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What is Moral injury?

Moral injury refers to the profound psychological distress that can arise from being exposed to various situations involving actions that go against one's core beliefs (e.g. Litz et al., 2009, Ter Heide & Olff, 2023). It occurs when individuals betray their own sense of right and wrong, leading to intense self-condemnation, spiritual struggles, and internal conflict regarding the moral implications of their actions. Experiencing moral injury carries significant emotional risks, as individuals may perceive their transgressions as irreparable, resulting in feelings of shame, guilt, despair, and loss of morale. Research suggests that moral injury is linked to cognitive and behavioral changes, including social withdrawal, suicidal tendencies, burnout, and psychiatric disorders such as depression and PTSD.



1. Translation and Validation of Moral Injury Scales in Brazil


Project group

PI: Bruno Messina Coimbra, PhD

Project group: Brendon Griffin, Chris Hoeboer, Shira Maguen, Andrea Feijo Mello, Marcelo Feijo Mello, Sonya Norman, Miranda Olff


The COVID-19 pandemic has exacerbated ethical dilemmas faced by healthcare workers globally, particularly in developing countries where resource scarcity is prevalent. This situation has contributed to the emergence of significant symptoms of moral injury among healthcare professionals. However, it is worth noting that the moral injury literature currently lacks sufficient representation from these countries.


Aims and method

As evidence from developing countries may help to bring more insight into the moral challenges imposed on healthcare workers globally, we aim to introduce moral injury studies in Brazil by translating and validating two scales to Brazilian Portuguese: the Moral Injury Symptom Scale (MISS-HP) and the Moral Injury Distress Scale (MIDS). Given the significant emotional burden experienced by Brazilian healthcare workers during the COVID-19 pandemic, this research holds particular relevance.

To ensure the validity of both the MISS-HP and the MIDS, we will follow the four-step guidelines outlined by the World Health Organization for scale translation and validation. Following this process, we intend to promote the study through social media platforms and recruit 300 healthcare workers in Brazil to participate in an online survey. To establish convergent and divergent validity, we

will employ scales that measure depression, anxiety, PTSD, burnout, and religious conflicts. Additionally, the construct validity of the Brazilian versions of the MISS-HP and the MIDS will be assessed using exploratory factor analysis. By undertaking these steps, we expect to contribute valuable insights into moral injury experienced by healthcare workers in Brazil.

Moral injury

Instruments to assess moral injury 

Morally injurious events

  • Moral Injury Events Scale (MIES)

9-items, English, freely available here

The MIES is a concise 9-item scale investigating exposure to potentially morally injurious events either perpetrated or witnessed by the individual, and betrayal experiences. Respondents are asked to indicate their level of agreement with each statement on the 9-item scale. Initially developed for veterans, the MIES has been subsequently adapted for use with civilian populations (Nash et al., 2013; Thomas et al., 2023).

Morally injurious events + moral injury sequelae

  • The Moral Injury and Distress Scale (MIDS)

18 items, English, available here

The MIDS offers a comprehensive evaluation of the emotional, cognitive, spiritual, social, and/or behavioral consequences stemming from potentially morally injurious events. Respondents are first asked to identify one or more events in which they were bothered by something that they did, failed to do, or witnessed and that transgressed their moral beliefs. If participants endorse the occurrence of such events, they respond an 18-item questionnaire measuring the intensity of morally injurious sequelae. The MIDS (in English) was validated among veterans, healthcare workers, and first responders (Norman et al., 2023).

  • The Occupational Moral Injury Scale (OMIS) 

20 items, English, available here:  

The OMIS is a 20-item measure of moral injury experiences in occupational settings. The OMIS is generalised enough in its wording to allow use across any occupational setting, without the requirement for alteration. The OMIS assesses five kinds of morally injurious events (MIEs; commission with agency, commission under duress, acts of omission, witnessing and betrayal) in addition to five primary markers of moral injury (guilt, shame, anger, loss of trust, existential conflict), applying a bifactor model structure to do so. Respondents are asked to rate on a 7-point likert scale how much they agree or disagree with 20 statements describing difficult workplace experiences. Examples of some of the items include, “I’m angry because my workplace expects a lot from employees but doesn’t look after us in turn”, “Ignoring my conscience in order to do my job has made it hard for me to trust myself”, and “I feel guilty over things I’ve been made to do at work that I don’t morally agree with”. The OMIS was developed and validated among frontline health and first responder workers (Thomas et al., 2023).

Moral injury sequelae

  • The Moral Injury Symptom Scale – Health Professionals (MISS-HP)

10 items, English, freely available here

The MISS-HP is designed to assess the severity of moral injury symptoms specifically among healthcare workers. This 10-item questionnaire asks respondents to rate their level of agreement, on a scale from 1 to 10, with each statement. The MISS-HP covers various aspects of moral injury, including feelings of betrayal, guilt, shame, moral concerns, religious struggle, loss of religious or spiritual faith, loss of meaning or purpose, difficulty forgiving, loss of trust, and self-condemnation. The scale aims to provide insight into the specific challenges and psychological impact of moral injury experienced by healthcare professionals (Mantri et al., 2020).

  • Expressions of Moral Injury Scale (EMIS)

17 items, English

The EMIS is a measure of moral injury-related outcomes through a 17-item scale. These items capture emotions, beliefs, attitudes, and behaviors that reflect moral injury. The EMIS has two dimensions: Self-Directed moral injury and Other-Directed moral injury. The former focuses on the psychological distress experienced by individuals due to their own moral transgressions or perceived moral failures, while the latter pertains to the emotional and psychological distress resulting from witnessing or being exposed to moral transgressions committed by others. The original version of the EMIS was specifically designed to evaluate moral injury outcomes within military populations. Subsequently, it was adapted for application among civilian populations as well (Currier et al., 2018; Thomas et al., 2013).


  • Currier, J. M., Farnsworth, J. K., Drescher, K. D., McDermott, R. C., Sims, B. M., & Albright, D. L. (2018). Development and evaluation of the Expressions of Moral Injury Scale-Military Version. Clinical psychology & psychotherapy, 25(3), 474–488.

  • Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695–706. 10.1016/j.cpr.2009.07.003

  • Mantri, S., Lawson, J. M., Wang, Z., & Koenig, H. G. (2020). Identifying Moral Injury in Healthcare Professionals: The Moral Injury Symptom Scale-HP. Journal of religion and health, 59(5), 2323–2340.

  • Nash, W. P., Marino Carper, T. L., Mills, M. A., Au, T., Goldsmith, A., & Litz, B. T. (2013). Psychometric evaluation of the Moral Injury Events Scale. Military medicine, 178(6), 646–652.

  • Norman, S. B., Griffin, B. J., Pietrzak, R. H., McLean, C., Hamblen, J. L., & Maguen, S. (2023). The Moral Injury and Distress Scale: Psychometric evaluation and initial validation in three high-risk populations. Psychological trauma : theory, research, practice and policy, 10.1037/tra0001533. Advance online publication.

  • Ter Heide, F.J.J. & Olff, M. (2023). Widening the scope: defining and treating moral injury in diverse populations, European Journal of Psychotraumatology,  14:2, DOI: 10.1080/20008066.2023.2196899

  • Thomas, V., Bizumic, B., Cruwys, T., & Walsh, E. (2023). Measuring civilian moral injury: Adaptation and validation of the Moral Injury Events Scale (Civilian) and Expressions of Moral Injury Scale (Civilian). Psychological trauma : theory, research, practice and policy, 10.1037/tra0001490. Advance online publication.

  • Thomas, V., Bizumic, B., & Quinn, S. (2023, May 30). The Occupational Moral Injury Scale (OMIS) - Development and Validation in Frontline Health and First Responder Workers. 

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