Moral Injury Research Articles

Correction to Williamson et al. (2023).

Military veterans experience a higher prevalence of mental health difficulties compared with the general population. Research has highlighted veterans who experience mental health difficulties have poorer treatment outcomes. Understanding veteran needs may help improve veteran mental health services and treatment outcomes. The aim of this study was to explore the complexity of health and well-being needs among a national clinical sample of veterans. In total, 989 veterans from a U.K. veterans mental health charity were invited to complete a questionnaire about their sociodemographic characteristics, military experiences, physical and mental health, and well-being. Of the invitees, 428 veterans (43.3%) completed the questionnaire. Common mental disorders, such as anxiety and depression, were the most frequently reported mental health difficulty (80.7%), followed by loneliness (79.1%) and perceived low social support (72.2%). Rates of PTSD were also high (68.7% any PTSD), with most participants experiencing complex PTSD (CPTSD; 62.5%) compared with PTSD (6.2%). Veterans with co-occurring CPTSD symptoms have poorer health due to a higher number of comorbidities, for instance between CPTSD and moral injury. Comorbidity appeared to be the norm rather than the exception within treatment-seeking veterans. As such, it seems important for veteran mental health services to take a holistic approach when supporting veterans. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Light Personality Style and Moral Injury Among Chinese Health Professionals.

Moral injury has attracted attention widely in various occupations, particularly health professionals. Personality traits involve the professional values in clinical decision-making associated with mental outcomes. The current study examines the relationship between "light personality" style and moral injury. Scores on three subscales of the Light Triad Scale were negatively correlated with the Moral Injury Symptoms Scale-Health Professional. Health professionals more likely to have light personality styles may be less likely to suffer from moral injury under high-stake situations. The findings provide evidence to better understand the inner core of the moral injury, suggesting a potential pathway to improve the moral well-being of health professionals by strengthening key elements of light personality.

Biopsychosocial Correlates and Individual Differences for Eliciting Moral Elevation in Veterans With PTSD: An Experimental Case Series.

A promising approach to enhancing trauma-focused treatment is moral elevation-feeling inspired by witnessing a virtuous act. This study explored potential links between eliciting elevation and relevant outcomes in a series of case examples. Veterans with probable posttraumatic stress disorder completed experimental tasks including a written trauma narrative exercise and watching elevation-eliciting videos. Participants also completed baseline assessments, repeated measures of trauma-related cognitions, emotions, elevation, and saliva sample collection. Four cases were identified and reviewed: two positive responders (high elevation after videos) and two nonresponders (restricted elevation response). Positive responder cases reported decreased cognitions, emotions, and moral injury distress from after the trauma narrative to after elevation exercises, whereas nonresponders reported minimal to no changes. Positive responders also demonstrated decreases in cortisol, whereas nonresponders demonstrated increases in cortisol. Future work should examine whether elevation contributes to changes in biopsychosocial outcomes and identify individual factors that indicate who might benefit from elevation-based interventions.

Moral Distress, Conscientious Practice, and the Endurance of Ethics in Health Care through Times of Crisis and Calm.

When health professionals experience moral distress during routine clinical practice, they are challenged to maintain integrity through conscientious practice guided by ethical principles and virtues that promote the dignity of all human beings who need care. Their integrity also needs preservation during a crisis like the COVID-19 pandemic, especially when faced with triage protocols that allocate scarce resources. Although a crisis may change our ability to provide life-saving treatment to all who need it, a crisis should not change the ethical values that should always be guiding clinical care. Enduring ethical commitments should encourage clinicians to base treatment decisions on the medical needs of individual patients. This approach contrasts with utilitarian attempts to maximize selected aggregate outcomes by using scoring systems that use short-term and possibly long-term prognostic estimates to discriminate between patients and thereby treat them unequally in terms of their eligibility for life-sustaining treatment. During times of crisis and calm, moral communication allows clinicians to exercise moral agency and advocate for their individual patients, thereby demonstrating conscientious practice and resisting influences that may contribute to compartmentalization, moral injury, and burnout.

Worsening of mental health outcomes in nursing home staff during the COVID-19 pandemic in Ireland.

Mental health issues in nursing home staff during the COVID-19 pandemic have been significant; however, it is not known if these issues persist following widespread vaccination and easing of restrictions. To quantify the mental health of nursing home staff at different timepoints during the COVID-19 pandemic in the Republic of Ireland. Two identical, online, cross-sectional, nationwide, anonymous surveys of Republic of Ireland nursing home staff at two timepoints (survey 1 (S1, n = 390): November 2020 to January 2021; survey 2 (S2, N = 229: November 2021 to February 2022) during the COVID-19 pandemic. Convenience sampling was used with staff self-selecting for participation. Methods included the World Health Organisation's Well-Being Index (WHO-5), the Impact of Events Scale-Revised (IES-R), the Moral Injury Events Scale (MIES), two Likert-scale items regarding suicidal ideation and planning, the Work Ability Score (WAS), the Brief Coping Orientation to Problems Experienced (Brief-COPE) Scale, and a 15-item questionnaire assessing perceptions of the outbreak with one additional Likert-scale item on altruism. Descriptive analysis examined differences between staff based on their classification in one of three groups: nurses, healthcare assistants (HCA) and nonclinical staff. Pseudonymous identifiers were used to link responses across surveys. An insufficient number of participants completed both surveys for linked analyses to be performed; therefore, we performed an ecological comparison between these two independent surveys. More staff reported moderate-severe post-traumatic stress symptoms (S1 45%; S2 65%), depression (S1: 39%; S2 57%), suicidal ideation (S1: 14%; S2 18%) and suicidal planning (S1: 9%; S2 15%) later in the pandemic. There was a higher degree of moral injury at S2 (S1: 20.8 standard deviation (SD) 9.1; S2: 25.7 SD (11.3)) and use of avoidant (maladaptive) coping styles at S2 (S1: 20.8 (6.3); S2 23.0 (6.3)) with no notable differences found in the use of approach (adaptive) coping styles. Staff reported more concerns at S2 regarding contracting COVID-19, social stigma, job stress, doubts about personal protective equipment and systems and processes. In comparison to our previous survey, mental health outcomes appear to have worsened, coping did not improve, and staff concerns, and worries appear to have increased as the pandemic progressed. Follow-up studies could help to clarify is there are any lingering problems and to assess if these issues are related to the pandemic and working conditions in nursing homes.

The Relationship Between Moral Injury Symptoms and Nursing Care Behaviors of Internal Medicine Nurses

Bu araştırma, dâhiliye hemşirelerinin ahlaki yaralanma semptomları ile hemşirelik bakım davranışları arasında ilişkiyi belirlemek amacıyla yapıldı. Çalışmanın örneklemini Türkiye’nin Doğu Karadeniz bölgesinde bulunan hastanelerde görev yapan 315 dâhiliye hemşiresi oluşturdu. Araştırmanın verileri, “Kişisel Bilgi Formu” ve “Ahlaki Yaralanma Semptom Ölçeği-Sağlık Bakım Profesyonelleri Versiyonu (AYSÖ-SBP)” ve “Bakım Davranışları Ölçeği (BDÖ)-24 ölçeği” kullanılarak 20 Nisan-30 Mayıs 2023 tarihleri arasında “Kartopu Örnekleme” ile toplandı. Hemşirelerin yaş ortalamaları 30,89±5,72 yıl ve meslekteki çalışma ortalamaları 6,56±5,45 yıl idi. Çalışmaya katılan hemşirelerin toplam “BDÖ-24” 5,21±0,76 puan ve “Saygılı olma” alt boyutu 5,21±0,81 puan, “Bağlılık” alt boyutu 5,12±0,80 puan, “Bilgi beceri” alt boyutu 5,39±0,77 puan, “Güvence” alt boyutu 5,16±0,85 puan; toplam “AYSÖ-SBP” 27,32±6,00 puan ve “Kınama” alt boyutu 6,21±2,66 puan, “Suçluluk/Utanç” alt boyutu 7,49±2,71 puan, “Manevi Sıkıntılar” alt boyutu 13,60±3,47 puan olarak tespit edildi. Ayrıca, çalışmaya katılan hemşirelerin yaşı ve çalışma yılı ile “BDÖ-24” ve alt boyut puan, “AYSÖ-SBP” ve alt boyut puan ortalamaları arasında korelasyon bulunmadı (p>0.05). Bu araştırmada, ahlaki yaralanma semptomları ile hemşirelik bakım davranışları arasında ilişki bulunmazken; ahlaki yaralanma düzeyleri düşük, bakım davranışları düzeyleri ise yüksek bulundu.

Coping, Supports and Moral Injury: Spiritual Well-Being and Organizational Support Are Associated with Reduced Moral Injury in Canadian Healthcare Providers during the COVID-19 Pandemic.

Healthcare providers (HCPs) have described the onset of shame- and trust-violation-related moral injuries (MI) throughout the COVID-19 pandemic. Previous research suggests that HCPs may turn to various coping methods and supports, such as spirituality/religiosity, substance use, friends/family or organizational support, to manage workplace stress. It remains unknown, however, if similar coping methods and supports are associated with MI among this population. We explored associations between MI (including the shame and trust-violation presentations individually) and coping methods and supports. Canadian HCPs completed an online survey about their mental health and experiences during the COVID-19 pandemic, including demographic indices (e.g., sex, age, mental health history) and measures of MI, organizational support, social support, spiritual well-being, self-compassion, alcohol use, cannabis use and childhood adversity. Three hierarchical multiple linear regressions were conducted to assess the associations between coping methods/supports and (i) MI, (ii) shame-related MI and (iii) trust-violation-related MI, when controlling for age, mental health history and childhood adversity. One hundred and seventy-six (N = 176) HCPs were included in the data analysis. Spiritual well-being and organizational support were each significantly associated with reduced total MI (p's < 0.001), shame-related MI (p = 0.03 and p = 0.02, respectively) and trust-violation-related MI (p's < 0.001). Notably, comparison of the standardized beta coefficients suggests that the association between trust-violation-related MI and both spiritual well-being and organizational support was more than twice as great as the associations between these variables and shame-related MI, emphasizing the importance of these supports and the trust-violation outcomes particularly. Mental health history (p = 0.02) and self-compassion (p = 0.01) were additionally related to shame-related MI only. Our findings indicate that heightened levels of spiritual well-being and organizational support were associated with reduced MI among HCPs during the COVID-19 pandemic. Rather than placing sole responsibility for mental health outcomes on HCPs individually, organizations can instead play a significant role in mitigating MI among staff by implementing evidence-informed organizational policies and interventions and by considering how supports for spiritual well-being may be implemented into existing models of care where relevant for employees.

Moral injury and the four pillars of bioethics

Health care providers experience moral injury when their internal ethics are violated. The routine and direct exposure to ethical violations makes clinicians vulnerable to harm. The fundamental ethics in health care typically fall into the four broad categories of patient autonomy, beneficence, nonmaleficence, and social justice. Patients have a moral right to determine their own goals of medical care, that is, they have autonomy. When this principle is violated, moral injury occurs. Beneficence is the desire to help people, so when the delivery of proper medical care is obstructed for any reason, moral injury is the result. Nonmaleficence, meaning do no harm, has been a primary principle of medical ethics throughout recorded history. Yet today, even the most advanced and safest medical treatments are associated with unavoidable, harmful side effects. When an inevitable side effect occurs, the patient is harmed, and the clinician is also at risk of moral injury. Social injustice results when patients experience suboptimal treatment due to their race, gender, religion, or other demographic variables. While minor ethical dilemmas and violations routinely in medical care and cannot be eliminated, clinicians can decrease the prevalence of a significant moral injury by advocating for the ethical treatment of patients, not only at the bedside but also by addressing the ethics of political influence, governmental mandates, and administrative burdens on the delivery of optimal medical care. Although clinicians can strengthen their resistance to moral injury by deepening their own spiritual foundation, that is not enough. Improvements in the ethics of the healthcare system as a whole are necessary to improve medical care and decrease moral injury.

Restore and Rebuild (R&R) – a feasibility pilot study of a co-designed intervention for moral injury-related mental health difficulties

ABSTRACT Background: Moral injury can significantly negatively impact mental health, but currently no validated treatment for moral injury-related mental health difficulties exists in a UK context. This study aimed to examine whether the Restore and Rebuild (R&R) treatment was feasible to deliver, acceptable and well tolerated by UK military veterans with moral injury related mental health difficulties. Method: The R&R treatment was delivered to 20 patients who reported distress related to exposure to a morally injurious event(s) during military service. R&R is a 20-session psychotherapy with key themes of processing the event, self compassion, connecting with others and core values. Treatment was delivered online, weekly, one-to-one by a single therapist. Qualitative interviews with patients and the therapist who delivered R&R were conducted to explore acceptability and analysed using thematic analysis. Results: Following treatment, patients experienced a significant reduction in symptoms of post-traumatic stress disorder, depression, alcohol misuse and moral injury related distress. R&R was found to be well tolerated by patients and improved their perceived wellbeing. Conclusions: These results provide preliminary evidence that veterans struggling with moral injury related mental ill health can benefit from R&R treatment.

When healers get wounded! Moral injury in healthcare providers during the COVID-19 pandemic in Pakistan.

Moral injury (MI) is a multi-faceted and multidimensional phenomenon. Occupational MI has been studied mainly among military personnel and first responders and is linked to mental health problems. MI encompasses negative moral emotions such as shame, guilt, and anger leading to distress, and impairment in social and occupational functioning. The COVID-19 pandemic predisposed healthcare providers to moral dilemmas, potentially morally injurious events (PMIEs), and MI. We aimed to assess the prevalence and predictors of MI in healthcare providers during the COVID-19 pandemic in Pakistan. This cross-sectional study was conducted in July-October 2021 among physician/clinician staff working at teaching hospitals in Lahore. The Moral Injury Symptoms Scale-Health Professionals (MISS-HP) was used to collect data. SPSS 26 was used for data analysis applying Wilcoxon Mann-Whitney U and Kruskal-Wallis tests on non-normally distributed data at α = 0.05. Predictors of MI were ascertained through Binary Logistic Regression analysis. Four hundred and twenty physicians responded to the questionnaires. The Median (IQR) MI scores were 37(28-47). Guilt, moral concerns, and shame were higher-scoring MI dimensions. 40.8% (n = 171) suffered from clinically significant distress and impaired functioning while 14.3% (n = 60) from severe distress. Gender, department, and history of psychiatric illness predicted higher levels of distress which were 1.9 times higher in females than males and 2.5 times higher with a history of psychiatric illness. Working on the front lines did not predict MI. Our findings highlight the substantial burden of MI in our sample during COVID-19, having implications for healthcare providers' well-being, healthcare quality, and service delivery. This calls for concerted efforts from all stakeholders to better prepare for future disasters through effective human-resource policies, pre-trauma exposure soft-skills training, effective teamwork and communication strategies; self-stewardship and resilience modules, and mental health support for healthcare providers. The dimensional construct of MI may vary across cultures; hence we recommend further cross-cultural research on MI in healthcare providers, particularly in the context of public health disasters.

Medicine shouldn't be this hard: The intersection of physician moral injury and patient healthcare experience in pediatric complex care.

Dr. Jay Neufeld's story in If I Betray These Words is a detailed account of one physician's catastrophic journey through moral injury when caring for pediatric patients with complex medical conditions [1]. Many clinicians may recognize Jay's journey in their own experiences, but what deserves parallel consideration are the journeys of patients and families when they are accompanied by physicians at risk of moral injury. This case study illustrates the tight link between drivers of physician moral injury and patients' negative healthcare experiences. These include (1) decisions directed by health insurance regulations and prior authorizations; (2) the electronic medical record (EMR); and (3) healthcare systems focused on revenue generation.

Physician distress: Where are we and what can be done.

Depression, suicidal ideation, burnout, and moral injury are on the rise among physicians. Depression and suicidal ideation are mental health disorders that result from multiple interacting factors including biological vulnerabilities and acute stressors. Medical treatment for depression and suicidal ideation is critical to interrupt the potentially deadly progression to suicide that occurs when one's ability to find hope and other solutions is clouded by despair. Yet, stigma and perceived stigma of seeking treatment for mental health disorders still plagues medical providers. Transitions during medical training and practice can be particularly vulnerable time periods, though newer evidence suggests that overall, physicians are not at an increased risk of suicide compared to the general population. While burnout and moral injury are common among rehabilitation physicians, unlike depression, they are not directly associated with suicidal ideation. Opportunities for continued improvement in mental health resources and institutional support exist across the spectrum from medical student to staff physician. With wellness now increasingly supported and promoted by various medical organizations and recognition of the importance of access to effective mental health treatment, regaining hope and positivity while restoring resiliency in physicians, trainees, and medical students is possible.

Financial medicine as a source of moral distress: An unrecognised pathway to moral injury in the South African EMS systems

IntroductionThe phenomenon of Financial Medicine is a wide spread practice within the South African prehospital domain, which remains poorly researched. Similarly the impact of this phenomenon is not well understood, with many healthcare providers grappling with the moral dilemmas introduced into the work systems through the effects of the practice of Financial Medicine. Persisting, repetitive moral dilemmas can lead to instances of Moral Distress and Moral Injury. The practice of Financial Medicine in the South African prehospital domain proves to introduce many moral dilemmas and subsequently can serve as a source of Moral Distress and Moral Injury. MethodsThis study used a qualitative research methodology in the form of a constructivist grounded theory design. Participants voluntarily consented to be enrolled into one-on-one in-depth interviews, and were selected using purposive and theoretical sampling techniques. Data was subjected to validated coding procedures and analysed using the constant comparative analysis approach, analytical diagramming, and supported by researcher theoretical sensitivity. ResultsThe sub-category presented in this study stems from the development of 6 final analytical labels that were abstracted in the process of a theory construction, not presented in this article. This sub-category is nested under 1 of the final analytical labels, and comprised of 3 preliminary analytical labels and an associated code and proposition list. ConclusionUnderstanding the sources of Moral Distress and Moral Injury within the South African prehospital domain are key steps in promoting and supporting the adoption and sustainability of ethical practices. This article presents a key finding that demonstrates a link between the experience of the phenomenon of Financial Medicine and the suffering of a Moral Injury by South African prehospital personnel.

A Review of Research on Moral Injury and Suicide Risk

A Review of Research on Moral Injury and Suicide Risk

Emerging Interventions for Moral Injury: Expanding Pathways to Moral Healing

Emerging Interventions for Moral Injury: Expanding Pathways to Moral Healing

Routine.

Written a year and a half into the pandemic during a particularly difficult week, this poem explores the moral injury and emotional distress that emergency physicians encounter and must process daily. These repeated microtraumas throughout our day frequently contribute to depersonalization and it is important to recognize those factors that "break the routine" and help to improve physician well-being.

Towards a Holistic Model of Care for Moral Injury: An Australian and New Zealand Investigation into the Role of Police Chaplains in Supporting Police Members following exposure to Moral Transgression

Police members can be exposed to morally transgressive events with potential for lasting psychosocial and spiritual harm. Through interviews with police members and police chaplains across Australia and New Zealand, this qualitative study explores the current role that police chaplains play in supporting members exposed to morally transgressive events. The availability of chaplains across police services and the close alignment between the support they offer, and the support sought by police, indicates they have an important role. However, a holistic approach should also consider organizational factors, the role of leaders, and access to evidence-based treatment in collaboration with mental health practitioners.

Moral Injury is a Risk Factor for Substance Use and Suicidality Among US Military Veterans with and withoutTraumatic Brain Injury.

A national survey of United States veterans was conducted, yielding 252 veterans with TraumaticBrain Injury (TBI) and 1235 veterans without TBI. Participants were asked questions about moral injury, suicidality, substance use, and other sociodemographic variables. Multivariable linear regression analysis was used to examine the previously described relationships. Increasing severity of moral injury was associated with higher scores on the substance use tool (b = 0.02, p = 0.04), although the magnitude of effect was not different from those without TBI (Z = - 0.57, p = 0.72). Increasing severity of moral injury was positively associated with suicidal behavior scores (b = 0.10, p < 0.01). The strength of this relationship was stronger in veterans with TBI than those without TBI (Z = 1.78, p = 0.04). Rehabilitation programs that treat veterans for TBI may need to consider the evaluation of moral injury given its association with adverse events in this population.

Ethical Decision Making in Disaster and Emergency Management: A Systematic Review of the Literature.

Ethical decision making in disaster and emergency management requires more than good intentions; it also asks for careful consideration and an explicit, systematic approach. The decisions made by leaders and the effects they have in a disaster must carry the confidence of the community to which they serve. Such decisions are critical in settings where resources are scarce; when decisions are perceived as unjust, the consequences may erode public trust, result in moral injury to staff, and cause community division. To understand how decisions in these settings are informed by ethics, a systematic literature review was conducted to determine what ethical guidance informs decision making in disaster and emergency management. This study found evidence of ethical guidance to inform decision making in disaster management in the humanitarian system, based on humanitarian principles. Evidence of the application of an ethical framework to guide or reference decision making was varied or absent in other emergency management agencies or systems. Development and validation of ethical frameworks to support decision making in disaster management practice is recommended.

How Military Chaplains Strengthen the Moral Resilience of Soldiers and Veterans: Results From a Case Studies Project in the Netherlands

AbstractIn spiritual care research, studies on military chaplaincy are underrepresented, and most available studies center on moral injury. This article contributes to the existing literature on spiritual care in the military by presenting a study of 13 case descriptions of spiritual care provision by military chaplains from the Netherlands. These were analyzed using the framework method, a qualitative method of systematically searching for patterns in data sets, in order to answer the question: How do military chaplains contribute to the moral resilience of soldiers and veterans experiencing moral stress? The analytical framework was constructed on the basis of Doehring’s (Pastoral Psychology, 64(5), 635–649, 2015) conceptual understanding of moral resilience as the outcome of processes of spiritual integration of moral stress in caregiving relationships. This study shows that soldiers experience moral stress when core values associated with ‘being a soldier’ conflict with expectations or actions of soldiers themselves or of others, with the way the military organization functions, or with the spiritual notion of ‘being a good, loving and loveworthy human being’. In their responses to moral stress, chaplains contribute to moral resilience by engaging in co-creating spiritual orienting frameworks which accommodate a sense of goodness of self and others and allow for nuanced, biographically rooted moral views. Soldiers experience conversations and brief encounters with chaplains as relational ‘moments of goodness’, which may also contribute to moral resilience.