A Study of Moral Distress, Moral Injury and Post-Traumatic Stress for Nurses

NCT07455370 | Enrolling By Invitation

• 2 other identifiers: 25-008396Mayo Clinic CTSA
• Study Type: observational
• Target: 21,300
• Locations: 1 country
• Sites: 3

Brief Summary

The goal of this descriptive study is to examine levels of moral distress (MD), moral injury (MI), \& post-traumatic stress (PTS) levels among nursing staff at Mayo Clinic. The main questions this study aims to answer are:

1. 1.Determine the levels of MD, MI, and PTS symptoms experienced by nurses who participate in the study.
2. 2.Evaluate differences in MD, MI, and PTS symptoms by setting, specialties, and geographic locations.
3. 3.Examine demographic and professional characteristics that are associated with high levels of MD, MI and PTS.

Conditions

Moral Injury; Moral Distress; Post-Traumatic Stress; Nurse Well-being; Wellbeing; Wellness, Psychological; Wellness; Nurses; Nurse Health

Keywords

Moral Injury; Moral Distress; Post-Traumatic Stress; Nurse Wellbeing; Nurse burnout

Outcome Measures

Primary Outcomes (3)

• Measure of Moral Distress-Healthcare Professionals (MMD-HP) Score

  The MMD-HP (Measure of Moral Distress-Healthcare Professionals) is a 27-item moral distress scale. A composite score is computed for items 1 - 25 and is obtained by multiplying the frequency scores (0 = Never to 4 = Very Frequently scale) and the distress scores (0 = None to 4 = Very Distressing scale) for each item; the products of these can range from 0 - 16. Higher scores indicate a greater deal of moral distress.

  Baseline

• Moral Injury Outcome Scale (MIOS) score

  The Moral Injury Outcome Scale (MIOS) is a 14-item self-reported survey divided into two subscales-shame-related and trust-violation related. Both the shame and trust-violated subscales are seven items per subscale. Respondents are asked to indicate how strongly they agree with each statement in the past month using a 5 point Likert scale where 0 = Strongly Disagree and 4 = Strongly Agree. The total score range for each subscale is 0 - 28, and the overall score range is 0 - 56. Symptom severity is categorized as follows: 14 - 28 indicates mild moral injury, 29 - 42 indicates moderate moral injury, and 35 - 56 indicates severe moral injury.

  Baseline

• Post-Traumatic Stress Disorder (PCL-5) score

  The PCL - 5 (Post-Traumatic Stress Disorder (PSTD) Checklist) is a 20-item self-reported survey that assesses the 20 DSM-5 symptoms of PTSD. Respondents are asked to indicate the frequency that each item occurs on a 5 point Likert scale where 0 = Not at All and 4 = Extremely. The total score is the sum of all 20 questions, with higher scores indicating a greater likelihood of PTSD.

  Baseline

Study Arms (1)

Mayo Clinic Nurses

Mayo Clinic Department of Nursing staff across the enterprise including advanced practice nurses, registered nurses, licensed practical nurses, and nursing support/unlicensed staff.

Other: Surveys

Interventions

Surveys OTHER

Participants will complete an electronic survey containing the Measure of Moral Distress- Healthcare Professionals (MMD-HP), Moral Injury Outcome Scale (MIOS) including functional outcome measures adapted from the Brief Inventory of Psychosocial Functioning, The PCL-5 Checklist for DSM-5 (Post-Traumatic Stress Disorder (PSTD) Checklist for the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5)) (PCL-5), and the Well-Being Index (WBI), additionally including a demographic questionnaire with wellbeing questions.

Mayo Clinic Nurses

Eligibility Criteria

• Sex: all
• Healthy Volunteers: No
• Age Groups: Child (0-17), Adult (18-64), Older Adult (65+)
• Sampling Method: Non-Probability Sample

Study Population

Mayo Clinic Department of Nursing Staff across all Mayo Clinic sites, including: Mayo Clinic in Rochester, Minnesota; Mayo Clinic in Arizona; Mayo Clinic in Florida; and Mayo Clinic Health System sites in the midwest.

You may qualify if:

• Mayo Clinic Department of Nursing Staff including:
• Registered nurses
• Licensed practical nurses
• Nursing support staff (including roles such as patient care assistants, patient care specialists, medical assistants, and nurse technicians)

You may not qualify if:

• Social workers
• Chaplains
• Unit coordinators
• Other staff who do not support direct patient care but are within the nursing department
• Other employees outside the Department of Nursing

Sponsors & Collaborators

• Mayo Clinic: lead
• Mayo Clinic Center for Clinical and Translational Science (CCaTS): collaborator

Study Sites (3)

Mayo Clinic

Phoenix, Arizona, 85054, United States

Location

Mayo Clinic

Jacksonville, Florida, 32250, United States

Location

Mayo Clinic

Rochester, Minnesota, 55905, United States

Location

Related Publications (25)

• Dyrbye LN, Johnson PO, Johnson LM, Satele DV, Shanafelt TD. Efficacy of the Well-Being Index to Identify Distress and Well-Being in U.S. Nurses. Nurs Res. 2018 Nov/Dec;67(6):447-455. doi: 10.1097/NNR.0000000000000313.

  PMID: 30138124 BACKGROUND

• Wortmann JH, Jordan AH, Weathers FW, Resick PA, Dondanville KA, Hall-Clark B, Foa EB, Young-McCaughan S, Yarvis JS, Hembree EA, Mintz J, Peterson AL, Litz BT. Psychometric analysis of the PTSD Checklist-5 (PCL-5) among treatment-seeking military service members. Psychol Assess. 2016 Nov;28(11):1392-1403. doi: 10.1037/pas0000260. Epub 2016 Jan 11.

  PMID: 26751087 BACKGROUND

• Houle SA, Ein N, Gervasio J, Plouffe RA, Litz BT, Carleton RN, Hansen KT, Liu JJW, Ashbaugh AR, Callaghan W, Thompson MM, Easterbrook B, Smith-MacDonald L, Rodrigues S, Belanger SAH, Bright K, Lanius RA, Baker C, Younger W, Bremault-Phillips S, Hosseiny F, Richardson JD, Nazarov A; Atlas Institute Moral Injury Research Community of Practice. Measuring moral distress and moral injury: A systematic review and content analysis of existing scales. Clin Psychol Rev. 2024 Mar;108:102377. doi: 10.1016/j.cpr.2023.102377. Epub 2023 Dec 27.

  PMID: 38218124 BACKGROUND

• Booth AT, Robinson KL. System-wide assessment using the Measure of Moral Distress - Healthcare professionals. Nurs Ethics. 2025 Aug;32(5):1629-1643. doi: 10.1177/09697330251324296. Epub 2025 Mar 3.

  PMID: 40033517 BACKGROUND

• D'Alessandro-Lowe AM, Patel H, Easterbrook B, Ritchie K, Brown A, Xue Y, Karram M, Millman H, Sullo E, Pichtikova M, Nicholson A, Heber A, Malain A, O'Connor C, Schielke H, Rodrigues S, Hosseiny F, McCabe RE, Lanius RA, McKinnon MC. The independent and combined impact of moral injury and moral distress on post-traumatic stress disorder symptoms among healthcare workers during the COVID-19 pandemic. Eur J Psychotraumatol. 2024;15(1):2299661. doi: 10.1080/20008066.2023.2299661. Epub 2024 Feb 9.

  PMID: 38334706 BACKGROUND

• Austin CL, Saylor R, Finley PJ. Moral distress in physicians and nurses: Impact on professional quality of life and turnover. Psychol Trauma. 2017 Jul;9(4):399-406. doi: 10.1037/tra0000201. Epub 2016 Oct 31.

  PMID: 27797570 BACKGROUND

• Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and Initial Psychometric Evaluation. J Trauma Stress. 2015 Dec;28(6):489-98. doi: 10.1002/jts.22059. Epub 2015 Nov 25.

  PMID: 26606250 BACKGROUND

• Schuster M, Dwyer PA. Post-traumatic stress disorder in nurses: An integrative review. J Clin Nurs. 2020 Aug;29(15-16):2769-2787. doi: 10.1111/jocn.15288. Epub 2020 May 5.

  PMID: 32372541 BACKGROUND

• Brennan CJ, Roberts C, Cole JC. Prevalence of occupational moral injury and post-traumatic embitterment disorder: a systematic review and meta-analysis. BMJ Open. 2024 Feb 20;14(2):e071776. doi: 10.1136/bmjopen-2023-071776.

  PMID: 38382965 BACKGROUND

• Weber MC, Smith AJ, Jones RT, Holmes GA, Johnson AL, Patrick RNC, Alexander MD, Miyazaki Y, Wright H, Ehman AC, Langenecker SA, Benight CC, Pyne JM, Harris JI, Usset TJ, Maguen S, Griffin BJ. Moral injury and psychosocial functioning in health care workers during the COVID-19 pandemic. Psychol Serv. 2023 Feb;20(1):19-29. doi: 10.1037/ser0000718. Epub 2022 Nov 10.

  PMID: 36355661 BACKGROUND

• Ehman AC, Smith AJ, Wright H, Langenecker SA, Benight CC, Maguen S, Pyne JM, Harris JI, Cooney N, Griffin BJ. Exposure to potentially morally injurious events and mental health outcomes among frontline workers affected by the coronavirus pandemic. Psychol Trauma. 2023 Mar;15(3):524-535. doi: 10.1037/tra0001345. Epub 2022 Aug 4.

  PMID: 35925697 BACKGROUND

• Hines SE, Chin KH, Glick DR, Wickwire EM. 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. 2021 Jan 9;18(2):488. doi: 10.3390/ijerph18020488.

  PMID: 33435300 BACKGROUND

• Papazoglou K, Chopko B. The Role of Moral Suffering (Moral Distress and Moral Injury) in Police Compassion Fatigue and PTSD: An Unexplored Topic. Front Psychol. 2017 Nov 15;8:1999. doi: 10.3389/fpsyg.2017.01999. eCollection 2017. No abstract available.

  PMID: 29187830 BACKGROUND

• Maguen S, Litz BT. Moral Injury in Veterans of War. PTSD Research Quarterly (RQ). 2012;23(1):1-3.

  BACKGROUND

• Gibbons SW, Shafer M, Hickling EJ, Ramsey G. How do deployed health care providers experience moral injury? Narrat Inq Bioeth. 2013 Winter;3(3):247-59. doi: 10.1353/nib.2013.0055.

  PMID: 24407133 BACKGROUND

• Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, Maguen S. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009 Dec;29(8):695-706. doi: 10.1016/j.cpr.2009.07.003. Epub 2009 Jul 29.

  PMID: 19683376 BACKGROUND

• Shay J. Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York, NY: Scribner; 1994. 246 p.

  BACKGROUND

• Yan GW. The Invisible Wound: Moral Injury and Its Impact on the Health of Operation Enduring Freedom/Operation Iraqi Freedom Veterans. Mil Med. 2016 May;181(5):451-8. doi: 10.7205/MILMED-D-15-00103.

  PMID: 27136652 BACKGROUND

• Horesh D, Brown AD. Traumatic stress in the age of COVID-19: A call to close critical gaps and adapt to new realities. Psychol Trauma. 2020 May;12(4):331-335. doi: 10.1037/tra0000592.

  PMID: 32271070 BACKGROUND

• Wingfield T, Taegtmeyer M. Healthcare workers and Coronavirus: Behind the stiff upper lip we are highly vulnerable Waltham, MA: The Conversation; 2020 [Available from: https://theconversation.com/healthcare-workers-and-coronavirus-behind-the-stiff-upper-lip-we-are-highly-vulnerable-133864.

  BACKGROUND

• Agazio J, Goodman P. Making the hard decisions: Ethical care decisions in wartime nursing practice. Nurs Outlook. 2017 Sep-Oct;65(5S):S92-S99. doi: 10.1016/j.outlook.2017.06.010. Epub 2017 Jun 30.

  PMID: 28807499 BACKGROUND

• Gibbons SW, Shafer M, Aramanda L, Hickling EJ, Benedek DM. Combat health care providers and resiliency: adaptive coping mechanisms during and after deployment. Psychol Serv. 2014 May;11(2):192-9. doi: 10.1037/a0033165. Epub 2013 Jul 15.

  PMID: 23855421 BACKGROUND

• American Association of Critical Care Nurses. AACN Public Policy Position Statement 2001. Aliso Viejo, CA: American Association of Critical Care Nurses; 2001.

  BACKGROUND

• Epstein EG, Whitehead PB, Prompahakul C, Thacker LR, Hamric AB. Enhancing Understanding of Moral Distress: The Measure of Moral Distress for Health Care Professionals. AJOB Empir Bioeth. 2019 Apr-Jun;10(2):113-124. doi: 10.1080/23294515.2019.1586008. Epub 2019 Apr 19.

  PMID: 31002584 BACKGROUND

• American Association of Critical Care Nurses. Moral distress public policy position statement. Aliso Viejo, CA: American Association of Critical Care Nurses; 2008.

  BACKGROUND

MeSH Terms

Conditions

Stress Disorders, Post-Traumatic; Psychological Well-Being

Interventions

Surveys and Questionnaires

Condition Hierarchy (Ancestors)

Stress Disorders, Traumatic; Trauma and Stressor Related Disorders; Mental Disorders; Personal Satisfaction; Behavior

Intervention Hierarchy (Ancestors)

Data Collection; Epidemiologic Methods; Investigative Techniques; Health Care Evaluation Mechanisms; Quality of Health Care; Health Care Quality, Access, and Evaluation; Public Health; Environment and Public Health

Study Officials

• Melissa A Wilson, PhD

  Mayo Clinic

  PRINCIPAL INVESTIGATOR

• Cindy Tofthagen, PhD

  Mayo Clinic

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: observational
• Observational Model: CASE ONLY
• Time Perspective: CROSS SECTIONAL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Senior Associate Consultant

Study Record Dates

• First Submitted: February 23, 2026
• First Posted: March 6, 2026
• Study Start: March 3, 2026
• Primary Completion: August 1, 2026
• Study Completion (Estimated): November 1, 2026
• Last Updated: June 23, 2026

Record last verified: 2026-06

Data Sharing

• IPD Sharing: Will not share

Locations

US (3)