Moral Injury Events Research Articles

Exploring the experience of cardiothoracic ICU clinicians during the COVID-19 pandemic: A grounded theory study.

Prior to the COVID-19 pandemic a flexible approach to visiting was adopted by many Intensive Care Units in the United Kingdom. Due to the rapid spread globally of COVID-19, significant policy changes were put in place, including the restriction on visitors to patients in hospital. Evidence has emerged demonstrating the negative impact of these restrictions on patients with COVID-19, their families and the staff caring for them. However, there is limited data about the impact of these restrictions in the non-COVID ICU environment. This study aimed to explore the experiences of staff caring for non-COVID-19 patients in a cardiothoracic critical care unit during the COVID-19 pandemic. This qualitative research study adopted a grounded theory methodological approach. This methodology was used due to the unique situation, with no prior research available. We recruited healthcare staff that worked in a cardiothoracic critical care unit during the COVID-19 pandemic. Semi structured interviews were carried out, transcribed, and analysed. Using the data collected, a theory was constructed. Interviews were carried out with 20 healthcare staff from a range of professions including nurses, doctors, and allied health professionals. Following data analysis four main categories emerged from the data: impact and implementation of visiting restrictions; the dehumanisation of patients; end-of-life care and witnessing distress. From these four categories, a theory has emerged suggesting that healthcare staff in a non-covid ICU were regularly exposed to potentially moral injurious events, despite being shielded from caring for patients with COVID-19. This study provides a theory that healthcare staff caring for non-COVID-19 critical care patients during the period of visiting restrictions were exposed to potentially morally injurious events. Repeated exposure to potentially morally injurious events can lead to the development of moral injury and its adverse consequences. This study highlights the need to support all staff in the post COVID era, including those who worked in a non-COVID environment.

Morally injurious events and posttraumatic embitterment disorder in U.K. health and social care professionals during COVID-19: A longitudinal web survey.

To longitudinally estimate the prevalence and predictors of potentially morally injurious events (PMIEs) and posttraumatic embitterment disorder (PTED) and in U.K. health and social care workers (HSCWs) during the COVID-19 pandemic. Additionally, to investigate the mechanism by which PMIEs increase embitterment by lowering personal belief in procedural justice, that is, the belief that they experience fair processes. An online longitudinal survey was hosted on Qualtrics between September-October 2020 and September-November 2021. Using Prolific, 400 HSCWs aged 18 or above and working in the United Kingdom during the pandemic were recruited. PMIEs were assessed using the Moral Injury Events Scale, and PTED was assessed using the PTED self-rating scale. Potential predictors were measured using surveys of exposure to occupational stressors, optimism, pessimism, self-esteem, resilient coping style, consideration of future consequences, and personal just world beliefs. Seventy-one percent of participants experienced at least one COVID-related PMIE and 20% displayed clinically relevant signs of PTED at Time 2 in 2021. Exposure to occupational stressors increased the risk of experiencing PMIEs and PTED, whereas personal belief in a procedurally just world protected against transgressions by others and betrayal PMIEs. Self-esteem was protective, and a resilient coping style was a risk for experiencing betrayal. PMIEs increased embitterment by lowering personal belief in procedural justice over a 12-month period. PMIEs and PTED are being experienced by U.K. HSCWs in 2020 and 2021, particularly in those exposed to work-related stressors. Exposure to PMIEs increases the risk of embitterment by lowering belief in procedural justice. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Investigating the relationship between compassion fatigue and moral injury in nurses.

Background: Compassion fatigue and professional quality of life are important in health and professional ethics. Aim: This study aimed to determine the relationship between compassion satisfaction, compassion fatigue, secondary traumatic stress, and moral injury in nurses. Research design: This research is a cross-sectional descriptive-analytical study. The research community of this research was all the nurses of the teaching hospitals of Ardabil city. Three questionnaires on demographic characteristics, the Professional Quality of Life Scale (ProQOL), and the Moral Injury Events Scale were used to collect data. SPSS (version 22) software was used for data analysis. Participants and research context: The study recruited 297 nurses randomly selected from five teaching hospitals in Ardabil city. Ethical considerations: Ethical approval was obtained from the Ardabil University of Medical Sciences ethics committee (with the code of ethics IR.ARUMS.REC.1401.198). Informed consent was obtained from the participants. Results: The results showed that the mean compassion satisfaction score of this study's participants was 37.61 ± 8.86, the mean compassion fatigue score of this study's participants was 28.73 ± 7.04, and the mean secondary traumatic stress score of this study's participants was 29.95 ± 7.84. The mean score of moral injury among nurses was 31.19 ± 8.54. The results showed a negative significant relationship between compassion satisfaction and moral injury (p < 0.001). Also, there is a positive significant relationship between compassion fatigue and secondary traumatic stress with moral injury (p < 0.001). Conclusion: The results of this study show a negative relationship between compassion satisfaction and moral injury. According to the results of the present study, nurse managers should implement educational interventions, create ethical processes, and clear ethical guidelines to reduce moral injury and increase compassion satisfaction.

The differential and accumulative impacts of self and other sources of moral injury on well-being in mental healthcare staff

PurposeResearch has established the prevalence and relevance of moral injury in healthcare workers, though less attention has been paid to the different classes of potentially morally injurious events (PMIEs) experienced by this population and their impact. This exploratory study sought to examine the frequency of self- and other-generated PMIE classes and their associations with demographic characteristics and well-being outcomes among mental healthcare staff.Design/methodology/approachSecondary analysis of data drawn from two cross-sectional surveys of 267 frontline and leadership staff from mental healthcare settings in the UK was conducted. Responses on the Moral Injury Events Scale and the Short Professional Quality of Life Scale were extracted for analysis.FindingsBetrayal by others was most frequently endorsed (61.8%), whilst self-transgressions were least frequently reported (25.5%). After controlling for the number of PMIE classes experienced, betrayal significantly predicted secondary traumatic stress (p = 0.01) and burnout (p = 0.04). Additionally, other transgressions significantly predicted secondary traumatic stress (p = 0.008). The predictive effects of self-transgressions on burnout, secondary traumatic stress and compassion satisfaction were all nonsignificant after controlling for the number of PMIE classes experienced.Practical implicationsFindings highlight differences in the frequency and impact of self and other PMIEs experienced by healthcare professionals. Reducing cumulative exposure to differential PMIE classes appears to be of critical importance to improving occupational well-being in this group.Originality/valueTo our knowledge, this study is the first to explore the associations between PMIE classes and occupational well-being in a mental healthcare population, inclusive of frontline and leadership staff.

The Internal Consistency of the Moral Injury Event Scale

Abstract: The Moral Injury Event Scale (MIES) is a tool for measuring exposure to potentially morally injurious event(s) and distress. Although it reported acceptable psychometric properties in its initial development studies, it has since been used in multiple contexts and populations without assessment of its changing properties. A reliability generalization of the MIES and its Sub-Scales was therefore undertaken. A systematic search of electronic databases (PsychINFO; PTSD Pubs; MEDLINE; Scopus; Web of Science) identified 42 studies reporting internal consistencies (Cronbach’s α) up to April 2022. Unfortunately, few studies reported any other form of reliability or validity metric (e.g., test-retest, inter-rater reliability). A random effects model with a Bayesian analytic framework and the DerSimonian-Laird (1986) estimate was used. The review found the MIES to be an internally consistent tool based on α estimates at both Full-scale (α = .88; 95% CI [.87–.89]) and Sub-scales (α = .82–.92; 95% CI [.79–.93]). The review uncovered high heterogeneity and inconsistencies in its administration and modification although figures generally remained above acceptable levels (α ≥ .70). Based on the review, the MIES represents an internally reliably tool for measuring potentially morally injurious events and distress at both Full and Sub-Scales according to pooled Cronbach’s α estimates.

Dispositional mindfulness moderates the links between potentially morally injurious event exposure and symptoms of anxiety and depression but not suicidal ideation.

Exposure to potentially morally injurious events (PMIEs) is a pervasive threat for military service members and may be associated with symptoms of anxiety, depression, and suicidal ideation. However, coping mechanisms, such as mindfulness, may ameliorate symptoms and improve recovery. Two studies were conducted to test dispositional mindfulness as a moderator of the links between PMIEs, as assessed using the Moral Injury Events Scale (i.e., total score and Self-Transgression, Other-Transgression, and Betrayal subscale scores), and symptoms of anxiety, depression, and suicidal ideation among different samples of active-duty soldiers in garrison. In Sample 1 (N = 310), mindfulness buffered the links between PMIE exposure and symptoms of both anxiety, ∆R2 =.02, and depression, ∆R2 =.03. In Sample 2 (N = 669), mindfulness moderated the link between the MIES Betrayal subscale and anxiety symptoms, ∆R2 =.01. The results suggest that dispositional mindfulness may be a protective factor against some of the negative impacts of PMIE exposure. Further implications are discussed.

Measuring civilian moral injury: Adaptation and validation of the Moral Injury Events Scale (Civilian) and Expressions of Moral Injury Scale (Civilian).

Moral injury (MI) research has been expanded to populations beyond the military in recent years. A key barrier to further research into MI in civilian populations is the lack of valid, reliable measures of the construct appropriate for general civilian use. This article addresses this barrier by adapting two existing military measures and exploring their psychometrics in a general civilian sample: the Moral Injury Events Scale-Civilian (MIES-C) and Expressions of Moral Injury Scale-Military (EMIS-C). A sample of civilian women (n = 192) and men (n = 88) completed the above measures, and additional scales designed to capture theoretically supported primary and secondary markers of MI (guilt, shame, anger; depression, posttraumatic stress symptoms, anxiety). Confirmatory factor analyses found that the factor structure of the MIES-C and EMIS-C replicated well within our civilian sample. Discriminant validity was indicated through a significant negative correlation with well-being. Both measures correlated as predicted with each other and measures of MI markers at the total score level. Correlations of individual subscales with each of these measures were more varied. Results shed light on differential relationships between the type of MI event and clinical outcomes, suggesting some conceptual differences in how MI is experienced in general civilian populations. Results suggest that civilian populations are also susceptible to MI, but that existing measures may have problems capturing this effectively. While the MIES-C and EMIS-C are supported for civilian use, further scale construction efforts for this population are warranted. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Moral Suffering in Frontline Social Care Workers: A Study of Moral Injury and Moral Distress

Introduction: Moral suffering (MS) is psycho-emotional harm derived from a conflict between one’s circumstances and one’s deeply held moral values. It includes the constructs of moral distress (MD) and moral injury (MI) and is characterized by constraints or mandates preventing the perceived morally correct event. Evidence has demonstrated the application of MS in helping professions, and research has linked MS to a deterioration of mental health, self-identity, worldview, and job-performance. Aims: In this study, we examined the relationship between MD, MI, burnout, and external/internal constraints in Frontline Social Care Workers (FSCWs) in the UK. Methods: We employed a quantitative, cross-sectional correlational design, recruiting 119 FSCWs (female = 91.6%, tenure 1–2 years = 27.4%) using convenience sampling. Participants completed an online survey including the Moral Injury Events Scale and the Copenhagen Burnout Inventory. Measures for MD, external constraints (stress, time, and resources), and internal constraints (psychological safety and preparedness) were informed by previous research. Results: Participants reported a significant prevalence of moderate-to-high MD (25.4%), MI (33.3%), and burnout (64.9%), and we found significant relationships between the constructs and dimensions. Constraints were significant predictors of MS (explaining 35.3% of MD variance and 30.1% of MI variance), with stress, time, and psychological safety making the strongest contributions. Conclusions: FSCWs can be examined as a unitary population experiencing morally challenging circumstances that may result in MS and burnout. Improved MS measures, increased awareness, and policy shifts are necessary to redefine the paradigm of work-related distress, taking systemic constraints and the potential for moral harm into account.

Moral injury and its mental health consequences among protesters: findings from Israel’s civil protest against the government's judicial reform

ABSTRACT Background: Government actions and participating in protracted-duration protests against it affect protesters' mental health, leading to high distress levels, such as posttraumatic and depressive symptoms. Aside from exposure to violence and other issues, protest participation can pose unique challenges to the protesters as they may be exposed to potentially morally injurious events (PMIEs), such as the betrayal of leaders they once trusted. This study's primary objective was to examine the extent of psychological difficulties among civilians participating in long-duration protests in Israel. More specifically, the study aimed to understand the contribution of exposure to protest-related PMIEs to psychological difficulties such as posttraumatic and depressive symptoms. Method: Participants comprised 4036 Israelis who were actively involved in the unfolding civil protest movement against the government-led judicial overhaul between January 2023 and August 2023. The protesters completed validated self-report questionnaires that included measures of PMIE exposure, PTSD and depressive symptoms. Results: About half (44.3%) of the sample met the criteria for self-report diagnosis of major depression and 10.6% for PTSD. Most of the protesters indicated their exposure to at least one moral injury event, with 63.9% reporting exposure to PMIE-Betrayal. Protesters exposed to PMIEs reported significantly higher levels of both PTSD and depression than non-PMIE-exposed protesters. Hierarchical regression analyses revealed that, beyond demographics and protest-related characteristics such as exposure to violence, PMIE dimensions significantly contributed to both PTSD and depression levels. Conclusions: The findings highlight the mental burden of protesters during the civil protests against the judicial overhaul in Israel. More central to the present research, the findings highlight the critical contribution of PMIEs exposure to this burden. Clinicians treating protesters coping with depression and PTSD following the civil actions should attend to their exposure to PMIEs, which may relate to the deleterious psychological effects among protesters.

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.

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.

Burnout following moral injury and dehumanization: A study of distress among Italian medical staff during the first COVID-19 pandemic period.

Italy was the first country outside Asia to deal with the early phase of the COVID-19 pandemic, and health care facilities and medical staff were not fully prepared. Research worldwide has documented the enormous effect of the COVID-19 pandemic on health care providers' mental health, including experiences of dehumanization, but less work has focused on factors which may influence the development of these outcomes in response to COVID-19-related stress. This study examined the association of dehumanization, self-efficacy, and alienation to burnout, depression, and PTSD among medical staff. Potential moderators included moral injury, professional role, COVID workload, and work in a critical care unit (CCU). Participants were recruited through the Internet. The sample consisted of 270 medical staff members who completed a self-report survey online. Instruments included: Human Traits Attribution Scale for dehumanization; NYP-Queens Survey-Self-Efficacy Subscale for self-efficacy; Moral Injury Events Scale for moral injury; Alienation Scale for alienation; PTSD-8 for posttraumatic stress disorder; Patient Health Questionnaire-9 for depression; and a single item for burnout. The analytic plan included ANOVAs, zero-order correlations, logistic regression analyses, multiple linear regression models, and parallel mediation. Results show that dehumanization was associated with higher levels of burnout, PTSD, and depressive symptoms and effects were consistent across professional role and work context. Dehumanization was significantly associated with PTSD symptoms only among those who had increased COVID-19-related caseloads. Moral injury was positively associated with dehumanization, displayed an independent association with all 3 mental health outcomes, over and above dehumanization, and tended to exacerbate the effects of dehumanization. The effect sizes across analyses were small to medium. This research confirms that the COVID-19 pandemic stressed Italian medical staff in a way not documented in the prepandemic literature. There is a need to support staff in their complex relationships and communication with patients. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Moral injury in psychiatric patients with personality and other clinical disorders: development, psychometric properties, and validity of the Moral Injury Events Scale–Civilian Version

ABSTRACT Background: Moral injury emerges when someone perpetrates, fails to prevent, or witnesses acts that violate their own moral or ethical code. Nash et al. [(2013). Psychometric evaluation of the moral injury events scale. Military Medicine, 178(6), 646–652] developed a short measure, the Moral Injury Events Scale (MIES) to facilitate the empirical study of moral injury in the military. Our study aimed to develop a civilian version of the measure (MIES–CV) and examine its psychometric properties in a sample of psychiatric inpatients . Methods: In this cross-sectional study, the sample comprised 240 adult patients (71.7% female) with a mean age of 31.57 (SD = 11.69). The most common diagnoses in the sample were anxiety disorders (58.3%), depressive disorders (53.8%), and borderline personality disorder (39.6%). Participants were diagnosed using structured clinical interviews and filled out psychological questionnaires. Results: Exploratory factor analysis suggested that Nash et al.’s model (Perceived Transgressions, Perceived Betrayals) represents the data well. This two-factor solution showed an excellent fit in the confirmatory factor analysis, as well. Meaningful associations were observed between moral injury and psychopathology dimensions, shame, reflective functioning, well-being, and resilience. The Perceived Betrayals factor was a significant predictor of bipolar disorders, PTSD, paranoid personality disorder, borderline personality disorder, and avoidant personality disorder. Conclusions: Our study demonstrated that this broad version of the MIES is a valid measure of moral injury that can be applied to psychiatric patients.

Using Behavioral Economics to Predict Sensitivity to Moral Injury in Military Recruits: Validation of the Moral Injury Purchase Task

Objective: The purpose of this study was to validate the Moral Injury Purchase Task, a novel behavioral economic tool, and to understand military recruits’ sensitivity to morally injurious events. Methods: Participants (N = 26) read a scenario that could prompt hypothetical feelings of moral injury and then reported the number of years they would purchase services – at varying price points – to help forget their experiences in war. Participants also completed the Moral Injury Events Scale (MIES). We calculated various demand indices and developed demand curves for military recruits and service/members veterans using Koffarnus et al’s equation. Results: Results showed that the demand curves for the 2 populations were not significantly different (F1, 438 = 5.30, p = .07) and the coefficient of determination was satisfactory when modeled on the entire sample (R2 = .90). MIES scores were positively associated with participants’ Pmax values (p = .03), providing preliminary evidence of convergent validity. Conclusions: This study provides initial evidence of the utility of using behavioral economics to assist in identifying recruits’ susceptibility to moral injury and thereby better target preventive services.

Measuring Moral Injury: Further Validation of the MIES-C and EMIS-C in a Civilian Population

Moral injury among civilians has garnered increased recognition in recent years. However, most moral injury measures have focused on military experiences, with language being military specific. This study aimed to further validate two self-report measures of civilian moral injury, the Moral Injury Events Scale - Civilian (MIES-C) and Expressions of Moral Injury Scale - Civilian (EMIS-C). Participants were 312 adults (99 males, 212 females, Mage = 37.24) who completed the MIES-C, EMIS-C, and a battery of associated measures on two occasions. For the MIES-C, four Confirmatory Factor Analysis (CFA) models were examined. A three-factor model, with covaried items, provided the best fit to the data. For the EMIS-C, three CFAs were examined. A two-factor model, with covaried items, and the bi-factor model provided the best fit to the data, with the two-factor model being preferred for reasons of parsimony and its absence of weak and negative item loadings. Both measures demonstrated acceptable test-retest reliability and convergent validity with associated measures of psychological distress. This study provides psychometrically sound tools for clinicians and researchers of civilian moral injury.

Exposure to potentially morally injurious events in U.K. health and social care workers during COVID-19: Associations with PTSD and complex PTSD.

Health and social care workers (HSCWs) have been shown to be at risk of exposure to potentially morally injurious events (PMIEs) and mental health problems during the COVID-19 pandemic. This study aimed to examine associations between exposure to PMIEs and meeting threshold criteria for probable posttraumatic stress disorder (PTSD) and probable complex PTSD (CPTSD) in U.K. HSCWs immediately after the peak of the first COVID-19 wave. Frontline HSCWs from across the United Kingdom working in diverse roles in hospitals, nursing or care homes, and other community settings were recruited to the Frontline-COVID study via social media. Participants (n = 1,056) completed a cross-sectional online survey (May 27, 2020-July 23, 2020) which assessed exposure to PMIEs (nine-item Moral Injury Events Scale), and meeting symptom thresholds for probable PTSD and probable CPTSD (International Trauma Questionnaire). PMIEs related to witnessing others' wrongful actions and betrayal events were more commonly endorsed than perceived self-transgressions. The rate of probable International Classification of Diseases, 11th Revision (ICD-11) PTSD was 8.3%, and of probable ICD-11 CPTSD was 14.2%. Betrayal-related PMIEs were a significant predictor of probable PTSD or probable CPTSD, together with having been redeployed during the pandemic. The only variable that differentially predicted probable CPTSD as compared with probable PTSD was not having had reliable access to personal protective equipment; none of the PMIE types were differential predictors for screening positive for probable PTSD versus probable CPTSD. Exposure to PIMEs could be important for PTSD and CPTSD development. Interventions for moral injury in HSCWs should be investigated. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Evaluating Moral Injury in Combat-Deployed and Non-Combat Military Personnel

The factorial structure, measurement invariance, and relevance to posttraumatic stress of the Moral Injury Event Scale (MIES) was evaluated in military personnel as a function of combat role. A total of 245 combat-deployed and 140 non-combat military personnel 19 to 83 years of age (M = 43.97, SD= 12.08) answered questions about their service role(s), deployment history, and military-related PTSD diagnosis history. They also completed the PTSD Checklist-Military Version 5, the Exposure to Danger and Combat scale, the Witnessing Consequences of War scale, and the MIES. Confirmatory factor analysis supported a three-factor model of the MIES consisting of transgressions-self, transgressions-others, and betrayal. This structure demonstrated configural but not metric or scalar invariance between combat and non-combat personnel. Clinical relevance of the measure was supported by regressions showing that the MIES subscales were associated with PTSD symptomatology and PTSD diagnosis independently of measures of combat-related physical dangers or witnessing the consequences of war. We conclude that the MIES can be used to measure three components of moral injury that are relevant to mental health outcomes in military personnel. However, failure of measurement invariance cautions against comparing MIES subscale scores between combat and non-combat personnel.

Supplemental Material for Measuring Civilian Moral Injury: Adaptation and Validation of the Moral Injury Events Scale (Civilian) and Expressions of Moral Injury Scale (Civilian)

Supplemental Material for Measuring Civilian Moral Injury: Adaptation and Validation of the Moral Injury Events Scale (Civilian) and Expressions of Moral Injury Scale (Civilian)

Emergence of probable PTSD among U.S. veterans over the military-to-civilian transition.

Despite theorizing that posttraumatic stress disorder (PTSD) symptomatology may be exacerbated during the military-to-civilian transition, little research has delved into the trajectory of trauma-related symptomatology or the impact of diverse factors on timing of PTSD onset. To understand risk and protective factors for PTSD during the transition into civilian life, this study examined demographic, experiential, and psychosocial characteristics that may explain variation in PTSD symptoms and timing of onset. A nationwide sample representing 48,965 U.S. veterans separating from military service in fall 2016 responded to six Web-based surveys over 3 years. Assessments included PTSD symptoms, stress, warfare exposures, military sexual trauma, moral injury events, resilience, and social support. Multivariable models estimated covariates of positive PTSD screen or symptoms. Trauma exposure during military service was high at 59%. Probable PTSD was detected in 26% of the sample at baseline, with additional cases in each survey wave for an overall rate of 30%. Meeting criteria for probable PTSD covaried with current stress, female gender, and minority race/ethnicity; baseline psychological resilience and concurrent social support mitigated the risk. PTSD symptoms correlated positively with stress levels at current and previous time points. Social support was protective but only when contemporaneous with the PTSD symptoms. This study illustrates the need for ongoing social support for veterans coping with symptoms of PTSD, life stressors, and postmilitary trauma, suggesting a countervailing influence of psychological resilience and contemporaneous (but not historical) social support on symptom exacerbation. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Moral injury associated with increased odds of past-year mental health disorders: a Canadian Armed Forces examination

ABSTRACT Background: Potentially morally injurious experiences (PMIEs) are common during military service. However, it is unclear to what extent PMIEs are related to well-established adverse mental health outcomes. Objective: The objective of this study was to use a population-based survey to determine the associations between moral injury endorsement and the presence of past-year mental health disorders in Canadian Armed Forces (CAF) personnel and Veterans. Methods: Data were obtained from the 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS). With a sample of 2,941 respondents, the weighted survey sample represented 18,120 active duty and 34,380 released CAF personnel. Multiple logistic regressions were used to assess the associations between sociodemographic characteristics (e.g. sex), military factors (e.g. rank), moral injury (using the Moral Injury Events Scale [MIES]) and the presence of specific mental health disorders (major depressive episode, generalized anxiety disorder, panic disorder, social anxiety disorder, PTSD, and suicidality). Results: While adjusting for selected sociodemographic and military factors, the odds of experiencing any past-year mental health disorder were 1.97 times greater (95% CI = 1.94–2.01) for each one-unit increase in total MIES score. Specifically, PTSD had 1.91 times greater odds (95% CI = 1.87–1.96) of being endorsed for every unit increase in MIES total score, while odds of past-year panic disorder or social anxiety were each 1.86 times greater (95% CI = 1.82–1.90) for every unit increase in total MIES score. All findings reported were statistically significant (p < .001). Conclusion: These findings emphasize that PMIEs are robustly associated with the presence of adverse mental health outcomes among Canadian military personnel. The results of this project further underscore the necessity of addressing moral injury alongside other mental health concerns within the CAF.