Properties of the modified self-forgiveness dual-process scale in populations at risk for moral injury.

Despite theory suggesting that self-forgiveness facilitates recovery from moral injury, no measure of self-forgiveness has been validated with individuals exposed to potentially morally injurious events (PMIEs). Military veterans, healthcare workers, and first responders who reported PMIE exposure (n = 924) completed the Self-Forgiveness Dual-Process Scale, which assesses two dimensions of the self-forgiveness process. The first dimension, value affirmation, refers to appraising personal responsibility and being willing to make amends for one's involvement in a PMIE. The second dimension, esteem restoration, refers to accepting oneself as valuable and capable of growth despite one's failures and imperfections. Exploratory and Confirmatory Factor Analyses replicated the original scale's two-factor structure in 10 items modified to apply to the diverse contexts in which PMIEs occur. Next, we found that the factor structure, item loadings, and item intercepts were fully or partially invariant across professions, genders, races, ages, and religious affiliations in a series of Multi-Group Confirmatory Factor Analyses. Finally, diverging patterns of associations between value affirmation and esteem restoration with moral distress, posttraumatic stress, depression, insomnia, functional impairment, and posttraumatic growth provide evidence of convergent and discriminant validity between the subscales. The modified self-forgiveness dual process scale is the first measure of self-forgiveness to be validated with individuals exposed to a PMIE. Researchers and clinicians can use the scale to examine how self-forgiveness (or difficulties with forgiving oneself) relates to moral injury.

Using the Moral Injury and Distress Scale to identify clinically meaningful moral injury.

Despite the proliferation of moral injury studies, a remaining gap is distinguishing moral injury from normative distress following exposure to potentially morally injurious events (PMIEs). Our goal was to leverage mental health and functional measures to identify clinically meaningful and functionally impairing moral injury using the Moral Injury and Distress Scale (MIDS). Participants who endorsed PMIE exposure (N = 645) were drawn from a population-based sample of military veterans, health care workers, and first responders. Using signal detection methods, we identified the optimally efficient MIDS score for detecting clinically significant posttraumatic stress and depressive symptom severity, trauma-related guilt, and functional impairment. The most efficient cut scores across outcomes converged between 24 and 27. We recommend a cut score of 27 given that roughly 70% of participants who screened positive on the MIDS at this threshold reported clinically significant mental health symptoms, and approximately 50% reported severe trauma-related guilt and/or functional impairment. Overall, 10.2% of respondents exposed to a PMIE screened positive for moral injury at this threshold, particularly those who identified as a member of a minoritized racial or ethnic group (17.9%) relative to those who identified as White, non-Hispanic (8.0%), aOR = 2.52, 95% CI [1.45, 4.42]. This is the first known study to establish a cut score indicative of clinically meaningful and impairing moral injury. Such scores may enhance clinicians' abilities to conduct measurement-based moral injury care by enabling them to identify individuals at risk of negative outcomes and better understand risk and protective factors for moral injury.

Implementing a Multi-Disciplinary, Evidence-Based Resilience Intervention for Moral Injury Syndrome: Systemic Barriers and Facilitators.

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.

The Impact of Adjustment on Workplace Attitudes and Behaviors Among Health Care Workers During the COVID-19 Pandemic.

OBJECTIVE: We examined the impact of health care workers' (HCWs) adjustment to the COVID-19 pandemic on their work-related attitudes and behaviors. METHODS: HCWs ( n = 1468) participated in an observational longitudinal study in which they completed surveys of anxiety and occupational health between 2020 and 2021. RESULTS: Most HCWs reported anxiety that was consistently below the diagnostic threshold (68%) or fell below the threshold within a year (16%). Others reported consistently high (14%) or increasing (2%) anxiety, especially women, younger HCWs, those with a weakened immune system, and allied health professionals. Consistently high or increasing anxiety was associated with poorer job satisfaction, work engagement, perceived supervisor support, burnout, and turnover intentions. CONCLUSIONS: Resources to support HCWs may be focused on those who report consistently high or increasing anxiety to minimize the effects of crises and disasters on the workforce.

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

OBJECTIVE: 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. METHOD: The MIDS was validated by surveying three groups: military veterans, healthcare workers, and first responders (N = 1,232). RESULTS: 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%). CONCLUSIONS: 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).

Associations of self-forgiveness processes with distress and well-being outcomes: Evidence from a longitudinal study of Indonesian adults.

To date, few empirical studies have examined the benefits of the processes involved in self-forgiveness-value reorientation and esteem restoration-for individual well-being using longitudinal data from non-Western samples. In this study, we take a step toward addressing this gap by analysing three waves of data collected among 595 Indonesians (Mage = 21.95, SD = 4.39). Applying the analytic templates for lagged exposure-wide and outcome-wide longitudinal designs, we performed a series of linear regressions to estimate associations of value reorientation and esteem restoration in Wave 2 with three indicators of distress and 10 indicators of well-being in Wave 3, adjusting for Wave 1 covariates. Value reorientation and esteem restoration were each associated with improvements in several well-being outcomes (six for value reorientation and three for esteem restoration), but both showed little evidence of associations with the distress outcomes. In a secondary analysis, those who scored higher on both value reorientation and esteem restoration (i.e., self-forgiveness group) in Wave 2 reported higher well-being on five outcomes in Wave 3 compared to those who scored lower on value reorientation, esteem restoration, or both (i.e., no or partial self-forgiveness group). We discuss some implications of the findings for conceptualising self-forgiveness and promoting well-being.

Moral injury and psychosocial functioning in health care workers during the COVID-19 pandemic.

Studies of moral injury among nonmilitary samples are scarce despite repeated calls to examine the prevalence and outcomes of moral injury among civilian frontline workers. The purpose of this study was to describe the prevalence of moral injury and to examine its association with psychosocial functioning among health care workers during the COVID-19 pandemic. We surveyed health care workers (N = 480), assessing exposure to potentially morally injurious events (PMIEs) and psychosocial functioning. Data were analyzed using latent class analysis (LCA) to explore patterns of PMIE exposure (i.e., classes) and corresponding psychosocial functioning. The minimal exposure class, who denied PMIE exposure, accounted for 22% of health care workers. The moral injury-other class included those who had witnessed PMIEs for which others were responsible and felt betrayed (26%). The moral injury-self class comprised those who felt they transgressed their own values in addition to witnessing others' transgressions and feeling betrayed (11%). The betrayal-only class included those who felt betrayed by government and community members but otherwise denied PMIE exposure (41%). Those assigned to the moral injury-self class were the most impaired on a psychosocial functioning composite, followed by those assigned to the moral injury-other and betrayal-only classes, and finally the minimal exposure class. Moral injury is prevalent and impairing for health care workers, which establishes a need for interventions with health care workers in organized care settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Moral injury and peri- and post-military suicide attempts among post-9/11 veterans.

BACKGROUND: Our goal was to examine the association between moral injury, mental health, and suicide attempts during military service and after separation by gender in post-9/11 veterans. METHODS: A nationally representative sample of 14057 veterans completed a cross-sectional survey. To examine associations of exposure to potentially morally injurious events (PMIEs; witnessing, perpetrating, and betrayal) and suicidal self-directed violence, we estimated two series of multivariable logistic regressions stratified by gender, with peri- and post-military suicide attempt as the dependent variables. RESULTS: PMIE exposure accounted for additional risk of suicide attempt during and after military service after controlling for demographic and military characteristics, current mental health status, and pre-military history of suicidal ideation and attempt. Men who endorsed PMIE exposure by perpetration were 50% more likely to attempt suicide during service and twice as likely to attempt suicide after separating from service. Men who endorsed betrayal were nearly twice as likely to attempt suicide during service; however, this association attenuated to non-significance after separation in the fully adjusted models. In contrast, women who endorsed betrayal were over 50% more likely to attempt suicide during service and after separation; PMIE exposure by perpetration did not significantly predict suicide attempts before or after service among women in the fully adjusted models. CONCLUSIONS: Our findings indicate that suicide assessment and prevention programs should consider the impact of moral injury and attend to gender differences in this risk factor in order to provide the most comprehensive care.

Exposure to potentially morally injurious events and mental health outcomes among frontline workers affected by the coronavirus pandemic.

OBJECTIVE: The current studies explored associations between exposure to potentially morally injurious events (PMIEs) and mental health outcomes among frontline workers affected by the coronavirus pandemic. METHOD: We administered online self-report surveys to emergency responders (N = 473) and hospital personnel (N = 854) in the Rocky Mountain region of the United States between April and June of 2020. Surveys assessed frequency and intensity of exposure to PMIEs alongside psychological and functional outcomes. RESULTS: Between 20% and 30% of frontline workers reported exposure to PMIEs of at least moderate frequency and intensity. Exposure to more intense PMIEs was associated with greater psychological symptoms (i.e., stress, depression, and anxiety) and functional impairment (i.e., professional burnout), especially among emergency responders who reported frequent exposure but also hospital workers who reported few exposures. CONCLUSION: Efforts to facilitate and maintain the well-being of the public health workforce should specifically address critical incidents encountered by frontline workers that have embedded moral and ethical challenges. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Research Gaps and Recommendations to Guide Research on Assessment, Prevention, and Treatment of Moral Injury Among Healthcare Workers.

Healthcare workers face numerous occupational stressors, including some that may challenge personal and shared morals and values. This is particularly true during disasters and crises such as the COVID-19 pandemic, which require critical decisions to be made with little time and information often under personal distress and situational constraints. Consequently, healthcare workers are at risk for moral injuries characterized by stress-related and functional impacts. Although research on the evaluation and treatment of moral injury among military veterans burgeoned in the recent decade, addressing moral injury in healthcare workers and other civilians remains an important gap. In this perspective piece, we identify research gaps and make recommendations to advance future work on assessment, prevention, and treatment of moral injury in healthcare workers. We draw on empirical studies of moral injury in veterans, limited studies of moral injury in health professionals, and our clinical experiences with healthcare workers affected by moral injury.

Social cognitive mechanisms in healthcare worker resilience across time during the pandemic.

PURPOSE: Healthcare workers are at increased risk for mental health problems during disasters such as the COVID-19 pandemic. Identifying resilience mechanisms can inform development of interventions for this population. The current study examined pathways that may support healthcare worker resilience, specifically testing enabling (social support enabled self-efficacy) and cultivation (self-efficacy cultivating support) models. METHODS: Healthcare workers (N = 828) in the Rocky Mountain West completed self-report measures at four time points (once per month from April to July of 2020). We estimated structural equation models to explore the potential mediating effects that received social support and coping self-efficacy had (at time 2 and time 3) between traumatic stress symptom severity (at time 1 and time 4). Models included covariates gender, age, minority status, and time lagged co-variations between the proposed mediators (social support and coping self-efficacy). RESULTS: The full model fit the data well, CFI = .993, SRMR = .027, RMSEA = .036 [90% CIs (0.013, 0.057)]. Tests of sequential mediation supported enabling model dynamics. Specifically, the effects of time 1 traumatic stress severity were mediated through received social support at time 2 and time 3 coping self-efficacy, in sequential order to reduce time 4 traumatic stress severity. CONCLUSIONS: Findings show the importance of received social support and coping self-efficacy in mitigating psychopathology risk. Interventions can support mental health by focusing on social resource engagement that facilitates coping empowerment, which may decrease risk for mental health job-related problems among frontline healthcare workers exposed to highly stressful events.

Trajectories of suicidal ideation following separation from military service: Overall trends and group differences.

BACKGROUND: Although the transition out of military service is a high-risk time for suicidal ideation (SI), a paucity of research examines the development of SI during this transition process and veteran subgroups at risk for SI as they readjust to civilian life. METHODS: A population-based, longitudinal post-9/11 veteran cohort reported SI frequency at 3, 9, 15, 21, and 27 months post-separation using the Patient Health Questionnaire-9. We identified distinct trajectories of SI over time (i.e., classes) using latent class growth analysis and examined demographic and military service predictors of class membership overall and by gender using multinomial logistic regression. RESULTS: Four SI trajectories that were similar across genders were identified: resilient (90.1%), delayed onset (5.0%), remitting (2.7%), and chronic (2.2%). Younger age, minority race/ethnicity, medical and other (vs. honorable) separation types, and Veterans Health Administration service utilization were associated with increased odds of assignment to a higher-risk trajectory (delayed onset, remitting, and/or chronic vs. resilient), whereas continued service in the National Guard/Reserves and officer rank was associated with lower odds of assignment to a higher-risk trajectory. CONCLUSIONS: Findings regarding veterans at greatest risk for SI following military separation can inform targeted assessment and early intervention efforts.

Trajectories of functioning in a population-based sample of veterans: contributions of moral injury, PTSD, and depression.

BACKGROUND: Although research has shown that exposure to potentially traumatic and morally injurious events is associated with psychological symptoms among veterans, knowledge regarding functioning impacts remains limited. METHODS: A population-based sample of post-9/11 veterans completed measures of intimate relationship, health, and work functioning at approximately 9, 15, 21, and 27 months after leaving service. Moral injury, posttraumatic stress, and depression were assessed at ~9 months post-separation. We used Latent Growth Mixture Models to identify discrete classes characterized by unique trajectories of change in functioning over time and to examine predictors of class membership. RESULTS: Veterans were assigned to one of four functioning trajectories: high and stable, high and decreasing, moderate and increasing, and moderate and stable. Whereas posttraumatic stress, depression, and moral injury associated with perpetration and betrayal predicted worse outcomes at baseline across multiple functioning domains, moral injury associated with perpetration and depression most reliably predicted assignment to trajectories characterized by relatively poor or declining functioning. CONCLUSIONS: Moral injury contributes to functional problems beyond what is explained by posttraumatic stress and depression, and moral injury due to perpetration and depression most reliably predicted assignment to trajectories characterized by functional impairment over time.

Mental health risks differentially associated with immunocompromised status among healthcare workers and family members at the pandemic outset.

The mental health of healthcare workers (HCWs) is critical to their long-term well-being and future disaster preparedness. Goal 1 of this study was to identify rates of mental health problems experienced by HCWs. Goal 2 was to test a model of risk stemming from pandemic-related stressors and vulnerability factors. This cross-sectional study included HCWs (N â€‹= â€‹2,246 [1,573 clinical providers; 673 non-clinical staff]) in the Rocky Mountain West who voluntarily completed an online survey in April/May 2020. Respondents completed measures for traumatic stress symptoms, depression, anxiety, alcohol use, and sleep. Logistic regressions stratified by professional role (clinical versus non-clinical) were specified to predict clinical screening cutoff (positive/negative) as a function of five pandemic-related stressors (immunocompromised self; immunocompromised household member; care provision to infected patients; clinical management role; positive cases). Results showed that more than half of HCWs surveyed (52.5%) screened positive (above cutoff) for traumatic stress, depression, or anxiety, with ~20% reporting problematic alcohol use, and variable insufficient sleep from ~10% off shift to ~50% on shift. Clinical employees with an immunocompromised household member had increased odds of screening positive for a mental health problem. Non-clinical HCWs who were immunocompromised were at elevated risk for screening positive a mental health problem. Being female, minority status, and younger increased odds for mental health problems. Implications include alleviating a portion of the mental health burden of HCWs involved in response to the SARS-CoV-2 pandemic by considering policies to protect immunocompromised HCWs and their families (e.g., vaccine priorities, telework options).

Patterns of exposure to potentially morally injurious events among Israeli combat veterans: A latent class analysis approach.

OBJECTIVE: Following exposure to events that transgress moral beliefs and expectations rooted in cultural, organizational, and group-based ethical rules, veterans can experience psychological, social, and spiritual problems referred to as Moral Injury (MI). We examined patterns of exposure to potentially morally injurious events (PMIEs) among Israeli veterans as well as psychological and functional correlates of exposure. METHOD: A sample of 381 Israeli veterans volunteered to complete a cross-sectional electronic survey between 2017-2018. Latent Class Analysis (LCA) was used to identify classes characterized by unique patterns of exposure to PMIEs and compare differences in psychological and functional problems. RESULTS: Three subgroups were identified: Moral Injury (12.1 %), Betrayal-Only (20.8 %), and Minimal Exposure (67.1 %). Whereas those in the betrayal-only class reported more traditional posttraumatic symptoms and those in the moral injury class reported more moral injury symptoms (i.e., guilt-related cognitions), some psychological problems were shared by veterans assigned to the moral injury and betrayal-only classes (e.g., entrapment). Importantly, while both those in the betrayal-only and moral injury classes had lower forgiveness relative to those in the minimal exposure class, those in the betrayal-only class received more familial support than did those in the moral injury class. CONCLUSIONS: The study's findings offer an overview of the complex associations between patterns of exposure to PMIEs and associated outcomes. Clinicians treating veterans coping with combat trauma should be aware of the unique and shared symptoms reported by those with moral injury and betrayal exposures.

Pandemic-related mental health risk among front line personnel.

The mental health of frontline workers is critical to a community's ability to manage crises and disasters. This study assessed risks for mental health problems (traumatic stress, depression, anxiety, alcohol use, insomnia) in association with pandemic-related stressors in a sample of emergency and hospital personnel (N = 571). Respondents completed self-report surveys online from April 1st to May 7th, 2020 in the Rocky Mountain region of the United States. Results showed that roughly fifteen to thirty percent of respondents screened positive for each disorder. Odds of screening positive were similar between groups for probable acute traumatic stress, depressive disorder, anxiety disorder, and alcohol use disorder; emergency personnel reported significantly higher rates of insufficient sleep than healthcare workers. Logistic regressions showed that respondents who reported having an immunocompromised condition had higher odds of acute traumatic stress, anxiety, and depression. Having an immunocompromised household member was associated with higher odds of insufficient sleep and anxiety. Being in a direct care provision role was associated with higher odds of screening positive for risky alcohol use. Being in a management role over direct care providers was associated with higher odds of screening positive for anxiety, risky alcohol use, and insufficient sleep. There was an inverse relationship between number of positive COVID-19 cases and anxiety, such that as positive cases went up, anxiety decreased. Overall, the mental health risks that we observed early in the COVID-19 pandemic are elevated above previous viral outbreaks (SARS) and comparable to rates shown in disasters (9/11 attacks; Hurricane Katrina).

Gender differences in prevalence and outcomes of exposure to potentially morally injurious events among post-9/11 veterans.

Our goal was to identify gender differences in the prevalence and outcomes of exposure to potentially morally injurious events (PMIEs) in a sample of U.S. military veterans. In a national sample of post-9/11 veterans (n = 7200) weighted to reflect the larger population of newly separated U.S. veterans, we conducted gender-stratified analyses of the prevalence of exposure to PMIEs and their associations with psychological and functional problems. Veterans reported exposures stemming from witnessing (27.9%), perpetrating (18.8%), and being betrayed (41.1%). Women more frequently reported witnessing- and betrayal-based PMIEs, but no gender differences were observed for perpetration-based PMIEs. Psychological distress was associated with witnessing and betrayal among women and with witnessing, betrayal, and perpetration among men. Whereas betrayal was most consistently associated with functional impairment across domains for women, perpetration was most consistently associated with functional impairment for men. Moral injury contributes to psychological and functional problems among a significant minority of military veterans, although effects vary based on PMIE type and gender. Implications for veterans and other populations who experience moral injury are discussed.

Profiles of moral distress and associated outcomes among student veterans.

OBJECTIVE: Military veterans who interpret their own or others' actions as moral transgressions are theorized to experience moral distress. The purpose of this study was to explore patterns of moral distress and associated psychological, social, and religious or spiritual problems among student veterans. METHOD: Student veterans (N = 498) retrospectively reported experiences of moral distress associated with deployment-related events in which they felt (a) troubled by what they witnessed, (b) troubled by what they did, (c) troubled by what they failed to do, (d) betrayed by military leaders, or (e) betrayed by fellow service members. RESULTS: Latent profile analysis revealed 5 response patterns: No Moral Distress (42%), Witnessing-Only (16%), Moral Distress-Other (19%; encompassing distress mostly from being betrayed by others), Moral Distress-Self (8%; encompassing distress mostly from one's own actions or inactions), and Moral Distress-Self and Other (15%). We compared scores on measures of posttraumatic stress, familial or social functioning, and religious or spiritual struggles between profiles and observed moderate to large differences. CONCLUSIONS: Whereas participants reported some problems (e.g., interpersonal conflict) regardless of whether they were exposed to a morally injurious event by witnessing, perpetrating, or being betrayed, in comparison to those reporting no moral distress, those who felt responsible for the event reported greater guilt and lack of purpose and those who held others responsible for the event reported greater posttraumatic stress. Participants who endorsed feeling betrayed by others' and troubled by their own actions reported multiple problems including posttraumatic stress, interpersonal difficulties, and religious or spiritual struggles. (PsycInfo Database Record (c) 2020 APA, all rights reserved).