Moral Injury: A Statewide Assessment on the Burden, Risk, and Protective Factors in Minnesota Firefighters

Abstract

IntroductionThe construct of moral injury is relatively new, primarily studied in trauma-exposed military personnel, and measurement scales recently available to screen symptoms of moral injury. However, no scale exists for firefighters; consequently, resulting in limited data for the risk and protective factors of moral injury in firefighters. Firefighters are considered one of the most stressful occupations, responding to critical incidents involving personal threat or harm to self, a violation of core beliefs about the world, and witnessing pain and suffering of others. Exposures to a single traumatic event or cumulative traumatic events can result in posttraumatic stress disorder (PTSD), depression, suicide ideation and possibly risk for moral injury. The objective of this study aims to address the gap in available instruments by developing a moral injury scale for firefighters and assess the potential risk and protective factors of moral injury in firefighters. MethodsA multi-phased study was conducted using qualitative methods to modify an established moral injury scale used in veterans by employing the Delphi method paired with cognitive interviewing with firefighters, and quantitative methods testing the psychometric properties. A cross-sectional study was conducted using dual-frame sampling methods to recruit Minnesota firefighters statewide assessing the association between moral injury and perceived stress towards traumatic calls, perception of being trained to cope with mental health of firefighting, and moral injury comorbidity with PTSD, depression, and suicide ideation. This study assessed the use of department debriefs and department resources (chaplains, critical incident stress management “CISM”, city employee assistance programs “CEAP”, and department employee assistance programs “DEAP”) and the protective effects for moral injury in trauma-exposed firefighters. ResultsPsychometric properties of the EMIS-F are comparable to the original military scale. The internal consistency of the EMIS-F was excellent (ω=0.94), inter-item correlations showed evidence of EMIS-F measuring a unidimensional construct (ρ=.30-.72). Multivariable analyses identified the risk factors for change in mean moral injury risk scores, which were firefighters self-reporting high perceived stress levels of calls involving fatalities (β=7.7) and children (β=3.1), and strongly disagreeing that they were trained to cope with mental health of firefighting (β=9.9). Firefighters with two or more mental health comorbidities showed over a 16.0 increase in mean moral injury risk scores, and greatly influenced by PTSD comorbidity. The protective factors of moral injury among firefighters self-reporting their most traumatic experience was those that used department debriefs and found them helpful, chaplains, and DEAP. Firefighters who found debriefs unhelpful showed evidence of debriefs as a risk factor for moral injury, in addition to using CEAP and CISM. Stigma showed evidence as a potential effect modifier regarding the impact or use of debriefs and increased moral injury risk scores. ConclusionThis study provides a reliable and valid moral injury scale that can be applied in research, clinical, and fire organization settings to screen symptoms of moral injury in firefighters. Knowledge of specific risk and protective factors presented not only serve for interventions, but an opportunity to evaluate and improve existing practices to enhance the well-being of firefighters.