Prevalence of moral injury in nationally representative samples of combat Veterans, healthcare workers, and first responders

Abstract: Background: Moral injury affects a variety of populations who make ethically complex decisions involving their own and others’ well-being, including combat veterans, healthcare workers, and first responders. Yet little is known about occupational differences in the prevalence of morally injurious exposures and outcomes in nationally representative samples of such populations. Objective: To examine prevalence of potentially morally injurious event (PMIE) exposure and clinically meaningful moral injury in three high-risk groups. Design: Cross-sectional survey with responses weighted to national geodemographic benchmarks. Participants: Combat veterans, healthcare workers, and first responders (N=1232) in the USA. Main Measure: Moral Injury and Distress Scale (MIDS). Key Results: Many combat veterans (49.3%), healthcare workers (50.8%), and first responders (41.6%) endorsed exposure to a PMIE. Clinically meaningful moral injury symptoms were endorsed by 6.5% of combat veterans, 7.3% of healthcare workers, and 4.1% of first responders. After adjusting for age, gender, race, and ethnicity, relative to first responders, combat veterans were more likely to endorse transgressing their values by what they did and healthcare workers were more likely to endorse witnessing others’ wrongful acts. Additionally, combat veterans (adjusted risk ratio (aRR) = 2.18, 95% confidence interval (95% CI) = 1.09, 2.16) and healthcare workers (aRR = 2.02, 95% CI = 1.03, 3.83) were over twice as likely to screen positive for clinically meaningful moral injury in comparison to first responders. No differences in exposures or outcomes emerged between combat veterans and healthcare workers. Conclusions: Results from these nationally representative samples of three high-risk populations suggest that exposure to PMIEs is common and a sizable minority report clinically meaningful moral injury.

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