Potentially morally injurious experiences and associated factors among Dutch UN peacekeepers: a latent class analysis.

Background: During peacekeeping missions, military personnel may be involved in or exposed to potentially morally injurious experiences (PMIEs), such as an inability to intervene due to a limited mandate. While exposure to such morally transgressive events has been shown to lead to moral injury in combat veterans, research on moral injury in peacekeepers is limited.Objective: We aimed to determine patterns of exposure to PMIEs and associated outcome- and exposure-related factors among Dutch peacekeepers stationed in the former Yugoslavia during the Srebrenica genocide.Method: Self-report data were collected among Dutchbat III veterans (N = 431). We used Latent Class Analysis to identify subgroups of PMIE exposure as assessed by the Moral Injury Scale-Military version. We investigated whether deployment location, posttraumatic stress disorder (PTSD), posttraumatic growth, resilience, and quality of life differentiated between latent classes.Results: The analysis identified a three-class solution: a high exposure class (n = 79), a moderate exposure class (n = 261), and a betrayal and powerlessness-only class (n = 135). More PMIE exposure was associated with deployment location and higher odds of having probable PTSD. PMIE exposure was not associated with posttraumatic growth. Resilience and quality of life were excluded from analyses due to high correlations with PTSD.Conclusions: Peacekeepers may experience varying levels of PMIE exposure, with more exposure being associated with worse outcomes 25 years later. Although no causal relationship may be assumed, the results emphasize the importance of better understanding PMIEs within peacekeeping.

Peacekeeping veterans reported different patterns of exposure to potentially morally injurious experiences: high exposure, moderate exposure, or experiences of betrayal and powerlessness only.Deployment location predicted the pattern of exposure.More exposure was associated with worse psychological outcomes 25 years later.

Moral injury and pre-deployment personality factors as contributors to psychiatric symptomatology among combatants: a two-year prospective study.

Background: Combatants who are exposed to events that transgress deeply held moral beliefs might face lasting psychopathological outcomes, referred to as Moral Injury (MI). However, knowledge about pre-deployment factors that might moderate the negative consequences of MI is sparse. In this prospective study, we examined pre-enlistment characteristics and pre-deployment personality factors as possible moderators in the link between exposure to potentially morally injurious events (PMIEs) and psychiatric symptomatology among Israeli active-duty combatants.Methods: A sample of 335 active-duty Israeli combatants participated in a 2.5-year prospective study with three waves of measurements (T1: 12 months before enlistment, T2: Six months following enlistment - pre-deployment, and T3: 18 months following enlistment - post-deployment). Participants' characteristics were assessed via semi-structured interviews (T1) and validated self-report measures of personality factors: emotional regulation, impulsivity, and aggression (T2) and combat exposure, PMIEs, psychiatric symptomology and posttraumatic symptoms (T3) between 2019 and 2021.Results: Pre-enlistment psychiatric difficulties and negative life events contributed to higher exposure to PMIEs post-deployment. Higher levels of pre-deployment aggression and lower levels of emotional regulation and impulsivity moderated the association between betrayal, PMIEs and psychiatric symptomology post-deployment, above and beyond pre-enlistment psychiatric difficulties and life events.Conclusions: Our results highlight that pre-deployment emotional regulation, impulsivity and aggressiveness levels should be assessed, screened, and identified among combatants, as they all facilitate psychiatric symptomology (and PTSS) after combatants are exposed to PMIEs of betrayal. Such pre-assessment will enable the identification of at-risk combatants and might provide them with tailor-made preparation regarding moral and ethical situations that should be investigated in future research.

Pre-enlistment psychiatric difficulties contributed to higher exposure to PMIEs post-deployment.Pre-deployment personality moderated the associations between PMIEs and psychiatric symptomatology among combatants.Higher levels of pre-deployment emotional regulation moderated the association between betrayal PMIEs and post-deployment PTSS symptoms.

Exposure to moral stressors and associated outcomes in healthcare workers: prevalence, correlates, and impact on job attrition.

Introduction: Healthcare workers (HCWs) often experience morally challenging situations in their workplaces that may contribute to job turnover and compromised well-being. This study aimed to characterize the nature and frequency of moral stressors experienced by HCWs during the COVID-19 pandemic, examine their influence on psychosocial-spiritual factors, and capture the impact of such factors and related moral stressors on HCWs' self-reported job attrition intentions.Methods: A sample of 1204 Canadian HCWs were included in the analysis through a web-based survey platform whereby work-related factors (e.g. years spent working as HCW, providing care to COVID-19 patients), moral distress (captured by MMD-HP), moral injury (captured by MIOS), mental health symptomatology, and job turnover due to moral distress were assessed.Results: Moral stressors with the highest reported frequency and distress ratings included patient care requirements that exceeded the capacity HCWs felt safe/comfortable managing, reported lack of resource availability, and belief that administration was not addressing issues that compromised patient care. Participants who considered leaving their jobs (44%; N = 517) demonstrated greater moral distress and injury scores. Logistic regression highlighted burnout (AOR = 1.59; p < .001), moral distress (AOR = 1.83; p < .001), and moral injury due to trust violation (AOR = 1.30; p = .022) as significant predictors of the intention to leave one's job.Conclusion: While it is impossible to fully eliminate moral stressors from healthcare, especially during exceptional and critical scenarios like a global pandemic, it is crucial to recognize the detrimental impacts on HCWs. This underscores the urgent need for additional research to identify protective factors that can mitigate the impact of these stressors.

This study explored the nature of moral stressors encountered by health care workers, along with impacts on moral injury and intentions to leave their jobs.Morally distressing encounters were common, with the most prevalent and distressing experiences being organizational or team-based in nature.Findings revealed that severity of moral injury, particularly related to trust violation or betrayal, was a key factor influencing healthcare workers' intentions to leave their jobs.

The independent and combined impact of moral injury and moral distress on post-traumatic stress disorder symptoms among healthcare workers during the COVID-19 pandemic.

Background: Healthcare workers (HCWs) across the globe have reported symptoms of Post-Traumatic Stress Disorder (PTSD) during the COVID-19 pandemic. Moral Injury (MI) has been associated with PTSD in military populations, but is not well studied in healthcare contexts. Moral Distress (MD), a related concept, may enhance understandings of MI and its relation to PTSD among HCWs. This study examined the independent and combined impact of MI and MD on PTSD symptoms in Canadian HCWs during the pandemic.Methods: HCWs participated in an online survey between February and December 2021, with questions regarding sociodemographics, mental health and trauma history (e.g. MI, MD, PTSD, dissociation, depression, anxiety, stress, childhood adversity). Structural equation modelling was used to analyze the independent and combined impact of MI and MD on PTSD symptoms (including dissociation) among the sample when controlling for sex, age, depression, anxiety, stress, and childhood adversity.Results: A structural equation model independently regressing both MI and MD onto PTSD accounted for 74.4% of the variance in PTSD symptoms. Here, MI was strongly and significantly associated with PTSD symptoms (ß = .412, p < .0001) to a higher degree than MD (ß = .187, p < .0001), after controlling for age, sex, depression, anxiety, stress and childhood adversity. A model regressing a combined MD and MI construct onto PTSD predicted approximately 87% of the variance in PTSD symptoms (r2 = .87, p < .0001), with MD/MI strongly and significantly associated with PTSD (ß = .813, p < .0001), after controlling for age, sex, depression, anxiety, stress, and childhood adversity.Conclusion: Our results support a relation between MI and PTSD among HCWs and suggest that a combined MD and MI construct is most strongly associated with PTSD symptoms. Further research is needed better understand the mechanisms through which MD/MI are associated with PTSD.

MI and MD were each independently associated with PTSD symptoms (including dissociation), when controlling for sex, age, childhood adversity, depression, anxiety and stress.Combining both MI and MD constructs into a single latent variable accounted for the greatest proportion of variance explained in PTSD symptoms among HCWs during the COVID-19 pandemic.Results suggest that expanding the construct of MI to include team and systemic organisational MD may be appropriate in the healthcare context.

Nurses' workload during the COVID-19 pandemic: potential for experiences of moral distress / Carga de trabajo de las enfermeras durante la pandemia de COVID-19: potencial para experiencias de sufrimiento moral / Sobrecarga de trabalho de enfermeiros na pandemia de COVID-19: potência para vivências de sofrimento moral

ABSTRACT Objectives: to understand nurses' experiences of moral distress related to work overload during the COVID-19 pandemic in Brazil. Methods: qualitative research, whose data collection occurred through individual interviews with 19 nurses who worked on the front line of COVID-19 in health services in southeastern Brazil. Data were analyzed using thematic content analysis. Results: work overload proved to be a powerful source of experiences of moral distress due to excessive working hours during vaccination, double working hours, a troubled relationship due to pressure from managers and the population and physical and mental exhaustion, which prevented nurses from act according to their judgment. Final Considerations: nurses' work overload reflects on quality patient care and prevents nurses from acting in accordance with their moral principles, generating moral distress in nurses.

RESUMEN Objetivos: comprender las experiencias de angustia moral de los enfermeros relacionadas con la sobrecarga de trabajo durante la pandemia de COVID-19 en Brasil. Métodos: investigación cualitativa, cuya recolección de datos ocurrió a través de entrevistas individuales con 19 enfermeros que actuaron en la primera línea de COVID-19 en servicios de salud de la región Sudeste de Brasil. Los datos fueron analizados mediante análisis de contenido temático. Resultados: la sobrecarga de trabajo resultó ser una poderosa fuente de experiencias de sufrimiento moral por exceso de jornada durante la vacunación, doble jornada laboral, relaciones conflictivas por presiones de los directivos y la población y agotamiento físico y mental, lo que impidió al enfermero actuar según su criterio. Consideraciones Finales: la sobrecarga de trabajo de las enfermeras se refleja en la calidad de la atención al paciente e impide que las enfermeras actúen de acuerdo con sus principios morales, generando sufrimiento moral en las enfermeras.

RESUMO Objetivos: compreender vivências de sofrimento moral de enfermeiros relacionadas à sobrecarga de trabalho durante a pandemia de COVID-19 no Brasil. Métodos: pesquisa qualitativa, cuja coleta de dados ocorreu através de entrevistas individuais com 19 enfermeiros que atuaram na linha de frente da COVID-19 em serviços de saúde da região Sudeste do Brasil. Os dados foram analisados mediante análise temática de conteúdo. Resultados: a sobrecarga de trabalho mostrou-se potente fonte para vivências de sofrimento moral devido à jornada de trabalho excessiva na vacinação, à dupla jornada de trabalho, à relação conturbada por pressão de gestores e população e ao esgotamento físico e mental, os quais impediam o enfermeiro de agir conforme o seu julgamento. Considerações Finais: a sobrecarga de trabalho dos enfermeiros reflete na assistência de qualidade ao paciente, e impede que os enfermeiros atuem conforme os seus princípios morais, gerando sofrimento moral nos enfermeiros.

On the path to recovery: traumatic stress research during the COVID-19 pandemic 2021-2023.

This Special Issue of the European Journal of Psychotraumatology (EJPT) presents 51 articles published between 2021 and 2023 and follows the Special Issue on pandemic-related traumatic stress research published in 2021 (O'Donnell, M. L., & Greene, T. [2021]. Understanding the mental health impacts of COVID-19 through a trauma lens. European Journal of Psychotraumatology, 12(1), 1982502). Research on traumatic stress during the pandemic has cast the spotlight on vulnerable populations and groups, notably front-line healthcare workers; people faced with major losses including the deaths of loved ones; those who personally survived debilitating and often life-threatening viral infection; and students who were isolated and experienced profound delays in their education, relationships, and emerging independence. The papers in this collection underscore the associations between COVID-19 related stressors and a plethora of adverse mental health sequelae, including posttraumatic stress reactions, and draw attention to the ubiquity of grief and moral injury and their wide-ranging and detrimental impact. Currently, there is a paucity of evidence on interventions to enhance resources, self-efficacy, and hope for affected groups and individuals through societal, organisational, and healthcare systems; however early research on the prevention of COVID-related traumatic stress disorders provides a basis for both hope and preparedness for the future.

Stressors and traumatic events occurring due to the COVID-19 pandemic are associated with a wide range of mental health problems, including posttraumatic stress reactions, especially among vulnerable groups (e.g., front-line healthcare workers, individuals who faced major losses such as the deaths of loved ones, those who survived debilitating and often life-threatening infection).Loss and moral injury are common and potentially debilitating features of the pandemic.Societal, organisational, and healthcare system interventions to enhance resources, efficacy, and hope for affected groups and individuals are still in the early stages, although preliminary research on the prevention of COVID-related traumatic stress disorders is promising.

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

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.

Participation in protests have high mental burden as about half of the sample met the criteria for self-report diagnosis of major depression and 10.6% for PTSD.Protesters exposed to protest-related PMIEs reported significantly higher levels of both PTSS and depression than non-PMIE-exposed protesters.The findings highlight the critical contribution of PMIE-betrayal exposure to both PTSS and depressive symptoms, above and beyond demographic and protest-related characteristics.

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.

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.

The Italian validation of the MIES adapted to the healthcare setting yielded a three-factor structure: (a) 'perceived transgressions by self'; (b) 'perceived transgressions by others'; (c) 'perceived betrayals by others'.Findings suggest that the MIES may be useful in capturing unique experiences of moral injury amongst healthcare workers engaged in a global health emergency.Future research should consider the role of individualising and social binding moral principles in shaping moral injury experiences among healthcare professionals across different socio-cultural settings.

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

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

Evidence before this study: Moral injury can negatively impact the mental health of military veterans. Currently no validated treatment for moral injury related mental health difficulties exists for UK military personnel/veterans.Added value of this study: Restore and Rebuild (R&R) is a co-designed psychotherapy for moral injury-related mental health difficulties. This study provides the first evidence that R&R treatment is associated with a significant improvement in patient symptoms of PTSD, depression, alcohol misuse and moral injury related distress. R&R was feasible to deliver, acceptable to patients and well tolerated.Implications of all the available evidence: These results provide preliminary evidence that veterans struggling with moral injury related mental ill health can benefit from R&R treatment. With further evaluation, R&R may be beneficial to other occupational groups affected by moral injury.

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

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.

The Moral Injury Events Scale­Civilian Version is a reliable and valid instrument.The original 2-factor solution (Perceived Transgressions, Perceived Betrayals) yielded a good fit to the data.Moral injury's Perceived Betrayals factor predicted bipolar disorders, PTSD, and three personality disorders (paranoid PD, borderline PD, avoidant PD).

'Against everything that got you into the job': experiences of potentially morally injurious events among Canadian public safety personnel.

Background: Moral injury (MI) has become a research and organizational priority as frontline personnel have, both during and in the years preceding the COVID-19 pandemic, raised concerns about repeated expectations to make choices that transgress their deeply held morals, values, and beliefs. As awareness of MI grows, so, too, does attention on its presence and impacts in related occupations such as those in public safety, given that codes of conduct, morally and ethically complex decisions, and high-stakes situations are inherent features of such occupations.Objective: This paper shares the results of a study of the presence of potentially morally injurious events (PMIEs) in the lived experiences of 38 public safety personnel (PSP) in Ontario, Canada.Method: Through qualitative interviews, this study explored the types of events PSP identify as PMIEs, how PSP make sense of these events, and the psychological, professional, and interpersonal impacts of these events. Thematic analysis supported the interpretation of PSP descriptions of events and experiences.Results: PMIEs do arise in the context of PSP work, namely during the performance of role-specific responsibilities, within the organizational climate, and because of inadequacies in the broader healthcare system. PMIEs are as such because they violate core beliefs commonly held by PSP and compromise their ability to act in accordance with the principles that motivate them in their work. PSP associate PMIEs, in combination with traumatic experiences and routine stress, with adverse psychological, professional and personal outcomes.Conclusion: The findings provide additional empirical evidence to the growing literature on MI in PSP, offering insight into the contextual dimensions that contribute to the sources and effects of PMIEs in diverse frontline populations as well as support for the continued application and exploration of MI in the PSP context.

The objective of this study was to understand the types of events that Canadian public safety personnel (PSP) experience as potentially morally injurious events (PMIEs) as well as the impacts that they associate with these events.The findings illuminate that contextual dimensions are significant in the origin of PMIEs, which PSP experience in the completion of routine duties, because of the organizational culture, or as a result of issues in the broader healthcare system, which led to many negative consequences in their personal and professional lives.PMIEs reduced the trust PSP had in their leadership and the healthcare system to protect the public and themselves, were associated with feelings of anger, frustration, resignation, and helplessness, and connected to internal struggles marked by inner conflict and the erosion of self-concept.

Widening the scope: defining and treating moral injury in diverse populations.

Moral injury is an emerging concept that captures the psychosocial consequences of involvement in and exposure to morally transgressive events. In the past decade, research on moral injury has grown exponentially. In this special collection we review papers on moral injury published in the European Journal of Psychotraumatology from its inception until December 2022, that have a primary focus on moral injury as evidenced by the words 'moral injury' in the title or abstract. We included 19 papers on quantitative (n = 9) and qualitative (n = 5) studies of different populations including (former) military personnel (n = 9), healthcare workers (n = 4) and refugees (n = 2). Most papers (n = 15) focused on the occurrence of potentially morally injurious experiences (PMIEs), moral injury and associated factors, while four papers primarily concerned treatment. Together, the papers offer a fascinating overview of aspects of moral injury in different populations. Research is clearly widening from military personnel to other populations such as healthcare workers and refugees. Focal points included the impact of PMIEs involving children, the association of PMIEs and personal childhood victimisation, the prevalence of betrayal trauma, and the relationship between moral injury and empathy. As for treatment, points of interest included new treatment initiatives as well as findings that PMIE exposure does not impede help-seeking behaviour and response to PTSD treatment. We further discuss the wide range of phenomena that fall under moral injury definitions, the limited diversity of the moral injury literature, and the clinical utility of the moral injury construct. From conceptualisation to clinical utility and treatment, the concept of moral injury matures. Whether or not moral injury becomes a formal diagnosis, the need to examine tailored interventions to alleviate moral injury is clear.

Moral injury is increasingly studied outside military populations, such as in healthcare workers and refugees.Among the most impactful potentially morally injurious experiences (PMIEs) are those involving children, but betrayal trauma may be the most prevalent type of PMIE.There is a need for tailored, evidence-based interventions to alleviate moral injury.

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

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.

Potentially morally injurious experiences are common during military service, but it is poorly understood how these experiences are related to other mental health disorders in Canadian Armed Forces members and Veterans.Following a series of multiple logistic regressions, the odds of experiencing a past-year mental health disorder were 1.97 (95% CI: = 1.94­2.01) times greater per unit increase in total Moral Injury Events Scale score.This emphasizes the association between morally injurious events and deleterious mental health outcomes in Canadian military personnel, and further highlights the importance of addressing moral injury in this population.

Silêncio na redação ­ a saúde mental de jornalistas na abordagem da comunicação de riscos / Silence in the newsroom ­ journalist's mental health from the risk communication approach / Silencio en la redacción ­ la salud mental de los periodistas en el abordaje de la comunicación de riesgo

Desde a década de 1990, o psiquiatra sul-africano Anthony Feinstein tem abordado o tema da saúde mental de jornalistas na cobertura de tragédias humanitárias, com foco no Transtorno do Estresse Pós-traumático (TEPT) e em moral injury (lesão moral), definido como uma ferida na alma. Em 2020, primeiro ano da pandemia da covid-19, o artigo "The covid reporters are not okay. Extremely not okay", da jovem jornalista Olivia Messer, trabalhando on-line, chamou a atenção não apenas para o tema da saúde mental dos repórteres, como também para a invisibilidade do assunto. Este artigo objetiva investigar como a comunicação de riscos pode contribuir para descortinar e enfrentar os riscos à saúde mental de jornalistas no Brasil, especialmente no contexto das redações híbridas e da plataformização do jornalismo, um dos campos que compõem o referencial teórico em seu cruzamento com a comunicação de riscos e a psiquiatra. A metodologia contempla a pesquisa bibliográfica nessas três áreas, a plataformização do jornalismo, a comunicação de riscos e a psiquiatria, a partir da conexão entre elas, e da análise de conteúdo, de base quantitativa, da cobertura do assunto pelos jornais Folha de S.Paulo e O Globo. Os resultados apontam a urgência da retirada do tema da invisibilidade midiática e social e confirmam a potencialidade da comunicação de riscos para o seu enfrentamento.

Since the 1990s, South African psychiatrist Anthony Feinstein has addressed the issue of the mental health of journalists covering humanitarian tragedies, focusing on Post-traumatic Stress Disorder (PTSD) and moral injury, defined as a wound in the soul. In 2020, the first year of the covid-19 pandemic, the article "The covid reporters are not okay. Extremely not okay", by young journalist Olivia Messer, working online drew attention not only to the issue of reporters' mental health, but also to the invisibility of the issue. This article aims to investigate how risk communication can contribute to uncover and address the risks to the mental health of journalists in Brazil, especially in the context of hybrid newsrooms and the plat-formization of journalism, one of the fields that make up the theoretical framework in its intersection with risk communication and psychiatry. The methodology includes bibliographic research in these three areas, platformization of journalism, risk communication and psychiatry, from the connection between them, and content analysis, of quantitative basis, of the coverage of the subject by Folha de S.Paulo and O Globo newspapers. The results point to the urgency of removing this issue of media and social invisibility and recognising the potential of risk communication to face it.

Desde la década de 1990, el psiquiatra sudafricano Anthony Feinstein ha abordado la cuestión de la salud mental de los periodistas que cubren tragedias humanitarias, centrándose en el Trastorno de Estrés Pos-traumático (TEPT) y el moral injury (el daño moral), definidos como una herida en el alma. En 2020, el primer año de la pandemia de covid-19, el artículo "The covid reporters are not okay. Extremely not okay", de la joven periodista Olivia Messer, que trabaja en línea, llamó la atención no sólo sobre la cuestión de la salud mental de los periodistas, sino también sobre la invisibilidad del tema. Este artículo pretende investigar cómo la comunicación de riesgo puede contribuir a descubrir y abordar los riesgos para la salud mental de los periodistas en Brasil, especialmente en el contexto de las redacciones híbridas y la plata-formización del periodismo, uno de los campos que conforman el marco teórico en su intersección con la comunicación de riesgo y la psiquiatría. La metodología contempla la investigación bibliográfica en estas tres áreas, plataformización del periodismo, comunicación de riesgo y la psiquiatría, a partir de la conexión entre ellas, y el análisis de contenido, de base cuantitativa, de la cobertura del tema por los periódicos Folha de S.Paulo y O Globo. Los resultados apuntan a la urgencia de sacar el tema de la invisibilidad mediática y social y confirman la potencialidad de la comunicación de riesgos para su confrontación

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.

We conducted the first meta-analysis of moral injury and mental health among healthcare workers.Moral injury is moderately associated with symptoms of PTSD, depression, anxiety, burnout, and suicidal ideation.There was a stronger association between MI and anxiety and depressive symptoms for samples with more nurses.

El descuido y lo inhóspito. Habitar tiempos de pandemia / The carelessness and the inhospitable. Inhabiting times of pandemic

La pandemia nos ha colocado en una situación de extrañamiento hacia nosotros mismos. Hemos sido muy conscientes de nuestravulnerabilidad y fragilidad. A través de los relatos de las experiencias vividas hemos conocido y asistido a circunstancias trágicas enlas que se han puesto de manifiesto lo inhóspito y el descuido. Nos ha conmocionado la toma de conciencia sobre la falta de recono-cimiento, de acompañamiento, de acogida. Las decisiones institucionales han primado la Salud Pública, el bien de todos, pero se hanolvidado de las biografías de las personas, llenas de sufrimiento. Y esto ha producido un daño moral, una pérdida de la confianza, unasensación de injusticia ante la que no se ha podido luchar. Por eso es necesaria una construcción de la hospitalidad que se puedelograr a través del cuidado. Un cuidado con dimensión política que se haga cargo de la realidad y que transforme la sociedad. Laclave es una responsabilidad solidaria. Ante la posibilidad de deshumanizarnos buscamos la hospitalidad como forma alternativa denarrar las vidas que tienen que reconstruirse, que tienen que reaprender cómo cuidarnos mutuamente en medio de las múltiplesposibilidades de extrañamiento que nos amenazan. La hospitalidad es el corazón de una ética narrativa a la altura de nuestro tiempo.(AU)

The pandemic has placed us in a situation of estrangement from ourselves. We have been acutely aware of our vulnerability andfragility. Through the stories of lived experiences, we have learned about and witnessed tragic circumstances in which inhospitalityand neglect have become evident. We have been shocked by the awareness of the lack of recognition, accompaniment and welcome.Institutional decisions have prioritized public health, the good for all, but have forgotten the biographies of people, full of suffering.And this has produced a moral damage, a loss of trust, a feeling of injustice that we have not been able to fight against. This is why itis necessary to build hospitality, which can be achieved through care. Care with a political dimension that takes charge of reality andtransforms society. The key is a responsibility in solidarity. Faced with the possibility of dehumanizing ourselves, we seek hospitalityas an alternative way of narrating lives that have to be reconstructed, that have to relearn how to take care of each other amidstthe multiple possibilities of estrangement that threaten us. Hospitality is at the heart of a narrative ethics at the height of our times.(AU)

Moral injury in civilians: associations with trauma exposure, PTSD, and suicide behavior.

Background: Moral injury (MI) describes emotional, spiritual, and social suffering that can arise following psychological trauma. Prior research in military pop ulations indicates the relevance of MI to adverse psychological outcomes, such as post-traumatic stress disorder (PTSD) and suicidal behaviours, and shows evidence for MI as a unique construct. Minimal studies of MI have been implemented in civilians, usually restricted to small samples with a specific set of traumatic experiences, despite the conceptual relevance of MI to non-military trauma reactions more broadly (e.g. feelings of betrayal towards a perpetrator of sexual abuse). Objective: To address this problem, we assessed MI in trauma-exposed civilians to examine ways in which this construct was related to and distinct from trauma and traumatic stress-related problems, including PTSD and depression. Method: We adapted an existing MI scale, Moral Injury Events Scale (MIES) and administered this measure to 81 men and women along with measures of trauma exposure, PTSD and depression, and also asked participants about past suicide attempts. Results: We observed that both greater exposure and distress related to potentially morally injurious events were associated with higher trauma exposure, particularly childhood maltreatment, as well as post-traumatic and depressive psychopathology. However, even after accounting for current PTSD and depression symptoms, MI exposure (F = 6.05, p = .017) was significantly higher among participants who had previously attempted suicide. Conclusions: These pilot data reveal the ways in which MI is associated with trauma exposure, PTSD and depression and highlight the salience of MI in civilians. Similarly, these data demonstrate the unique relevance of MI to suicide behaviours, independent of post-traumatic psychopathology, indicating that this construct may be an understudied contributor to suicide risk in civilians.

Antecedentes: El daño moral (DM) describe el sufrimiento emocional, espiritual y social que puede surgir después de un trauma psicológico. Investigaciones previas en poblaciones militares indican la relevancia del DM para los desenlaces psicológicos adversos, como trastorno de estrés postraumático (TEPT) y las conductas suicidas, y muestran evidencia de que el DM es un constructo único. Se han implementado mínimos estudios de DM en civiles, usualmente restringidos a pequeñas muestras con un conjunto específico de experiencias traumáticas, a pesar de la relevancia conceptual de DM para las reacciones de trauma no militares más amplias (p.Ej., Sentimientos de traición hacia un perpetrador de abuso sexual).Objetivo: Para abordar este problema, evaluamos el DM en civiles expuestos a trauma para examinar las formas en que este constructo se relacionaba y se diferenciaba de los problemas relacionados con el trauma y el estrés traumático, incluidos el trastorno de estrés postraumático y la depresión.Método: Adaptamos una escala de DM existente, la Escala de eventos de daños morales y administramos esta medida a 81 hombres y mujeres junto con medidas de exposición al trauma, TEPT y depresión, y también preguntamos a los participantes sobre intentos suicidas pasados.Resultados: Observamos que tanto una exposición mayor como la angustia relacionada con eventos de potencial daño moral se asociaron con mayor exposición a trauma, particularmente al maltrato infantil, así como a psicopatología postraumática y depresiva. Sin embargo, incluso después de tener en cuenta los síntomasde TEPT actuales y depresión, la exposición a DM (F = 6.05, p = .017) fue significativamente mayor entre los participantes que habían intentado suicidio previamente.Conclusiones: Estos datos piloto revelan las formas en que el DM se asocia con la exposición al trauma, TEPT y depresión y resaltan la importancia del DM en la población civil. De manera similar, estos datos demuestran la relevancia única del DM para los comportamientos suicidas, independientemente de la psicopatología postraumática, lo que indica que este constructo puede ser un contribuyente subestudiado del riesgo de suicidio en la población civil.

Moral injury and mental health outcomes among Israeli health and social care workers during the COVID-19 pandemic: a latent class analysis approach.

BACKGROUND: The COVID-19 pandemic poses unique challenges to health and social care workers (HSCWs) who face morally challenging and life-threatening decisions. Following exposure to events that transgress moral beliefs and expectations, HSCWs might experience psychological, social, and spiritual problems referred to as Moral Injury (MI). OBJECTIVE: The objectives of this study were to examine patterns of exposure to potentially morally injurious events (PMIEs) among HSCWs and their associations with MI, mental health outcomes and psychological correlates. METHOD: A sample of 296 Israeli HSCWs volunteered to complete a cross-sectional electronic survey with validated self-report questionnaires in February and March 2021. Latent Class Analysis (LCA) was used to identify classes characterized by unique patterns of exposure to PMIEs. Socio-demographic, work and COVID-related variables were used to predict patterns of exposure to PMIEs, and differences in mental-health outcomes and psychological correlates between classes were assessed. RESULTS: Three subgroups were identified: 'high exposure' (19.5%), 'betrayal-only' (31.3%), and 'minimal exposure' (49.4%). Perceived stress increases the odds for inclusion in the 'high exposure' and 'betrayal-only' classes. Participants in both the High Exposure class and the betrayal-only classes reported higher levels of depressive, anxiety, posttraumatic and more moral injury symptoms as compared to the 'minimal exposure' class. Importantly, both 'high exposure' and 'betrayal-only' classes reported lower levels of self-compassion and higher levels of self-criticism, relative to those in the 'minimal exposure' class. CONCLUSIONS: The study's findings offer an overview of the complex associations between patterns of exposure to PMIEs and associated predictors and outcomes. Clinicians treating HSCWs coping with COVID-19 related stress should be aware of the contribution of exposure to PMIEs to HSCWs' distress and to the unique constellation of high self-criticism and low self-compassion among HSCWs with exposure to PMIEs.

Antecedentes: La pandemia por la COVID-19 presenta desafíos únicos para los trabajadores sociales y de la salud (TSSs), quienes atraviesan decisiones moralmente desafiantes y potencialmente mortales. Luego de la exposición a eventos que transgreden las creencias y expectativas morales, los TSSs podrían experimentar problemas psicológicos, sociales y espirituales conocidos como daño moral (DM).Objetivo: Los objetivos de este estudio fueron el evaluar los patrones de exposición a eventos potencialmente dañinos para la moral (EPDMs) en los TSSs y el evaluar sus asociaciones con el DM, con consecuencias para la salud mental y con correlatos psicológicos.Métodos: Se constituyó una muestra de 296 TSSs israelíes voluntarios, la cual completó un sondeo electrónico transversal de cuestionarios de autorreporte durante febrero y marzo del 2021. Se empleó el análisis de clase latente (ACL) para identificar clases caracterizadas por patrones únicos de exposición a EPDMs. Se emplearon variantes sociodemográficas, laborales y asociadas a la COVID-19 para predecir patrones de exposición a EPDMs. También se evaluaron las diferencias en las consecuencias sobre la salud mental y correlatos psicológicos entre las clases.Resultados: Se identificaron tres subgrupos: 'Alta exposición' (19,5%), 'solo traición' (31,3%) y 'exposición mínima' (49,4%). El estrés percibido incrementa el riesgo para ser incluido en las clases de 'alta exposición' y de 'solo traición'. Los participantes tanto de la clase de 'alta exposición' como de 'solo traición' reportaron niveles más altos de síntomas depresivos, de ansiedad, postraumáticos y de daño moral comparado con la clase de 'exposición mínima'. De manera importante, tanto la clase de 'alta exposición' como la de 'solo traición' reportaron niveles más bajos de autocompasión y niveles más altos de autocrítica en comparación con la clase de 'exposición mínima'.Conclusiones: Los hallazgos del estudio revelan el panorama de las asociaciones complejas entre los patrones de exposición a EPDMs y predictores y consecuencias asociadas. Los clínicos que tratan a los TSSs que afrontan estrés asociado a la COVID-19 deberían estar informados respecto a la contribución que tiene la exposición a EPDMs sobre el distrés de los TSSs y respecto a la singular constelación de una alta autocrítica y baja autocompasión entre los TSSs con exposición a EPDMs.

Moral suffering in assistance to childbirth: situations present in the work of nurses of obstetric centers and maternities / Sufrimiento moral en la asistencia en el nacimiento: situaciones presentes en el trabajo de enfermeros de centros obstétricos y maternidades / Sofrimento moral na assistência ao nascimento: situações presentes no trabalho de enfermeiros de centros obstétricos e maternidades

ABSTRACT Objective: to know the situations found in the work of nurses working in maternity hospitals and obstetric centers that can lead to moral suffering. Method: qualitative, exploratory and descriptive study, developed with 14 nurses working in bstetric centers and maternities of two hospitals in southern Brazil. Data were collected from October 2015 to January 2016, through a semi-structured interview, analyzed based on Content Analysis. Results: there was an occurrence of moral distress related to the activities that supplanted nurses' execution capacity, leading them to prioritize administrative and managerial activities, for which they are charged by the institutions, failing to participate directly in the care, an aspect enhanced by the quantitative nursing professionals. Asymmetric relations of power and conflicting interactions compose an atmosphere of toleration for the autonomy of the nurses, preventing them from acting in harmony with their knowledge and moral values. The fruitless attempts to change the dehumanizing context through advocacy and the visualization of disrespectful, interventionist and violent behaviors against women, generate moral suffering. Conclusion: the plurality of nurse actions, reduced autonomy, disrespect for their practice and the visualization of dehumanizing behaviors generate moral suffering. It is important to seek alternatives so that nurses may act and advocate in line with their moral knowledge and values, in an autonomous and empowered way, aiming to provide a dignified and safe childbirth assistance, and an environment that respects the woman and her autonomy.

RESUMEN Objetivo: conocer las situaciones presentes en el trabajo de enfermeros que actúan en maternidades y centros obstétricos que pueden llevar al sufrimiento moral. Método: estudio cualitativo, exploratorio y descriptivo, desarrollado con 14 enfermeros que actúan en centros obstétricos y maternidades de dos hospitales del sur de Brasil. Se recolectaron los datos de octubre de 2015 a enero de 2016, por medio de entrevista semiestructurada, y se analizaron en base al Análisis de Contenido. Resultados: se pudo comprobar los hechos de sufrimiento moral relacionados a actividades que suplantan capacidades de ejecución de enfermeros, llevándolos a priorizar las actividades de gestión y gerencial que son cobradas por las instituciones, dejando de participar directamente del cuidado, aspecto que se potencia por lo cuantitativo inadecuado de profesionales de enfermería. Las relaciones asimétricas de poder y las interacciones conflictivas forman un ambiente de parálisis de la autonomía del enfermero, no permitiéndole actuar en consonancia con sus saberes y valores morales. Los infructíferos intentos de modificar el contexto deshumanizador a través de las leyes y la visualización de conductas no respetuosas, intervencionistas y violentas contra las mujeres generan sufrimiento moral. Conclusión: la pluralidad de haceres del enfermero, la reducida autonomía, el no respeto en relación a su práctica y la visualización de conductas deshumanizadoras generan sufrimiento moral. Se destaca la importancia de buscar alternativas para que los enfermeros puedan actuar y abogar en consonancia con sus saberes y valores morales, de modo autónomo y empoderado, con el objetivo de propiciar un cuidado en el nacimiento digno y seguro, y un ambiente en que se respete a la mujer y su autonomía.

RESUMO Objetivo: conhecer as situações presentes no trabalho de enfermeiros atuantes em maternidades e centros obstétricos que podem conduzir ao sofrimento moral. Método: estudo qualitativo, exploratório e descritivo, desenvolvido com 14 enfermeiros atuantes em centros obstétricos e maternidades de dois hospitais do sul do Brasil. Os dados foram coletados de outubro de 2015 a janeiro de 2016, por meio de entrevista semiestruturada, analisados com base na Análise de Conteúdo. Resultados: verificou-se ocorrência do sofrimento moral relacionado às atividades que suplantam as capacidades de execução pelos enfermeiros, levando-os a priorizar as atividades administrativas e gerenciais, das quais os mesmos são cobrados pelas instituições, deixando de participar diretamente da assistência, aspecto potencializado pelo quantitativo inadequado de profissionais de enfermagem. Relações assimétricas de poder e interações conflituosas compõem uma ambiência de tolhimento da autonomia do enfermeiro, impedindo-o de agir em consonância com seus saberes e valores morais. As infrutíferas tentativas de mudar o contexto desumanizador por meio da advocacia e a visualização de condutas desrespeitosas, intervencionistas e violentas contra as mulheres, geram sofrimento moral. Conclusão: a pluralidade de fazeres do enfermeiro, a reduzida autonomia, o desrespeito em relação à sua prática e a visualização de condutas desumanizadoras geram sofrimento moral. Destaca-se a importância de buscar alternativas para que os enfermeiros possam agir e advogar em consonância com seus saberes e valores morais, de modo autônomo e empoderado, visando propiciar uma assistência ao nascimento digna e segura, e uma ambiência que respeite a mulher e sua autonomia.

Acreditação hospitalar: a excelência como fonte de sofrimento moral para enfermeiros / Hospital accreditation: excellence as a source of moral distress for nurses

Objetivo: Analisar a prática profissional de enfermeiros em um hospital privado acreditado, sob o prisma da ética da virtude. Metodologia: Estudo de caso qualitativo, realizado em um Hospital Privado “Acreditado com Excelência” em Minas Gerais. Os participantes foram 13 enfermeiros. A coleta de dados foi realizada mediante entrevista individual seguindo roteiro semiestruturado e observação e submetidos à Análise Temática de Conteúdo. Resultados: Foram identificadas contradições entre os valores que norteiam a organização do trabalho na instituição, cujo enfoque é a acreditação e os valores dos enfermeiros, os quais são voltados para o cuidado. Conclusão: A contradição encontrada distancia o enfermeiro de sua prática, colocando-o em confronto com a sua profissão, provocando sofrimento moral.

Objective: To analyze the professional practice of nurses in an accredited private hospital, under the prism of virtue ethics. Methodology: Case study with a qualitative approach performed in a Private Hospital “Excelent in Accreditation” in Minas Gerais. The participants were 13 nurses. The data collection was performed through an individual interview following a semistructured script and observation and, submitted to the Thematic Content Analysis. Results: Contradictions were identified among the values that guide the organization of work in the institution, whose enforcement is the accreditation and values of nurses, which are focused on care. Conclusion: The contradiction found distances the nurses from their practice, putting them in confrontation with their profession, provoking the moral suffering.

Objetivo: Analizar la práctica profesional de enfermeros en un hospital privado acreditado, bajo el prisma de la ética de la virtud. Metodología: Estudio de caso cualitativo realizado en un Hospital Privado “Acreditado con Excelencia” en Minas Gerais. Participaron del estudio 13 enfermeros. La recolección de datos fue realizada mediante entrevista individual siguiendo itinerario semiestructurado y observación y sometidos al Análisis Temático de Contenido. Resultados: Se identificaron contradicciones entre los valores que orientan la organización del trabajo en la institución, cuyo ahorque es la acreditación y los valores de los enfermeros, los cuales se dirigen al cuidado. Conclusión: La contradicción encontró distancia al enfermero de su práctica, colocándolo en confrontación con su profesion, provocando el sufrimiento moral.