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Moral injury among physicians and other health professionals has attracted attention in the mainstream literature, this study aim to assess the psychometric properties of the 10-item Moral Injury Symptoms Scale-Health Professional (MISS-HP) among healthcare professionals in China. A total of 583 nurses and 2423 physicians were recruited from across mainland China. An online survey was conducted from March 27 to April 26, 2020 (during the middle of the COVID-19 pandemic) using the Chinese version of the MISS-HP. Reliability was assessed by internal consistency reliability and test-retest reliability. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were performed to determine scale structure. Cronbach's α of the scale for both samples was acceptable (0.71 for nurses and 0.70 for physicians), as was test-retest reliability (ICCs for the individual items ranged from 0.41 to 0.74, with 0.77 for the overall scale in physicians). EFA suggested three factors, and the CFA indicated good fit to the data. Convergent validity was demonstrated with the 4-item Expressions of Moral Injury Scale (r = 0.45 for physicians, r = 0.43 for nurses). Discriminant validity was demonstrated by correlations with burnout and well-being (r = 0.34-0.47), and concurrent validity was suggested by correlations with depression and anxiety symptoms (r = 0.37-0.45). Known groups validity was indicated by a higher score in those exposed to workplace violence (B = 4.16, 95%CI: 3.21-5.10, p < 0.001). The MISS-HP demonstrated acceptable reliability and validity in a large sample of physicians and nurses in mainland China, supporting its use as a screening measure for moral injury symptoms among increasingly stressed health professionals in this country during the COVID-19 pandemic.

In Sin Sick, Joshua Pederson draws on the latest research about identifying and treating the pain of perpetration to advance and deploy a literary theory of moral injury that addresses fictional representations of the mental anguish of those who have injured or killed others. Pederson's work foregrounds moral injury, a recent psychological concept distinct from trauma that is used to describe the psychic wounds suffered by those who breach their own deeply held ethical principles. Complementing writings on trauma theory that posit the textual manifestation of trauma as absence, Sin Sick argues that moral injury appears in literature in a variety of forms of excess. Pederson closely reads works by Dostoevsky ( Crime and Punishment ), Camus ( The Fall ), and veterans of the wars in Iraq and Afghanistan (Brian Turner's Here, Bullet; Kevin Powers' The Yellow Birds; Phil Klay's Redeployment; and Roy Scranton's War Porn ), contending that recognizing and understanding the suffering of perpetrators, without condoning their crimes, enriches the experience of reading—and of being human.

The impact of the COVID-19 pandemic on healthcare systems has been unprecedented, and the psychological effects on cancer patients and health care professionals are likely to be significant and long-lasting. The traditional methods of face-to-face health care interactions have been replaced by virtual consultations to reduce exposure to COVID-19 infection. This has put the healthcare professional under tremendous psychological pressure and led to considerable anxiety and distress among cancer patients. Treatment decisions have had to be adjusted to account for a healthcare system that has been temporarily consumed by the care of people with COVID-19, and this has put cancer patients at risk of inferior outcomes. This has had the potential to cause moral injury and psychological distress to health care professionals as well as patients, who have had to deal with a range of stressors due to the uncertainty, sense of loss of control, reduced accessibility to medications and social support, changes to personal circumstances (e.g. financial pressures) and fear of death due to COVID-19 infection. Long term consequences also include post-traumatic responses and complex grief reactions. Cancer services in particular should gear themselves to recognize and monitor these effects and allocate adequate resources to combat them in the months and years to come.

An infographic model of moral injury (MI) is introduced in this conceptual paper that distinguishes the development of a worldview discrepancy-induced genus of MI, called complex moral injury (C-MI), from a standard expression of moral injury (S-MI), clearly delineated as perpetration-focused and a violation of moral belief in the contemporary view. It builds upon a previous essay that examined the potential of paradoxical circumstance (e.g., clashes of value, competing moral expectations, and moral paradox) to inflict MI among military personnel during wartime (Fleming in J Relig Health 60(5):3012–3033, 2021). Accordingly, it heeds Litz et al.’s recommendation to expand the research of MI beyond the effects of perpetration and investigate the impact of morally injurious events that shake one’s core moral beliefs about the world and self (Litz et al. in Clin Psychol Rev 29(8):695–706, 2009). A review of definitional, scale, and qualitative studies shows evidence of a nuanced and complex form of MI that presents as moral disorientation and is a response to a disruption and subsequent failure of foundational moral beliefs to adequately appraise ethical problems and inform moral identity. Interrelations between MI, assumptive world, and meaning theories suggest the mechanism of C-MI and potential therapies. Case studies from a Veterans Administration hospital in the United States and a walk through the diagram will help illustrate the model. Clinical implications of a definition that includes morally injurious events that shatter fundamental moral assumptions are discussed. The role of chaplains in facilitating acceptance and meaning-making processes is recommended for C-MI recovery. Acknowledging the model’s need for empirical support, a plausible scale is discussed for future research.

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.

Background: Stressful events occur several times during work among healthcare professionals. Especially, during the COVID-19 pandemic, healthcare professionals have had to deal with a variety of ethical dilemmas causing high levels of moral injury. Aim: To translate and validate the Moral Injury Symptom Scale-Healthcare Professionals (MISS-HP) in Greek. Methods: We conducted our study with 345 nurses in Greece during August 2023. We employed the forward-backward method to translate the MISS-HP in Greek. We examined the construct validity of the MISS-HP by performing confirmatory factor analysis. We estimated concurrent validity of the HP by it with the Moral Distress Thermometer (MDT), the Quiet Quitting Scale (QQS), and single item burnout measure. Results: We found that the MISS-HP had exceptional reliability since all intraclass correlation coefficients in test-rest reliability analysis were higher than 0.990. Moreover, all correlations were statistically significant (p<0.001 in all cases). Additionally Cronbachs coefficient alpha for the MISSHP was 0.636. Our CFA confirmed the three-factors structure of the Greek version of the MISS-HP: guilt/shame factor, spiritual troubles factor, and condemnation factor. All model fit indices in CFA were were excellent. In particular, x2/df was 1.316, RMSEA was 0.030, GFI was 0.979, AGFI was 0.959, TEI was 0.975, IFI was 0.985, NFI was 0.939, and CFI was 0.984. We found that the concurrent validity of the Greek version of the MISS-HP was very good. In particular, we found statistically significant correlations between the MISS-HP and MDT (r=0.46, pO.001), QQS (r=0.41, pO.001), and the single item burnout measure (r=0.11, p<0.04). Conclusions: The \"Moral Injury Symptom Sc ale-Healthcare Professionals\" is a reliable and valid tool to measure moral injury among healthcare professionals.

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.

Moral injury syndrome (MIS) is a mental health (MH) problem that substantially affects resilience; the presence of MIS reduces responsiveness to psychotherapy and increases suicide risk. Evidence-based treatment for MIS is available; however, it often goes untreated. This project uses principles of the Consolidated Framework for Implementation Research (CFIR) to assess barriers and facilitators to the implementation of Building Spiritual Strength (BSS), a multi-disciplinary treatment for MIS. Interviews were conducted with chaplains and mental health providers who had completed BSS facilitator training at six sites in the VA. Data were analyzed using the Hamilton Rapid Turnaround method. Findings included multiple facilitators to the implementation of BSS, including its accessibility and appeal to VA chaplains; leadership by VA chaplains trained in the intervention; and effective collaboration between the chaplains and mental health providers. Barriers to the implementation of BSS included challenges in engaging mental health providers and incorporating them as group leaders, veterans' lack of familiarity with the group format of BSS, and the impact of the COVID-19 pandemic. Results highlight the need for increased trust and collaboration between VA chaplains and mental health providers in the implementation of BSS and treatment of MIS.

Almost five million Americans volunteered to serve in the U.S. armed forces between 2001 and 2021 and returned home as discharged veterans. Among them, 30,177 men and women have taken their own lives, an awful toll that is more than five times the number of Americans killed in combat in our twenty-first century wars. As part of the roundtable, “Moral Injury, Trauma, and War,” this essay argues that the reasons are many, but one major factor may be the moral pain that many experience in wartime and the vast emptiness they often encounter when their military service ends. Our society has an obligation to the post–9/11 veterans to understand their experiences and truly welcome them back. The rising toll of veteran suicides suggests there is little time to lose.

How can spiritual care help veterans struggling with military moral injury? An evidence-based, intercultural approach to spiritual care is proposed. Evidence-based care uses research on military moral injury and religious and spiritual struggles to understand when religious and spiritual practices, beliefs, and values are helping or harming veterans. Intercultural spiritual care recognizes the complex, distinctive ways veterans’ values, beliefs, coping, and spiritual practices are shaped by interacting cultural systems, especially military training and cultures. Pastoral theologian Larry Graham’s ( Sacred Spaces: The E-Journal of the American Association of Pastoral Counselors 5, 146–171, 2017 ) writing on moral injury and lamentation is used to develop two spiritual care strategies: sharing anguish and interrogating suffering. Spiritual care begins with lamenting the shared anguish of moral injury using intrinsically meaningful spiritual practices to help veterans compassionately accept the emotions arising from moral injury so intensely felt in their bodies. The second strategy is sharing the lament of interrogating suffering through exploring values, beliefs, and coping arising from moral injury. A literary case study of a young female veteran based on Cara Hoffman’s ( 2014 ) novel Be Safe, I Love You illustrates this evidence-based intercultural approach to spiritual care of military moral injury.