Abstract
Objectives
Workers in high-stakes occupations, such as first responders, are at risk of exposure to potentially morally injurious events (PMIEs) and moral injury, yet research with first responders has been scarce. This study aimed to assess the frequency of exposure to PMIEs, the prevalence of moral injury, and the correlation between moral injury and other mental health symptoms.
Methods
In this cross-sectional study, firefighters, emergency medical technicians (EMTs), and paramedics working for a large urban Fire Department in California were invited to complete an online, confidential survey using validated scales to assess exposure to PMIEs, moral injury symptoms, and symptoms of posttraumatic stress disorder, anxiety, depression, alcohol use, and burnout between February 21, 2024, and April 16, 2024. We calculated item frequencies and correlation and reliability analysis on each scale separately and between the total scores from all measures using Pearson, polyserial, and polychoric methods. Reliability was assessed using Guttman’s lambda and Cronbach’s alpha.
Results
Participants (N = 292) endorsed a range of PMIEs, including exposure by commission (48.6%), omission (48.6%), and witnessing (80.8%). Among those that reported PMIE exposure and moral injury symptoms (N = 147), 18.4% met the threshold for clinically meaningful moral injury. Moral injury symptoms were strongly correlated with each of the mental health measures (r = 0.49-0.59), with the exception of alcohol use (r = 0.08).
Conclusion
Exposure to PMIEs was common in these professional first responders, and a substantial proportion of participants reported clinically meaningful moral injury symptoms. These data fill an important gap and provide information that can help with moral injury assessment and treatment for first responders.
Keywords: moral injury, first responders, mental health, paramedics, emergency medical technicians, firefighters, burnout
The Bottom Line.
Given the limited research on moral injury among first responders in a fire department, our goal was to assess the frequency of exposure to morally injurious events, the prevalence of moral injury, and the relationship between moral injury and other common mental health symptoms. We found that 80.8% witnessed and 48.6% did something or failed to do something that went against their morals or values. Among these first responders working in an urban fire department, 18.4% had clinically meaningful moral injury symptoms. Moral injury symptoms were strongly related to posttraumatic stress disorder, depression, and anxiety symptoms but not to alcohol use.
1. Introduction
1.1. Background
Moral injury is defined as the biopsychosocial, behavioral, and spiritual problems that may occur for individuals in high-risk occupations resulting from acting, failing to act, or witnessing events that transgress moral beliefs and expectations.1,2 Although moral injury has been most comprehensively studied in veterans of war, there is now greater recognition that those in high-stakes occupations, such as first responders and healthcare workers, are at risk of developing moral injury due to ongoing exposure to potentially morally injurious events (PMIEs), which are precursors to moral injury. Guilt and shame are often hallmark symptoms of moral injury and may cause downstream problems with multiple areas of functioning.3 Among healthcare workers, there is growing evidence that moral injury is associated with a host of adverse outcomes such as functional impairment and higher rates of anxiety, depression, posttraumatic stress disorder (PTSD) symptoms, and burnout.4, 5, 6, 7 In both healthcare workers and veterans, moral injury has been associated with suicide ideation and attempts.4,8
Given that moral injury is a fairly new construct in the mental health scientific literature, there have not yet been epidemiological prevalence studies in the general population. Studies have also been limited by the fact that until the last few years, there have not been moral injury measures that index both exposure to morally injurious events and moral injury symptoms, both of which are needed to measure moral injury. Finally, there is only one known measure that was developed over the last few years that (1) was initially validated in multiple high-risk populations, (2) indexes both moral injury exposure and symptoms, and (3) has a cut score that can be used to determine prevalence (versus just a symptom severity score).9, 10, 11, 12, 13 We expect that over the next few years, there will be prevalence studies in the general population conducted, but thus far, moral injury studies have only been conducted in specific populations at high risk for moral injury by virtue of their occupations, such as veterans and healthcare workers.14 Even with these high-risk groups, due to the moral injury measurement issues outlined above, existing studies most typically report correlates of moral injury or symptom severity rather than prevalence.9 Prior studies also report the prevalence of exposure to PMIEs, but without the subsequent prevalence of moral injury.9
1.2. Importance
Exposure to PMIEs is common in high-risk professions where individuals face occupational stressors that may challenge personal and shared morals and values, and some of these individuals may experience morally injurious symptoms.12 A recent study found that 10.2% of individuals drawn from a population-based sample of 3 high-risk groups (veterans, healthcare workers, and first responders) screened positive for clinically meaningful moral injury—a level of moral distress that impairs functioning in important aspects of a person’s life, impacts core beliefs about the self, and/or causes harmful self-destructive behaviors.14 Importantly, those who identified as a member of a minority racial or ethnic group were more than twice as likely to report clinically meaningful moral injury (17.9%) than those who identified as White (8%).
Despite growing evidence that moral injury occurs in high-risk groups, research with first responders has been scarce. First responders are often among the first to arrive on the scene in emergencies and disasters and are called on to make challenging and life-or-death decisions in high-stress situations.15 A scoping review determined that there were no empirical studies of moral injury in first responders, and work in this area was sorely needed.16 Most existing work with first responders examining moral injury is either theoretical or qualitative with small samples.17,18 The one known empirical study to date examined a diverse occupational group of first responders (eg, emergency medical technicians (EMTs), paramedics, firefighters, and police officers) and found that 42% endorsed exposure to PMIEs and, of these, 9% reported clinically meaningful moral injury.14 However, significant gaps remain in our understanding of certain first responders, such as firefighters, EMTs, and paramedics.
1.3. Goals of This Investigation
The goal of this study was to better understand the types of PMIEs and moral injury symptoms reported, the prevalence of moral injury, and associations between moral injury and other mental health symptoms in a group of first responders who are currently working in the field.
2. Methods
2.1. Design and Setting
Firefighters, EMTs, paramedics, and others employed by a large urban Fire Department in Northern California were invited to participate in a cross-sectional study. An email was sent to a department-wide listserv of approximately 1790 members inviting them to take a voluntary anonymous survey about moral injury. The email stated that the survey would take participants approximately 15 minutes to complete, that participants could skip any questions they did not wish to answer, and that they would be provided with a $10 e-gift card to Amazon for completing the survey. The initial email was sent out to the listserv on February 21, 2024. A second email reminder was sent to the listserv on April 11, 2024. The survey was closed on April 16, 2024.
Upon opening the survey, participants were given a written online consent notice and asked to affirm their consent to participate. Any participant who did not consent was taken to the end of the survey. The study protocol was approved by the San José State University Institutional Review Board, which waived a requirement for signed consent as the survey data were collected anonymously.
2.2. Measures
We included a measure of moral injury and brief symptom screening measures of PTSD, depression, anxiety, alcohol use, and burnout. We also collected demographic and work characteristics. Each is described in greater detail below.
2.2.1. The Moral Injury and Distress Scale
The Moral Injury and Distress Scale (MIDS) is comprised of 2 parts.12,13 Part 1 contains 6 items that assess 3 types of PMIE exposures: (1) participating in a PMIE by commission (“I acted in ways that violated my own morals or values;” “I am bothered by what I did”), (2) participating in a PMIE by omission (“I violated my own morals or values by failing to do something I should have done;” “I am bothered by what I did not do”), and (3) witnessing a PMIE (“I saw things that violated my own morals or values;” “I am bothered by what I saw”). Participants indicated the extent to which they were exposed to and bothered by each using a 5-point response format (0 = not at all, 4 = extremely). Consistent with the guidelines for the MIDS, we created binary variables by collapsing responses into 2 categories: those who denied exposure (“not at all”) and those who endorsed exposure (“A little bit” to “Extremely”).13
Participants who endorsed 1 or more of the part 1 items were asked to complete part 2 items. Part 2 starts by asking participants to briefly describe the event or series of events that is most troubling to them. Descriptions of the PMIEs were reviewed in detail by 2 of our authors (Miranda Worthen and Soma de Bourbon) to ensure that they were valid. Based on the PMIE(s) identified, participants were then asked 18 questions that assess cognitive, emotional, behavioral, social, and religious/spiritual reactions indexed to the PMIE or series of PMIEs. Example items include “I think about how I should have been able to do more” and “I don’t seek support because I worry others would not understand.” Participants responded to each symptom item using a 5-point response format (0 = not at all, 1 = a little, 2 = moderately, 3 = quite a bit, and 4 = extremely). Consistent with MIDS guidelines, we aggregated item responses into a sum score (possible range: 0 to 72), such that higher scores indicate greater moral distress severity. Additionally, those who attained a sum score of 27 or higher were deemed to have clinically meaningful moral injury based on the recommended scale cut score.13
2.2.2. Posttraumatic Stress Symptoms
Posttraumatic stress symptoms were assessed using the primary care PTSD screen (PC-PTSD).19 The PC-PTSD is a 5-item instrument used to assess PTSD symptoms. A participant must first endorse exposure to a traumatic event and is then asked about whether they experienced 5 related symptoms in the past month. More specifically, individuals are asked about re-experiencing symptoms, avoidance, arousal, emotional numbness, and maladaptive cognitions related to the trauma. Item responses are dichotomous, and a cut score of 4 positively endorsed items indicates a positive PTSD screen.
2.2.3. Depression Symptoms
Depression symptoms were assessed using the Patient Health Questionnaire-2 (PHQ-2) for depression.20 The screener assesses for depressed mood and anhedonia over the past 2 weeks on a 4-point scale from “not at all” to “nearly every day.” Sum scores range from 0 to 6, and scores ≥3 indicate a positive depression screen.
2.2.4. Anxiety Symptoms
Anxiety symptoms were assessed using the General Anxiety Disorder (GAD-2).21 The screener assesses for feeling nervous, anxious, or on edge as well as worrying on a 4-point scale from “not at all” to “nearly every day.” Sum scores range from 0 to 6, and scores ≥3 indicate a positive anxiety screen.
2.2.5. Alcohol Use
Alcohol use was assessed using the Alcohol Use Disorders Identification Test (AUDIT-C), a 3-item screener assessing for frequency and amount of alcohol use over the past year, and instances of binge drinking.22 Sum scores range from 0 to 12, with scores ≥4 indicating a positive screen for men and scores ≥3 indicating a positive screen for women.
2.2.6. Burnout
Burnout was assessed using the single-item Mini-Z measure rated on a 5-point scale; 1 = “I enjoy my work. I have no symptoms of burnout;” to 5 = “I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help.” The presence of burnout was indicated by a rating score ≥3. The Mini-Z has been validated against the emotional exhaustion subscale of the Maslach Burnout Inventory with a correlation of 0.64 (P < .001).23
2.2.7. Demographic and Work Characteristics
Demographic and work characteristics were assessed through a series of questions asking participants to report their age, gender, race or ethnicity, sexual orientation, education level, disability status, language, and veteran status. Participants were also asked their primary job classification (EMT, paramedic, firefighter, or other) and their years in the occupation. The exact wording of the questions and response options is provided in Table S1.
2.3. Data Analysis
We calculated item frequencies for all survey items. We examined the difference in PMIE exposure and moral injury by role and career length. We also conducted correlation and reliability analysis on the MIDS, MIDS symptoms, PC-PTSD, PHQ-2, GAD-2, and AUDIT-C separately. We ran correlations between the total scores from all measures. Prior to reliability and correlation analysis, all items were assessed for near-zero variance (NZV—extremely low response rate),24 given that items with NZV can generate nonsensical or missing values in analyses. Depending on the structure of the items being compared (continuous, categoric, or ordinal), we used either Pearson, polyserial, point-biserial, or polychoric methods to calculate the correlation coefficients.25,26 Reliability was assessed using Guttman’s lambda and Cronbach’s alpha.27, 28, 29, 30 All analysis was conducted in R (version 4.3).31
3. Results
3.1. Participants
Of the approximately 1790 individuals who were invited to participate through the listserv, 357 (357/1790 = 20%) opened the survey and 353 consented to participate in the study. Sixty participants who consented did not answer any survey items. There were 293 participants who answered at least 1 of the first 6 items assessing exposure to potentially morally injurious events (PMIEs). After answering the PMIE assessment, 193 participants continued through additional survey questions, 99 participants exited the survey, and 1 participant was excluded after review by 2 authors because their responses were deemed invalid (Fig. 1).
Figure 1.
Flow chart of participants included in the study.
Of the participants who responded to demographic and workplace questions (193), participants were predominantly male (73%), White (61%), and heterosexual (88%). Further, nearly half of the respondents worked as paramedics or EMTs (49%), with about 38% working as firefighters. Participants endorsed a range of years in the profession, with 42% reporting 20 or more years. See Table 1 for additional participant details.
Table 1.
Respondent demographic characteristics.
| Characteristic | N (%)a |
|---|---|
| Total | 193 |
| Age (mean [SD]) | 43.34 (8.94) |
| Missing | 6 |
| Gender (%) | |
| Men | 138 (73.4) |
| Women | 45 (23.9) |
| Nonbinary | 5 (2.7) |
| Missing | 4 |
| Race/ethnicity (%) | |
| Alaska Native, American Indian, or Indigenous | 8 (4.4) |
| Asian | 28 (15.4) |
| Black, African American, or African | 13 (7.1) |
| Hispanic, Latinx, or Chicanx | 29 (15.9) |
| Multiracial or multi-ethnic | 21 (11.5) |
| White | 111 (61.0) |
| A racial or ethnic identity not listed here | 7 (3.8) |
| Missing | 7 |
| Sexual orientation (%) | |
| Heterosexual | 160 (87.9) |
| Lesbian, gay, bisexual, queer, two-spirit, or others | 22 (12.1) |
| Missing | 9 |
| Education | |
| High school or equivalent | 38 (20.3) |
| Associate’s degree | 56 (29.9) |
| Bachelor’s degree | 72 (38.5) |
| Graduate or professional degree | 21 (11.2) |
| Missing | 5 |
| Disability (%) | 15 (7.9) |
| Missing | 3 |
| Language (%) | |
| English is the only language I speak | 135 (71.4) |
| English is my primary language, but I speak one or more other languages | 51 (27.0) |
| English is not my primary language, but I speak one or more other languages | 3 (1.6) |
| Missing | 3 |
| Veteran (%) | 8 (4.2) |
| Missing | 3 |
| Primary job (%) | |
| Paramedic/emergency medical technician | 94 (49.2) |
| Firefighter | 73 (38.2) |
| Other | 24 (12.6) |
| Missing | 2 |
| Years in occupation (%) | |
| 0-9 | 39 (20.5) |
| 10-19 | 71 (37.4) |
| 20+ | 80 (42.1) |
| Missing | 2 |
There were 193 participants who completed this portion of the survey. N and % are out of the respondents who answered each demographic question.
3.2. Moral Injury
Of the 292 respondents, 244 (83.6%) endorsed at least 1 of the MIDS PMIE items (MIDS part 1). Participants endorsed exposure to PMIE through commission (48.6%, N = 142), omission (48.6%, N = 142), and witnessing (80.8%, N = 236). Participants endorsing at least 1 MIDS PMIE were asked about their MIDS symptoms (MIDS part 2). Of the 147 participants who responded to at least 1 of the MIDS symptom items, the median moral injury severity score was 15.0 (IQR, 6.0-24.0) and 27 were considered to have clinically meaningful moral injury (a MIDS symptom score of ≥27). Clinically meaningful moral injury was thus reported by 18.4% of participants who answered any of the moral injury symptom questions and by 9.2% of the entire sample (Fig. 1).
When examining the MIDS symptom items endorsed (Table 2), the most frequently endorsed items included (1) “I think about how I should have been able to do more” (76.7%), (2) “I feel betrayed by leaders or institutions” (76.5), and (3) “I feel powerless” (72.4). In reliability analysis, all MIDS symptom items were moderately to strongly correlated (Fig. 2) and were very consistent with high alpha and lambda (0.90 and 0.94, respectively).
Table 2.
MIDS symptom item frequencies.
| Symptom item | Not at all N (%) |
A little bit N (%) |
Moderately N (%) |
Quite a bit N (%) |
Extremely N (%) |
|---|---|---|---|---|---|
| MIDS 1: I think about how I should have been able to do more. | 34 (23.3%) | 53 (36.3%) | 31 (21.2%) | 23 (15.8%) | 5 (3.4%) |
| MIDS 2: I have withdrawn from others more often. | 60 (41.7%) | 37 (25.7%) | 23 (16.0%) | 16 (11.1%) | 8 (5.6%) |
| MIDS 3: I feel guilty. | 47 (32.9%) | 63 (43.1%) | 15 (10.5%) | 15 (10.5%) | 3 (2.1%) |
| MIDS 4: I doubt my own judgment. | 70 (48.6%) | 51 (35.4%) | 15 (10.4%) | 5 (3.5%) | 3 (2.1%) |
| MIDS 5: I do not feel like I deserve to be happy. | 105 (72.4%) | 23 (15.9%) | 12 (8.3%) | 3 (2.1%) | 2 (1.4%) |
| MIDS 6: I self-sabotage things in my life more often (relationships, things at work). | 87 (60.4%) | 38 (26.4%) | 12 (8.3%) | 6 (4.2%) | 1 (0.7%) |
| MIDS 7: I feel helpless. | 62 (42.8%) | 41 (28.3%) | 24 (16.6%) | 14 (9.7%) | 4 (2.8%) |
| MIDS 8: My life feels like it has less purpose. | 85 (59.0%) | 32 (22.2%) | 14 (9.7%) | 8 (5.6%) | 5 (3.5%) |
| MIDS 9: I am worried that bad things will happen to me or my loved ones. | 57 (39.6%) | 41 (28.5%) | 22 (15.3%) | 18 (12.5%) | 6 (4.2%) |
| MIDS 10: I have punished myself. | 95 (66.4%) | 30 (21.0%) | 10 (7.0%) | 6 (4.2%) | 2 (1.4%) |
| MIDS 11: I feel disgusted. | 66 (45.8%) | 36 (25.0%) | 18 (12.5%) | 17 (11.8%) | 7 (4.9%) |
| MIDS 12: I do not seek support because I feel like I do not deserve it. | 107 (75.3%) | 26 (18.3%) | 6 (4.2%) | 2 (1.4%) | 1 (0.7%) |
| MIDS 13: I do not seek support because I worry others would not understand. | 80 (54.8%) | 27 (18.5%) | 19 (13.0%) | 12 (8.2%) | 8 (5.5%) |
| MIDS 14: I feel betrayed by leaders or institutions. | 34 (23.4%) | 30 (20.7%) | 21 (14.5%) | 23 (15.9%) | 37 (25.5%) |
| MIDS 15: I feel powerless. | 40 (27.6%) | 45 (31.0%) | 24 (16.6%) | 22 (15.2%) | 14 (9.7%) |
| MIDS 16: I should not be forgiven. | 119 (82.6%) | 18 (12.5%) | 6 (4.2%) | 0 (0.0%) | 1 (0.7%) |
| MIDS 17: My spirituality/faith is no longer a source of comfort. | 104 (74.3%) | 19 (13.6%) | 7 (5.0%) | 2 (1.4%) | 8 (5.7%) |
| MIDS 18: I do not take good care of myself. | 76 (52.4%) | 37 (25.5%) | 23 (15.9%) | 5 (3.4%) | 4 (2.8%) |
MIDS, Moral Injury and Distress Scale; PMIE, potentially morally injurious events.
Total N for each MIDS symptom item ranges from 140 to 146. Percentage for each MIDS symptom item is out of the total number of nonmissing responses to the specific MIDS symptom item.
Figure 2.
Correlation of the MIDS symptoms items among first responders. MIDS, Moral Injury And Distress Scale.
Compared with firefighters, paramedics and EMTs were more likely to endorse exposure to PMIE through commission (31.5% versus 48.9%, P = .03) and through witnessing (61.1% versus 79.8%, P < .01) (Table 3). There was no statistically significant difference in endorsing exposure by omission, moral injury symptom severity, or the frequency of clinically meaningful moral injury by role in the department. There was a weak, positive correlation between career length and moral injury severity, but this did not reach statistical significance, and there was no correlation between years of experience and meeting the cutoff for clinically meaningful moral injury.
Table 3.
Exposure to PMIEs and moral injury by job classification.
| N (%) | Paramedic/EMT | Firefighter | Other | |
|---|---|---|---|---|
| Totala | 292 (100) | 94 (100) | 73 (100) | 24 (100) |
| Any exposure to potentially morally injurious events endorsed | 244 (83.6) | 76 (80.9) | 46 (63.0) | 23 (95.8) |
| Exposure by commission | 142 (48.6) | 46 (48.9) | 23 (31.5) | 17 (70.8) |
| Exposure by omission | 142 (48.6) | 44 (46.8) | 24 (33.3) | 18 (75.0) |
| Exposure by witnessing | 236 (80.8) | 75 (79.8) | 44 (61.1) | 23 (95.8) |
| Symptom total score (mean [SD]) | 15.66 (12.11) | 15.60 (11.41) | 15.04 (13.11) | 18.00 (11.54) |
| MIDS symptom threshold (≥27) | 27 (18.4) | 15 (20.0) | 6 (13.0) | 5 (21.7) |
EMT, emergency medical technician; MIDS, Moral Injury and Distress Scale; PMIE, potentially morally injurious event.
There were 292 participants who answered survey questions assessing their exposure to PMIEs. Of those, 191 participants answered a question identifying their job classification. There were 147 participants who answered MIDS symptom questions. Denominators vary due to missing data.
3.3. Concurrent Outcomes
Correlations with the MIDS total score and each of the mental health measures appear in Figure 3. The MIDS symptom score was strongly correlated with burnout (r = 0.58), PTSD (r = 0.49), anxiety (r = 0.55), and depression (r = 0.59). The MIDS symptom score had little correlation with alcohol use (r = 0.08). See Tables S2, S3, S4, and S5 for correlations and reliability statistics for all concurrent outcomes.
Figure 3.
Correlations of the MIDS symptoms total score and mental health symptoms scores. AUDIT-C, Alcohol Use Disorders Identification Test; GAD-2, General Anxiety Disorder-2; MIDS, Moral Injury and Distress Scale; PC-PTSD, primary care posttraumatic stress disorder screen; PHQ-2, Patient Health Questionnaire-2.
4. Limitations
There are several important limitations to this study. First, although our main source of recruitment was through a first responder listserv, we do not know how many people read about our study, which makes it challenging to know our true nonresponse rate. Consequently, we can only be sure that those 357 individuals who opened the survey took the first step toward participation. Second, with limited demographic information due to missing data from respondents who exited the study early, we were unable to better understand nonresponse bias using any of the current methods (post-stratification, propensity score, covariate balancing, etc.). Comparing study participants who completed the entire survey to the department’s workforce demographic data, respondents were slightly more likely to be female (23.9% of respondents, compared with 16.7% of department employees) and White (61.0% of respondents, compared with 50.1% of department employees). A recent systematic review and meta-analysis of moral injury measures found that little research had examined the psychometric performance of these tools across diverse populations,9 but one study with a diverse occupational group found that those who identified as a member of a minoritized racial or ethnic group had more than twice the prevalence of clinically meaningful moral injury compared with White, non-Hispanic participants.13 Third, we do not have more specific information about why some individuals who started the survey were not able to complete it. Fourth, although we used correlations as a straightforward method to determine relationships between moral injury and common mental health outcomes due to the lack of research in this area with first responders, a possible limitation is that there could be potential confounding due to unobserved variables that influence these relationships. Given that we found strong relationships between moral injury and common mental health symptoms in this group, a next step could be to conduct a larger study that assesses these relationships through regression analyses to reduce potential confounding.
5. Discussion
This is the first known study to examine the prevalence of exposure to PMIEs and moral injury symptoms exclusively among US first responders in the fire service, including paramedics, emergency medical technicians, and firefighters. We found that exposure to PMIEs was very common (83.6%), with 48.6% of participants reporting that they did or failed to do something that went against their morals or values and 80.8% reporting witnessing such an event. We also found a wide range of endorsed moral injury symptoms related to these exposures, with the vast majority wishing they could have done more in the situation and feeling betrayed. Additionally, we found that of those participants who reported their moral injury symptoms, 18.4% had clinically meaningful moral injury. If we include all of the participants who started to take the survey but either were not asked or chose not to respond to moral injury symptom questions (an additional 145 participants), the prevalence of moral injury is 9%.
Given that studies on moral injury and first responders are scarce, this study fills a critical knowledge gap in first responders, specifically for those in the fire service. The one known study of first responders assessing moral injury included a wide range of first responders, and some who were not currently working as first responders. Using the same scale, we used in the present study, Maguen et al13 found that 41.6% of first responders reported exposure to a PMIE with 30.2% endorsing exposure to commission, 25.2% endorsing exposure by omission, and 38.9% endorsing exposure by witnessing, and that 4% met the criteria for clinically meaningful moral injury. Our sample helps elucidate that for those actively working in a first responder role, exposure to PMIEs and prevalence of moral injury may be higher and deserving of attention.
It is critical to note that first responders represent a highly trained and resilient group.32,33 There are many more individuals who report exposure to PMIEs than those who report significant moral injury symptoms, which is a testament to their strong training and workforce preparation. Additionally, for those who are experiencing moral injury, it is critical to identify these individuals to connect them with assistance; moral injury symptoms are impairing and are associated with functional impacts, including potential struggles with employment and relationships.3,7 Given that there are now moral injury measures validated with various groups, including first responders,12 this represents a significant advancement in our ability to identify and care for those who are experiencing significant symptoms.
We found that although moral injury is a unique construct with distinguishing signs and symptoms, there is also a strong correlation between moral injury symptoms and positive screens for PTSD, depression, and anxiety symptoms. These findings are consistent with relationships between moral injury and mental health symptoms among other high-risk groups, such as veterans and healthcare workers,3,34 and demonstrate these relationships also hold true in first responders. Future longitudinal research could help determine which set of symptoms emerges first, which would help with efforts to identify and treat each issue. Our assessment suggests an interrelationship between moral injury and most mental health outcomes. This underscores the importance of integrated interventions that can help improve multiple mental health symptoms, an important area for future investigation. Interestingly, moral injury was not associated with alcohol use, which differs from prior studies. More specifically, prior empirical studies have found a relationship between moral injury and substance use in veterans.35,36 We are not aware of any studies examining the relationship between moral injury and substance use disorders in first responders, but it may be that use patterns in this group vary from veterans, thereby making the relationship with moral injury more complex. Future qualitative studies may help elucidate the relationship between these variables. Moral injury was also strongly correlated with burnout. Because the two constructs are often conflated, it is important to highlight that in this sample, similar to healthcare workers, moral injury and burnout are two important, related, and yet distinct constructs that should be evaluated.37,38 Being able to identify and distinguish moral injury from each of these other constructs will allow for the most targeted ability to assess and intervene at the individual, group, and institutional level.
To our knowledge, this is the first study of its kind to attempt to assess moral injury in first responders currently in the fire department workforce. These data fill an important gap and provide information that can help with moral injury assessment and treatment of this important group.
Author Contributions
SM: conceptualization, methodology, visualization, writing—original draft, and writing—review and editing.
SdB: conceptualization, methodology, visualization, data collection, and writing—review and editing.
AB: formal analysis, visualization, writing—original draft, and writing—review and editing.
MM: conceptualization, and writing—review and editing.
AS: conceptualization, and writing—review and editing.
DN: writing—review and editing.
JG: conceptualization, and writing—review and editing.
SP: conceptualization, and writing—review and editing.
MW: conceptualization, methodology, visualization, data collection, formal analysis, project administration, funding acquisition, writing—original draft, and writing—review & editing.
Funding and Support
National Science Foundation, SCC-CIVIC-FA Track B: Participatory Action Research to Enhance Equity and Prevent Moral Injury in Community Paramedicine (Project Number: 2322023; PI: Worthen).
Conflict of Interest
All authors have affirmed they have no conflicts of interest to declare.
Acknowledgments
The authors wish to thank all the study participants who shared their experiences with us.
Footnotes
Supervising Editors: Elizabeth Donnelly, PhD, MPH and Juan March, MD
Supplementary material associated with this article can be found in the online version at https://doi.org/10.1016/j.acepjo.2025.100259.
Supplemental Material
References
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