Measuring moral distress and moral injury: A systematic review and content analysis of existing scales

Stephanie A. Houle, Natalie Ein, Julia Gervasio, Rachel A. Plouffe, Brett T. Litz, R. Nicholas Carleton, Kevin T. Hansen, Jenny J. W. Liu, Andrea R. Ashbaugh, Walter Callaghan, Megan M. Thompson, Bethany Easterbrook, Lorraine Smith-MacDonald, Sara Rodrigues, Stéphanie A. H. Bélanger, Katherine Bright, Ruth A. Lanius, Clara Baker, William Younger, Suzette Bremault-PhillipsFardous Hosseiny, J. Don Richardson, Anthony Nazarov (Lead / Corresponding author), Atlas Institute Moral Injury Research Community of Practice

Research output: Contribution to journalReview articlepeer-review

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Background: Moral distress (MD) and moral injury (MI) are related constructs describing the negative consequences of morally challenging stressors. Despite growing support for the clinical relevance of these constructs, ongoing challenges regarding measurement quality risk limiting research and clinical advances. This study summarizes the nature, quality, and utility of existing MD and MI scales, and provides recommendations for future use.

Method: We identified psychometric studies describing the development or validation of MD or MI scales and extracted information on methodological and psychometric qualities. Content analyses identified specific outcomes measured by each scale.

Results: We reviewed 77 studies representing 42 unique scales. The quality of psychometric approaches varied greatly across studies, and most failed to examine convergent and divergent validity. Content analyses indicated most scales measure exposures to potential moral stressors and outcomes together, with relatively few measuring only exposures (n = 3) or outcomes (n = 7). Scales using the term MD typically assess general distress. Scales using the term MI typically assess several specific outcomes.

Conclusions: Results show how the terms MD and MI are applied in research. Several scales were identified as appropriate for research and clinical use. Recommendations for the application, development, and validation of MD and MI scales are provided.

Original languageEnglish
Article number102377
Number of pages17
JournalClinical psychology review
Early online date27 Dec 2023
Publication statusPublished - Mar 2024


  • Moral distress
  • Moral injury
  • Psychometrics
  • Scale development
  • Measurement

ASJC Scopus subject areas

  • Psychiatry and Mental health
  • Clinical Psychology


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