and possible moral injury are risk factors for a range of difficulties impacting individual functioning. Although exposure to PMIEs is a somewhat common product of war, qualitative methods to understand Veterans' experiences of moral injury and Veterans Affairs treatment are limited. To better characterize Veterans' experiences, 14 male warzone Veterans who reported moral injury post-warzone deployment and completed posttraumatic stress disorder treatment in the past year were asked to describe their military service as part of a qualitative study. Through thematic analysis, we found two moral injury-consistent themes and four subthemes. The first theme was "military experiences were associated with morally questioning one's self" with subthemes of "moral shift" and "depersonalization." The second theme was "military experiences were associated with morally questioning others" with subthemes of "disillusionment" and "resignation." Based on these findings, we conclude with a discussion of treatment implications for moral injury.

A growing body of research highlights the experiences of moral injury among healthcare professionals during the COVID-19 pandemic. Moral injury (i.e., participating in or witnessing acts that violate one's central moral values), is associated with a host of psychological sequelae and corresponding negative psychosocial impacts. There is a lack of research examining the experiences of moral injury among those working in long-term care settings during the COVID-19 pandemic. Given the drastic impact that the COVID-19 pandemic has had on long-term care facilities in Canada, it is important to understand the experiences of moral injury among those working in long-term care settings to inform the development of effective prevention and intervention strategies. The objectives of this study were to understand the experiences and impact of moral injury among Canadian frontline long-term care workers (staff and management) during the COVID-19 pandemic. Participants (N = 32 long-term care staff and management working in Ottawa and Manitoba) completed in-depth, semi-structured qualitative interviews and clinical diagnostic assessments (Mini International Neuropsychiatric Interviews; MINI; Version 7.0.2) between March 2021-June 2021. The core category of our qualitative grounded theory model of moral injury in long-term care exemplified four shared types of morally injurious experiences, paired with cognitive, affective, and physiological symptom domains. Seven associated main themes emerged, contributing to the experiences and impact of moral injury in long-term care: 1) Beliefs about older adults and long-term care; 2) Interpretation of morally injurious experiences; 3) Management of morally injurious experiences; 4) Long-term care pandemic impacts; 5) Personal pandemic impacts; 6) Structural impacts in long-term care; and 7) Mental health needs and supports. Clinical assessments demonstrated anxiety disorders (n = 4) and feeding and eating disorders (n = 3) were among the most frequently classified current psychiatric disorders among long-term care workers. This is the first Canadian study to examine the experiences and impact of moral injury in long-term care during the COVID-19 pandemic using qualitative and clinical diagnostic methodologies. Implications and insights for screening and intervention are offered.

Background: Moral injury describes the impact of witnessing or being part of events that violate one’s values. Initially described in relation to conflict and war, recent work shows that moral injury is a relevant concept for professionals working in emergency situations. Emergency responders work in contexts of human suffering and make complex decisions in time-pressured, high-stakes situations, but emergency responders’ viewpoints regarding moral injury and how strongly they align with different viewpoints is currently not well understood. Objective: We sought to investigate how moral injury is conceptualised and how emergency responders in the United Kingdom (UK) relate to experiences of moral injury. Method: In this Q-methodology (mixed-methods) study, seven experts co-created a set of 45 opinion statements (Q-set) capturing different facets of moral injury in the context of emergency responding. Subsequently, N = 21 emergency responders (police, fire service, emergency medicine, ambulance, and community first-response staff) completed an online Q-sort task, sorting statements according to how much they identified with them. Results: A by-person factor analysis yielded a three-factor solution mapping onto theoretical positions of moral injury, including loss of trust in others (Factor 1), loss of trust in oneself (Factor 2), and loss of trust in authority (Factor 3). Conclusions: Our findings support the assumption that moral injury is not a unitary concept but instead comprises different facets that people may identify with to a greater or lesser extent, depending on their role. Our results suggest differences between police vs. hospital ward workers and length of time in the profession. Future research into tailored relational and systemic interventions may be required to address the variety of experiences of moral injury in emergency responders.

There is an increasing attention for the role of military chaplains (MCs) in supporting veterans with moral injury. However, research into how veterans experience the support of MCs remains scarce. Moreover, no studies to date have explored this question in a Dutch contex, while this is relevant as it can offer insight into what forms of care are helpful in predominantly secular societies. This article presents a study from the Netherlands, involving 12 veterans. Using a longitudinal qualitative approach, we explored how the one-on-one conversations with MCs unfold over time. Our study shows that three types of moral questions underly experiences of moral injury. Veterans see the conversations with MCs as an opportunity to exchange thoughts and perspectives concerning these ongoing moral struggles, a process that we conceptualize as 'moral learning'. Over time, we found 5 types of change in veterans' experience of moral injury. The conversations with MCs helped veterans to: share their stories, thoughts and worries; grow personally; better understand and accept certain events; feel a stronger connection with others; critically engage with the Dutch Ministry of Defence. This study raises questions about the centrality of the morally injurious events in chaplaincy interventions that are described in the literature. It suggests that supporting veterans in dealing with questions about the good life and about the conduct of the military may be just as or even more important as reflecting on morally injurious events. Moreover, the study highlights the importance of engaging with seemingly mundane, everyday issues when addressing the moral dimensions of veterans' struggles. This counters the focus on grand concepts like "forgiveness," "acceptance," "reconciliation," "restitution" and "vindication" which are usually emphasized in the literature about chaplaincy in the context of moral injury. The study shows that it is through reflection on the everyday that these larger concepts gain relevance and meaning within veterans' lives.

Moral injury can be understood, in large part, as an experience of profound loss and grief with individual and systemic consequences. Through that lens, the author draws on several composite vignettes of veterans and their families situated in faith communities to explore the range of losses that is often entailed in an experience of moral injury and possible characteristics of grief arising from such personal, lifelong, relational, and generational loss. She also pursues the relevance and usefulness of theoretical concepts regarding grief such as ambiguous loss and resilience for understanding and responding to those affected by moral injury and their relational systems. The author also addresses theoretical frames such as intersectionality to illumine how contextual complexities of identity such as race and gender inform our understanding and strategies for responding to grief associated with moral injury. In addition to these theoretical resources, she draws on theological perspectives that are helpful in the face of radical, dehumanizing evil such as forms of lament and the relation between protest and hope. In particular, she explores the value of ritual for practices of care as resources for healing, both for veterans and their families affected by moral injury and for faith communities who may come to recognize their own complicity in moral injury. She also briefly considers the possibilities of public rituals for bearing witness to communal aspects of responsibility in moral injury. The author draws on Jewish, Christian, and Muslim resources for practices of ritual care.

The coronavirus severe acute respiratory syndrome (COVID-19) pandemic has placed increased stress on healthcare workers (HCWs). While anxiety and post-traumatic stress have been evaluated in HCWs during previous pandemics, moral injury, a construct historically evaluated in military populations, has not. We hypothesized that the experience of moral injury and psychiatric distress among HCWs would increase over time during the pandemic and vary with resiliency factors. From a convenience sample, we performed an email-based, longitudinal survey of HCWs at a tertiary care hospital between March and July 2020. Surveys measured occupational and resilience factors and psychiatric distress and moral injury, assessed by the Impact of Events Scale-Revised and the Moral Injury Events Scale, respectively. Responses were assessed at baseline, 1-month, and 3-month time points. Moral injury remained stable over three months, while distress declined. A supportive workplace environment was related to lower moral injury whereas a stressful, less supportive environment was associated with increased moral injury. Distress was not affected by any baseline occupational or resiliency factors, though poor sleep at baseline predicted more distress. Overall, our data suggest that attention to improving workplace support and lowering workplace stress may protect HCWs from adverse emotional outcomes.