The Moral Injury and Distress Scale: Psychometric Evaluation and Initial Validation in Three High-Risk Populations

Objective: The concept of moral injury resonates with impacted populations, but research has been limited by existing measures, which have primarily focused on war veterans and asked about exposure to potentially morally injurious events (PMIEs) rather than PMIE exposure outcomes. Our goal was to develop and examine the psychometric properties of the Moral Injury and Distress Scale (MIDS), a new measure of the possible emotional, cognitive, behavioral, social, and/or spiritual sequelae of PMIE exposure. Method: The MIDS was validated by surveying three groups: military veterans, healthcare workers, and first responders (N= 1,232). Results: Most respondents (75.0%; n = 924) reported PMIE exposure. Analyses yielded 18 items that contributed to a single latent factor representing moral distress with fully or partially invariant configurations, loadings, and intercepts across occupational groups. The MIDS full-scale score demonstrated excellent internal consistency (alpha =.95) and moderate 2-week stability (r =.68, p,.001, n= 155). For convergent validity, associations between the MIDS and PMIE exposure measures, as well as putative indicators of moral injury (e.g., guilt, shame), were positive and large (r =.59-.69, p,.001), as were correlations with posttraumatic stress, depressive, and insomnia symptoms (r =.51-.67, p,.001). The MIDS was a stronger predictor of functioning than PMIE exposure measures, explaining seven times greater unique variance (9% vs. 1%-1.3%). Conclusions: The MIDS is the first scale to assess moral injury symptoms indexed to a specific PMIE that is validated across several high-risk populations.