Moral Injury: Need and Development of a Measurement Scale for Firefighters

Douglas DeMoulin, Jeanette Irene Harris, Patricia M. McGovern, Timothy J. Beebe, Timothy R. Church, Hyun Kim

Research output: Contribution to journalReview articlepeer-review


Moral injury is extensively studied among trauma-exposed veterans. Two measurement scales are available to screen for symptoms of moral injury among trauma-exposed veterans; however, no measurement scale exists screening for symptoms of moral injury among trauma-exposed firefighters. The objective of this study aims to address the gap in available instruments by developing a moral injury assessment scale for firefighters. Through this project, a psychometrically accepted moral injury scale will be available to researchers, clinicians, and fire organizations to assess moral injury in trauma-exposed firefighters. Military studies found that moral injury and posttraumatic stress disorder (PTSD) are distinct constructs and can co-exist. PTSD is prevalent in firefighters and despite subject experts expressing the need to expand research efforts to first responders (e.g., firefighters), no moral injury scale is available assessing these symptoms. Exploratory themes are recently emerging in these occupations. The EMIS-F yielded almost perfect interrater reliability across raters (.97). Psychometric properties of the EMIS-F were comparable to the military version, yielding excellent internal consistency (ω = 0.94), in addition to the self-directed (ω = 0.92) and others-directed (ω = 0.89) moral injury subscales. Inter-item and item-total correlations are within acceptable ranges (ρ = 0.30–0.73) to empirically conclude the EMIS-F measures a unidimensional construct. Item-total correlations did not detract from the consistency of the overall scale and independently demonstrated positive correlations with the EMIS-F (ρ =.62–79). The EMIS-F demonstrated strong convergent validity with validated measures of PTSD (ρ =.61), depression (ρ =.50), and suicide ideation (ρ =.38), and evidence of divergent validity with strong support systems (ρ = −.14).

Original languageEnglish (US)
Pages (from-to)404-430
Number of pages27
JournalCurrent Treatment Options in Psychiatry
Issue number4
StatePublished - Dec 2023

Bibliographical note

Publisher Copyright:
© 2023, The Author(s), under exclusive licence to Springer Nature Switzerland AG.


  • Firefighter
  • Moral injury
  • PTSD
  • Posttraumatic stress disorder
  • Scale modification
  • Trauma


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