Compromised Conscience: A Scoping Review of Moral Injury Among Firefighters, Paramedics, and Police Officers

Abstract

BackgroundPublic Safety Personnel (e.g., firefighters, paramedics, and police officers) are routinely exposed to human suffering and need to make quick, morally challenging decisions. Such decisions can affect their psychological wellbeing. Participating in or observing an event or situation that conflicts with personal values can potentially lead to the development of moral injury. Common stressors associated with moral injury include betrayal, inability to prevent death or harm, and ethical dilemmas. Potentially psychologically traumatic event exposures and post-traumatic stress disorder can be comorbid with moral injury; however, moral injury extends beyond fear to include spiritual, cognitive, emotional or existential struggles, which can produce feelings of severe shame, guilt, and anger.ObjectiveThis scoping review was designed to identify the extant empirical research regarding the construct of moral injury, its associated constructs, and how it relates to moral distress in firefighters, paramedics, and police officers.MethodsA systematic literature search of peer-reviewed research was conducted using databases MEDLINE, EMBASE, APA PsychInfo, CINHAL PLUS, Web of Science, SCOPUS, and Google Scholar. Included studies were selected based on the inclusion criteria before being manually extracted and independently screened by two reviewers.ResultsThe initial database search returned 777 articles, 506 of which remained after removal of duplicates. Following review of titles, abstracts, and full texts, 32 studies were included in the current review. Participants in the articles were primarily police officers, with fewer articles focusing on paramedics and firefighters. There were two studies that included mixed populations (i.e., one study with police officers, firefighters, and other emergency service workers; one study with paramedic and firefighter incident commanders). Most studies were qualitative and focused on four topics: values, ethical decision-making, organizational betrayal, and spirituality.ConclusionPublic safety organizations appear to recognize the experience of moral distress or moral injury among public safety personnel that results from disconnects between personal core values, formal and informal organizational values, vocational duties, and expectations. Further research is needed to better understand moral distress or moral injury specific to public safety personnel and inform training and treatment in support of public safety personnel mental health.

Development and preliminary evaluation of the moral injury assessment for public safety personnel.

“…The present investigation extends the study of MI to the work-related experiences of PSP. Despite the emerging recognition of the relevance of MI within this population (Lentz et al, 2021), the MIA-PSP is the first tool to capture aspects of MI uniquely relevant to PSP. Our approach, which integrated phenomenological and syndromal perspectives guided by theory and clinical expertise, resulted in a measure of morally injurious experiences in PSP with promising psychometric properties.…”

Moral Injury: An Increasingly Recognized and Widespread Syndrome

“…Research indicates that police (Papazoglou & Chopko, 2017 ; Papazoglou et al, 2020 ), paramedics and emergency medical technicians (Murray, 2019 ), firemen and other first responders (Joannou et al, 2017 ; Lentz et al, 2021 ) are at increased risk of MI because of their repeated exposure to violence, trauma, and severe injuries as part of their daily work. There are times when decision must be made (or errors in judgment) that may lead to loss of life, over which there is much remorse.…”

Meat in a Seat: A Grounded Theory Study Exploring Moral Injury in Canadian Public Safety Communicators, Firefighters, and Paramedics

“…To date, there is very little research examining MI in PSP, and the available research has been primarily theoretical in nature or has examined constructs related to moral suffering. A recent scoping review of the evidence-based literature did not identify any studies related to MI and PSP; however, it was determined that there was evidence for four MI associated constructs-values, moral decision-making, organizational betrayal, and spirituality-within PSP literature [21].…”