As our understanding of moral injury continues to evolve, researchers and clinicians have developed several validated measurement tools to assess both the exposure to morally injurious events and their psychological impact. In this post, we'll explore the four primary measures used to evaluate moral injury, their specific applications, and their strengths and limitations.
Moral Injury Events Scale (MIES)
Overview
The MIES, developed by Nash and colleagues (2013), is a 9-item self-report measure that focuses on assessing exposure to morally injurious events. This scale has become one of the foundational tools in moral injury assessment.
Key Features
- Measures both witnessed and perpetrated acts
- Evaluates perceived betrayals by leaders or trusted individuals
- Uses a 6-point Likert scale from "strongly agree" to "strongly disagree"
Strengths
- Brief and easy to administer
- Strong psychometric properties
- Well-validated in military populations
- Clear, straightforward language
Limitations
- Originally developed for military context
- May not capture all types of moral injury
- Limited assessment of psychological impact
Moral Injury Symptom Scale (MISS)
Overview
The MISS, a more recent addition to the field, focuses on the psychological and behavioral symptoms that may result from moral injury. This scale takes a broader approach to understanding the impact of moral injury.
Key Features
- Assesses psychological symptoms
- Evaluates behavioral changes
- Includes items related to spiritual/religious impacts
- Measures social relationship effects
Strengths
- Comprehensive symptom assessment
- Applicable across different populations
- Good internal consistency
- Captures both immediate and long-term impacts
Limitations
- Longer administration time
- May require clinical interpretation
- Some items may overlap with other conditions
Expressions of Moral Injury Scale (EMIS)
Overview
The EMIS focuses on how moral injury manifests in daily life and relationships. This scale is particularly valuable for understanding the social and interpersonal dimensions of moral injury.
Key Features
- Measures self-directed emotions
- Assesses other-directed emotions
- Evaluates behavioral expressions
- Includes items about meaning-making
Strengths
- Captures nuanced expressions of moral injury
- Strong focus on relational aspects
- Useful for treatment planning
- Good discriminant validity
Limitations
- May be influenced by cultural factors
- Requires careful interpretation
- Not as widely validated as some other measures
Moral Injury Questionnaire (MIQ)
Overview
The MIQ takes a broad approach to assessing moral injury, incorporating elements of both exposure and impact. This measure is particularly useful for initial screenings.
Key Features
- Comprehensive assessment
- Includes both events and reactions
- Measures cognitive, emotional, and behavioral responses
- Incorporates existential/spiritual components
Strengths
- Broad coverage of moral injury domains
- Useful for screening
- Applicable across different contexts
- Good reliability
Limitations
- Length may be challenging in some settings
- May require follow-up assessment
- Cultural considerations needed
Best Practices for Implementation
Choosing the Right Measure
1. Consider your specific assessment needs
2. Account for the population being assessed
3. Think about time and resource constraints
4. Factor in the intended use of the results
Administration Guidelines
- Ensure appropriate clinical support is available
- Consider timing of administration
- Provide clear instructions
- Be prepared for emotional responses
Interpretation Considerations
- Use in conjunction with clinical interview
- Consider cultural and contextual factors
- Look for patterns across subscales
- integrate with other assessment data
Future Directions
The field of moral injury assessment continues to evolve, with researchers working on:
- Development of population-specific measures
- Integration of cultural considerations
- Creation of brief screening tools
- Refinement of existing measures
Conclusion
Each of these validated measures brings unique strengths to the assessment of moral injury. The choice of measure should be guided by specific clinical needs, population characteristics, and intended use. As our understanding of moral injury continues to grow, these measures will likely evolve and improve, providing even better tools for assessment and treatment planning.
Training
GIDII Advocacy has developed a training package on Moral Injury that is in addition to the documentary, Shattered. The training features a powerful dramatisation film showing how excessive confidence in authority can jeopardize psychological and physical safety. In hierarchical systems, deference to those at the top can lead to dangerous consequences. It can also cause a moral injury.
This is especially critical for organizations aiming to help the community, as their authority demands higher accountability.
​
​Excessive confidence in authority can create dangerous blind spots in workplace safety, both physically and psychologically. This dramatization explores the impact of "moral injury"—when employees are told to trust in leadership even when faced with unsafe conditions or toxic cultures. By showcasing  a real-world example, when a system fails this case study illustrates how unchecked authority can suppress critical thinking, silence concerns, and perpetuate harmful environments, leading to severe emotional and physical consequences. Learn how to recognize and address these risks to protect your workforce and foster a culture of open communication and safety.
Use the discussion guides to explore what is moral injury and find constructive solutions to avoid harmful outcomes in your organisation.
Includes 6 powerful international case studies introduce the dramatisation prompting the viewer to consider ethical challenges that left unaddressed all had devastating consequences.
Comments