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jha 2026, 28(4): 43-56 |
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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. ,
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Table 1. Item reliability and descriptive statistics
Table 2. Exploratory factor analysis for the Persian version of the moral injury symptoms scale-health professional
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Introduction
Nurses, as the final safeguard for patient safety, often develop a culture of perfectionism, setting unrealistically high standards and finding it difficult to accept mistakes [1]. New nurses, especially those with less than three years of experience, view perfectionism as part of their professional identity [2]. Research shows that perfectionism is more common among nursing students than in the general population [3]. Despite their pursuit of perfection, nurses often face healthcare conditions that fall short of their ideals [4]. This gap between expectations and reality can cause moral distress when external pressures force them to act against their ethical values [5]. Repeated exposure to such situations leads to lasting emotional strain, referred to as moral residue [6]. Because the core principle of nursing is “do no harm,” violating it frequently triggers moral distress [7].
When nurses repeatedly face situations that violate their moral values or witness unethical behavior, they may develop moral injury, a deeper and more lasting form of distress. Unlike moral distress, which arises from external pressures, moral injury results from direct or indirect involvement in actions that conflict with one’s ethical beliefs [8, 9]. It manifests as guilt, shame, and a sense of moral failure [8, 10, 11], and is associated with burnout, depression, anxiety, post-traumatic stress, and even suicidal thoughts [12, 13].
In healthcare, moral injury is especially concerning among nurses, who often face ethical conflicts, organizational pressures, and system failures that place them in morally challenging situations. Patient safety incidents, events causing preventable harm, frequently arise from system-level problems such as poor policies, inadequate resources, or communication gaps [14, 15]. Despite these systemic causes, nurses often blame themselves, experiencing guilt and self-doubt [16]. This culture of self-blame discourages error reporting and increases vulnerability to moral injury [17-19]. The accumulation of guilt can make such experiences deeply traumatic [4]. Although moral injury significantly affects healthcare professionals, its identification and management remain limited due to lack of valid assessment tools. Most existing instruments were developed for military populations [20, 21]. The Moral Injury Symptoms Scale–Health Professional (MISS-HP) is currently the only validated tool designed for healthcare workers [22]. However, because cultural and contextual factors shape how moral injury manifests, this study aimed to evaluate the psychometric properties of the Persian version of the MISS-HP (P-MISS-HP) among Iranian nurses.
Methods
Design and participants: This cross-sectional study, conducted in 2025, evaluated the psychometric properties of the Persian version of the Moral Injury Symptoms Scale–Health Professional (P-MISS-HP) among nurses. A total of 220 nurses from hospitals affiliated with Urmia University of Medical Sciences were selected using stratified random sampling to ensure representation from different departments. Participants were randomly divided into two groups of 110 each for exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Eligibility criteria included at least one year of work experience and the provision of informed consent. Incomplete questionnaires were excluded. The sample size met standard recommendations for factor analysis.
Translation: The translation process followed a standard forward-backward translation methodology to ensure linguistic and cultural equivalence [23]. Two translators produced independent Persian versions, which were reviewed and merged by the research team. Two bilingual experts then back-translated the final version into English, and comparisons confirmed conceptual consistency. Permission to adapt and validate the scale was obtained from the original author, Dr. Harold G. Koenig (Duke University) [24].
Measures: sociodemographic variables including data on age, gender, marital status, education, work experience, and hospital ward were collected from participants. The MISS-HP evaluates 10 aspects of moral injury, including betrayal, guilt, shame, moral concerns, loss of trust and meaning, difficulty forgiving, self-condemnation, religious struggle, and loss of faith. It measures both psychological and spiritual dimensions. Items are rated on a 10-point visual analogue scale ranging from 1 (“strongly disagree”) to 10 (“strongly agree”). To reduce bias, four items (5, 6, 7, and 10) are positively worded and reverse-scored. The total score ranges from 10 to 100, with higher scores reflecting greater moral injury [22].
Face and content validity: Face validity was assessed through interviews with 10 nurses, and minor wording modifications were made for clarity and cultural relevance. Five nursing experts reviewed the content for clarity, relevance, and completeness, confirming its suitability for the target population.
Reliability: Internal consistency was evaluated using Cronbach’s alpha and McDonald’s omega (acceptable if >0.70) [25, 26]. Item–total correlations above 0.30 were also considered satisfactory, confirming good reliability of the scale [27].
Construct validity: EFA was conducted with data from 110 participants using the maximum likelihood method with Oblimin rotation. Sampling adequacy was assessed through the KMO test and Bartlett’s test of sphericity. The number of factors was determined using parallel analysis, and items with factor loadings below 0.4 were removed. CFA was then performed on data from another 110 participants to validate the constructs. Model fit was evaluated using CFI, GFI, and RMSEA, with CFI and GFI > 0.90 and RMSEA < 0.08.
Convergent and discriminant validity: Convergent and discriminant validity were assessed using CFA following the Fornell-Larcker criteria. Convergent validity was confirmed when standardized loadings exceeded 0.5, composite reliability (CR) was greater than the average variance extracted (AVE), and AVE was above 0.5 [28]. Discriminant validity was established when the maximum shared variance (MSV) was lower than the AVE and the Heterotrait-Monotrait (HTMT) ratio was below 0.90 [29]. Statistical analyses were conducted using Jamovi 2.4.14 and Amos 24 software.
Results
A total of 220 nurses participated, with a mean age of 33.59 years (SD = 6.59) and an average of 10.19 years of work experience (SD = 6.79). Most participants were female (81.4%), married (86.8%), and held a bachelor's degree (85.5%). About 13.2% worked in critical care units. Age (r = 0.568, p < 0.001) and work experience (r = 0.796, p < 0.001) showed significant positive correlations with moral injury scores. Single nurses reported higher moral injury scores than married nurses (60.41 vs. 50.70, p = 0.023).
Reliability: Item-total correlations exceeded 0.5 for all items except item 4 (0.239). Item 10 had the highest mean moral injury score. Removal of any item did not affect internal consistency. Cronbach’s alpha and McDonald’s omega indicated high reliability for the overall scale (0.901 and 0.904), as well as for the first (0.899 and 0.901) and second factors (0.896 and 0.903) (Table 1).
Nurses, as the final safeguard for patient safety, often develop a culture of perfectionism, setting unrealistically high standards and finding it difficult to accept mistakes [1]. New nurses, especially those with less than three years of experience, view perfectionism as part of their professional identity [2]. Research shows that perfectionism is more common among nursing students than in the general population [3]. Despite their pursuit of perfection, nurses often face healthcare conditions that fall short of their ideals [4]. This gap between expectations and reality can cause moral distress when external pressures force them to act against their ethical values [5]. Repeated exposure to such situations leads to lasting emotional strain, referred to as moral residue [6]. Because the core principle of nursing is “do no harm,” violating it frequently triggers moral distress [7].
When nurses repeatedly face situations that violate their moral values or witness unethical behavior, they may develop moral injury, a deeper and more lasting form of distress. Unlike moral distress, which arises from external pressures, moral injury results from direct or indirect involvement in actions that conflict with one’s ethical beliefs [8, 9]. It manifests as guilt, shame, and a sense of moral failure [8, 10, 11], and is associated with burnout, depression, anxiety, post-traumatic stress, and even suicidal thoughts [12, 13].
In healthcare, moral injury is especially concerning among nurses, who often face ethical conflicts, organizational pressures, and system failures that place them in morally challenging situations. Patient safety incidents, events causing preventable harm, frequently arise from system-level problems such as poor policies, inadequate resources, or communication gaps [14, 15]. Despite these systemic causes, nurses often blame themselves, experiencing guilt and self-doubt [16]. This culture of self-blame discourages error reporting and increases vulnerability to moral injury [17-19]. The accumulation of guilt can make such experiences deeply traumatic [4]. Although moral injury significantly affects healthcare professionals, its identification and management remain limited due to lack of valid assessment tools. Most existing instruments were developed for military populations [20, 21]. The Moral Injury Symptoms Scale–Health Professional (MISS-HP) is currently the only validated tool designed for healthcare workers [22]. However, because cultural and contextual factors shape how moral injury manifests, this study aimed to evaluate the psychometric properties of the Persian version of the MISS-HP (P-MISS-HP) among Iranian nurses.
Methods
Design and participants: This cross-sectional study, conducted in 2025, evaluated the psychometric properties of the Persian version of the Moral Injury Symptoms Scale–Health Professional (P-MISS-HP) among nurses. A total of 220 nurses from hospitals affiliated with Urmia University of Medical Sciences were selected using stratified random sampling to ensure representation from different departments. Participants were randomly divided into two groups of 110 each for exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Eligibility criteria included at least one year of work experience and the provision of informed consent. Incomplete questionnaires were excluded. The sample size met standard recommendations for factor analysis.
Translation: The translation process followed a standard forward-backward translation methodology to ensure linguistic and cultural equivalence [23]. Two translators produced independent Persian versions, which were reviewed and merged by the research team. Two bilingual experts then back-translated the final version into English, and comparisons confirmed conceptual consistency. Permission to adapt and validate the scale was obtained from the original author, Dr. Harold G. Koenig (Duke University) [24].
Measures: sociodemographic variables including data on age, gender, marital status, education, work experience, and hospital ward were collected from participants. The MISS-HP evaluates 10 aspects of moral injury, including betrayal, guilt, shame, moral concerns, loss of trust and meaning, difficulty forgiving, self-condemnation, religious struggle, and loss of faith. It measures both psychological and spiritual dimensions. Items are rated on a 10-point visual analogue scale ranging from 1 (“strongly disagree”) to 10 (“strongly agree”). To reduce bias, four items (5, 6, 7, and 10) are positively worded and reverse-scored. The total score ranges from 10 to 100, with higher scores reflecting greater moral injury [22].
Face and content validity: Face validity was assessed through interviews with 10 nurses, and minor wording modifications were made for clarity and cultural relevance. Five nursing experts reviewed the content for clarity, relevance, and completeness, confirming its suitability for the target population.
Reliability: Internal consistency was evaluated using Cronbach’s alpha and McDonald’s omega (acceptable if >0.70) [25, 26]. Item–total correlations above 0.30 were also considered satisfactory, confirming good reliability of the scale [27].
Construct validity: EFA was conducted with data from 110 participants using the maximum likelihood method with Oblimin rotation. Sampling adequacy was assessed through the KMO test and Bartlett’s test of sphericity. The number of factors was determined using parallel analysis, and items with factor loadings below 0.4 were removed. CFA was then performed on data from another 110 participants to validate the constructs. Model fit was evaluated using CFI, GFI, and RMSEA, with CFI and GFI > 0.90 and RMSEA < 0.08.
Convergent and discriminant validity: Convergent and discriminant validity were assessed using CFA following the Fornell-Larcker criteria. Convergent validity was confirmed when standardized loadings exceeded 0.5, composite reliability (CR) was greater than the average variance extracted (AVE), and AVE was above 0.5 [28]. Discriminant validity was established when the maximum shared variance (MSV) was lower than the AVE and the Heterotrait-Monotrait (HTMT) ratio was below 0.90 [29]. Statistical analyses were conducted using Jamovi 2.4.14 and Amos 24 software.
Results
A total of 220 nurses participated, with a mean age of 33.59 years (SD = 6.59) and an average of 10.19 years of work experience (SD = 6.79). Most participants were female (81.4%), married (86.8%), and held a bachelor's degree (85.5%). About 13.2% worked in critical care units. Age (r = 0.568, p < 0.001) and work experience (r = 0.796, p < 0.001) showed significant positive correlations with moral injury scores. Single nurses reported higher moral injury scores than married nurses (60.41 vs. 50.70, p = 0.023).
Reliability: Item-total correlations exceeded 0.5 for all items except item 4 (0.239). Item 10 had the highest mean moral injury score. Removal of any item did not affect internal consistency. Cronbach’s alpha and McDonald’s omega indicated high reliability for the overall scale (0.901 and 0.904), as well as for the first (0.899 and 0.901) and second factors (0.896 and 0.903) (Table 1).
Table 1. Item reliability and descriptive statistics
| Item | Mean | SD | Item-rest correlation | If item dropped | |
| α | ω | ||||
| Q1. I have experienced a sense of betrayal by healthcare professionals I once trusted. | 4.25 | 2.29 | 0.688 | 0.871 | 0.880 |
| Q2. I carry feelings of guilt for not being able to prevent someone from suffering serious harm or losing their life. | 4.55 | 2.72 | 0.606 | 0.876 | 0.885 |
| Q3. I feel a deep sense of shame about my actions or inactions while taking care of my patients. | 4.05 | 2.52 | 0.596 | 0.876 | 0.886 |
| Q4. It troubles me that I have behaved in ways that go against my personal morals or values. | 5.79 | 2.70 | 0.239 | 0.901 | 0.904 |
| Q5. The majority of my colleagues in the healthcare field can be relied upon. | 5.06 | 2.55 | 0.643 | 0.873 | 0.882 |
| Q6. I have a strong awareness of what gives my professional life purpose and meaning. | 5.03 | 2.55 | 0.624 | 0.874 | 0.883 |
| Q7. I have found a way to forgive myself for what has happened to me or to those under my care. | 5.03 | 2.54 | 0.687 | 0.870 | 0.878 |
| Q8. When I reflect on my career, I often struggle with the feeling that I have not been successful. | 4.03 | 2.68 | 0.798 | 0.861 | 0.869 |
| Q9. At times, I wonder if my actions or inactions in patient care have led to divine punishment. | 4.47 | 2.86 | 0.759 | 0.864 | 0.874 |
| Q10. Going through these experiences has, in many ways, deepened my religious or spiritual faith. | 5.83 | 3.04 | 0.602 | 0.877 | 0.884 |
Ω: McDonald's omega coefficient; α: Cronbach's alpha coefficient
Construct validity: The KMO value was 0.820, and Bartlett’s test was significant (χ² = 778, df = 45, p < 0.001), confirming data suitability for factor analysis. EFA (maximum likelihood, Oblimin rotation) revealed two factors: shame/guilt/condemnation (items 9, 2, 3, 8, 1) and spiritual troubles (items 6, 7, 5, 10), each explaining 31.6% of the total variance. Item 4 was excluded due to low factor loading (Table 2). The CFA based on the two-factor structure showed excellent model fit (CMIN = 37.013, DF = 26, CMIN/DF = 1.424, CFI = 0.988, NFI = 0.961, IFI = 0.988, RFI = 0.933, TLI = 0.979, RMSEA = 0.062) (Figure 1). In the CFA model, circles represent latent variables, rectangles denote observed variables, unidirectional arrows show factor loadings, and bidirectional arrows indicate correlations between latent variables.
Convergent and discriminant validity: Convergent validity was supported, with AVE values of 0.725 and 0.790 (both > 0.50) and CR values of 0.920 and 0.937, indicating strong construct reliability. Discriminant validity was also confirmed as the correlation between the two factors (0.80) was lower than the square roots of their AVE (0.851 and 0.889), and the MSV (0.589) was lower that the AVE values. The HTMT ratio of 0.621 further supported the discriminant validity of the constructs.
Discussion
This study evaluated the psychometric properties of the Persian version of the Moral Injury Symptom Scale–Health Professional (MISS-HP) among Iranian nurses. The findings demonstrated strong validity and reliability, consistent with the original version. However, the factor structure differed: while the original scale included three factors (guilt/shame, spiritual troubles, and self-condemnation), the Persian version revealed two factors, including shame/guilt/condemnation and spiritual troubles. The merging of guilt/shame and self-condemnation suggests cultural and occupational differences in how Iranian nurses perceive and experience moral injury. Item 4 (“I am troubled by actions that go against my morals or values”) was excluded due to a low factor loading, reducing the Persian version from 10 to nine items. Similar exclusions have been reported in other cultural adaptations, where certain items may not equally reflect moral distress across populations. This omission may reflect the specific psychological and ethical challenges faced by Iranian nurses within the country’s complex healthcare context.
In the first factor, Item 9 (“feeling punished by God”) had the highest loading, while Item 1 (“betrayal”) had the lowest. The second factor, spiritual troubles, was consistent with the original scale, with minor variations in item order. Item 10 (“loss of religious faith”) showed the highest loading in this factor, likely reflecting the strong role of religious beliefs in shaping the moral perspectives of Iranian healthcare professionals [22]. Most items in the Persian version aligned closely with the original scale, indicating strong conceptual equivalence. High AVE values confirmed convergent validity, and the Fornell-Larcker criterion supported discriminant validity. The merging of guilt, shame, and condemnation into one factor may reflect broader cultural views on morality among Iranian nurses. Item 6, concerning finding meaning in healthcare work, may hold different significance in Iran, where economic challenges and emigration pressures are common [30]. The increasing prevalence of suicidal tendencies among Iranian healthcare professionals further highlights the psychological and occupational burdens in this group [31].
Convergent and discriminant validity: Convergent validity was supported, with AVE values of 0.725 and 0.790 (both > 0.50) and CR values of 0.920 and 0.937, indicating strong construct reliability. Discriminant validity was also confirmed as the correlation between the two factors (0.80) was lower than the square roots of their AVE (0.851 and 0.889), and the MSV (0.589) was lower that the AVE values. The HTMT ratio of 0.621 further supported the discriminant validity of the constructs.
Discussion
This study evaluated the psychometric properties of the Persian version of the Moral Injury Symptom Scale–Health Professional (MISS-HP) among Iranian nurses. The findings demonstrated strong validity and reliability, consistent with the original version. However, the factor structure differed: while the original scale included three factors (guilt/shame, spiritual troubles, and self-condemnation), the Persian version revealed two factors, including shame/guilt/condemnation and spiritual troubles. The merging of guilt/shame and self-condemnation suggests cultural and occupational differences in how Iranian nurses perceive and experience moral injury. Item 4 (“I am troubled by actions that go against my morals or values”) was excluded due to a low factor loading, reducing the Persian version from 10 to nine items. Similar exclusions have been reported in other cultural adaptations, where certain items may not equally reflect moral distress across populations. This omission may reflect the specific psychological and ethical challenges faced by Iranian nurses within the country’s complex healthcare context.
In the first factor, Item 9 (“feeling punished by God”) had the highest loading, while Item 1 (“betrayal”) had the lowest. The second factor, spiritual troubles, was consistent with the original scale, with minor variations in item order. Item 10 (“loss of religious faith”) showed the highest loading in this factor, likely reflecting the strong role of religious beliefs in shaping the moral perspectives of Iranian healthcare professionals [22]. Most items in the Persian version aligned closely with the original scale, indicating strong conceptual equivalence. High AVE values confirmed convergent validity, and the Fornell-Larcker criterion supported discriminant validity. The merging of guilt, shame, and condemnation into one factor may reflect broader cultural views on morality among Iranian nurses. Item 6, concerning finding meaning in healthcare work, may hold different significance in Iran, where economic challenges and emigration pressures are common [30]. The increasing prevalence of suicidal tendencies among Iranian healthcare professionals further highlights the psychological and occupational burdens in this group [31].
Table 2. Exploratory factor analysis for the Persian version of the moral injury symptoms scale-health professional
| Item | Factor | Uniqueness | |
| 1 | 2 | ||
| Q9. At times, I wonder if my actions or inactions in patient care have led to divine punishment. | 0.930 | 0.188 | |
| Q2. I carry feelings of guilt for not being able to prevent someone from suffering serious harm or losing their life. | 0.900 | 0.280 | |
| Q3. I feel a deep sense of shame about my actions or inactions while taking care of my patients. | 0.794 | 0.408 | |
| Q8. When I reflect on my career, I often struggle with the feeling that I have not been successful. | 0.644 | 0.227 | |
| Q1. I have experienced a sense of betrayal by healthcare professionals I once trusted. | 0.469 | 0.571 | |
| Q6. I have a strong awareness of what gives my professional life purpose and meaning. | 0.887 | 0.244 | |
| Q7. I have found a way to forgive myself for what has happened to me or to those under my care. | 0.863 | 0.238 | |
| Q5. The majority of my colleagues in the healthcare field can be relied upon. | 0.852 | 0.266 | |
| Q10. Going through these experiences has, in many ways, deepened my religious or spiritual faith. | 0.731 | 0.441 | |
Note. 'Maximum likelihood' extraction method was used in combination with a 'oblimin' rotation
.PNG)
The findings align with other cultural adaptations of the MISS-HP. The Chinese, Turkish, and Indian versions also identified three factors, though item distributions differed. In the Chinese version, Zhizhong et al. [32] reported three factors among nurses and doctors during the COVID-19 pandemic: items 2, 3, and 4 in the first factor; items 5, 6, and 10 in the second; and items 1, 7, 8, and 9 in the third, explaining 59.2% and 58.9% of the total variance, respectively. Similarly, the Turkish version identified three factors, condemnation, guilt/shame, and moral distress, accounting for 84.48% of the total variance [33]. The Indian version included three factors: shame/guilt (items 2, 3, and 4), distrust (items 5, 6, and 10), and forgiveness (items 1, 7, 8, and 9), arranged differently from both the Persian and original versions [34]. In the German version, item 10 was removed due to its low correlation with the total score, with EFA identifying three factors covering approximately half of the total variance [35]. The Persian version exhibited excellent internal consistency, with Cronbach's alpha and McDonald's omega coefficients of 0.901 and 0.904, respectively. The composite reliability (CR) values were also above the acceptable threshold, reinforcing the scale’s reliability. In contrast, the original version had a Cronbach's alpha of 0.73, which was lower than the Persian version [22]. The Cronbach's alpha values for the Indian, Turkish, Chinese, and German versions were 0.77, 0.91, 0.70, and 0.75, respectively, all within the acceptable range [32-35]. Furthermore, our study revealed a positive correlation between age and work experience with moral injury scores, consistent with previous research suggesting that cumulative exposure to ethical challenges may elevate the risk of moral injury [8]. Repeated exposure to distressing situations contributes to burnout and moral distress, particularly in high-stress healthcare environments.
Limitation
This study has some limitations. First, the sample was limited to nurses from hospitals affiliated with Urmia University of Medical Sciences, which may limit the generalizability of the results. Second, using self-report questionnaires may have introduced biases such as social desirability. Future studies should include more diverse samples and use mixed method designs to provide a deeper understanding of moral injury among nurses. The study did not perform a test-retest assessment of the tool. This was primarily due to the need to maintain full confidentiality and anonymity of participants. Additionally, operational barriers, such as rotating shifts and high workload, made it difficult to access the same participants again within a short timeframe. Future research is recommended to use longitudinal designs to evaluate the stability of the instrument.
Conclusion
The Persian version of the MISS-HP demonstrates strong psychometric properties and is a reliable tool for assessing moral injury among Iranian nurses. However, interpretation should consider cultural factors. Further research is recommended to validate and generalize the tool across diverse regions and healthcare professional groups in Iran.
Declarations
Ethical considerations: The study was approved by the Ethics Committee of Urmia University of Medical Sciences (IR.UMSU.REC.1402.375). Participants were informed about the study’s objectives and provided written informed consent. Participation was voluntary, questionnaires were anonymous, and data were used solely for research purposes. The study complied with the 2013 Declaration of Helsinki to ensure participants’ rights and well-being.
Funding: This research was financially supported by Urmia University of Medical Sciences, Urmia, Iran. Funder had no roles in conducting the research, data collection, and analysis and paper preparation.
Conflict of interests: None
Consent for publication: Permission for the translation and psychometric evaluation of this instrument was obtained from the original developer.
Authors’ contributions: V.SH: Study design, data collection, writing – original draft, final approval. Z.H: Study design, data collection, writing – original draft, final approval. R.S: Study design, data collection, writing – original draft, final approval. R.G.G: Study design, data analysis, project administration, writing – original draft, final approval. All authors have read and approved the final version of the manuscript.
Data availability: The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.
AI deceleration: ChatGPT by OpenAI was used for editing the English section of this manuscript. All content generated or edited using this tool was thoroughly reviewed and approved by the authors.
Acknowledgments: The authors thank the Vice President of Research at Urmia University of Medical Sciences, all the nurses working in hospitals, and the hospital administrators for their support and cooperation.
Limitation
This study has some limitations. First, the sample was limited to nurses from hospitals affiliated with Urmia University of Medical Sciences, which may limit the generalizability of the results. Second, using self-report questionnaires may have introduced biases such as social desirability. Future studies should include more diverse samples and use mixed method designs to provide a deeper understanding of moral injury among nurses. The study did not perform a test-retest assessment of the tool. This was primarily due to the need to maintain full confidentiality and anonymity of participants. Additionally, operational barriers, such as rotating shifts and high workload, made it difficult to access the same participants again within a short timeframe. Future research is recommended to use longitudinal designs to evaluate the stability of the instrument.
Conclusion
The Persian version of the MISS-HP demonstrates strong psychometric properties and is a reliable tool for assessing moral injury among Iranian nurses. However, interpretation should consider cultural factors. Further research is recommended to validate and generalize the tool across diverse regions and healthcare professional groups in Iran.
Declarations
Ethical considerations: The study was approved by the Ethics Committee of Urmia University of Medical Sciences (IR.UMSU.REC.1402.375). Participants were informed about the study’s objectives and provided written informed consent. Participation was voluntary, questionnaires were anonymous, and data were used solely for research purposes. The study complied with the 2013 Declaration of Helsinki to ensure participants’ rights and well-being.
Funding: This research was financially supported by Urmia University of Medical Sciences, Urmia, Iran. Funder had no roles in conducting the research, data collection, and analysis and paper preparation.
Conflict of interests: None
Consent for publication: Permission for the translation and psychometric evaluation of this instrument was obtained from the original developer.
Authors’ contributions: V.SH: Study design, data collection, writing – original draft, final approval. Z.H: Study design, data collection, writing – original draft, final approval. R.S: Study design, data collection, writing – original draft, final approval. R.G.G: Study design, data analysis, project administration, writing – original draft, final approval. All authors have read and approved the final version of the manuscript.
Data availability: The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.
AI deceleration: ChatGPT by OpenAI was used for editing the English section of this manuscript. All content generated or edited using this tool was thoroughly reviewed and approved by the authors.
Acknowledgments: The authors thank the Vice President of Research at Urmia University of Medical Sciences, all the nurses working in hospitals, and the hospital administrators for their support and cooperation.
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
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