Measuring moral distress and moral injury: A systematic review and content analysis of existing scales

Stephanie A Houle; Natalie Ein; Julia Gervasio; Rachel A Plouffe; Brett T Litz; R Nicholas Carleton; Kevin T Hansen; Jenny J W Liu; Andrea R Ashbaugh; Walter Callaghan; Megan M Thompson; Bethany Easterbrook; Lorraine Smith-MacDonald; Sara Rodrigues; Stéphanie A H Bélanger; Katherine Bright; Ruth A Lanius; Clara Baker; William Younger; Suzette Bremault-Phillips; Fardous Hosseiny; J Don Richardson; Anthony Nazarov; Atlas Institute Moral Injury Research Community of Practice

doi:10.1016/j.cpr.2023.102377

Measuring moral distress and moral injury: A systematic review and content analysis of existing scales

Clin Psychol Rev. 2024 Mar:108:102377. doi: 10.1016/j.cpr.2023.102377. Epub 2023 Dec 27.

Authors

Stephanie A Houle¹, Natalie Ein², Julia Gervasio³, Rachel A Plouffe⁴, Brett T Litz⁵, R Nicholas Carleton⁶, Kevin T Hansen³, Jenny J W Liu², Andrea R Ashbaugh⁷, Walter Callaghan⁸, Megan M Thompson⁹, Bethany Easterbrook¹⁰, Lorraine Smith-MacDonald¹¹, Sara Rodrigues¹², Stéphanie A H Bélanger¹³, Katherine Bright¹⁴, Ruth A Lanius¹⁵, Clara Baker³, William Younger³, Suzette Bremault-Phillips¹⁶, Fardous Hosseiny¹², J Don Richardson¹⁷, Anthony Nazarov¹⁸; Atlas Institute Moral Injury Research Community of Practice

Affiliations

¹ MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Research Directorate, Veterans Affairs Canada, Charlottetown, Canada.
² MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada.
³ MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada.
⁴ MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychology, University of Dundee, Dundee, UK.
⁵ Department of Psychiatry, Boston University, Boston, USA; Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, USA; Department of Psychological and Brain Sciences, Boston University, Boston, USA.
⁶ Department of Psychology, University of Regina, Regina, Canada.
⁷ School of Psychology, University of Ottawa, Ottawa, Canada.
⁸ Department of Anthropology, University of Toronto, Toronto, Canada.
⁹ Defence Research and Development Canada, Toronto, Canada.
¹⁰ MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, Canada.
¹¹ St. Stephens College, University of Alberta, Edmonton, Canada.
¹² The Atlas Institute for Veterans and Families, Ottawa, Canada.
¹³ Royal Military College of Canada, Kingston, Canada.
¹⁴ Nursing and Midwifery, Mount Royal University, Calgary, Canada.
¹⁵ Department of Psychiatry, Western University, London, Canada.
¹⁶ Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada.
¹⁷ MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada; St. Joseph's Operational Stress Injury Clinic, St. Joseph's Health Care London, London, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada.
¹⁸ MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada. Electronic address: anthony.nazarov@sjhc.london.on.ca.

PMID: 38218124
DOI: 10.1016/j.cpr.2023.102377

Abstract

Background: Moral distress (MD) and moral injury (MI) are related constructs describing the negative consequences of morally challenging stressors. Despite growing support for the clinical relevance of these constructs, ongoing challenges regarding measurement quality risk limiting research and clinical advances. This study summarizes the nature, quality, and utility of existing MD and MI scales, and provides recommendations for future use.

Method: We identified psychometric studies describing the development or validation of MD or MI scales and extracted information on methodological and psychometric qualities. Content analyses identified specific outcomes measured by each scale.

Results: We reviewed 77 studies representing 42 unique scales. The quality of psychometric approaches varied greatly across studies, and most failed to examine convergent and divergent validity. Content analyses indicated most scales measure exposures to potential moral stressors and outcomes together, with relatively few measuring only exposures (n = 3) or outcomes (n = 7). Scales using the term MD typically assess general distress. Scales using the term MI typically assess several specific outcomes.

Conclusions: Results show how the terms MD and MI are applied in research. Several scales were identified as appropriate for research and clinical use. Recommendations for the application, development, and validation of MD and MI scales are provided.

Keywords: Measurement; Moral distress; Moral injury; Psychometrics; Scale development.

Publication types

Systematic Review
Review

MeSH terms

Humans
Morals
Psychometrics
Reproducibility of Results
Stress Disorders, Post-Traumatic* / diagnosis
Surveys and Questionnaires