Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium
Potentially morally injurious events (PMIEs) entail acts of commission (e.g., cruelty, proscribed or prescribed violence) or omission (e.g., high stakes failure to protect others) and bearing witness (e.g., to grave inhumanity, to the gruesome aftermath of violence), or being the victim of others�...
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| Format: | Article |
| Language: | English |
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Frontiers Media S.A.
2022-07-01
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| Series: | Frontiers in Psychiatry |
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| Online Access: | https://www.frontiersin.org/articles/10.3389/fpsyt.2022.923928/full |
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| author | Brett T. Litz Rachel A. Plouffe Anthony Nazarov Dominic Murphy Andrea Phelps Alanna Coady Stephanie A. Houle Lisa Dell Sheila Frankfurt Gadi Zerach Yossi Levi-Belz The Moral Injury Outcome Scale Consortium Andrea Ashbaugh Julie Yeterian Danielle Berke Jessica Carney Mackenzie Cummings Ruth Chartoff Stephanie Ellickson-Larew Breanna Grunthal Maya Bina N. Vannini Frank Weathers Luke Rusowicz-Orazem Patrick Smith Fardous Hosseiny Lisa King J. Don Richardson Alexandra McIntyre-Smith David Forbes Kim Jones Ellie Lawrence-Wood Kelsey Madden Kim Murray |
| author_facet | Brett T. Litz Rachel A. Plouffe Anthony Nazarov Dominic Murphy Andrea Phelps Alanna Coady Stephanie A. Houle Lisa Dell Sheila Frankfurt Gadi Zerach Yossi Levi-Belz The Moral Injury Outcome Scale Consortium Andrea Ashbaugh Julie Yeterian Danielle Berke Jessica Carney Mackenzie Cummings Ruth Chartoff Stephanie Ellickson-Larew Breanna Grunthal Maya Bina N. Vannini Frank Weathers Luke Rusowicz-Orazem Patrick Smith Fardous Hosseiny Lisa King J. Don Richardson Alexandra McIntyre-Smith David Forbes Kim Jones Ellie Lawrence-Wood Kelsey Madden Kim Murray |
| author_sort | Brett T. Litz |
| collection | DOAJ |
| description | Potentially morally injurious events (PMIEs) entail acts of commission (e.g., cruelty, proscribed or prescribed violence) or omission (e.g., high stakes failure to protect others) and bearing witness (e.g., to grave inhumanity, to the gruesome aftermath of violence), or being the victim of others' acts of commission (e.g., high stakes trust violations) or omission (e.g., being the victim of grave individual or systemic failures to protect) that transgress deeply held beliefs and expectations about right and wrong. Although there is a proliferation of interest in moral injury (the outcome associated with exposure to PMIEs), there has been no operational definition of the putative syndrome and no standard assessment scheme or measure, which has hampered research and care in this area. We describe an international effort to define the syndrome of moral injury and develop and validate the Moral Injury Outcome Scale (MIOS) in three stages. To ensure content validity, in Stage I, we conducted interviews with service members, Veterans, and clinicians/Chaplains in each country, inquiring about the lasting impact of PMIEs. Qualitative analysis yielded six operational definitions of domains of impact of PMIEs and components within domains that establish the parameters of the moral injury syndrome. From the domain definitions, we derived an initial pool of scale items. Stage II entailed scale refinement using factor analytic methods, cross-national invariance testing, and internal consistency reliability analyses of an initial 34-item MIOS. A 14-item MIOS was invariant and reliable across countries and had two factors: Shame-Related (SR) and Trust-Violation-Related (TVR) Outcomes. In Stage III, MIOS total and subscale scores had strong convergent validity, and PMIE-endorsers had substantially higher MIOS scores vs. non-endorsers. We discuss and contextualize the results and describe research that is needed to substantiate these inaugural findings to further explore the validity of the MIOS and moral injury, in particular to examine discriminant and incremental validity. |
| first_indexed | 2024-04-13T21:32:01Z |
| format | Article |
| id | doaj.art-dc1f820aa9fc4fc1b660f2e10c1ec141 |
| institution | Directory Open Access Journal |
| issn | 1664-0640 |
| language | English |
| last_indexed | 2024-04-13T21:32:01Z |
| publishDate | 2022-07-01 |
| publisher | Frontiers Media S.A. |
| record_format | Article |
| series | Frontiers in Psychiatry |
| spelling | doaj.art-dc1f820aa9fc4fc1b660f2e10c1ec1412022-12-22T02:29:08ZengFrontiers Media S.A.Frontiers in Psychiatry1664-06402022-07-011310.3389/fpsyt.2022.923928923928Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale ConsortiumBrett T. Litz0Rachel A. Plouffe1Anthony Nazarov2Dominic Murphy3Andrea Phelps4Alanna Coady5Stephanie A. Houle6Lisa Dell7Sheila Frankfurt8Gadi Zerach9Yossi Levi-Belz10The Moral Injury Outcome Scale ConsortiumAndrea AshbaughJulie YeterianDanielle BerkeJessica CarneyMackenzie CummingsRuth ChartoffStephanie Ellickson-LarewBreanna GrunthalMaya Bina N. VanniniFrank WeathersLuke Rusowicz-OrazemPatrick SmithFardous HosseinyLisa KingJ. Don RichardsonAlexandra McIntyre-Smith David ForbesKim JonesEllie Lawrence-WoodKelsey MaddenKim MurrayPsychiatry Department, VA Boston Healthcare System, Boston University, Boston, MA, United StatesPsychiatry Department, The MacDonald Franklin Operational Stress Injury Research Centre, University of Western Ontario, London, ON, CanadaPsychiatry Department, The MacDonald Franklin Operational Stress Injury Research Centre, University of Western Ontario, London, ON, CanadaKing's Centre for Military Health Research, Kings College London, London, United KingdomPsychology Department, Phoenix Australia - Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, VIC, AustraliaVA Boston Healthcare System, Boston, MA, United StatesPsychology Department, University of Ottawa, Ottawa, ON, CanadaPsychology Department, Phoenix Australia - Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, VIC, AustraliaCenter of Excellence for Research on Returning War Veterans, Central Texas Veterans Health Care System, Temple, TX, United StatesPsychology Department, Ariel University, Ariel, IsraelBehavioral Sciences Department, Ruppin Academic Center, Emek Hefer, IsraelPotentially morally injurious events (PMIEs) entail acts of commission (e.g., cruelty, proscribed or prescribed violence) or omission (e.g., high stakes failure to protect others) and bearing witness (e.g., to grave inhumanity, to the gruesome aftermath of violence), or being the victim of others' acts of commission (e.g., high stakes trust violations) or omission (e.g., being the victim of grave individual or systemic failures to protect) that transgress deeply held beliefs and expectations about right and wrong. Although there is a proliferation of interest in moral injury (the outcome associated with exposure to PMIEs), there has been no operational definition of the putative syndrome and no standard assessment scheme or measure, which has hampered research and care in this area. We describe an international effort to define the syndrome of moral injury and develop and validate the Moral Injury Outcome Scale (MIOS) in three stages. To ensure content validity, in Stage I, we conducted interviews with service members, Veterans, and clinicians/Chaplains in each country, inquiring about the lasting impact of PMIEs. Qualitative analysis yielded six operational definitions of domains of impact of PMIEs and components within domains that establish the parameters of the moral injury syndrome. From the domain definitions, we derived an initial pool of scale items. Stage II entailed scale refinement using factor analytic methods, cross-national invariance testing, and internal consistency reliability analyses of an initial 34-item MIOS. A 14-item MIOS was invariant and reliable across countries and had two factors: Shame-Related (SR) and Trust-Violation-Related (TVR) Outcomes. In Stage III, MIOS total and subscale scores had strong convergent validity, and PMIE-endorsers had substantially higher MIOS scores vs. non-endorsers. We discuss and contextualize the results and describe research that is needed to substantiate these inaugural findings to further explore the validity of the MIOS and moral injury, in particular to examine discriminant and incremental validity.https://www.frontiersin.org/articles/10.3389/fpsyt.2022.923928/fullmoral injury syndromemoral injury outcome scalemultinationalpsychometric evaluationmoral injury outcome scale consortium |
| spellingShingle | Brett T. Litz Rachel A. Plouffe Anthony Nazarov Dominic Murphy Andrea Phelps Alanna Coady Stephanie A. Houle Lisa Dell Sheila Frankfurt Gadi Zerach Yossi Levi-Belz The Moral Injury Outcome Scale Consortium Andrea Ashbaugh Julie Yeterian Danielle Berke Jessica Carney Mackenzie Cummings Ruth Chartoff Stephanie Ellickson-Larew Breanna Grunthal Maya Bina N. Vannini Frank Weathers Luke Rusowicz-Orazem Patrick Smith Fardous Hosseiny Lisa King J. Don Richardson Alexandra McIntyre-Smith David Forbes Kim Jones Ellie Lawrence-Wood Kelsey Madden Kim Murray Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium Frontiers in Psychiatry moral injury syndrome moral injury outcome scale multinational psychometric evaluation moral injury outcome scale consortium |
| title | Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium |
| title_full | Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium |
| title_fullStr | Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium |
| title_full_unstemmed | Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium |
| title_short | Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium |
| title_sort | defining and assessing the syndrome of moral injury initial findings of the moral injury outcome scale consortium |
| topic | moral injury syndrome moral injury outcome scale multinational psychometric evaluation moral injury outcome scale consortium |
| url | https://www.frontiersin.org/articles/10.3389/fpsyt.2022.923928/full |
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