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

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.

Highlights

• Important measurement issues exist for scales of moral distress and moral injury.
• Many scales conflate measurement of exposure and expression/outcomes.
• Most scales of “moral distress” should only be used to assess exposure.
• The Moral Injury Outcome Scale is currently the most robust measure of moral injury.
• Better delineation of potential moral stressors and outcomes is sorely needed.