Morally injurious events and posttraumatic embitterment disorder during COVID-19

Brennan, C. J., McKay, M. T., & Cole, J. C. (2025). Morally injurious events and posttraumatic embitterment disorder in U.K. health and social care professionals during COVID-19: A longitudinal web survey.Psychological Trauma: Theory, Research, Practice, and Policy, 17(2), 264–273. https://doi.org/10.1037/tra0001723

Rationale

The COVID-19 pandemic placed unprecedented strain on health and social care workers (HSCWs) in the U.K., who faced long hours, exposure to the virus, and difficult working conditions.

These challenges could lead to potentially morally injurious events (PMIEs) and post-traumatic embitterment disorder (PTED).

Previous research has shown a high prevalence of PMIEs and moral injury among HCWs during the pandemic (Akhtar et al., 2022; Boscarino et al., 2022; Trifunovic-Koenig et al., 2022).

Moral injury is a complex psychological and spiritual response to events that violate an individual’s moral code, often leading to feelings of shame, guilt, and betrayal.

PTED, on the other hand, is characterized by persistent and pervasive feelings of bitterness, injustice, and resentment following a negative life event.

While there is growing evidence of the impact of moral injury on mental health, there is limited research on PTED in this population and the relationship between moral injury and PTED.

The present study aimed to address these gaps by longitudinally investigating the prevalence, predictors, and the mechanism linking PMIEs and PTED in U.K. HSCWs during the COVID-19 pandemic.

Specifically, the study sought to:

1. Estimate the prevalence of PMIEs and PTED in U.K. HSCWs during the COVID-19 pandemic.
2. Identify the predictors of PMIEs and PTED, including exposure to occupational stressors, personality traits, and coping styles.
3. Investigate the mechanism by which PMIEs increase embitterment, focusing on the role of personal belief in procedural justice.

Method

The study employed a longitudinal online survey design.

Participants were recruited via Prolific and completed two surveys, 12 months apart.

The surveys assessed PMIEs, PTED, exposure to occupational stressors, and various personality traits.  

The sample consisted of 400 HSCWs aged 18 or above, working in the United Kingdom during the COVID-19 pandemic.

Measures

• Moral Injury Events Scale (MIES): Assesses exposure to PMIEs.  
• PTED Self-Rating Scale: Measures embitterment following negative life events.  
• Occupational stressors scale: Measures exposure to COVID-19 specific stressors.  
• Revised Life Orientation Test: Assesses generalized optimism and pessimism.  
• Rosenberg Self-Esteem Scale: Measures self-esteem.  
• Brief Resilience Coping Scale: Assesses the ability to cope with stress adaptively.  
• BJW Scale: Measures personal belief in a just world.  
• Consideration of Future Consequences Scale (CFC-14): Assesses consideration of future and immediate consequences of actions.  
• Marlowe–Crowne Social Desirability Scale: Measures social desirability.  

Results

Hypothesis 1

The prevalence of PMIEs and PTED in U.K. HSCWs in 2021 will be high.  

• Result: Supported. 71% of participants experienced at least one PMIE, and 20% displayed clinically relevant signs of PTED at Time 2 in 2021.  

Hypothesis 2

Exposure to occupational stressors will be a risk factor for PMIEs and PTED.  

• Result: Supported. Exposure to occupational stressors increased the risk of experiencing PMIEs and PTED.  

Hypothesis 3

Personal belief in a procedurally just world will be a protective factor against PMIEs and PTED.  

• Result: Partially Supported. Belief in a procedurally just world protected against transgressions by others and betrayal PMIEs, but it was not a significant predictor of PTED after controlling for baseline levels.  

Hypothesis 4

Self-esteem will be a protective factor, and a resilient coping style will be a risk factor for experiencing PMIEs and PTED.  

• Result: Partially Supported. Self-esteem was a protective factor against transgressions-self and betrayal PMIEs, but not PTED. A resilient coping style was a risk factor for betrayal PMIEs only.  

Hypothesis 5

PMIEs will longitudinally predict PTED by reducing belief in procedural justice.  

• Result: Supported. PMIEs indirectly predicted PTED by weakening belief in procedural justice at T2, even after controlling for baseline levels. The direct effect of PMIEs on PTED was no longer significant after controlling for baseline PTED.  

Insight

The study provides important insights into the mental health of U.K. HSCWs during the COVID-19 pandemic.

The high prevalence of PMIEs and PTED highlights the significant impact of the pandemic on this group.

The findings also shed light on the factors that contribute to PMIEs and PTED, such as exposure to occupational stressors and a lack of belief in procedural justice.

The study extends previous research by demonstrating the longitudinal relationship between PMIEs and PTED and identifying the mediating role of procedural justice beliefs.  

Clinical Implications

The findings have implications for policymakers and practitioners working with HSCWs.

It is essential to address occupational stressors and promote a sense of procedural justice in the workplace to mitigate the risk of PMIEs and PTED.

Organizations should provide adequate support and resources to HSCWs who have experienced PMIEs or are struggling with PTED.  

Additionally, research should explore the long-term impact of PMIEs and PTED on HSCWs’ mental health and well-being.

Strengths

• Longitudinal design: Allowed for the examination of the temporal relationship between PMIEs and PTED.  
• Large sample size: Provided sufficient power to detect significant effects.  
• Use of validated measures: Ensured the reliability and validity of the data.  
• Comprehensive assessment of predictors: Included a wide range of factors that could contribute to PMIEs and PTED.  

Limitations

• Self-report measures: May be subject to bias.  
• Online survey: May not be representative of all U.K. HSCWs.  
• Focus on COVID-19: Findings may not be generalizable to other contexts.  

References

Primary reference

Brennan, C. J., McKay, M. T., & Cole, J. C. (2025). Morally injurious events and posttraumatic embitterment disorder in U.K. health and social care professionals during COVID-19: A longitudinal web survey.Psychological Trauma: Theory, Research, Practice, and Policy, 17(2), 264–273. https://doi.org/10.1037/tra0001723

Other references

Akhtar, M., Faize, F. A., Malik, R. Z., & Tabusam, A. (2022). Moral injury and psychological resilience among healthcare professionals amid COVID-19 pandemic. Pakistan Journal of Medical Sciences, 38(5),
1338–1342. https://doi.org/10.12669/pjms.38.5.5122

Boscarino, J. A., Adams, R. E., Wingate, T. J., Boscarino, J. J., Urosevich, T. G., Hoffman, S. N., Kirchner, H. L., Figley, C. R., & Nash, W. P. (2022). Impact and risk of moral injury among deployed veterans: Implications for veterans and mental health. Frontiers in Psychiatry, 13, Article 899084. https://doi.org/10.3389/fpsyt.2022.899084

Trifunovic-Koenig, M., Strametz, R., Gerber, B., Mantri, S., & Bushuven, S. (2022). Validation of the German version of the moral injury symptom and support scale for health professionals (G-MISS-HP) and its correlation to the second victim phenomenon. International Journal of Environmental
Research and Public Health, 19(8), Article 4857. https://doi.org/10.3390/ijerph19084857