Volume 28, Issue 4 (3-2026)
jha 2026, 28(4): 43-56 |
Back to browse issues page
Download citation:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
Shojaeimotlagh V, Habibpour Z, Sodeify R, Ghanei Gheshlagh R. Psychometric evaluation of the Persian version of the moral injury symptoms scale–health professional among Iranian nurses. jha 2026; 28 (4) :43-56
URL: http://jha.iums.ac.ir/article-1-4733-en.html
URL: http://jha.iums.ac.ir/article-1-4733-en.html
1- Department of Medical Surgical Nursing, School of Nursing and Midwifery, Urmia University of Medical Sciences, Urmia, Iran
2- Determinants of Nursing, Khoy University of Medical Sciences, Khoy, Iran.
3- Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran. & Nursing Department, Faculty of Health Sciences, Biruni University, Istanbul, Turkey. ,rezaghanei30@gmail.com
2- Determinants of Nursing, Khoy University of Medical Sciences, Khoy, Iran.
3- Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran. & Nursing Department, Faculty of Health Sciences, Biruni University, Istanbul, Turkey. ,
Abstract: (245 Views)
Introduction: Moral injury is a form of psychological trauma experienced by healthcare workers, leading to guilt, shame, emotional distress, and reduced morale. This study evaluated the psychometric properties of the Persian version of the Moral Injury Symptoms Scale-Health Professional (P-MISS-HP) among Iranian nurses.
Methods: A cross-sectional study was conducted in 2025 in Urmia, Iran. The scale was translated using a forward–backward translation approach. Face, content, and construct validity were assessed in a sample of 220 nurses randomly divided into two groups. Exploratory factor analysis (EFA) using maximum likelihood and Oblimin rotation was conducted in one group; and confirmatory factor analysis (CFA) was performed in the other. Reliability was assessed using Cronbach’s alpha and McDonald’s omega coefficients. Convergent and discriminant validity were evaluated using average variance extracted (AVE), composite reliability (CR), maximum shared variance (MSV), and the Heterotrait-Monotrait (HTMT) ratio.
Results: EFA identified two factors, shame/guilt/condemnation and spiritual troubles, explaining 63.2% of the variance; one item was removed. CFA confirmed this two-factor model with strong fit indices (CMIN/DF = 1.424, CFI = 0.988, RMSEA = 0.062). Internal consistency was high (α = 0.901, ω = 0.904). Convergent validity (AVE > 0.50, CR > 0.90), and discriminant validity (MSV < AVE, HTMT = 0.621) were also confirmed
Conclusion: The Persian version of the Moral Injury Symptoms Scale-Health Professional demonstrated strong psychometric qualities and is a reliable instrument for assessing moral injury among Iranian nurses.
Methods: A cross-sectional study was conducted in 2025 in Urmia, Iran. The scale was translated using a forward–backward translation approach. Face, content, and construct validity were assessed in a sample of 220 nurses randomly divided into two groups. Exploratory factor analysis (EFA) using maximum likelihood and Oblimin rotation was conducted in one group; and confirmatory factor analysis (CFA) was performed in the other. Reliability was assessed using Cronbach’s alpha and McDonald’s omega coefficients. Convergent and discriminant validity were evaluated using average variance extracted (AVE), composite reliability (CR), maximum shared variance (MSV), and the Heterotrait-Monotrait (HTMT) ratio.
Results: EFA identified two factors, shame/guilt/condemnation and spiritual troubles, explaining 63.2% of the variance; one item was removed. CFA confirmed this two-factor model with strong fit indices (CMIN/DF = 1.424, CFI = 0.988, RMSEA = 0.062). Internal consistency was high (α = 0.901, ω = 0.904). Convergent validity (AVE > 0.50, CR > 0.90), and discriminant validity (MSV < AVE, HTMT = 0.621) were also confirmed
Conclusion: The Persian version of the Moral Injury Symptoms Scale-Health Professional demonstrated strong psychometric qualities and is a reliable instrument for assessing moral injury among Iranian nurses.
Type of Study: Research |
Subject:
Health Services Management
Received: 2025/10/5 | Accepted: 2026/02/17 | Published: 2026/03/6
Received: 2025/10/5 | Accepted: 2026/02/17 | Published: 2026/03/6
supplement [PDF 198 KB] (21 Download)
References
1. Frost RO, Marten P, Lahart C, Rosenblate R. The dimensions of perfectionism. Cognitive Therapy Research. 1990;14:449-68. [DOI:10.1007/BF01172967]
2. Deppoliti D. Exploring how new registered nurses construct professional identity in hospital settings. The Journal of Continuing Education in Nursing. 2008;39(6):255-62. [DOI:10.3928/00220124-20080601-03]
3. Kelly J, Clark H. Perfectionism among nursing students. International Journal of Nursing and Clinical Practices. 2017;4:237. [DOI:10.15344/2394-4978/2017/237]
4. Stovall M, Hansen L, van Ryn M. A critical review: moral injury in nurses in the aftermath of a patient safety incident. Journal of Nursing Scholarship. 2020;52(3):320-8. [DOI:10.1111/jnu.12551]
5. 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 Empirical Bioethics. 2019;10(2):113-24. [DOI:10.1080/23294515.2019.1586008]
6. Epstein EG, Hamric AB. Moral distress, moral residue, and the crescendo effect. The Journal of Clinical Ethics. 2009;20(4):330-42. [DOI:10.1086/JCE200920406]
7. Santos JO, Silva A, Munari DB, Miasso AI. Feelings of nursing professionals after the occurrence of medication errors. Acta Paulista de Enfermagem. 2007;20:483-8. [DOI:10.1590/S0103-21002007000400016]
8. Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clinical Psychology Review. 2009;29(8):695-706. [DOI:10.1016/j.cpr.2009.07.003]
9. Shay J. Moral injury. Psychoanalytic Psychology. 2014;31(2):182. [DOI:10.1037/a0036090]
10. Shay J. Achilles in Vietnam: combat trauma and the undoing of character. New York: Scribner; 1994.
11. Drescher KD, Foy DW, Kelly C, Leshner A, Schutz K, Litz B. An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology. 2011;17(1):8-13. [DOI:10.1177/1534765610395615]
12. Jinkerson JD. Defining and assessing moral injury: a syndrome perspective. Traumatology. 2016; 22 (2): 122. [DOI:10.1037/trm0000069]
13. Currier JM, McCormick W, Drescher KD. How do morally injurious events occur? a qualitative analysis of perspectives of veterans with PTSD. Traumatology. 2015;21(2):106. [DOI:10.1037/trm0000027]
14. Williamson V, Stevelink SA, Greenberg N. Occupational moral injury and mental health: systematic review and meta-analysis. The British Journal of Psychiatry. 2018;212(6):339-46. [DOI:10.1192/bjp.2018.55]
15. Reason J. Human error: models and management. British Medical Journal Publishing. 2000;320(7237):768-70. [DOI:10.1136/bmj.320.7237.768]
16. James JT. A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety. 2013;9(3):122-8. [DOI:10.1097/PTS.0b013e3182948a69]
17. Berlinger N. After harm: medical error and the ethics of forgiveness. Johns Hopkins University Press Baltimore, MD; 2005.
18. Scott SD. The second victim experience: mitigating the harm; devastating clinical events can traumatize the healthcare workers involved. American Nurse Today. 2015;10(9):8-11. Available from: https://www.myamericannurse.com/wp-content/uploads/2015/09/ant9-Second-victim-820.pdf
19. Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider "second victim" after adverse patient events. BMJ Quality and Safety. 2009;18(5):325-30. [DOI:10.1136/qshc.2009.032870]
20. Treiber LA, Jones JH. Devastatingly human: an analysis of registered nurses' medication error accounts. Qualitative Health Research. 2010;20(10):1327-42. [DOI:10.1177/1049732310372228]
21. Bryan CJ, Bryan AO, Anestis MD, Anestis JC, Green BA, Etienne N, et al. Measuring moral injury: psychometric properties of the moral injury events scale in two military samples. Assessment. 2016;23(5):557-70. [DOI:10.1177/1073191115590855]
22. Currier JM, Holland JM, Drescher K, Foy D. Initial psychometric evaluation of the moral injury questionnaire-military version. Clinical Psychology Psychotherapy. 2015;22(1):54-63. [DOI:10.1002/cpp.1866]
23. Mantri S, Lawson JM, Wang Z, Koenig HG. Identifying moral injury in healthcare professionals: the moral injury symptom scale-HP. Journal of Religion and Health Affairs. 2020;59:2323-40. [DOI:10.1007/s10943-020-01065-w]
24. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000;25(24):3186-91.
https://doi.org/10.1097/00007632-200012150-00014 [DOI:10.1097/00007632-200012150- 0014]
25. Gjersing L, Caplehorn JR, Clausen T. Cross-cultural adaptation of research instruments: language, setting, time and statistical considerations. BMC Medical Research Methodology. 2010;10:1-10.
https://doi.org/10.1186/1471-2288-10-13 [DOI:10.1186/1471-2288- 0-13]
26. McDonald RP. Test theory: a unified treatment. Psychology Press; 2013. [DOI:10.4324/9781410601087]
27. Zhizhong W, Koenig HG, Yan T, Jing W, Mu S, Hongyu L, et al. Psychometric properties of the moral injury symptom scale among Chinese health professionals during the COVID-19 pandemic. BMC Psychiatry. 2020; 20:1-10. [DOI:10.1186/s12888-020-02954-w]
28. Trifunovic-Koenig M, Strametz R, Gerber B, Mantri S, Bushuven S. 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 Public Health. 2022;19(8):4857. [DOI:10.3390/ijerph19084857]
29. Üstün G. Psychometric properties of the Turkish version of the moral injury symptom scale-healthcare professional. Journal of Psychiatric Nursing/Psikiyatri Hemsireleri Dernegi. 2022;13(1). [DOI:10.14744/phd.2021.34603]
30. Singhal K, Chukkali S. Psychometric properties of the moral injury symptom scale among Indian healthcare professionals. Psychology Research Behavior Management. 2023:1439-44. [DOI:10.2147/PRBM.S404094]
31. McDonald RP. Test theory: a unified treatment. New York, NY: Psychology Press; 2013. [DOI:10.4324/9781410601087]
32. Tavakol M , Dennick R. Making sense of Cronbach's alpha. International Journal of Medical Education. 2011; 2:53. [DOI:10.5116/ijme.4dfb.8dfd]
33. Nunnally J, Bernstein I. Psychometric theory. 3rd ed. New York, NY: McGraw‑Hill; 1994.
34. Kline RB. Principles and practice of structural equation modeling. 4th ed. New York, NY: Guilford Press; 2016.
35. Sharif Nia H, Pahlevan Sharif S, Boyle C, Yaghoobzadeh A, Tahmasbi B, Rassool GH, et al. The factor structure of the spiritual well-being scale in veterans experienced chemical weapon exposure. Journal of Religion and Health. 2018;57:596-608. [DOI:10.1007/s10943-017-0458-1]
36. Shahsavari A, Sharif-Nia H, Hejazi S, Arghaee A, Roshan-Nejad M. The Farsi version of medication administration hassles scale in elderlies with chronic diseases: a psychometric study. BMC Geriatrics. 2025;25:161. [DOI:10.1186/s12877-025-05804-0]
Send email to the article author
| Rights and permissions | |
 |
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
Site Keywords
Health, Administration, Scientific Article, Iran University of Medical Sciences,
