Proposing the Integrated Pathway Model of Moral Injury (IPM-MI) : A Moderated Mediation Analysis of Moral Injury Among Secure Mental Healthcare Staff

Moral injury is a prevalent issue for secure mental healthcare staff, though understanding of the underlying mechanisms is limited. This multi-study paper explores several developmental, cognitive and emotional pathways to moral injury and associated wellbeing outcomes. Frontline and support staff from secure mental healthcare services were recruited to two cross-sectional studies (n = 527 and n = 325, respectively), and completed several questionnaires. In the first study, findings indicated a serial mediating effect of childhood trauma symptoms, early maladaptive schemas, and maladaptive metacognitions in the pathway between exposure to potentially morally injurious events and moral injury symptoms. Moderating effects of social and organisational support were also apparent. Findings from study two supported pathways between moral injury and psychological, somatic and functional outcomes, which were mediated by negative emotional schema, with limited mediating effects for expressive suppression. Moderating effects of alexithymia on several mediating pathways were also noted. The results support a developmental-cognitive model to account for the development of moral injury and associated adverse well-being outcomes in secure mental healthcare staff. Drawing on the findings and wider literature, the Integrated Pathway Model of Moral Injury (IPM-MI) is proposed and discussed, offering a novel theoretical account that may inform several potential prevention and intervention strategies.