Moral Injury Symptoms Research Articles

Moral Injury: A Theme in Search of Definition

Moral injury refers to a complex psychological condition that is assumed to emerge following exposure to distressing events that challenge the moral values or ethical beliefs of individuals by direct commission, omission, observation, or betrayal by a trusted leader. Moral injury can be found across various occupational domains, such as military, healthcare, and law enforcement. Symptoms of moral injury can include guilt, a sense of moral disorientation, struggle with spiritual or existential issues, and more. This paper aims to summarize current debates on the definition, symptomatology, and assessment of moral injury. Furthermore, it discusses the conceptual and psychological overlap and differences between moral injury and Post-Traumatic Stress Disorder (PTSD) and addresses current therapeutic approaches for treating patients with moral injury.

Associations between Adverse Childhood Experiences (ACEs) and Complex-PTSD, moral injury and perceived social support: A latent class analysis

BackgroundAdverse Childhood Experiences (ACEs), including childhood abuse and neglect, are consistently linked to poorer mental health and psychosocial outcomes in adulthood. Complex-posttraumatic stress disorder (C-PTSD) and moral injury are two conditions which can cause significant distress and functional impairment in individuals affected by trauma. However, not much is known about the complex relationships between ACEs, C-PTSD and moral injury. Furthermore, while perceived social support is a commonly cited protective factor for C-PTSD, there is little understanding about how it relates to ACEs in traumatised populations. The aim of this study was to investigate ACEs in a trauma-affected sample of UK military veterans using latent class analysis. Secondly, the study tested for associations between latent classes of ACEs, severity of C-PTSD and moral injury, and levels of perceived social support. MethodData was collected from a UK military veterans mental health charity, from a clinical sample (N = 336) who were receiving treatment for mental health difficulties. Participants completed standardised measures of ACEs, C-PTSD, moral injury, and perceived social support. Data was analysed using a bias-adjusted 3-step approach latent class analysis. Wald statistics were used to test for associations between classes of ACEs and C-PTSD, moral injury and perceived social support. FindingsA two-class model was found to be the best fit for the data, which depicted two classes of ACEs within the sample. The classes showed a distinction between a group of participants who were more likely to endorse experiencing high levels of ACEs, and a separate group who endorsed relatively lower levels of ACEs. As such, the model was interpreted as depicting a low-ACEs (class 1) vs. high-ACEs (class 2) distinction. 56 % of participants fell into class 1 (low ACEs) with 44 % in class 2 (high ACEs). Participants in class 2 (high ACEs) were significantly more likely to score highly for symptoms of C-PTSD and moral injury, and to report lower levels of perceived social support. ConclusionThe present study is the first to report a two-class model of low vs high-ACEs in a clinical sample of UK military veterans. It also describes how membership of the high-ACEs class was significantly associated with higher scores for key mental health and psychosocial variables in C-PTSD, moral injury and perceived social support. The findings have important clinical implications in highlighting the possible role of ACEs in understanding the aetiology of psychopathology in military populations affected by trauma. It also adds to the growing literature which demonstrates how many military personnel experience significant levels of pre-existing trauma and adversity before entering service, and how this can contribute to the development of complex mental health outcomes in adulthood.

An exploratory examination of the symptoms of moral injury and posttraumatic growth in veterinary professionals following exposure to potentially morally injurious events

Through their occupational role, veterinary professionals are regularly exposed to potentially morally injurious events (PMIEs). These events can elicit negative (pathogenic) psychological outcomes of moral distress. However, PMIEs can also result in positive (salutogenic) outcomes of posttraumatic growth. Both outcomes are characterised by specific symptomology that is suggestive of a pathogenic or salutogenic trajectory. This study employed data from 194 veterinary professionals from Australia and New Zealand and sought to examine symptoms experienced by professionals following exposure to PMIEs. Respondents reported more symptoms of moral distress than posttraumatic growth following PMIE exposure. Negative symptoms included both affective and work-related factors including consideration of leaving the profession, while positive factors included increased confidence, personal growth, and staff cohesion. Potential factors contributing to the disparity in salutogenic and pathogenic outcomes are discussed. An integrated approach comprising both individual- and organisation-level factors is recommended to facilitate more salutogenic outcomes for veterinary professionals following PMIE exposure.

Psychometric evaluation of a Spanish translation of the moral injury symptom scale for healthcare professionals

BackgroundMoral injury is prevalent among health care professionals, especially nurses. It can have negative personal consequences for clinicians, and indirectly impact the quality of patient care. Although nurses around the world experienced moral injury during the pandemic, it will continue to be a professional challenge. Thus, this study aimed to determine the psychometric properties of a scale measuring moral injury translated into Spanish.MethodsA methodological study with a cross-sectional approach was conducted. After translating the Moral Injury Symptom Scale for Healthcare Professionals (MISS-HP) into Peruvian Spanish (MISS-HP-S) using International Test Commission methods, data were collected using online survey methods from a sample of 720 Peruvian nurses. Analytical methods included exploratory and confirmatory factor analysis, and invariance by age were examined. The corrected homogeneity index, ordinal alpha, and McDonald’s omega allowed the evaluation of internal reliability.ResultsFindings from this sample of nurses who were mostly female (92%), from coastal Peru (57%), and averaged 39 (± 11) years of age, provided support for the validity and reliability of the MISS-HP-S. Structural validity was endorsed by findings indicating consistent factorial structure and adequate invariance among different age groups. In this study, three factors were observed: guilt/shame, condemnation, and spiritual strength. Internal consistency values included an ordinal alpha of 0.795 and McDonald’s omega of 0.835.ConclusionThese findings differ from those reported from previous studies in other cultural contexts, suggesting the influence of cultural and sample-specific factors in the perception of moral injury among Peruvian nurses. Because this evidence supports the validity of the MISS-HP-S, it can be used in professional practice and in future research to identify and address situations that contribute to nurse moral injury.

A Palliative Care Curriculum May Promote Resident Self-Reflection and Address Moral Injury

IntroductionThere is a lack of formal palliative care education for surgical trainees, and the demanding nature of surgical training and exposure to challenging clinical scenarios can contribute to moral injury. We developed a palliative care curriculum to promote self-reflection, aiming to address moral injury in residents. MethodsFive 1-h palliative care sessions were delivered over the academic year to all post-graduate year (PGY) levels covering the following topics: personal awareness, delivering bad news, surgical palliation for cancer pathology, surgical palliation for noncancer pathology, and urgent palliative care. The curriculum focused on reflection and small group discussions. The Moral Injury Symptom Scale-Health Professional was administered to assess feelings of moral injury. Descriptive statistics, chi-squared analysis, and Mann–Whitney U-test were used to compare the demographics and survey responses. Results23 participants completed the preintervention survey, and 9 participants completed it postintervention. Over 50% of participants were PGY1 or PGY2 residents. Preintervention, 52% of participants reported feeling guilt over failing to save someone from being seriously injured or dying. 30% of participants reported that the feelings of guilt, shame, or distrust impaired their ability to function in relationships, at work, or other areas of life to at least a moderate degree. ConclusionsThe described palliative care curriculum accomplishes several goals as follows: it educates residents on palliative care topics, teaches communication tools, encourages self-reflection, and provides space for building peer relationships. The ease of implementation makes this curriculum applicable across various types of institutions, offering the potential to positively impact surgical training on a national scale.

The "Double Victim Phenomenon"-Results From a National Pilot Survey on Second Victims in German Family Caregivers (SeViD-VI Study).

Second-victim phenomena may lead to severe reactions like depression or posttraumatic disorder, as well as dysfunction and absenteeism. Medical error as a cause for second victims is not limited to professionals, as family caregivers care for millions of patients at home. It remains unclear whether these are first, second, or double victims in case of error. This explorative study investigated whether second victim effects and signs of moral injury are detectable in family caregivers and whether existing instruments are applicable in lay persons. In an open convenience sampling online survey, we recruited 66 German family caregivers. Propensity score matching was conducted to obtain a balanced sample of family caregivers and qualified nurses who took part in the previous study by adjusting for age and sex. The groups were compared regarding the German Version of the Second Victim Experience and Support Tool-Revised and the German version of the Moral Injury Symptom and Support Scale for Health Professionals. Sixty-six caregivers participated, of whom 31 completed the survey. Of all, 58% experienced a second victim-like effect, 35% experienced a prolonged effect, and 45% reported to still suffer from it. In a matched sample (22 family caregivers and 22 nurses), no significant differences were observed between the groups. Regarding the limitations of this pilot study, demanding for resampling in larger populations, we could show that second victim effects and moral injury are detectable in family caregivers by validated instruments and are not inferior to professionals' experiences. Concerning the demand for further studies, we confirmed the applicability of the testing instruments but with need for item reduction to lower response burden.

Cross-cultural adaptation and psychometric validation of <i>The Continuous Traumatic Stress Response Scale</i>: Ukrainian version

Adapting and validating diagnostic tools aimed to evaluate the post-traumatic effects of war in low-income countries is essential for assessing needs and planning support programs. This paper will describe the process of cross-cultural adaptation and psychometric validation of the Continuous Traumatic Stress Response (CTSR) Scale for war-affected Ukraine. The study includes Phase 1, Translation and cross-cultural adaptation of the Scale, and Phase 2, Psychometric validation of the Scale. Cross-cultural adaptation goes through four stages: forward translation, expert panel review and back translation (n=3), pretesting and cognitive interviewing mental health professionals (n=8), and final version. Psychometric validation includes exploratory (n=200) and confirmatory (n=219) factor analyses, internal consistency, construct validity and test-retest reliability. Findings from the current research indicate that the components identified through factor analyses differed from those in the original questionnaire. While all original items in the questionnaire were retained, they merged into two new factors: “Exhaustion and Rage” and “Fear and Betrayal”. The results show that the overall Cronbach’s Alpha is .858, indicating a high level of internal consistency. Significant correlations exist between the total CTSR Scale score, the subscale scores, PTSD (PCL-5), moral injury (MISS-C-SF), depression (PHQ-9), and anxiety (GAD-7) symptoms, indicating construct validity. The findings demonstrate the test-retest reliability of the CTSR Scale and have practical implications for how it could be implemented in trauma-informed care. Disclosure Statement The authors reported no potential conflicts of interest. * Corresponding author: Larysa Zasiekina, 0000-0001-8456-0774zasyekina.larisa@vnu.edu.ua

Development and validation of the Moral Injury Symptom Scale – Clinician Version – Short Form (MISS-CV-SF)

Background Moral injury occurs when one witnesses or perpetrates an act that transgresses strongly held moral beliefs and expectations. First documented among active military and veterans, moral injury is increasingly studied in healthcare personnel impacted by the coronavirus pandemic. Measurement of moral injury among this population, particularly nurses, is still in its infancy. Objective To develop the Moral Injury Symptom Scale – Clinician-Short Form and validate it among United States based acute care nurses. Methods The Moral Injury Symptom Scale – Military Version was modified for a healthcare audience. 174 acute care nurses responded to a survey package including the scale and related instruments. Reliability and validity, including convergent and discriminant validities, were assessed, and a cutoff score was calculated using the area under the receiver operating characteristic curve. Results Reliability (Cronbach α = .75) and validity were established and a cutoff score of 41, based on functional impairment caused by moral injury, demonstrated 86.4% sensitivity and 69.6% specificity. Nurses who screened positive for moral injury experienced higher depression, anxiety, work exhaustion, interpersonal disengagement, emotional exhaustion, and depersonalization. Conclusions The Moral Injury Symptom Scale – Clinician Version – Short Form is a valid and reliable instrument with strong psychometric properties that can assess moral injury in acute care nurses, a population at risk due to the challenges of providing care during the pandemic. Appropriate measurement and establishing prevalence should prompt support and intervention from healthcare organizations.

From active duty to activism: how moral injury and combat trauma drive political activism and societal reintegration among Israeli veterans.

This article deals with combat experiences and their consequences and could be potentially disturbing. Moral injury (MI) is a severe form of combat trauma that shatters soldiers' moral bearings as the result of killing in war. Among the myriad ways that moral injury affects veterans' reintegration into civilian life, its impact on political and societal reintegration remains largely unstudied but crucial for personal, community, and national health. 13 in-depth interviews examine combat soldiers' exposure to potentially morally injurious events (PMIEs) that include killing enemy combatants, harming civilians, and betrayal by commanders, the military system, and society. Interviewees also described their political activities (e.g., voting, fundraising, advocacy, protest) and social activism (e.g., volunteering, teaching, charitable work). Interviewees also completed the Moral Injury Symptom Scale. Two distinct narratives process PMIEs. In a humanitarian narrative, soldiers hold themselves or their in-group morally responsible for perpetrating, witnessing, or failing to prevent a morally transgressive act such as killing or injuring civilians or placing others at unnecessary risk. In contrast, a national security perspective blames an out-group for leaving soldiers with no choice but to act in ways that trigger moral distress. Associated with shame and guilt, the humanitarian perspective triggered amends-making and social activism after discharge. In contrast, a national security perspective associated with anger and frustration fostered protest and intense political activism. Despite its harmful health effects, moral trauma and injury can drive intense political and social activism, depending upon the narrative veterans adopt to interpret PMIEs. Aside from moral injury's personal, familial, and social effects, moral injury drives veterans' return to the political arena of civil society. As such, veterans play a central role in politics and dramatically affect post-war policy in democratic nations following conflict.

Moral injury among women military veterans and demand for cigarettes: A behavioral economic investigation using a hypothetical purchase task

ObjectivesUnlike the United States general population, veteran women – as opposed to veteran men – have greater smoking prevalence; yet, little is known regarding factors that influence smoking in veteran women. The purpose of this study was to begin examining the relationship between a psychological concept known as moral injury and demand for cigarettes among veteran women. MethodsVeteran women who smoke (n = 44) were recruited for this cross-sectional study from Amazon MTurk, Reddit, and a veteran-serving non-profit organization in June–July 2023. Consenting participants received $2 for completing the cigarette purchase task (CPT), Fagerstrom Test for Nicotine Dependence (FTND), and the military version of the Moral Injury Symptom Scale (MISS-M-SF). We examined five CPT demand indices and calculated a modified exponential demand model stratified by moral injury severity status (i.e., probable vs. unlikely). ResultsProbable morally injured women exhibited significantly higher relative reinforcing value (RRV) for smoking than unlikely morally injured women (F1, 920 = 9.16, p = 0.003). Average cigarette consumption at $0 (i.e., Q0) was 48.56% higher (M = 22.24 vs. M = 13.55) in probable compared to unlikely morally injured women (p = 0.04, Hedge's g = 0.74). FTND scores were significantly correlated with Pmax (i.e., demand elasticity point) and Omax (i.e., maximum expenditure) values in both populations (rs = 0.42–0.68, ps < 0.05). ConclusionsWe provide preliminary evidence of the relatively high RRV of smoking in morally injured veteran women. Continued research is needed to refine the characterization of this relationship.

Ready to bleed when touched – Moral Injury in the Special Operations Forces military population

Abstract The armed forces combine different military populations with specific patterns of psycho-medical challenges and needs. The Special Operations Forces (SOF) exhibit one such pattern because they undergo more rigorous selection procedures, train differently and generally engage in different types of missions than other military populations. The aim of this commentary is to briefly introduce the psycho-medical patterns of SOF while paying particular attention to the growing discussion of Moral Injury (MI) in this military population. The mental health construct of MI refers to the persistent psycho-social harm resulting from exposure to events that clash with an individual’s moral beliefs. So far, research has focused on causes and symptoms of MI, less on prevention strategies and early intervention opportunities. This article advocates making a regular screening for symptoms of MI an element of routine physical check-ups of SOF to identify MI-related problems earlier and destigmatise mental health struggles, thereby countering severe manifestations of MI and alleviating suicidality rates in the SOF military population.

Critical Care Nurses' Moral Resilience, Moral Injury, Institutional Betrayal, and Traumatic Stress After COVID-19.

Traumatic stress and moral injury may contribute to burnout, but their relationship to institutional betrayal and moral resilience is poorly understood, leaving risk and protective factors understudied. To examine traumatic stress symptoms, moral injury symptoms, moral resilience, and institutional betrayal experienced by critical care nurses and examine how moral injury and traumatic stress symptoms relate to moral resilience, institutional betrayal, and patient-related burnout. This cross-sectional study included 121 critical care nurses and used an online survey. Validated instruments were used to measure key variables. Descriptive statistics, regression analyses, and group t tests were used to examine relationships among variables. Of participating nurses, 71.5% reported significant moral injury symptoms and/or traumatic stress. Both moral injury symptoms and traumatic stress were associated with burnout. Regression models showed that institutional betrayal was associated with increased likelihood of traumatic stress and moral injury. Increases in scores on Response to Moral Adversity subscale of moral resilience were associated with a lower likelihood of traumatic stress and moral injury symptoms. Moral resilience, especially response to difficult circumstances, may be protective in critical care environments, but system factors (eg, institutional betrayal) must also be addressed systemically rather than relying on individual-level interventions to address nurses' needs.

Prevalence of occupational moral injury and post-traumatic embitterment disorder: a systematic review and meta-analysis

ObjectivesOccupational moral injury and post-traumatic embitterment disorder (PTED) describe the psychological distress caused by exposure to injustice at work. This meta-analysis aims to determine the prevalence of occupational moral injury...

The Moral Injury and Distress Scale: Psychometric evaluation and initial validation in three high-risk populations.

The concept of moral injury resonates with impacted populations, but research has been limited by existing measures, which have primarily focused on war veterans and asked about exposure to potentially morally injurious events (PMIEs) rather than PMIE exposure outcomes. Our goal was to develop and examine the psychometric properties of the Moral Injury and Distress Scale (MIDS), a new measure of the possible emotional, cognitive, behavioral, social, and/or spiritual sequelae of PMIE exposure. The MIDS was validated by surveying three groups: military veterans, healthcare workers, and first responders (N = 1,232). Most respondents (75.0%; n = 924) reported PMIE exposure. Analyses yielded 18 items that contributed to a single latent factor representing moral distress with fully or partially invariant configurations, loadings, and intercepts across occupational groups. The MIDS full-scale score demonstrated excellent internal consistency (α = .95) and moderate 2-week stability (r = .68, p < .001, n = 155). For convergent validity, associations between the MIDS and PMIE exposure measures, as well as putative indicators of moral injury (e.g., guilt, shame), were positive and large (r = .59-.69, p < .001), as were correlations with posttraumatic stress, depressive, and insomnia symptoms (r = .51-.67, p < .001). The MIDS was a stronger predictor of functioning than PMIE exposure measures, explaining seven times greater unique variance (9% vs. 1%-1.3%). The MIDS is the first scale to assess moral injury symptoms indexed to a specific PMIE that is validated across several high-risk populations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Moral injury and mental health among health-care workers during the COVID-19 pandemic: meta-analysis.

Background: During the COVID-19 pandemic, health-care workers (HCWs) may have been confronted with situations that may culminate in moral injury (MI). MI is the psychological distress that may result from perpetrating or witnessing actions that violate one's moral codes. Literature suggests that MI can be associated with mental health problems.Objective: We aimed to meta-analytically review the literature to investigate whether MI is associated with symptoms of posttraumatic stress disorder (PTSD), anxiety, depression, burnout, and suicidal ideation among active HCWs during the COVID-19 pandemic.Method: We searched eight databases for studies conducted after the onset of the COVID-19 pandemic up to 18 July 2023, and performed random-effects meta-analyses to examine the relationship between MI and various mental health outcomes.Results: We retrieved 33 studies from 13 countries, representing 31,849 individuals, and pooled 79 effect sizes. We found a positive association between MI and all investigated mental health problems (rs = .30-.41, all ps < .0001). Between-studies heterogeneity was significant. A higher percentage of nurses in the samples was associated with a stronger relationship between MI and depressive and anxiety symptoms. Samples with a higher percentage of HCWs providing direct care to patients with COVID-19 exhibited a smaller effect between MI and depressive and anxiety symptoms. We observed a stronger effect between MI and PTSD symptoms in US samples compared to non-US samples.Conclusion: We found that higher MI is moderately associated with symptoms of PTSD, anxiety, depression, burnout, and suicidal ideation among HCWs during the COVID-19 pandemic. Our findings carry limitations due to the array of MI scales employed, several of which were not specifically designed for HCWs, but underscore the need to mitigate the effect of potentially morally injurious events on the mental health of HCWs.

Moral Injury Among Transplant Providers: Evaluating the Effects of Training in End-of-Life Counseling.

Ethical issues are pervasive in healthcare, but few specialties rival the moral complexity of transplant medicine. Transplant providers must regularly inform patients that they are no longer eligible to receive a potentially life-saving operation and the stress of these conversations poses a high risk of moral injury. Training in end-of-life counseling (EOLC) has proven to significantly reduce provider stress and burnout. The purpose of this study was to determine whether training in EOLC reduces levels of moral injury among transplant providers. This was a mixed methods study. We interviewed 10 patient participants and administered a survey to staff in the solid organ transplant department at the University of Kansas Health System. Respondents indicated whether they had received training in EOLC and completed the standardized Moral Injury Symptom Scale-Healthcare Professionals version (MISS-HP). A two-sample, one-sided t-test compared levels of moral injury between trained and untrained staff. Subsequently, we conducted semi-structured interviews with transplant providers, then performed inductive coding followed by thematic network analysis. Thirty-seven percent (14/38) of respondents reported a moral injury score at or above the threshold for psychosocial dysfunction associated with moral injury. Analysis revealed no difference in moral injury scores between the trained and untrained groups (p = 0.362, power (1-β) = 0.842). Thematic network analysis demonstrated high-level themes of "challenges", "training", and "stress relief". Our study demonstrated a concerning prevalence of moral injury among transplant staff and suggested that EOLC training did not significantly mitigate the threat of moral injury.

Burnout, moral injury, and suicidal/self-harm ideation among healthcare professionals in Mainland China: Insights from an online survey during the COVID-19 pandemic.

This survey explored the relationships between burnout, moral injury, and suicidal/self-harm ideation among Chinese health professionals in mainland China. Health professionals were surveyed online using the Maslach Burnout Inventory-Human Services Survey for Medical Personnel, Patient Health Questionnaire-9, and the Moral Injury Symptom Scale-Health Professional version. A total of 6,146 health professionals participated in the study. The average age of participants was 34.9 ± 8.5years, and suicidal/self-harm ideation was present in 2,338 participants (38.0%). The prevalence of suicidal/self-harm ideation was more common among those with severe burnout (vs. mild burnout), particularly in the dimensions of emotional exhaustion, depersonalization, and decreased personal accomplishment. The prevalence of suicidal/self-harm ideation among those with significant moral injury symptoms was higher than in those without moral injury. Unconditional logistic regression analysis demonstrated that those with moderate or severe emotional exhaustion, moderate or severe reduced sense of professional accomplishment, and moderate or severe depersonalization were at increased risk of suicidal/self-harm ideation.Structural equation modelling demonstrated that burnout significantly mediated the relationship between moral injury and suicidal/self-harm ideation. The proportion of mediation (PM) by burnout was 43.0%. This study found that burnout and moral injury were significant predictors of suicidal/self-harm ideation among health professionals in China. Both moral injury and burnout had positive and direct effects on suicidal/self-harm ideation, and burnout mediated the relationship between moral injury and suicidal/self-harm ideation. Interventions to address moral injury and subsequent burnout in Chinese healthcare workers may enhance the mental health of these healthcare professionals and increase the quality of care that they provide.

Prevalence of Moral Injury, Burnout, Anxiety, and Depression in Healthcare Workers 2 Years in to the COVID-19 Pandemic.

COVID-19 has led to marked increases in healthcare worker distress. Studies of these phenomena are often limited to a particular element of distress or a specific subset of healthcare workers. We administered the Moral Injury Symptom Scale for Healthcare Professionals, Copenhagen Burnout Inventory, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7 via online survey to 17,000 employees of a large academic medical center between December 2021 and February 2022. A total of 1945 participants completed the survey. Across all roles, the prevalence of moral injury, burnout, depression, and anxiety were 40.9%, 35.3%-60.6%, 25.4%, and 24.8%, respectively. Furthermore, 8.1% had been bothered by thoughts that they would be better off dead or of hurting themselves for "several days" or more frequently. Healthcare workers across all roles and practice settings are experiencing unsustainable levels of distress, with 1 in 12 regularly experiencing thoughts of self-harm.

Is nurses' clinical competence associated with their moral identity and injury?

The enhancement of nursing care quality is closely related to the clinical competence of nurses, making it a crucial component within health systems. The present study investigated the relationship between nurses' clinical competence, moral identity, and moral injury during the COVID-19 outbreak. This cross-sectional study was carried out among frontline nurses, using the Moral Identity Questionnaire (MIQ), the Moral Injury Symptom Scale-Healthcare Professionals version (MISS-HP), and the Competency Inventory for Registered Nurse (CIRN) as data collection tools. and research context: The research population for this study consisted of all frontline nurses (n = 251) employed in a hospital in southern Iran. Sampling was conducted between May 1, 2021 and September 30, 2021, during the COVID-19 outbreak. The present study received approval from the research ethics committee of Rafsanjan University of Medical Sciences, with project No. 99267 and code of ethics ID No. IR. RUMS.REC.1399.262, dated 15.02.2021. According to the study findings, 42.2% of the nurses demonstrated high clinical competence, while 51.4% exhibited moderate clinical competence. The results indicated a positive correlation between moral identity and clinical competence but a negative correlation between moral injury and clinical competence. Furthermore, the variables of moral identity and moral injury were found to predict 10% of the variance in clinical competence. According to the results, moral identity and moral injury had an impact on the clinical competence of nurses. Therefore, implementing a program aimed at enhancing moral identity and providing training strategies to address moral injury during crises like the COVID-19 pandemic can lead to improvements in nurses' clinical competence and the overall quality of care they provide.

Moral Injury Among Interventional Radiologists

To evaluate moral injury (MI) among interventional radiologists using validated assessment tools. An anonymous 29-question online survey was distributed to interventional radiologists using the Society of Interventional Radiology Connect Open Forum website, Twitter, Facebook, LinkedIn, and electronic mail. The survey consisted of demographic and practice environment questions, a global quality of life (QoL) scale (scored 1-100), the MI Symptom Scale‑Healthcare Professional (MISS-HP) (scored 1-100), and two open-ended questions. A MISS-HP score ≥36 was indicative of experiencing MI. P<.05 was considered statistically significant for all two-sided tests. Beginning on March 30, 2023, 365 surveys were completed over 5days. Of the respondents, 299 (81.9%) were male, 65 (17.8%) were female, and one preferred not to disclose gender. The respondents included practicing interventional radiologists (299; 81.9%) and interventional radiologists-in-training (66; 18.1%). Practice settings included academic (146; 40.0%), community (121; 33.2%), hybrid (84; 23.0%), or other (14; 3.8%) centers. Mean QoL was 71.1±17.0 (range: 0-100) suggestive of "good" QoL. Mean QoL in the MI subgroup was significantly different from that for the rest of the group (67.6±17.0 vs. 76.6±16.0; P<0.05). 223 (61.1%) respondents scored ≥36 on the MISS-HP, and thus were categorized as having profession-related MI. Mean MISS-HP was 39.9±12.6 (range: 10-83). Mean MISS-HP in the MI subgroup was significantly different from that for the rest of the group (47.4±9.6 vs. 28.0±5.7; P<0.05). There was a negative correlation between MI and QoL (r=-0.4; P<0.001). Most common themes for greatest contribution to MI were ineffective leadership, barriers to patient care, corporatization of medicine, non-physician administration, performing futile procedures, turf battles, and reduced resources. Most common themes for ways to reduce MI were more autonomy, less bureaucracy, more administrative support, physician-directed leadership, adequate staffing, changes to the medical system, physician unionization, transparency with insurance companies, more time off, and leaving medicine/retirement. MI is prevalent among interventional radiologists, and it negatively correlates with QoL. Future work should investigate causative factors and mitigating solutions.