Skip to main content Accessibility help
×
Home

Occupational moral injury and mental health: systematic review and meta-analysis

  • Victoria Williamson (a1), Sharon A.M. Stevelink (a1) and Neil Greenberg (a1)

Abstract

Background

Many people confront potentially morally injurious experiences (PMIEs) in the course of their work which can violate deeply held moral values or beliefs, putting them at risk for psychological difficulties (e.g. post-traumatic stress disorder (PTSD), depression, etc.).

Aims

We aimed to assess the effect of moral injury on mental health outcomes.

Method

We conducted a systematic review and meta-analysis to assess the association between work-related PMIEs and mental health disorders. Studies were independently assessed for methodological quality and potential moderator variables, including participant age, gender and PMIE factors, were also examined.

Results

Thirteen studies were included, representing 6373 participants. PMIEs accounted for 9.4% of the variance in PTSD, 5.2% of the variance in depression and 2.0% of the variance in suicidality. PMIEs were associated with more symptoms of anxiety and behavioural problems (e.g. hostility), although this relationship was not consistently significant. Moderator analyses indicated that methodological factors (e.g. PMIE measurement tool), demographic characteristics and PMIE variables (e.g. military v. non-military context) did not affect the association between a PMIE and mental health outcomes.

Conclusions

Most studies examined occupational PMIEs in military samples and additional studies investigating the effect of PMIEs on civilians are needed. Given the limited number of high-quality studies available, only tentative conclusions about the association between exposure to PMIEs and mental health disorders can be made.

Declaration of interest

None.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Occupational moral injury and mental health: systematic review and meta-analysis
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Occupational moral injury and mental health: systematic review and meta-analysis
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Occupational moral injury and mental health: systematic review and meta-analysis
      Available formats
      ×

Copyright

Corresponding author

Correspondence: Victoria Williamson, Kings Centre for Military Health Research, Institute of Psychology, Psychiatry and Neuroscience, King's College London, London SE5 9RJ, UK. Email: victoria.williamson@kcl.ac.uk

References

Hide All
1Litz, BT, Stein, N, Delaney, E, Lebowitz, L, Nash, WP, Silva, C, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev 2009; 29: 695706.
2Farnsworth, JK, Drescher, KD, Nieuwsma, JA, Walser, RB, Currier, JM. The role of moral emotions in military trauma: implications for the study and treatment of moral injury. Rev Gen Psychol 2014; 18(4): 249. doi:10.1037/gpr0000018.
3Frankfurt, S, Frazier, P. A review of research on moral injury in combat veterans. Mil Psychol 2016; 28: 318–30.
4Bryan, AO, Bryan, CJ, Morrow, CE, Etienne, N, Ray-Sannerud, B. Moral injury, suicidal ideation, and suicide attempts in a military sample. Traumatology (Tallahass Fla) 2014; 20: 154–60.
5Bryan, CJ, Bryan, AO, Anestis, MD, Anestis, JC, Green, BA, Etienne, N, et al. Measuring moral injury. Assessment 2016; 23: 557–70.
6Drescher, KD, Foy, DW, Kelly, C, Leshner, A, Schutz, K, Litz, B. An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology (Tallahass Fla) 2011; 17: 813.
7Nash, WP, Marino Carper, TL, Mills, MA, Au, T, Goldsmith, A, Litz, BT. Psychometric evaluation of the moral injury events scale. Mil Med 2013; 178: 646–52.
8Backholm, K, Idås, T. Ethical dilemmas, work-related guilt, and posttraumatic stress reactions of news journalists covering the terror attack in Norway in 2011. J Trauma Stress 2015; 28: 142–8.
9Komarovskaya, I, Maguen, S, McCaslin, SE, Metzler, TJ, Madan, A, Brown, AD, et al. The impact of killing and injuring others on mental health symptoms among police officers. J Psychiatr Res 2011; 45: 1332–6.
10Lamiani, G, Borghi, L, Argentero, P. When healthcare professionals cannot do the right thing: a systematic review of moral distress and its correlates. J Health Psychol 2017; 22: 5167.
11Oh, Y, Gastmans, C. Moral distress experienced by nurses. Nurs Ethics 2015; 22: 1531.
12Dombo, EA, Gray, C, Early, BP. The trauma of moral injury: beyond the battlefield. J Relig Spiritual Soc Work Soc Thought 2013; 32: 197210.
13Moher, D, Liberati, A, Tetzlaff, J, Altman, DG, Grp, P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement (Reprinted from annals of internal medicine). Phys Ther 2009; 89: 873–80.
14Currier, JM, Holland, JM, Drescher, K, Foy, D. Initial psychometric evaluation of the moral injury questionnaire-military version. Clin Psychol Psychother 2015; 22: 5463.
15Ajetunmobi, O. Making Sense of Critical Appraisal. Arnold, 2002.
16Crane, M, Phillips, J, Karin, E. Trait perfectionism strengthens the negative effects of moral stressors occurring in veterinary practice. Aust Vet J 2015; 93: 354–60.
17Currier, JM, Holland, JM, Rojas-Flores, L, Herrera, S, Foy, D. Morally injurious experiences and meaning in Salvadorian teachers exposed to violence. Psychol Trauma Theory, Res Pract Policy 2015; 7: 2433.
18Dennis, PA, Dennis, NM, Van Voorhees, EE, Calhoun, PS, Dennis, MF, Beckham, JC. Moral transgression during the Vietnam War: a path analysis of the psychological impact of veterans’ involvement in wartime atrocities. Anxiety, Stress Coping 2017; 30: 188201.
19Ferrajão, PC, Oliveira, RA. Self-awareness of mental states, self-integration of personal schemas, perceived social support, posttraumatic and depression levels, and moral injury: a mixed-method study among Portuguese war veterans. Traumatology (Tallahass Fla) 2014; 20: 277–85.
20Ritov, G, Barnetz, Z. The interrelationships between moral attitudes, posttraumatic stress disorder symptoms and mixed lateral preference in Israeli reserve combat troops. Int J Soc Psychiatry 2014; 60(6): 606–12. doi:10.1177/0020764013502469.
21Tripp, JC, McDevitt-Murphy, ME, Henschel, AV. Firing a weapon and killing in combat are associated with suicidal ideation in OEF/OIF veterans. Psychol Trauma Theory, Res Pract Policy 2016; 8: 626–33.
22Wilk, JE, Bliese, PD, Thomas, JL, Wood, MD, McGurk, D, Castro, CA, et al. Unethical battlefield conduct reported by soldiers serving in the Iraq War. J Nerv Ment Dis 2013; 201: 259–65.
23Beck, AT, Steer, RA. Manual for the beck anxiety inventory. Psychological Corporation, 1990.
24Dozois, DJA, Covin, R. The Beck Depression Inventory-II (BDI-II), Beck Hopelessness Scale (BHS), and Beck Scale for Suicide Ideation (BSS). In Comprehensive Handbook of Psychological Assessment Volume 2, Personality Assessment (eds. MJ Hilsenroth, DL Segal): 50–69. John Wiley & Sons, 2004.
25Blake, DD, Weathers, FW, Nagy, LM, Kaloupek, DG, Gusman, FD, Charney, DS, et al. The development of a clinician-administered PTSD Scale. J Trauma Stress 1995; 8(1): 7590. doi:10.1007/BF02105408.
26Weiss, DS, Brunet, A, Best, SR, Metzler, TJ, Liberman, A, Marmar, CR. Frequency and severity approaches to indexing exposure to trauma: the critical incident history questionnaire for police officers. JoTS 2010; 23(6): 734–43. doi:10.1002/jts.20576.
27Han, K, Weed, NC, Calhoun, RF, Butcher, JN. Psychometric characteristics of the MMPI-2 Cook-Medley Hostility scale. J Pers Assess 1995; 65(3): 567–85. doi:10.1207/s15327752jpa6503_15.
28Lovibond, S, Lovibond, P. Depression anxiety and stress scale. Manual for the Depression and Anxiety Stress Scales. DASS Publications, 1995.
29King, LA, King, DW, Vogt, DS, Knight, J, Samper, RE. Deployment Risk and Resilience Inventory: a collection of measures for studying deployment-related experiences of military personnel and veterans. Mil Psych 2006; 18(2): 89120. doi:10.1207/s15327876mp1802_1.
30Spitzer, RL, Kroenke, JP, Williams, L. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006; 166(10): 1092–7. doi:10.1001/archinte.166.10.1092.
31Horowitz, L, Wilner, M, Alvarez, N, Weiss, W, Marmar, DS, Neal, CR, et al. Impact of event scale – revised. Psychosom Med 1979; 41: 209–18.
32Cohen, S, Hoberman, H. Interpersonal support evaluation list (ISEL). J Appl Soc Psychol 1983; 58: 304–9. doi:10.1017/CBO9781107415324.004.
33King, LA, King, DW, Leskin, G, Foy, DW. The Los Angeles symptom checklist: a self-report measure of posttraumatic stress disorder. Assessment 1995; 2(1): 117.
34Lauterbach, D, Vrana, S, King, DW, King, LA. Psychometric properties of the civilian version of the Mississippi PTSD Scale. J Trauma Stress 1997; 10(3): 499513. doi:10.1023/A:1024801607043.
35Watson, D, Clark, LA, Tellegen, A. Development and validation of brief measures of positive and negative affect: the PANAS scales. J Pers Soc Psychol 1988; 54(6): 1063.
36Gameroff, MJ, Wickramaratne, P, Weissman, MM. Testing the Short and Screener versions of the Social Adjustment Scale – Self-report (SAS-SR). Int J Methods Psychiatr Res 2012; 21(1): 5265. doi:10.1002/mpr.358.
37Linehan, MM, Clinics, T. Suicidal behaviors questionnaire. Assessment 2001; 8(4): 443–54.
38Beck, AT, Kovacs, M, Weissman, A. Assessment of suicidal intention: the scale for suicide ideation. J Consult Clin Psychol 1979; 47(2): 343. doi:10.1037/0022-006X.47.2.343.
39Spielberger, CD. State-trait anger expression inventory. J Am Coll Cardiol 1988; 36: 1781–8. doi:10.1177/0306624X9804200206.
40Wilson, JP, Zigelbaum, SD. The Vietnam veteran on walk: The relation of post-traumatic stress disorder to criminal behaviour. Behav Sci Law 1983; 1(3): 6983. doi:10.1002/bsl.2370010308.
41Viechtbauer, W. Conducting meta-analyses in R with the meta for package. J Stat Softw 2010; 6(3): 148. doi:10.1103/PhysRevB.91.121108.
42Field, AP. Meta-analysis of correlation coefficients: a Monte Carlo comparison of fixed- and random-effects methods. Psychol Methods 2001; 6: 161–80.
43Rosenthal, R. Writing meta-analytic reviews. Psychol Bull 1995; 118: 183–92.
44Cohen, J. Statistical Power Analysis for the Behavioral Sciences. Elsevier, 1988.
45Hedges, LV, Vevea, JL. Fixed- and random-effects models in meta-analysis. Psychol Methods 1998; 3: 486504.
46Huedo-Medina, TB, Sánchez-Meca, J, Marín-Martínez, F, Botella, J. Assessing heterogeneity in meta-analysis: Q statistic or I2 index? Psychol Methods 2006; 11: 193206.
47Borenstein, M, Hedges, LV, Higgins, JPT, Rothstein, HR. Introduction to Meta-Analysis. John Wiley & Sons, 2011.
48Bakermans-Kranenburg, MJ, van IJzendoorn, MH, Juffer, F. Less is more: meta-analyses of sensitivity and attachment interventions in early childhood. Psychol Bull 2003; 129: 195215.
49Begg, CB, Mazumdar, M. Operating characteristics of a rank correlation test for publication bias. Biometrics 1994; 50: 1088.
50Egger, M, Smith, GD, Schneider, M, Minder, C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315: 629–34.
51Duval, S, Tweedie, R. Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000; 56: 455–63.
52Weathers, FW, Litz, BT, Herman, DS, Huska, JA, Keane, TM. The PTSD Checklist (PCL): Reliability, Validity, and Diagnostic Utility. Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies, San Antonio, TX, October, 1993.
53Beck, A, Steer, R, Brown, G. Beck Depression Inventory-II (BDI-II). The Psychological Corporation, 1993.
54Kroenke, K, Spitzer, RL, Williams, JBW. The PHQ-9. J Gen Intern Med 2001; 16: 606–13.
55Derogatis, LR. BSI Brief Symptom Inventory: Administration, Scoring, and Procedure Manual (4th edn). National Computer Systems, 1993.
56Smith, BW, Dalen, J, Wiggins, K, Tooley, E, Christopher, P, Bernard, J. The brief resilience scale: assessing the ability to bounce back. Int J Behav Med 2008; 15(3): 194200. doi:10.1080/10705500802222972.
57Moyo, H. Pastoral care in the healing of moral injury: a case of the Zimbabwe National Liberation War Veterans. HTS Teol Stud/Theol Stud 2015; 71: 111.
58American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, (5th edn). American Psychiatric Association, 2013.
59Hunt, MR. Ethics beyond borders: how health professionals experience ethics in humanitarian assistance and development work. Dev World Bioeth 2008; 8: 5969.
60Schwartz, L, Sinding, C, Hunt, M, Elit, L, Redwood-Campbell, L, Adelson, N, et al. Ethics in humanitarian aid work: learning from the narratives of humanitarian health workers. AJOB Prim Res 2010; 1: 4554.
61Griffith, J. Suicide and war: the mediating effects of negative mood, posttraumatic stress disorder symptoms, and social support among Army National Guard soldiers. Suicide Life Threat Behav 2012; 42: 453–69.
62LeardMann, CA, Powell, TM, Smith, TC, Bell, MR, Smith, B, Boyko, EJ, et al. Risk factors associated with suicide in current and former US military personnel. JAMA 2013; 310(5): 496506. doi:10.1001/jama.2013.65164.
63Worthen, M, Ahern, J. The causes, course, and consequences of anger problems in veterans returning to civilian life. J Loss Trauma 2014; 19: 355–63.
64Epstein, EG, Delgado, S. Understanding and addressing moral distress. Online J Issues Nurs 2010; 15(3). doi:10.3912/OJIN.Vol15No03Man01.

Keywords

Type Description Title
WORD
Supplementary materials

Williamson et al. supplementary material
Tables S1-S3

 Word (58 KB)
58 KB

Occupational moral injury and mental health: systematic review and meta-analysis

  • Victoria Williamson (a1), Sharon A.M. Stevelink (a1) and Neil Greenberg (a1)

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Occupational moral injury and mental health: systematic review and meta-analysis

  • Victoria Williamson (a1), Sharon A.M. Stevelink (a1) and Neil Greenberg (a1)
Submit a response

eLetters

No eLetters have been published for this article.

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *