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First Scale to Assess Moral Injury Symptoms in Military and Civilian Populations

September 19, 2023

Takeaway: The Moral Injury and Distress Scale (MIDS) is the first measure to assess moral injury symptoms, indexed to a specific event, which is validated across several high-risk populations, including Veterans, healthcare workers, and first responders.

Moral injury refers to the emotional, cognitive, behavioral, social, and/or spiritual impacts of participating in or witnessing a highly stressful event that transgresses one’s core moral beliefs or expectations. Research on moral injury proliferated over the last decade, most commonly in studies of combat Veterans. There also is a growing interest in moral injury among civilian populations, such as healthcare workers entrenched in the COVID-19 pandemic. Research showing that moral injury is common, distressing, and impairing across populations has revealed a need for a measure suitable for diverse populations. Thus, investigators with the National Center for PTSD, led by Sonya B. Norman, PhD, and HSR&D investigators, Shira Maguen, PhD and Brandon Griffin, PhD, developed and tested the Moral Injury and Distress Scale (MIDS)—a new measure of moral injury applicable to a wide range of potentially morally injurious event (PMIEs) and populations. Using the newly developed MIDS, they surveyed 1,232 combat Veterans, healthcare workers, and first responders, of which 75% reported exposure to a PMIE. Participants also reported on the severity of any mental health symptoms (i.e., depression, PTSD, insomnia, alcohol use) and functional impairment they were experiencing.


The MIDS contains 18 items that are summed to create a total score with excellent internal consistency and good stability across repeated administrations. The single-factor structure generally replicated across populations, allowing for group comparisons revealing similar levels of moral injury symptom severity among combat Veterans, healthcare workers, and first responders. Associations of scores on the MIDS with measures of PMIE exposure and putative indicators of moral injury (e.g., guilt, shame) were positive and large, as were correlations with measures of the most closely related post-traumatic psychopathology, including PTSD symptoms, depression, insomnia, and psychosocial impairment. Further, the MIDS was a stronger predictor of functional impairment than existing measures of PMIE exposure, explaining more unique variance (9% vs. 1%–1.3%) in difficulties experienced at work and school, in close relationships, and with self-care.

Investigators also aim to validate the MIDS in other populations, such as active-duty military personnel, child protective services workers, border patrol agents, medical students, displaced populations, teachers, and those exposed to mass violence events (e.g., school shootings).

Norman S, Griffin B, Pietrzak R, McLean C, Hamblen J, and Maguen S. The Moral Injury and Distress Scale: Psychometric evaluation and initial validation in three high-risk populations. Psychological Trauma. June 22, 2023; online ahead of print.

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