Concept Of Moral Injury Research Articles

Moral injury in a global health emergency: a validation study of the Italian version of the Moral Injury Events Scale adjusted to the healthcare setting

ABSTRACT Background: When exposed to events that transgress one’s moral beliefs, a plethora of negative consequences may follow, which are captured by the concept of moral injury (MI). Despite its relevance to experiences of healthcare workers during a global health emergency, there is lack of validated MI instruments adapted to the healthcare setting. Objective: The present study aims to provide a validation of the Italian version of the Moral Injury Events Scale (MIES) adjusted to the healthcare setting by assessing its factor structure, internal consistency and construct validity. Methods: A sample of 794 healthcare workers (46% nurses, 51% female) engaged in hospital facilities during the COVID-19 pandemic in Italy completed measures of MI, PTSD, anxiety, depression, burnout, meaning in life and positive affect. Results: Using an exploratory structural equation modelling (ESEM) we assessed the scale factor structure for the entire sample and separately for nurse professional and female healthcare worker groups. Findings support a three-factor solution: Factor 1 ‘perceived transgressions by others’; Factor 2 ‘perceived transgressions by self’; and Factor 3 ‘perceived betrayals by others’. Findings also indicate some level of convergence with measures of PTSD, anxiety, depression and burnout. Conclusion: Results suggest that the MIES may be useful in capturing unique experiences of moral injury amongst healthcare workers engaged in a global health emergency. The low range correlations with measures of psychological distress might potentially indicate that MI, which captures cognitive value judgements rather than manifest symptomatology, may uniquely explain a certain amount of variance. Implications for the development of new empirically derived and theoretical guided tools are discussed, highlighting the need for future research to examine the role of individualising and social binding moral principles in gaining a more nuanced understanding of moral injury experiences amongst healthcare professionals across different socio-cultural settings.

Guilt and Shame As a Result of Violating Beliefs: “Moral Injury”

This study on moral injury, which has a content as old as the history of humanity, is believed to contribute significantly to the relevant literature. Despite the limited number of sources in the literature on the subject, which are mostly related to veterans with war experience or limited to the field of religious psychology, this study is expected to fill the gap and provide valuable insights. The study attempted to clarify the distinction between moral injury, which involves a psychological injury caused by a dilemma, and post-traumatic stress disorder, which shares similar features with moral injury and arises after experiencing a traumatic event. As part of this study, psychotherapy approaches within the scope of interventions for the symptoms of moral injury were also included and the issue was tried to be addressed from a mental health perspective. In this context, “mindfulness-oriented meditation”, “self- compassion”, “spiritually-oriented counseling”, and “work focused on forgiving oneself and others”, whose effectiveness has been tested, are included. The issue of moral injury was addressed with psychology- spirituality dimensions; the scope of the study was further expanded with intervention-treatment titles. This study summarizes moral injury’s conceptual framework and focuses on interventions and treatment approaches. As a result, the concept of moral injury was addressed holistically and contributed to the conceptual framework.

Examining the Association Between Moral Injury and Suicidal Behavior in Military Populations: A Systematic Review.

The increasing number of suicides among military populations cannot be fully accounted for by conventional risk factors like Post-Traumatic Stress Disorder (PTSD). As a result, researchers and theorists propose that delving into the concept of Moral Injury could offer a more comprehensive understanding of the phenomenon of suicide. Moral Injury is not currently a recognized mental health disorder but can be associated with PTSD. Moral Injury is a multi-dimensional issue that profoundly affects emotional, psychological, behavioral, social, and spiritual well-being. The objective of this systematic review is to examine the association between Moral Injury and suicidal behavior (suicide ideation, plans and or suicide attempt) within military populations. The review will specifically concentrate on identifying and analyzing studies that have investigated the connection between these variables, with a specific focus on the context of military personnel both serving and former serving members. Of the 2214 articles identified as part of this review, 12 studies satisfied the research criteria with a total participant sample having an average age of 40.7years. The male population accounted for 78.6% of the overall sample. Two studies were identified as high-quality, while the remaining ten were rated as moderate. The analysis of these twelve studies consistently affirms a connection between Moral Injury and suicidal behavior; most obviously, that exposure to morally injurious events substantially amplify the risk of suicide, with higher levels of potential exposure being linked to increased Moral Injury and heightened levels of suicidal behavior. Our review uncovered noteworthy findings regarding the association between Moral Injury and suicidal behavior, marking a pioneering effort in exploring this association and offering valuable insights into this emerging issue. Several limitations are noted regarding this review and recommendations are made concerning the need to prioritize, expand and employ longitudinal research designs that include non-military populations such as first responders (e.g., police, paramedics, firefighters) and medical, nursing, or allied health professionals-all disciplines known to be impacted by Moral Injury.

The space in between: Notes on a research-based play about moral injury and the transition to civilian life

LAY SUMMARYDominant biomedical framings of military trauma and resulting treatment approaches for mental health issues can sometimes fall short for military members and Veterans and risk individualizing and pathologizing normal human reactions to the emotions at the core of moral injury. Accordingly, philosophical and aesthetic exploration are warranted. This research-based theatre project was inspired by the work of Jonathan Shay, who looked to ancient Greek theatre to develop his concept of moral injury and argued that healing can only take place in community. In-depth interviews with nine Canadian Armed Forces Veterans led to the creation of a research-based play in which each scene represents one of the major themes identified during or after interview sessions (family, betrayal, brotherhood and mothering, public honour, sickness and coping). Sub-themes (heroism, the body, militarized masculinity, the role of women) became smaller or transition scenes in the play.

Critical intercession for non-religious Canadian Veterans on the intersections of moral injury, religion, and spirituality

LAY SUMMARYWith the concept of moral injury being adopted as a way of understanding psychological distress experienced by Veterans, there is a growing interest in what role religion or spirituality might play as a factor in the risk of, or resilience against, experiencing this form of trauma. There is also interest in how religion and spirituality might be used to help treat moral injuries. However, most of the research to date has been conducted with American Christian Veterans and military service members. What is in question is whether these ideas work in the context of Veterans and service members of the Canadian Armed Forces. This article presents a critical warning about how the use of religion and spirituality might possibly cause harm instead of helping as intended.

A Relational Conception of Justice: The Theory of Recognition and Moral Injury -Proposals for a Practical Evaluative Framework-

Primarily developed within political philosophy, comprehensive theories of justice are often considered abstract and transcendental for sociological, political, or economic applications and thus, often require further conceptual and analytical clarifications. This need is apparent in recognition theory, a contemporary theory of justice pioneered by Axel Honneth. In it, he underlines the importance of recognition in intersubjective and mutual relations with significant others, legal institutions, and wider society, the denial of which leads to particular forms of injustice, conceptualised as moral injuries. To overcome the functional weakness inherent in recognition theory’s relatively abstract nature, this article clarifies the distinction between its “space” and “object” of evaluation to advance its practical usefulness in assessing disadvantage. In doing so, it first examines the theory of recognition as well as the concept of moral injury and addresses issues researchers and practitioners need to be attentive to concerning the categorisation of the good, the promise of recognition, and the pressing problem of unwarranted claims. Having taken these clusters of concerns into account, this article identifies (1) deformative identity formation, (2) invisibilisation, and (3) stigmatization as morally injurious acts and proposes three dimensions of evaluation, namely physical integrity, moral accountability, and personal autonomy, upon which certain forms of injustices that disadvantaged individuals or groups experience can be assessed within the normative framework of the theory of recognition.

Supporting nurse leaders to recognise and mitigate the effects of moral injury.

The concept of moral injury has been around for several decades, yet its effect on nurses remains under-recognised. Moral injury is defined as the biopsychosocial harm that arises from a violation of one's moral code, meaning that a person is powerless to uphold and enact what they believe is morally right. The coronavirus disease 2019 (COVID-19) pandemic has brought the issue of moral injury into focus because many nurses and other healthcare professionals have encountered potentially morally injurious events, resulting in increased pressure and emotional demands. It is essential that nurse leaders recognise moral injury if its effects are to be addressed. This article describes moral injury and its effects on nurses, and offers nurse leaders a practical framework for mitigating this issue. The framework aims to support nurse leaders to increase their understanding of moral injury, address any ethical challenges, ensure they are adequately prepared to provide support to nurses, and enhance their awareness of various interventions that can mitigate moral injury.

Relating to moral injuries: Dutch mental health practitioners on moral injury among military and police workers

In recent years the concept of moral injury has become a common term to describe the lasting impact of moral transgressions on frontline workers. This article aims to broaden the largely clinical debate by involving the views of a diverse group of mental health practitioners who support military and police personnel in the Netherlands. These practitioners are chaplains, confidential counsellors, social workers, psychologists and integrity officers. How do these practitioners describe the moral injuries of servicemen and police officers and how do they think these should be approached? Through interviews with thirty different practitioners this study shows that definitions of moral injuries diverge considerably. In addition, the article analyses six different approaches to moral injuries. These range from framing moral injury as an exceptional problem that requires specific expertise, to seeing it as a broad issue that places workers in a larger moral community. An analysis of this variety both serves as an indication of possible ways to deal with moral injuries, and as a basis for a critical reflection on the implications of various approaches.

An Exploration of Implicit Racial Bias as a Source of Diagnostic Error.

Recent events led this author to realize that an error made during the Vietnam War by him and others had been due to focusing too narrowly on predisposing factors for PTSD while failing to consciously acknowledge acute systemic stressors. In not accepting that along with the stress of combat, Black troops daily experienced acute pervasive systemic racism, he failed to understand correctly their disproportionately higher levels of PTSD when compared to white troops. Motivating factors to examine this error included a recent movie by Spike Lee. Oral histories of Black veterans were then used to research the experience of Blacks in the military in two world wars and the Vietnam War. Little change in the treatment of Black service members was evident across the time frame which included WWI, WWII and the Vietnam War. An understanding of Shay's concept of moral injury was found very valuable in understanding the consequences of PTSD.

6.M. Workshop: Moral distress and moral injury in the public health community in times of COVID-19

During the COVID-19 pandemic, many health professionals endured moral distress and moral injury. Whereas many stories about moral distress in hospitals and care facilities were shared, little is known about moral injury among health care personnel and among public health professionals. This workshop wants to offer an opportunity to open a conversation about moral injury in general, in health care personnel and in in public health experts. The public health community should not shy away from openly discussing moral injury and moral distress due to the the Covid-19 pandemic. It is necessary to collect the stories about the situations where members of the public health community were hindered in doing what was the ethically appropriate action due to circumstances beyond their control.Objectives of this workshop are: Clarifying the concept of moral injury and moral distressUnderstanding what ‘ethically appropriate actions' are in times of a pandemicOffering a platform for sharing stories of moral distress Key messages Moral distress and moral injury are potential modifiable mental conditions in times of disaster and stressIdentifying determinants of moral distress and moral injury is necessary to optimize Public health responses to disasters

Warnings against romanticising moral injury.

Interest in the concept of moral injury among researchers, clinicians and policy makers can have undesirable consequences that are rarely considered. It can lead to misunderstanding of post-traumatic stress disorder, risks of primary and secondary gains for affected individuals and tertiary gains for third parties. This editorial calls for critical assessment of this sensitive matter.

Understanding and mitigating moral injury in nurses.

Moral injury may be experienced when a person perpetrates, witnesses or fails to prevent an act that conflicts with their moral values and beliefs. The concept of moral injury has its origins in the context of military personnel encountering ethically challenging decisions during armed conflict. The term has been applied to healthcare and moral injury is increasingly acknowledged to be a challenge for healthcare professionals. Nurses across all specialties and settings are frequently required to make or witness ethically challenging decisions about patient care. The coronavirus disease 2019 (COVID-19) pandemic has increased nurses' risk of sustaining moral injury. This article discusses the manifestations of moral injury and its associated risk factors, including the effects of the COVID-19 pandemic. It also outlines various strategies that can be used to mitigate and/or prevent moral injury in nurses.

Rethinking trauma: A case series and proposed refinements to criterion A for post-traumatic stress disorder in DSM-5

The traumatic event is a core requirement in the diagnosis of Post-Traumatic Stress Disorder (PTSD), and is defined in the Diagnostic and Statistical Manual’s (DSM’s) criteria of PTSD as Criterion A. This remains the case, despite opposing views from prior literature that the trauma response can occur without Criterion A. This article explores a definition for psychological trauma, from its etymology to a historical perspective, before examining the evolution of PTSD’s Criterion A across time in various editions of the DSM. The concept of moral injury is also examined, in terms of its correlation with psychological trauma and its impact on the pathological trauma response. A case series of vignettes from the authors’ clinical experience is presented, where PTSD symptoms have been noted in the absence of Criterion A. This is supplemented by the authors’ analyses about how the various life adversities across the cases fall short of Criterion A. Two key features (the imminence of a perceived threat, and the perceived loss of control experienced as a result) of a traumatic event are proposed to refine the definition of psychological trauma. It is hoped that these would serve to improve the current understanding and definition of psychological trauma. Keywords: Psychological trauma; Traumatic event; PTSD.

The Trauma of Autopsy and the Transgression of History in Josephus’ Jewish War

Abstract In the opening of the Jewish War, Josephus claims not only that his history represents the true and full account of the war, but that, in violation of Greek historiographical conventions, its language expresses his personal grief. Josephus’ expression of personal emotion differentiates him from the Greek tradition, in which lament is customarily expressed in other genres. Josephus borrows instead from the biblical tradition of lament to mourn the fall of Jerusalem. The concept of moral injury from trauma studies describes the psychological damage caused by betrayal in combat settings, a phenomenon which Josephus’ comments about the causes of the disaster resemble. This elucidates why Josephus emphasizes his emotions in his history, drawing on past Jewish responses to imperial-colonial encounters to shape his personalized response to the catastrophe of his own day.

No Guilt, No Shame: Discerning Signs of Post-Conflict Moral Injury in Atmospheres of Political Impunity

Social scientists in the United States have published extensively on the concept of moral injury among soldiers in the past decade. Contemporary research gestures principally to expressions of guilt or shame as the primary mechanisms by which one can discern moral injury in a soldier. Guilt and shame are understood to be the emotional responses to the a soldier’s realization that they have taken life (or witnessed the taking of life) especially in an atrocity; such feelings tend to be amplified in the face of hostility to recent military missions (and, implicitly, military actors) on the part of the American populace. Scholars of moral injury point to the U.S. war in Vietnam, and to some extent those in Iraq and Afghanistan, as conflicts which left veterans with a sense of “all-encompassing absurdity and moral inversion.” What happens to our understanding of how to recognize moral injury, this article asks, if we expand our investigation of moral injury beyond the framework of an increasingly anti-war United States populace, and consider wars that are civil in nature as opposed to waged on foreign grounds? Focusing on non-US geopolitical sites where cultures of impunity have taken root post-conflict, this article finds that guilt and shame suddenly become considerably less productive tools by which to identify the moral cost of war to combatants. Recuperating an original formulation of moral injury suggested by Robert Jay Lifton in the late 1960s and early 1970s, and interpreting it alongside a close-reading of documentary cinema featuring perpetrators of atrocities in Indonesia, Cambodia and Lebanon, this article proposes that we broaden our criteria for perceiving moral injury beyond the filters of guilt and shame if we hope to arrive at a more universal understanding of the phenomenon.

Readers' Disgust in the Case of Rebekah, Jacob, Isaac, and Esau: Perverters of Justice?

ABSTRACT Popular readings, for example, sermons appear to exonerate Rebekah and Jacob (Gen. 25: 19-34; Gen 27-29, 33), as if they want to salvage the relation between faith and good character. Scholarly readings are more ready to question Rebekah and Jacob on a continuum between Rebekah and Jacob as deceitful and rescuing the Abrahamic covenant. Who are to be regarded as the perpetrators perverting justice in this narrative? In this essay, I would optfor Esau as the injured party of the fraud perpetrated by his mother and brother. The argument starts with the notion of moral perversity as framed by the concept of moral injury as well as disgust expressed at moral digressions. This discussion will be followed by an explanation of four sermons on Jacob, Esau, Rebekah, and Isaac. The argument will be directed to a discussion of selected scholarly interpretations of the story cycle. Keywords: Rebekah, Jacob, Esau; Isaac, Perpetrator Studies, Sermons, Covenant, Reception, Contextualisation, Ethics of Interpretation, Decolonization, Postcolonialism

Moral injury in paramedicine

World Mental Health Day took place on 10th October 2019. In this issue's comment, Esther Murray discusses the concept of moral injury and why it is becoming increasingly relevant to the modern-day paramedic.

Oral History, Moral Injury, and Vietnam Veterans

Moral injury is a relatively new concept in the field of clinical psychology. Coauthors Napoli (Brooklyn College), and Vietnam veterans Brinson, Kenny, and Furey, employing the notion of “shared authority,” revisited oral histories conducted more than a decade ago to see if they could identify instances or episodes in those interviews that might be interpreted or explained using the concept of moral injury. Analysis revealed that indeed, moral injury can be a valuable interpretive tool for oral historians and interviewees but that it must be treated with some degree of caution.

Moral injury in relation to public debates: The role of societal misrecognition in moral conflict-colored trauma among soldiers

The last decade has witnessed fast-growing scholarly interest in the concept of moral injury, which addresses the link between the ethics of military intervention and deployment-related suffering. However, current research on moral injury, predominantly psychological in nature, tends to approach the phenomenon as an internally contained disorder. Consequently, it medicalizes moral injury and de-contextualizes it from the people who send soldiers to conflict zones and ‘welcome’ them back. This article addresses the ways in which the experience of moral injury is embedded in and shaped by public debates on military intervention, drawing on relevant literature from the fields of psychology, philosophy, and social sciences, and on in-depth qualitative interviews collected in 2016 and 2017 with 80 Dutch veterans. The article examines the explicit public condemnation experienced by Dutch veterans deployed to Bosnia as peacekeepers, and the more subtle public misunderstanding experienced by Dutch veterans deployed to Afghanistan as combat soldiers. It demonstrates that public criticism and admiration may both be experienced as misrecognition, and, in turn, societal misrecognition may directly or indirectly contribute to moral injury. Moreover, not only soldiers and veterans may struggle with the moral significance of military intervention, but society as well.

Physical and Mental Health Consequences of War-related Stressors Among Older Adults: An Analysis of Posttraumatic Stress Disorder and Arthritis in Northern Vietnamese War Survivors.

We examine the impacts of trauma exposures and family stressors associated with the Vietnam War on musculoskeletal health and posttraumatic stress disorder (PTSD) outcomes in elderly Vietnamese who were widely impacted by the war as young adults. Noting that wars' impacts extend beyond male veterans in most survivor populations, we give attention to male and female war survivors placed in a variety of roles vis-a-vis the war. Utilizing data from the 2010 Vietnam Health and Aging Pilot Study (N = 405), we use logistic and Poisson regression models to estimate the effect of wartime trauma exposures and family stressors on disabling arthritis and PTSD symptoms in male and female northern Vietnamese adults aged 55 and older. The odds of experiencing recent PTSD symptoms are greater in respondents who report involvement in killing/causing severe injury and who observed war atrocities. In women, PTSD is positively correlated with war era child death and spousal separation. Arthritis also exhibits a significant, positive association with killing/causing severe injury. Our study provides insights into the burden of conflict upon health among populations of the global south that survived war and are now entering older adulthood. The pattern of results, indicating greatest suffering among those who inflicted or failed to prevent bodily harm or loss of life, is consistent with the concept of moral injury.