Webb, E. L., Ireland, J. L., & Lewis, M. (2025).
Issues in Mental Health Nursing, 46(5), 420–435.
Abstract
Moral injury is a prevalent issue for secure mental healthcare staff, though understanding of the underlying mechanisms is limited. This multi-study paper explores several developmental, cognitive and emotional pathways to moral injury and associated wellbeing outcomes. Frontline and support staff from secure mental healthcare services were recruited to two cross-sectional studies (n = 527 and n = 325, respectively), and completed several questionnaires. In the first study, findings indicated a serial mediating effect of childhood trauma symptoms, early maladaptive schemas, and maladaptive metacognitions in the pathway between exposure to potentially morally injurious events and moral injury symptoms. Moderating effects of social and organisational support were also apparent. Findings from study two supported pathways between moral injury and psychological, somatic and functional outcomes, which were mediated by negative emotional schema, with limited mediating effects for expressive suppression. Moderating effects of alexithymia on several mediating pathways were also noted. The results support a developmental-cognitive model to account for the development of moral injury and associated adverse well-being outcomes in secure mental healthcare staff. Drawing on the findings and wider literature, the Integrated Pathway Model of Moral Injury (IPM-MI) is proposed and discussed, offering a novel theoretical account that may inform several potential prevention and intervention strategies.
Here are some thoughts:
This article proposes the Integrated Pathway Model of Moral Injury (IPM-MI), a novel theoretical framework developed to explain the development and consequences of moral injury among secure mental healthcare staff. Through two cross-sectional studies, the research identifies key developmental, cognitive, and emotional pathways. Study 1 found that the relationship between exposure to potentially morally injurious events (PMIEs) and moral injury symptoms is serially mediated by childhood trauma symptoms, early maladaptive schemas (particularly negative self-schemas), and maladaptive metacognitions. Social and organizational support were found to moderate these pathways, buffering the impact of trauma. Study 2 revealed that the link between moral injury and adverse outcomes—such as psychological distress, somatic symptoms, nightmares, and impairments in self and interpersonal functioning—is primarily mediated by negative emotional schemas. The role of expressive suppression was limited, only appearing in the pathway to interpersonal impairment. Alexithymia moderated the effect of emotional schemas on psychological distress and self-functioning.
The key insights are that moral injury in this high-risk workforce is not just a reaction to workplace events but is deeply influenced by pre-existing developmental vulnerabilities and higher-order cognitive processes (thoughts about thoughts and emotions). The proposed IPM-MI integrates these findings, emphasizing that systemic and organizational factors (like support systems and a non-punitive culture) are critical roots of the problem, while cognitive and meta-cognitive processes are primary intervention targets. The model suggests that effective prevention and intervention must address both the organizational environment and individual cognitive-emotional patterns, rather than focusing solely on emotion regulation.
