{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T02:24:08Z","timestamp":1791167048891,"version":"4.1.0"},"reference-count":69,"publisher":"MDPI AG","issue":"19","license":[{"start":{"date-parts":[[2023,9,23]],"date-time":"2023-09-23T00:00:00Z","timestamp":1695427200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Atlas Institute for Veterans and Families","award":["2122-HQ-000407"],"award-info":[{"award-number":["2122-HQ-000407"]}]},{"name":"Homewood Health Inc.","award":["2122-HQ-000407"],"award-info":[{"award-number":["2122-HQ-000407"]}]},{"name":"Canadian Institutes of Health Research","award":["2122-HQ-000407"],"award-info":[{"award-number":["2122-HQ-000407"]}]},{"name":"Public Health Agency of Canada","award":["2122-HQ-000407"],"award-info":[{"award-number":["2122-HQ-000407"]}]},{"name":"Homewood Chair in Mental Health and Trauma at McMaster University","award":["2122-HQ-000407"],"award-info":[{"award-number":["2122-HQ-000407"]}]},{"name":"Harris Woodman Chair in Psyche and Soma at Western University","award":["2122-HQ-000407"],"award-info":[{"award-number":["2122-HQ-000407"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Healthcare providers (HCPs) have described the onset of shame- and trust-violation-related moral injuries (MI) throughout the COVID-19 pandemic. Previous research suggests that HCPs may turn to various coping methods and supports, such as spirituality\/religiosity, substance use, friends\/family or organizational support, to manage workplace stress. It remains unknown, however, if similar coping methods and supports are associated with MI among this population. We explored associations between MI (including the shame and trust-violation presentations individually) and coping methods and supports. Canadian HCPs completed an online survey about their mental health and experiences during the COVID-19 pandemic, including demographic indices (e.g., sex, age, mental health history) and measures of MI, organizational support, social support, spiritual well-being, self-compassion, alcohol use, cannabis use and childhood adversity. Three hierarchical multiple linear regressions were conducted to assess the associations between coping methods\/supports and (i) MI, (ii) shame-related MI and (iii) trust-violation-related MI, when controlling for age, mental health history and childhood adversity. One hundred and seventy-six (N = 176) HCPs were included in the data analysis. Spiritual well-being and organizational support were each significantly associated with reduced total MI (p\u2019s &lt; 0.001), shame-related MI (p = 0.03 and p = 0.02, respectively) and trust-violation-related MI (p\u2019s &lt; 0.001). Notably, comparison of the standardized beta coefficients suggests that the association between trust-violation-related MI and both spiritual well-being and organizational support was more than twice as great as the associations between these variables and shame-related MI, emphasizing the importance of these supports and the trust-violation outcomes particularly. Mental health history (p = 0.02) and self-compassion (p = 0.01) were additionally related to shame-related MI only. Our findings indicate that heightened levels of spiritual well-being and organizational support were associated with reduced MI among HCPs during the COVID-19 pandemic. Rather than placing sole responsibility for mental health outcomes on HCPs individually, organizations can instead play a significant role in mitigating MI among staff by implementing evidence-informed organizational policies and interventions and by considering how supports for spiritual well-being may be implemented into existing models of care where relevant for employees.<\/jats:p>","DOI":"10.3390\/ijerph20196812","type":"journal-article","created":{"date-parts":[[2023,9,24]],"date-time":"2023-09-24T10:48:31Z","timestamp":1695552511000},"page":"6812","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":16,"title":["Coping, Supports and Moral Injury: Spiritual Well-Being and Organizational Support Are Associated with Reduced Moral Injury in Canadian Healthcare Providers during the COVID-19 Pandemic"],"prefix":"10.3390","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7482-0656","authenticated-orcid":false,"given":"Andrea M.","family":"D\u2019Alessandro-Lowe","sequence":"first","affiliation":[{"name":"Department of Psychology Neuroscience and Behaviour, McMaster University, Hamilton, ON L8S 4L6, Canada"},{"name":"Homewood Research Institute, Guelph, ON N13 6K9, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3142-3992","authenticated-orcid":false,"given":"Mauda","family":"Karram","sequence":"additional","affiliation":[{"name":"Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kim","family":"Ritchie","sequence":"additional","affiliation":[{"name":"Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada"},{"name":"Trent\/Fleming School of Nursing, Trent University, Peterborough, ON K9L 0G2, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea","family":"Brown","sequence":"additional","affiliation":[{"name":"Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Heather","family":"Millman","sequence":"additional","affiliation":[{"name":"Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1983-5441","authenticated-orcid":false,"given":"Emily","family":"Sullo","sequence":"additional","affiliation":[{"name":"Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yuanxin","family":"Xue","sequence":"additional","affiliation":[{"name":"Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada"},{"name":"Temetry Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mina","family":"Pichtikova","sequence":"additional","affiliation":[{"name":"Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada"},{"name":"Department of Applied Psychology and Human Development, University of Toronto, Toronto, ON M5S 1V6, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hugo","family":"Schielke","sequence":"additional","affiliation":[{"name":"Homewood Health Centre, Guelph, ON NIE 6K9, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ann","family":"Malain","sequence":"additional","affiliation":[{"name":"Homewood Health Centre, Guelph, ON NIE 6K9, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charlene","family":"O\u2019Connor","sequence":"additional","affiliation":[{"name":"Homewood Health Centre, Guelph, ON NIE 6K9, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ruth","family":"Lanius","sequence":"additional","affiliation":[{"name":"Homewood Research Institute, Guelph, ON N13 6K9, Canada"},{"name":"Lawson Health Research Institute, University of Western Ontario, London, ON N6C 2R5, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Randi E.","family":"McCabe","sequence":"additional","affiliation":[{"name":"Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada"},{"name":"St. Joseph\u2019s Healthcare Hamilton, Hamilton, ON L8N 4A6, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Margaret C.","family":"McKinnon","sequence":"additional","affiliation":[{"name":"Homewood Research Institute, Guelph, ON N13 6K9, Canada"},{"name":"Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada"},{"name":"St. Joseph\u2019s Healthcare Hamilton, Hamilton, ON L8N 4A6, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,9,23]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"590","DOI":"10.1177\/0969733020966776","article-title":"Moral Injury in Healthcare Professionals: A Scoping Review and Discussion","volume":"28","author":"Stolt","year":"2021","journal-title":"Nurs. Ethics"},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Ritchie, K., D\u2019Alessandro-Lowe, A.M., Brown, A., Millman, H., Pichtikova, M., Xue, Y., Altman, M., Beech, I., Karram, M., and Hoisseny, F. (2023). The Hidden Crisis: Understanding Potentially Morally Injurious Events Experienced by Healthcare Providers during COVID-19 in Canada. Int. J. Environ. Res. Public Health, 20.","DOI":"10.3390\/ijerph20064813"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1153","DOI":"10.3389\/fpsyt.2022.863232","article-title":"Potential Circumstances Associated with Moral Injury and Moral Distress in Healthcare Workers and Public Safety Personnel across the Globe during COVID-19: A Scoping Review","volume":"13","author":"Xue","year":"2022","journal-title":"Front. Psychiatry"},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Riedel, P.L., Kreh, A., Kulcar, V., Lieber, A., and Juen, B. (2022). A Scoping Review of Moral Stressors, Moral Distress and Moral Injury in Healthcare Workers during COVID-19. Int. J. Environ. Res. Public Health, 19.","DOI":"10.3390\/ijerph19031666"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"784523","DOI":"10.3389\/fpsyt.2021.784523","article-title":"Healthcare Workers and COVID-19-Related Moral Injury: An Interpersonally-Focused Approach Informed by PTSD","volume":"12","author":"Ritchie","year":"2022","journal-title":"Front. Psychiatry"},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Hines, S.E., Chin, K.H., Glick, D.R., and Wickwire, E.M. (2021). Trends in Moral Injury, Distress, and Resilience Factors among Healthcare Workers at the Beginning of the COVID-19 Pandemic. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph18020488"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"695","DOI":"10.1016\/j.cpr.2009.07.003","article-title":"Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy","volume":"29","author":"Litz","year":"2009","journal-title":"Clin. Psychol. Rev."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"182","DOI":"10.1037\/a0036090","article-title":"Moral Injury","volume":"31","author":"Shay","year":"2014","journal-title":"Psychoanal. Psychol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"341","DOI":"10.1002\/jts.22405","article-title":"Introduction to the Special Issue on Moral Injury: Conceptual Challenges, Methodological Issues, and Clinical Applications","volume":"32","author":"Litz","year":"2019","journal-title":"J. Trauma Stress"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"249","DOI":"10.1007\/s10943-017-0531-9","article-title":"The Moral Injury Symptom Scale-Military Version","volume":"57","author":"Koenig","year":"2018","journal-title":"J. Relig. Health"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"2192622","DOI":"10.1080\/20008066.2023.2192622","article-title":"Moral Injury Associated with Increased Odds of Past-Year Mental Health Disorders: A Canadian Armed Forces Examination","volume":"14","author":"Easterbrook","year":"2023","journal-title":"Eur. J. Psychotraumatol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"264","DOI":"10.1177\/0844562120961894","article-title":"Mental Disorder Symptoms Among Nurses in Canada","volume":"53","author":"Stelnicki","year":"2021","journal-title":"Can. J. Nurs. Res."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"277","DOI":"10.1177\/0844562120961988","article-title":"Exposures to Potentially Psychologically Traumatic Events among Nurses in Canada","volume":"53","author":"Stelnicki","year":"2021","journal-title":"Can. J. Nurs. Res."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"581","DOI":"10.1177\/1048291117732301","article-title":"Assaulted and Unheard: Violence Against Healthcare Staff","volume":"27","author":"Brophy","year":"2017","journal-title":"New Solut."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1111\/j.1442-2018.2010.00514.x","article-title":"Stress and Coping in Singaporean Nurses: A Literature Review","volume":"12","author":"Lim","year":"2010","journal-title":"Nurs. Health Sci."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1097\/00063110-200502000-00005","article-title":"The Psychological Impact of Severe Acute Respiratory Syndrome Outbreak on Healthcare Workers in Emergency Departments and How They Cope","volume":"12","author":"Wong","year":"2005","journal-title":"Eur. J. Emerg. Med."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Karram, M., D\u2019Alessandro-Lowe, A.M., Ritchie, K., Brown, A., Xue, Y., Pichtikova, M., Altman, M., Beech, I., Millman, H., and Hosseiny, F. (2023). A Qualitative Approach to Understanding Canadian Healthcare Workers\u2019 Use of Coping Strategies during the COVID-19 Pandemic. Int. J. Environ. Res. Public Health, 20.","DOI":"10.3390\/ijerph20032551"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"701127","DOI":"10.3389\/fpsyt.2021.701127","article-title":"Psychological Impact of Exposure to the COVID-19 Sanitary Crisis on French Healthcare Workers: Risk Factors and Coping Strategies","volume":"12","author":"Vancappel","year":"2021","journal-title":"Front. Psychiatry"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"124","DOI":"10.1016\/j.genhosppsych.2021.08.008","article-title":"Coping Strategies Adopted by Australian Frontline Health Workers to Address Psychological Distress during the COVID-19 Pandemic","volume":"72","author":"Smallwood","year":"2021","journal-title":"Gen. Hosp. Psychiatry"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.genhosppsych.2020.06.007","article-title":"Psychological Distress, Coping Behaviors, and Preferences for Support among New York Healthcare Workers during the COVID-19 Pandemic","volume":"66","author":"Shechter","year":"2020","journal-title":"Gen. Hosp. Psychiatry"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Budzy\u0144ska, N., and Mory\u015b, J. (2023). Anxiety and Depression Levels and Coping Strategies among Polish Healthcare Workers during the COVID-19 Pandemic. Int. J. Environ. Res. Public Health, 20.","DOI":"10.3390\/ijerph20043319"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Haor, B., Antczak-Komoterska, A., Kozyra, J., Gr\u0105czewska, N., G\u0142owacka, M., Biercewicz, M., Kr\u00f3likowska, A., Jab\u0142o\u0144ska, R., and Grzelak, L. (2023). System of Work and Stress-Coping Strategies Used by Nurses of a Polish Hospital during the COVID-19 Pandemic. Int. J. Environ. Res. Public Health, 20.","DOI":"10.3390\/ijerph20064871"},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Chow, S.K., Francis, B., Ng, Y.H., Naim, N., Beh, H.C., Ariffin, M.A.A., Yusuf, M.H.M., Lee, J.W., and Sulaiman, A.H. (2021). Religious Coping, Depression and Anxiety among Healthcare Workers during the COVID-19 Pandemic: A Malaysian Perspective. Healthcare, 9.","DOI":"10.3390\/healthcare9010079"},{"key":"ref_24","first-page":"1","article-title":"The Relationship between Anxiety and Depression Levels with Perceived Stress and Coping Strategies in Health Care Workers during the COVID-19 Pandemic","volume":"55","author":"Besirli","year":"2021","journal-title":"Med. Bull. Sisli Etfal Hosp."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1893","DOI":"10.1111\/jonm.13336","article-title":"Psychological Resilience, Coping Behaviours and Social Support among Health Care Workers during the COVID-19 Pandemic: A Systematic Review of Quantitative Studies","volume":"29","author":"Labrague","year":"2021","journal-title":"J. Nurs. Manag."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Flores, B., Castillo, B., M\u00e9ndez, C., Rojop, J., Contreras, M., Hern\u00e1ndez, O., G\u00f3mez, Q., Tapia, R., Qui\u00f1ones, R., and Santab\u00e1rbara, J. (2023). Mental Health Disorders and Coping Strategies in Healthcare Workers during the COVID-19 Pandemic: An Analytical Cross-Sectional Study in Southeastern Mexico. Int. J. Environ. Res. Public, 20.","DOI":"10.3390\/ijerph20054230"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"33","DOI":"10.1037\/bul0000316","article-title":"Examining Moderators of the Relationship between Social Support and Self-Reported PTSD Symptoms: A Meta-Analysis","volume":"147","author":"Zalta","year":"2021","journal-title":"Psychol. Bull."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"395","DOI":"10.1111\/jonm.13168","article-title":"Fear of COVID-19, Psychological Distress, Work Satisfaction and Turnover Intention among Frontline Nurses","volume":"29","author":"Labrague","year":"2021","journal-title":"J. Nurs. Manag."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Griffin, B.J., Cornish, M.A., Maguen, S., and Worthington, E.L. (2020). Forgiveness as a Mechanism of Repair Following Military-Related Moral Injury. Addressing Moral Inj. Clin. Pract., 71\u201386.","DOI":"10.1037\/0000204-005"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"621","DOI":"10.1037\/tra0000447","article-title":"Moral Injury and Suicidality Among Combat-Wounded Veterans: The Moderating Effects of Social Connectedness and Self-Compassion","volume":"11","author":"Kelley","year":"2019","journal-title":"Psychol. Trauma"},{"key":"ref_31","first-page":"422773","article-title":"Spirituality and Moral Injury among Military Personnel: A Mini-Review","volume":"10","author":"Pike","year":"2019","journal-title":"Front. Psychiatry"},{"key":"ref_32","first-page":"417669","article-title":"Spiritual Dimensions of Moral Injury: Contributions of Mental Health Chaplains in the Canadian Armed Forces","volume":"9","author":"Morin","year":"2018","journal-title":"Front. Psychiatry"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"e1920","DOI":"10.7205\/MILMED-D-17-00099","article-title":"Spirituality and Mental Well-Being in Combat Veterans: A Systematic Review","volume":"182","author":"Norris","year":"2017","journal-title":"Mil. Med."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"2180706","DOI":"10.1080\/20008066.2023.2180706","article-title":"Associations between Trauma and Substance Use among Healthcare Workers and Public Safety Personnel during the SARS-CoV-2 Pandemic: The Mediating Roles of Dissociation and Emotion Dysregulation","volume":"14","author":"Patel","year":"2023","journal-title":"Eur. J. Psychotraumatol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"405","DOI":"10.1002\/jts.22404","article-title":"Associations Among Exposure to Potentially Morally Injurious Experiences, Spiritual Injury, and Alcohol Use Among Combat Veterans","volume":"32","author":"Battles","year":"2019","journal-title":"J. Trauma Stress"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"382","DOI":"10.1080\/10926770902881489","article-title":"Social Cognition and Interpersonal Impairments in Trauma Survivors with PTSD","volume":"18","author":"Nietlisbach","year":"2009","journal-title":"J. Aggress. Maltreat Trauma"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"267","DOI":"10.1177\/1048291120974358","article-title":"Sacrificed: Ontario Healthcare Workers in the Time of COVID-19","volume":"30","author":"Brophy","year":"2021","journal-title":"New Solut."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1684","DOI":"10.3389\/fpsyg.2020.01684","article-title":"The Psychological Impact of the COVID-19 Outbreak on Health Professionals: A Cross-Sectional Study","volume":"11","author":"Giusti","year":"2020","journal-title":"Front. Psychol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"605","DOI":"10.1080\/15298868.2018.1508494","article-title":"New Frontiers in Understanding the Benefits of Self-Compassion","volume":"17","author":"Bluth","year":"2018","journal-title":"Self Identity"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"645","DOI":"10.1080\/15298868.2018.1436587","article-title":"The Forest and the Trees: Examining the Association of Self-Compassion and Its Positive and Negative Components with Psychological Functioning","volume":"17","author":"Neff","year":"2018","journal-title":"Self Identity"},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Rushforth, A., Durk, M., Rothwell-Blake, G.A.A., Kirkman, A., Ng, F., and Kotera, Y. (2023). Self-Compassion Interventions to Target Secondary Traumatic Stress in Healthcare Workers: A Systematic Review. Int. J. Environ. Res. Public Health, 20.","DOI":"10.3390\/ijerph20126109"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1080\/15298860309032","article-title":"Self-Compassion: An Alternative Conceptualization of a Healthy Attitude Toward Oneself","volume":"2","author":"Neff","year":"2003","journal-title":"Self Identity"},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Shahsavarinia, K., Amiri, P., Mousavi, Z., Gilani, N., Saadati, M., and Soleimanpour, H. (2022). Prediction of PTSD Related to COVID-19 in Emergency Staff Based on the Components of Self-Compassion and Perceived Social Support. BMC Psychiatry, 22.","DOI":"10.1186\/s12888-022-04017-8"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1097\/NMD.0000000000000798","article-title":"Moral Injury and Religiosity in US Veterans with Posttraumatic Stress Disorder Symptoms","volume":"206","author":"Koenig","year":"2018","journal-title":"J. Nerv. Ment. Dis."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"61","DOI":"10.4037\/ccn2018674","article-title":"The Role of Spirituality Among Military En Route Care Nurses: Source of Strength or Moral Injury?","volume":"38","author":"Simmons","year":"2018","journal-title":"Crit. Care Nurse"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1546084","DOI":"10.1080\/20008198.2018.1546084","article-title":"The Relation between Adverse Childhood Experiences and Moral Injury in the Canadian Armed Forces","volume":"10","author":"Battaglia","year":"2019","journal-title":"Eur. J. Psychotraumatol."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"71","DOI":"10.3138\/jmvfh-2020-0036","article-title":"Examining the Associations among Moral Injury, Difficulties with Emotion Regulation, and Symptoms of PTSD, Depression, Anxiety, and Stress among Canadian Military Members and Veterans: A Preliminary Study","volume":"7","author":"Protopopescu","year":"2021","journal-title":"J. Mil. Veteran Fam. Health"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1606625","DOI":"10.1080\/20008198.2019.1606625","article-title":"Lifetime Traumatic Stressors and Adverse Childhood Experiences Uniquely Predict Concurrent PTSD, Complex PTSD, and Dissociative Subtype of PTSD Symptoms Whereas Recent Adult Non-Traumatic Stressors Do Not: Results from an Online Survey Study","volume":"10","author":"Frewen","year":"2019","journal-title":"Eur. J. Psychotraumatol."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1016\/j.jbi.2008.08.010","article-title":"Research Electronic Data Capture (REDCap)-A Metadata-Driven Methodology and Workflow Process for Providing Translational Research Informatics Support","volume":"42","author":"Harris","year":"2009","journal-title":"J. Biomed. Inf."},{"key":"ref_50","doi-asserted-by":"crossref","unstructured":"Harris, P.A., Taylor, R., Minor, B.L., Elliott, V., Fernandez, M., O\u2019Neal, L., McLeod, L., Delacqua, G., Delacqua, F., and Kirby, J. (2019). The REDCap Consortium: Building an International Community of Software Platform Partners. J. Biomed. Inf., 95.","DOI":"10.1016\/j.jbi.2019.103208"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"923928","DOI":"10.3389\/fpsyt.2022.923928","article-title":"Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium","volume":"13","author":"Litz","year":"2022","journal-title":"Front. Psychiatry"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1016\/S0749-3797(98)00017-8","article-title":"Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study","volume":"14","author":"Felitti","year":"1998","journal-title":"Am. J. Prev. Med."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1207\/s15327752jpa5201_2","article-title":"The Multidimensional Scale of Perceived Social Support","volume":"52","author":"Zimet","year":"2010","journal-title":"J. Personal. Assess."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"500","DOI":"10.1037\/0021-9010.71.3.500","article-title":"Perceived Organizational Support","volume":"71","author":"Eisenberger","year":"1986","journal-title":"J. Appl. Psychol."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"77","DOI":"10.3390\/rel2010077","article-title":"Spiritual Well-Being as a Component of Health-Related Quality of Life: The Functional Assessment of Chronic Illness Therapy\u2014Spiritual Well-Being Scale (FACIT-Sp)","volume":"2","author":"Bredle","year":"2011","journal-title":"Religions"},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"791","DOI":"10.1111\/j.1360-0443.1993.tb02093.x","article-title":"Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption-II","volume":"88","author":"Saunders","year":"1993","journal-title":"Addiction"},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"137","DOI":"10.1016\/j.drugalcdep.2010.02.017","article-title":"An Improved Brief Measure of Cannabis Misuse: The Cannabis Use Disorders Identification Test-Revised (CUDIT-R)","volume":"110","author":"Adamson","year":"2010","journal-title":"Drug Alcohol. Depend."},{"key":"ref_58","unstructured":"IBM Corp IMB SPSS Statistics for Macintosh, Version 29."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"1198","DOI":"10.1080\/01621459.1988.10478722","article-title":"A Test of Missing Completely at Random for Multivariate Data with Missing Values","volume":"83","author":"Little","year":"1988","journal-title":"J. Am. Stat. Assoc."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1037\/trm0000069","article-title":"Defining and Assessing Moral Injury: A Syndrome Perspective","volume":"22","author":"Jinkerson","year":"2016","journal-title":"Traumatol. (Tallahass Fla)"},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"426415","DOI":"10.3389\/fpsyt.2018.00619","article-title":"Chaplaincy, Spiritual Care and Moral Injury: Considerations Regarding Screening and Treatment","volume":"9","author":"Carey","year":"2018","journal-title":"Front. Psychiatry"},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1093\/geront\/42.suppl_3.24","article-title":"A Biopsychosocial-Spiritual Model for the Care of Patients at the End of Life","volume":"42","author":"Sulmasy","year":"2002","journal-title":"Gerontologist"},{"key":"ref_63","first-page":"4","article-title":"Systemic Assessment and Treatment of Depression and Anxiety in Families: The BPSS Model in Practice","volume":"25","author":"Layne","year":"2006","journal-title":"J. Syst. Ther."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"e135","DOI":"10.1192\/bjo.2021.972","article-title":"Spirituality, Moral Injury and Mental Health among Chinese Health Professionals","volume":"7","author":"Wang","year":"2021","journal-title":"BJPsych Open"},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1097\/NNA.0000000000001103","article-title":"Organizational Impact on Healthcare Workers\u2019 Moral Injury During COVID-19: A Mixed-Methods Analysis","volume":"52","author":"Nelson","year":"2022","journal-title":"J. Nurs. Adm."},{"key":"ref_66","doi-asserted-by":"crossref","unstructured":"Alonso-Prieto, E., Longstaff, H., Black, A., and Virani, A.K. (2022). COVID-19 Outbreak: Understanding Moral-Distress Experiences Faced by Healthcare Workers in British Columbia, Canada. Int. J. Environ. Res. Public Health, 19.","DOI":"10.3390\/ijerph19159701"},{"key":"ref_67","doi-asserted-by":"crossref","unstructured":"Kreh, A., Brancaleoni, R., Magalini, S.C., Chieffo, D.P.R., Flad, B., Ellebrecht, N., and Juen, B. (2021). Ethical and Psychosocial Considerations for Hospital Personnel in the COVID-19 Crisis: Moral Injury and Resilience. PLoS ONE, 16.","DOI":"10.1371\/journal.pone.0249609"},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"310","DOI":"10.1037\/0033-2909.98.2.310","article-title":"Stress, Social Support, and the Buffering Hypothesis","volume":"98","author":"Cohen","year":"1985","journal-title":"Psychol. Bull."},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1002\/cpp.2607","article-title":"Moral Injury, Mental Health and Behavioural Health Outcomes: A Systematic Review of the Literature","volume":"29","author":"Hall","year":"2022","journal-title":"Clin. Psychol. Psychother."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/20\/19\/6812\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T20:56:37Z","timestamp":1760129797000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/20\/19\/6812"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,9,23]]},"references-count":69,"journal-issue":{"issue":"19","published-online":{"date-parts":[[2023,10]]}},"alternative-id":["ijerph20196812"],"URL":"https:\/\/doi.org\/10.3390\/ijerph20196812","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,9,23]]}}}