Validation of the Expressions of Moral Injury Scale‐Military version‐Short Form

Abstract

Military personnel may encounter morally injurious events that lead to emotional, social, and spiritual suffering that transcend and/or overlap with mental health diagnoses (e.g., post-traumatic stress disorder [PTSD]). Advancement of scientific research and potential clinical innovation for moral injury (MI) requires a diversity of measurement approaches. Drawing on results from the bifactor model in Currier et al.'s (2017) psychometric evaluation of the Expressions of Moral Injury Scale-Military version (EMIS-M), this study validated a four-item short form of the instrument with two samples of veterans with a history of war-zone service. Namely, despite the reduced number of items, the EMIS-M-Short Form (SF) yielded favourable internal consistency and comparable levels of convergent validity with theoretically related constructs (e.g., PTSD and struggles with morality and ultimate meaning) as the full-length version. Notwithstanding the possible utility of distinguishing betweenself-and other-directed forms of MI, factor analytic results further revealed that the EMIS-M-SF was best conceptualized with a unidimensional factorial model that might allow for a general assessment of MI-related outcomes. Overall, these initial results suggest that the EMIS-M-SF may hold promise as a short, reliable, and valid assessment of overall outcomes related to a possible MI.

Moral Injury: An Increasingly Recognized and Widespread Syndrome

“…Research indicates that MI is not a benign syndrome. MI in Veterans and active duty military has been associated with numerous adverse mental health outcomes, including greater severity of PTSD (Bryan et al, 2016;Koenig et al, 2018a;Nash et al, 2013), depression and anxiety (Currier et al, 2018;Evans et al, 2018;Koenig et al, 2018aKoenig et al, , 2018bVolk & Koenig, 2019) and increased risk of suicide (Ames et al, 2019;Bryan et al, 2013Bryan et al, , 2014Bryan et al, , 2015Nieuwsma et al, 2021). Even after controlling for PTSD symptom severity, the presence of MI remains a significant risk factor for depression, anxiety, and suicide (Bryan et al, 2013(Bryan et al, , 2014(Bryan et al, , 2015Nash et al, 2010Nash et al, , 2013, further justifying the claim that this condition is a distinct syndrome separate from PTSD.…”

“…The following have been found to be associated with MI in current or former members of the military: younger age (Koenig et al, 2018c;Volk & Koenig, 2019), white race (Koenig et al, 2018c;Wisco et al, 2017), lower education (Volk & Koenig, 2019;Wisco et al, 2017), less income/unemployed (Wisco et al, 2017), low social support or poor quality of relationships (Koenig et al, 2018c;Nash et al, 2013;Volk & Koenig, 2019), lower religiosity (particularly among those with more severe PTSD; Koenig et al, 2018c), greater combat exposure or aftermath violence (Currier et al, 2018;Wisco et al, 2017), multiple deployments (Wisco et al, 2017), greater physical disability or chronic pain (Koenig et al, 2018a), alcohol and drug abuse (Nieuwsma et al, 2021), and service branch (Army; Wisco et al, 2017). As noted above, depression and anxiety are strongly correlated with MI in almost all of these studies.…”

“…Initially published online in the Journal of Religion and Health in December of 2017, the first such scale was the 45-item Moral Injury Symptom Scale-Military Version-Long Form (MISS-M-LF) (Koenig et al, 2018a ). This was quickly followed by publication of the 17-item Expressions of Moral Injury Scale-Military Version (EMIS-M) (Currier et al, 2018 ), the 10-item Moral Injury Symptom Scale-Military Version-Short Form (MISS-M-SF; Table 1 ) (Koenig et al, 2018b ), and the 4-item version of the EMIS-M (Currier et al, 2020 ). These scales typically assessed self-directed symptoms of MI (guilt, shame, self-condemnation) and “other-directed” symptoms (anger toward others, feelings of betrayal).…”

Psychometric properties of the moral injury symptom scale among Chinese health professionals during the COVID-19 pandemic

“…The first measure to assess MI symptoms only was the 45-item Moral Injury Symptoms Scale-Military Version-Long Form (MISS-M-LF) [ 12 ], followed soon by the publication of the 17-item Expressions of Moral Injury Scale-Military Version (EMIS-M) by Currier and colleagues [ 13 ]. The MISS-M-LF was then shorted by Koenig and colleagues to a 10-item version (MISS-M-SF) [ 14 ], and this was later followed by a 4-item short version of the EMIS-M [ 15 ]. Those measures were all developed in samples of active duty military or war veterans.…”

Psychometric Properties of the Moral Injury Symptom Scale among Chinese Health Professionals during the COVID-19 Pandemic

“…The rst measure to assess MI symptoms only was the 45-item Moral Injury Symptoms Scale-Military Version-Long Form (MISS-M-LF) [12], followed soon by the publication of the 17-item Expressions of Moral Injury Scale-Military Version (EMIS-M) by Currier and colleagues [13]. The MISS-M-LF was then shorted by Koenig and colleagues to a 10-item version (MISS-M-SF) [14], and this was later followed by a 4-item short version of the EMIS-M [15]. Those measures were all developed in samples of active duty military or war veterans.…”