Litz Brett T, Plouffe Rachel A, Nazarov Anthony, Murphy Dominic, Phelps Andrea, Coady Alanna, Houle Stephanie A, Dell Lisa, Frankfurt Sheila, Zerach Gadi, Levi-Belz Yossi
Psychiatry Department, VA Boston Healthcare System, Boston University, Boston, MA, United States.
Psychiatry Department, The MacDonald Franklin Operational Stress Injury Research Centre, University of Western Ontario, London, ON, Canada.
Front Psychiatry. 2022 Jul 5;13:923928. doi: 10.3389/fpsyt.2022.923928. eCollection 2022.
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 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: (SR) and (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.
潜在的道德伤害事件（PMIEs）包括作为行为（如残忍、被禁止或规定的暴力行为）或不作为行为（如在高风险情况下未能保护他人）以及见证行为（如目睹严重的不人道行为、暴力的可怕后果），或者成为他人作为行为（如严重违反信任）或不作为行为（如成为严重的个人或系统性保护失败的受害者）的受害者，这些行为违反了人们对是非的根深蒂固的信念和期望。尽管对道德伤害（与接触PMIEs相关的结果）的兴趣激增，但尚未对这种假定的综合征进行操作性定义，也没有标准的评估方案或测量方法，这阻碍了该领域的研究和护理。我们描述了一项国际努力，分三个阶段定义道德伤害综合征并开发和验证道德伤害结果量表（MIOS）。为确保内容效度，在第一阶段，我们在每个国家对现役军人、退伍军人以及临床医生/牧师进行了访谈，询问PMIEs的持久影响。定性分析得出了PMIEs的六个操作性定义以及确定道德伤害综合征参数的领域内的组成部分。从这些领域定义中，我们得出了量表项目的初始池。第二阶段需要使用因子分析方法、跨国不变性测试以及对初始34项MIOS进行内部一致性可靠性分析来完善量表。一个14项的MIOS在各国具有不变性且可靠，并有两个因子：（SR）和（TVR）结果。在第三阶段，MIOS总分和子量表得分具有很强的收敛效度，认可PMIEs的人比不认可的人MIOS得分显著更高。我们讨论并将结果置于背景中，并描述为证实这些初步发现所需的研究，以进一步探索MIOS和道德伤害的有效性，特别是检验区分效度和增量效度。
