Measuring moral distress and moral injury: A systematic review and content analysis of existing scales

BACKGROUND

Moral distress (MD) and moral injury (MI) are related constructs describing the negative consequences of morally challenging stressors. Despite growing support for the clinical relevance of these constructs, ongoing challenges regarding measurement quality risk limiting research and clinical advances. This study summarizes the nature, quality, and utility of existing MD and MI scales, and provides recommendations for future use.

METHOD

We identified psychometric studies describing the development or validation of MD or MI scales and extracted information on methodological and psychometric qualities. Content analyses identified specific outcomes measured by each scale.

RESULTS

We reviewed 77 studies representing 42 unique scales. The quality of psychometric approaches varied greatly across studies, and most failed to examine convergent and divergent validity. Content analyses indicated most scales measure exposures to potential moral stressors and outcomes together, with relatively few measuring only exposures (n = 3) or outcomes (n = 7). Scales using the term MD typically assess general distress. Scales using the term MI typically assess several specific outcomes.

CONCLUSIONS

Results show how the terms MD and MI are applied in research. Several scales were identified as appropriate for research and clinical use. Recommendations for the application, development, and validation of MD and MI scales are provided.

Exposure to moral stressors and associated outcomes in healthcare workers: prevalence, correlates, and impact on job attrition

Introduction: Healthcare workers (HCWs) often experience morally challenging situations in their workplaces that may contribute to job turnover and compromised well-being. This study aimed to characterize the nature and frequency of moral stressors experienced by HCWs during the COVID-19 pandemic, examine their influence on psychosocial-spiritual factors, and capture the impact of such factors and related moral stressors on HCWs' self-reported job attrition intentions.Methods: A sample of 1204 Canadian HCWs were included in the analysis through a web-based survey platform whereby work-related factors (e.g. years spent working as HCW, providing care to COVID-19 patients), moral distress (captured by MMD-HP), moral injury (captured by MIOS), mental health symptomatology, and job turnover due to moral distress were assessed.Results: Moral stressors with the highest reported frequency and distress ratings included patient care requirements that exceeded the capacity HCWs felt safe/comfortable managing, reported lack of resource availability, and belief that administration was not addressing issues that compromised patient care. Participants who considered leaving their jobs (44%; N = 517) demonstrated greater moral distress and injury scores. Logistic regression highlighted burnout (AOR = 1.59; p < .001), moral distress (AOR = 1.83; p < .001), and moral injury due to trust violation (AOR = 1.30; p = .022) as significant predictors of the intention to leave one's job.Conclusion: While it is impossible to fully eliminate moral stressors from healthcare, especially during exceptional and critical scenarios like a global pandemic, it is crucial to recognize the detrimental impacts on HCWs. This underscores the urgent need for additional research to identify protective factors that can mitigate the impact of these stressors.

Grandiose narcissism indirectly associates with lower psychopathology across five countries

Using five independent non-clinical cross-cultural samples (total N = 3649; overall Mage = 29.31; 31% male and 69% female), this study explored the extent to which Dark Triad traits were indirectly associated with symptoms of psychopathology through mental toughness. Although Machiavellianism and psychopathy have not been studied extensively in this context, previous research (both cross-sectional and longitudinal) reports that grandiose narcissism increases mental toughness contributing indirectly to positive outcomes such as lower anxiety, stress, and depression. Accordingly, this study examined Machiavellianism, psychopathy, and narcissism in the context of mental toughness and psychopathology. A particular focus was placed on investigating negative relationships between grandiose narcissism and psychopathology. Participants completed self-report measures assessing the Dark Triad, mental toughness, and psychopathology. In all samples, grandiose narcissism exerted moderate negative, indirect associations with anxiety, stress, and depression through mental toughness. Relationships between Machiavellianism and psychopathy and psychopathology were generally weak and positive but varied across countries. Findings provided further cross-cultural support for a mediation model in which grandiose narcissism is related to higher mental toughness and lower psychopathology. Outcomes from this study indicate that exploration of the link between grandiose narcissism and resilience traits such as mental toughness can provide important conceptual insights into the adaptive properties of narcissism, and help to explain why grandiose narcissism is associated with a decrease in some psychopathological symptoms.

The mediating roles of workplace support and ethical work environment in associations between leadership and moral distress: a longitudinal study of Canadian health care workers during the COVID-19 pandemic

Introduction

The COVID-19 pandemic has resulted in heightened moral distress among health care workers (HCWs) worldwide. Past research has shown that effective leadership may mitigate potential for the development of moral distress. However, no research to date has considered the mechanisms by which leadership might have an influence on moral distress. We sought to evaluate longitudinally whether Canadian HCWs' perceptions of workplace support and ethical work environment would mediate associations between leadership and moral distress.

Methods

A total of 239 French- and English-speaking Canadian HCWs employed during the COVID-19 pandemic were recruited to participate in a longitudinal online survey. Participants completed measures of organizational and supervisory leadership at baseline and follow-up assessments of workplace support, perceptions of an ethical work environment, and moral distress.

Results

Associations between both organizational and supervisory leadership and moral distress were fully mediated by workplace supports and perceptions of an ethical work environment.

Discussion

To ensure HCW well-being and quality of care, it is important to ensure that HCWs are provided with adequate workplace supports, including manageable work hours, social support, and recognition for efforts, as well as an ethical workplace environment.

Telehealth experiences in Canadian veterans: associations, strengths and barriers to care during the COVID-19 pandemic

INTRODUCTION

Identifying barriers to care in veteran populations is critical, as veterans face increased social isolation, relationship strains and financial insecurities. For Canadian veterans experiencing barriers to accessing healthcare, telehealth may be a promising alternative with comparable effectiveness to in-person services; however, the potential benefits and limitations of telehealth require further examination to determine its long-term utility, and to inform health policy and planning. The goal of the present research was to identify predictors and barriers to telehealth usage in Canadian veterans in the context of the COVID-19 pandemic.

METHODS

Data were drawn from baseline data of a longitudinal survey examining the psychological functioning of Canadian veterans during the COVID-19 pandemic. Participants were 1144 Canadian veterans aged 18-93 years (M_age=56.24, SD=12.92; 77.4% men). We assessed reported telehealth use (ie, for mental healthcare, physical healthcare), healthcare access (ie, difficulty accessing care, avoidance of care) and mental health and stress since the beginning of the COVID-19 pandemic, sociodemographic variables and open-ended responses about telehealth experiences.

RESULTS

Findings suggest that sociodemographic factors and previous telehealth use were significantly associated with telehealth use during the COVID-19 pandemic. Qualitative evidence highlighted both the benefits (eg, reducing barriers of access) and drawbacks (eg, not all services can be delivered) of telehealth services.

CONCLUSIONS

This paper provided a deeper understanding of Canadian veterans' experiences with accessing telehealth care during the COVID-19 pandemic. While for some, the use of telehealth mitigated perceived barriers (eg, safety concerns of leaving home), others felt that not all health services could be appropriately carried out through telehealth. Altogether, findings support the use of telehealth services in increasing care accessibility for Canadian veterans. Continued use of quality telehealth services may be a valuable form of care that extends the reach of healthcare professionals.

Impact of the COVID-19 pandemic on the mental health and well-being of Veterans' spouses: a cross sectional analysis

BACKGROUND

COVID-19 has negatively impacted the mental health and well-being of both Canadians and the world as a whole, with Veterans, in particular, showing increased rates of depression, anxiety, and PTSD. Spouses and common-law partners often serve as primary caregivers and sources of support for Veterans, which may have a deleterious effect on mental health and increase risk of burnout. Pandemic related stressors may increase burden and further exacerbate distress; yet the effect of the pandemic on the mental health and well-being of Veterans' spouses is currently unknown. This study explores the self-reported mental health and well-being of a group of spouses of Canadian Armed Forces Veterans and their adoption of new ways to access healthcare remotely (telehealth), using baseline data from an ongoing longitudinal survey.

METHODS

Between July 2020 and February 2021, 365 spouses of Veterans completed an online survey regarding their general mental health, lifestyle changes, and experiences relating to the COVID-19 pandemic. Also completed were questions relating to their use of and satisfaction with health-care treatment services during the pandemic.

RESULTS

Reported rates of probable major depressive disorder (MDD), generalized anxiety disorder (GAD), alcohol use disorder (AUD), and PTSD were higher than the general public, with 50-61% believing their symptoms either directly related to or were made worse by the pandemic. Those reporting being exposed to COVID-19 were found to have significantly higher absolute scores on mental health measures than those reporting no exposure. Over 56% reported using telehealth during the pandemic, with over 70% stating they would continue its use post-pandemic.

CONCLUSIONS

This is the first Canadian study to examine the impact of the COVID-19 pandemic specifically on the mental health and well-being of Veterans' spouses. Subjectively, the pandemic negatively affected the mental health of this group, however, the pre-pandemic rate for mental health issues in this population is unknown. These results have important implications pertaining to future avenues of research and clinical/programme development post-pandemic, particularly relating to the potential need for increased support for spouses of Veterans, both as individuals and in their role as supports for Veterans.

The Revised Assessment of Sadistic Personality (ASP-8): Evidence for Validity across Four Countries

Subclinical sadism, characterized by infliction of cruelty, aggression, or humiliation on another for subjugation or pleasure, provides important information in the prediction of aversive behaviors that have implications for individuals' and society's well-being worldwide. Given sadism's universal relevance, it is imperative that researchers ensure valid and reliable trait measurement not only among English-speaking individuals, but also cross-nationally among countries in which sadism remains relatively understudied. The objective of the current research was to validate the revised version of the Assessment of Sadistic Personality (ASP-8) (Plouffe et al., 2017) across samples of Russian (n = 1087, M_age = 37.36, SD = 10.36), Greek (n = 1195, M_age = 35.64, SD_age = 13.08), Serbian (n = 443, M_age = 28.10, SD_age = 6.60), and British (n = 511, M_age = 28.50, SD_age = 11.62) adults. Overall, results supported the reliability, dimensionality, and scalar/partial scalar measurement invariance of the ASP-8 across cross-national samples. Convergent and discriminant validity were mostly supported through correlations with general personality traits, the Dark Triad, emotional intelligence, mental toughness, depression, anxiety, stress, satisfaction with life, aggression, and attitudes toward social groups. Based on our findings, we recommend the use of the ASP-8 in future investigations of aversive traits.

Moral injury associated with increased odds of past-year mental health disorders: a Canadian Armed Forces examination

Background: Potentially morally injurious experiences (PMIEs) are common during military service. However, it is unclear to what extent PMIEs are related to well-established adverse mental health outcomes.Objective: The objective of this study was to use a population-based survey to determine the associations between moral injury endorsement and the presence of past-year mental health disorders in Canadian Armed Forces (CAF) personnel and Veterans.Methods: Data were obtained from the 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS). With a sample of 2,941 respondents, the weighted survey sample represented 18,120 active duty and 34,380 released CAF personnel. Multiple logistic regressions were used to assess the associations between sociodemographic characteristics (e.g. sex), military factors (e.g. rank), moral injury (using the Moral Injury Events Scale [MIES]) and the presence of specific mental health disorders (major depressive episode, generalized anxiety disorder, panic disorder, social anxiety disorder, PTSD, and suicidality).Results: While adjusting for selected sociodemographic and military factors, the odds of experiencing any past-year mental health disorder were 1.97 times greater (95% CI = 1.94-2.01) for each one-unit increase in total MIES score. Specifically, PTSD had 1.91 times greater odds (95% CI = 1.87-1.96) of being endorsed for every unit increase in MIES total score, while odds of past-year panic disorder or social anxiety were each 1.86 times greater (95% CI = 1.82-1.90) for every unit increase in total MIES score. All findings reported were statistically significant (p < .001).Conclusion: These findings emphasize that PMIEs are robustly associated with the presence of adverse mental health outcomes among Canadian military personnel. The results of this project further underscore the necessity of addressing moral injury alongside other mental health concerns within the CAF.

Psychometric Evaluation of the Moral Injury Events Scale in Two Canadian Armed Forces Samples

Moral injury (MI) is defined as the profound psychological distress experienced in response to perpetrating, failing to prevent, or witnessing acts that transgress personal moral standards or values. Given the elevated risk of adverse mental health outcomes in response to exposure to morally injurious experiences in military members, it is critical to implement valid and reliable measures of MI in military populations. We evaluated the reliability, convergent, and discriminant validity, as well as the factor structure of the commonly used Moral Injury Events Scale (MIES) across two separate active duty and released Canadian Armed Forces samples. In Study 1, convergent and discriminant validity were demonstrated through correlations between MIES scores and depression, anxiety, posttraumatic stress disorder, anger, adverse childhood experiences, and combat experiences. Across studies, internal consistency reliability was high. However, dimensionality of the MIES remained unclear, and model fit was poor across active and released Canadian Armed Forces samples. Practical and theoretical implications are discussed.

Validation of the mental health continuum: Short form among Canadian Armed Forces personnel

BACKGROUND

Compared to the general Canadian population, military members exhibit a higher prevalence of depressive disorders, anxiety disorders, and post-traumatic stress disorder. However, there is a paucity of research investigating the extent to which military members experience positive mental health. Validation of positive mental health measures, including the Mental Health Continuum - Short Form (MHC-SF), is necessary to determine whether well-being can be assessed in a valid and reliable manner among Canadian Armed Forces (CAF) military members. The purpose of this research was to assess the internal consistency reliability, convergent validity, factor structure, and measurement invariance of the MHC-SF among CAF Regular Force and Reserve Force military members.

DATA AND METHODS

Data were drawn from the nationally representative 2013 Canadian Forces Mental Health Survey (CFMHS) conducted by Statistics Canada. A random sample of 8,200 CAF military personnel completed the CFMHS, representing 64,400 Regular Force and 4,460 Reserve Force CAF personnel.

RESULTS

As expected, all three MHC-SF subscales (psychological, social, and emotional well-being) correlated positively with life satisfaction, self-rated mental health, sense of belonging, and social support, and correlated negatively with psychological distress and disability due to health conditions. Internal consistency was high. Confirmatory factor analysis supported the three-factor structure of the MHC-SF, and measurement invariance was satisfied.

INTERPRETATION

Findings provided support for the reliability, convergent validity, factorial validity, and measurement invariance of the MHC-SF among both Regular Force and Reserve Force military samples. Therefore, researchers and clinicians can reliably implement the MHC-SF as a tool to assess, interpret, and predict military members' psychological, social, and emotional well-being.

Examining the Relationships Between Childhood Exposure to Intimate Partner Violence, the Dark Tetrad of Personality, and Violence Perpetration in Adulthood

Intimate partner violence (IPV) is a major international public health concern that poses significant mental and physical health risks for affected individuals. To improve prevention efforts, it is imperative that researchers and government bodies understand risk factors for IPV. One such risk factor concerns the extent to which violence is intergenerational, such that exposure to violence predisposes individuals to engage in violence toward intimate partners. The purpose of this research is to assess childhood exposure to violence as a risk factor for perpetration of IPV in adulthood, and to evaluate the Dark Tetrad personality traits as mediators in this relationship. We recruited 153 men and 246 women (age range = 18-73, M_age = 33.50, SD_age = 10.26) through Amazon's Mechanical Turk to complete a series of questionnaires and an open-ended IPV perpetration assessment. Results showed no relationship between IPV perpetration and childhood IPV exposure, indicating that mediation analyses were not possible. Possible explanations are discussed. Follow-up exploratory analyses demonstrated that gender moderated the relationships between childhood IPV exposure and levels of Factor 1 psychopathy and Machiavellianism. Specifically, men who were exposed to IPV in childhood were more likely to develop higher levels of Factor 1 psychopathy and Machiavellianism, whereas women were not. Overall, our findings highlight the importance of providing researchers and clinicians with a greater understanding of environmental events preceding maladaptive trait development. It is also important for researchers and clinicians to consider gender differences in pathways between exposure to IPV and subsequent development of dark personality traits. Theoretical and practical implications are discussed.

Well-being of Canadian Armed Forces Veterans and Spouses of Veterans During the COVID-19 Pandemic: Protocol for a Prospective Longitudinal Survey

BACKGROUND

The COVID-19 pandemic has resulted in significant changes to everyday life, including social distancing mandates, changes to health care, and a heightened risk of infection. Previous research has shown that Canadian Armed Forces (CAF) veterans are at higher risk of developing mental and physical health conditions. Veterans and their families may face unique social challenges that can compound with pandemic-related disruptions to negatively impact well-being.

OBJECTIVE

This study aims to longitudinally characterize the mental health of CAF veterans and spouses of CAF veterans throughout the pandemic and to understand the dynamic influences of pandemic-related stressors on psychological health over time.

METHODS

We employed a prospective longitudinal panel design using an online data collection platform. Study participation was open to all CAF veterans and spouses of CAF veterans residing in Canada. Participants were asked to complete a comprehensive battery of assessments representing psychological well-being, chronic pain, health care access patterns, physical environment, employment, social integration, and adjustment to pandemic-related lifestyle changes. Follow-up assessments were conducted every 3 months over an 18-month period. This study was approved by the Western University Health Sciences and Lawson Health Research Institute Research Ethics Boards.

RESULTS

Baseline data were collected between July 2020 and February 2021. There were 3 population segments that participated in the study: 1047 veterans, 366 spouses of veterans, and 125 veterans who are also spouses of veterans completed baseline data collection. As of November 2021, data collection is ongoing, with participants completing the 9- or 12-month follow-up surveys depending on their date of self-enrollment. Data collection across all time points will be complete in September 2022.

CONCLUSIONS

This longitudinal survey is unique in its comprehensive assessment of domains relevant to veterans and spouses of veterans during the COVID-19 pandemic, ranging from occupational, demographic, social, mental, and physical domains, to perceptions and experiences with health care treatments and access. The results of this study will be used to inform policy for veteran and veteran family support, and to best prepare for similar emergencies should they occur in the future.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/34984.

Risk Factors for Moral Injury Among Canadian Armed Forces Personnel

OBJECTIVES

The traumatic nature of high-risk military deployment events, such as combat, is well-recognized. However, whether other service-related events and demographic factors increase the risk of moral injury (MI), which is defined by consequences of highly stressful and morally-laden experiences, is poorly understood. Therefore, the objective of this study was to examine determinants of MI in Canadian Armed Forces (CAF) personnel.

METHODS

Data were obtained from the 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS; unweighted n = 2,941). To identify military characteristics, sociodemographic variables, and deployment-related factors associated with increased levels of MI, a series of multiple linear regressions were conducted across deployed and non-deployed groups.

RESULTS

When all variables were considered among the deployed personnel, rank, experiencing military related sexual trauma, child maltreatment (i.e., physical abuse, emotional abuse and neglect), and stressful deployment experiences were significant predictors of increased MI total scores (β = 0.001 to β = 0.51, p < 0.05). Feeling responsible for the death of an ally and inability to respond in a threatening situation were the strongest predictors of MI among stressful deployment experiences. Within the non-deployed sample, experiencing military-related or civilian sexual trauma and rank were significant predictors of increased MI total scores (β = 0.02 to β = 0.81, p < 0.05).

CONCLUSION

Exposure to stressful deployment experiences, particularly those involving moral-ethical challenges, sexual trauma, and childhood maltreatment were found to increase levels of MI in CAF personnel. These findings suggest several avenues of intervention, including education and policies aimed at mitigating sexual misconduct, as well as pre-deployment training to better prepare military personnel to deal effectively with morally injurious experiences.

Mental health services use among Canadian Armed Forces members and Veterans: Data from the 2018 Canadian Armed Forces members and Veterans mental health follow-up survey (CAFMVHS)

Background

Differences in healthcare delivery systems and pathways to mental healthcare for Canadian Armed Forces (CAF) members and Veterans may contribute to variations in mental health services use (MHSU) and the factors associated with it. We: (1) estimated the prevalence of past 12-month MHSU (≥1 visit with a medical or mental health professional); and (2) identified sociodemographic, military-, trauma-, and health-related variables associated with MHSU among CAF members and Veterans.

Methods

The current study used data from the 2018 CAF Members and Veterans Mental Health Follow-Up Survey (CAFVMHS). Model variables were selected a priori, and their respective associations with MHSU were estimated among (1) CAF members and (2) Veterans using separate multivariable logistic regression models.

Results

Similar proportions of CAF members and Veterans reported past 12-month MHSU (26.9 vs. 27.5%, respectively). For both CAF members and Veterans, meeting criteria for at least one past 12-month MH disorder was associated with past 12-month MHSU [adjusted odds ratio (AOR) = 7.80, 95% confidence interval (CI) = 7.18-8.46; and AOR = 11.82, 95% CI: 11.07-12.61, respectively). Past-year suicide ideation, a history of sexual trauma, and endorsement of adverse childhood experiences were also significantly associated with MHSU among CAF members and Veterans.

Significance

Similar to previous research, meeting screening criteria for a past 12-month MH disorder was strongly associated with MHSU among both samples. This study extends our existing knowledge about factors associated with MHSU among CAF members and Veterans, and offers direction for future research to increase MHSU.

Well-being of Canadian Veterans during the COVID-19 pandemic: cross-sectional results from the COVID-19 Veteran well-being study

BACKGROUND

The impacts of the COVID-19 pandemic have disproportionally affected different population groups. Veterans are more likely to have pre-existing mental health conditions compared to the general Canadian population, experience compounded stressors resulting from disruptions to familial, social, and occupational domains, and were faced with changes in health-care delivery (e.g. telehealth). The objectives of this study are to assess (a) the mental health impact of COVID-19 and related life changes on the well-being of Veterans and (b) perceptions of and satisfaction with changes in health-care treatments and delivery during the pandemic.

METHODS

A total of 1136 Canadian Veterans participated in an online survey. Participants completed questions pertaining to their mental health and well-being, lifestyle changes, and concerns relating to the COVID-19 pandemic, as well as experiences and satisfaction with health-care treatments during the pandemic.

RESULTS

Results showed that 55.9% of respondents reported worse mental health functioning compared to before the pandemic. The frequency of probable posttraumatic stress disorder, major depressive disorder, generalized anxiety disorder, alcohol use disorder, and suicidal ideation were 34.2%, 35.3%, 26.8%, 13.0%, and 22.0%, respectively. Between 38.6% and 53.1% of respondents attributed their symptoms as either directly related to or exacerbated by the pandemic. Approximately 18% of respondents reported using telehealth for mental health services during the pandemic, and among those, 72.8% indicated a choice to use telehealth even after the pandemic.

CONCLUSIONS

This study found that Veterans experienced worsening mental health as a result of the COVID-19 pandemic. The use of telehealth services was widely endorsed by mental health treatment-seeking Veterans who transitioned to virtual care during the pandemic. Our findings have important clinical and programmeadministrator implications, emphasizing the need to reach out to support veterans, especially those with pre-existing mental health conditions and to enhance and maintain virtual care even post-pandemic.

Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium

Potentially morally injurious events (PMIEs) entail acts of commission (e.g., cruelty, proscribed or prescribed violence) or omission (e.g., high stakes failure to protect others) and bearing witness (e.g., to grave inhumanity, to the gruesome aftermath of violence), or being the victim of others' acts of commission (e.g., high stakes trust violations) or omission (e.g., being the victim of grave individual or systemic failures to protect) that transgress deeply held beliefs and expectations about right and wrong. Although there is a proliferation of interest in moral injury (the outcome associated with exposure to PMIEs), there has been no operational definition of the putative syndrome and no standard assessment scheme or measure, which has hampered research and care in this area. We describe an international effort to define the syndrome of moral injury and develop and validate the Moral Injury Outcome Scale (MIOS) in three stages. To ensure content validity, in Stage I, we conducted interviews with service members, Veterans, and clinicians/Chaplains in each country, inquiring about the lasting impact of PMIEs. Qualitative analysis yielded six operational definitions of domains of impact of PMIEs and components within domains that establish the parameters of the moral injury syndrome. From the domain definitions, we derived an initial pool of scale items. Stage II entailed scale refinement using factor analytic methods, cross-national invariance testing, and internal consistency reliability analyses of an initial 34-item MIOS. A 14-item MIOS was invariant and reliable across countries and had two factors: Shame-Related (SR) and Trust-Violation-Related (TVR) Outcomes. In Stage III, MIOS total and subscale scores had strong convergent validity, and PMIE-endorsers had substantially higher MIOS scores vs. non-endorsers. We discuss and contextualize the results and describe research that is needed to substantiate these inaugural findings to further explore the validity of the MIOS and moral injury, in particular to examine discriminant and incremental validity.

Gender Differences or Gender Bias?

Abstract. Sadism, defined by the infliction of pain and suffering on others for pleasure or subjugation, has recently garnered substantial attention in the psychological research literature. The Assessment of Sadistic Personality (ASP) was developed to measure levels of everyday sadism and has been shown to possess excellent reliability and validity using classical test theory methods. However, it is not known how well ASP items discriminate between respondents of different trait levels, or which Likert categories are endorsed by persons of various trait levels. Additionally, individual items should be evaluated to ensure that men and women of similar levels of sadism have an equal probability of response endorsement. The purpose of this research was to apply item response theory (IRT) and differential item functioning (DIF) to investigate item properties of the ASP across its three translations: English, Polish, and Italian. Overall, the results of the IRT analysis showed that with the exception of Item 9, the ASP demonstrated sound item properties. The DIF rate analyses identified two items from each questionnaire that were of practical significance across gender. Implications of these results are discussed.

Four Decades of Military Posttraumatic Stress: Protocol for a Meta-analysis and Systematic Review of Treatment Approaches and Efficacy

BACKGROUND

Over 85% of active members of the Canadian Armed Forces have been exposed to potentially traumatic events linked to the development of posttraumatic stress disorder (PTSD). At the time of transition to civilian life, as high as 1 in 8 veterans may be diagnosed with PTSD. Given the high prevalence of PTSD in military and veteran populations, the provision of effective treatment considering their unique challenges and experiences is critical for mental health support and the well-being of these populations.

OBJECTIVE

This paper presents the protocol for a meta-analysis and systematic review that will examine the effectiveness of treatment approaches for military-related PTSD.

METHODS

This PROSPERO-preregistered meta-analysis is being conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and Cochrane guidelines. A comprehensive search of the literature was conducted using the databases PsycInfo, Medline, Embase, CINAHL, and ProQuest Dissertation & Theses. Effect sizes will be computed based on changes in PTSD symptom scores over time across studies using validated PTSD scales. A multilevel meta-analysis will examine the overall effects, between-study effects, and within-study effects of available evidence for PTSD treatments in military populations. Effect sizes will be compared between pharmacotherapeutic, psychotherapeutic, and alternative/emerging treatment interventions. Finally, meta-regression and subgroup analyses will explore the moderating roles of clinical characteristics (eg, PTSD symptom clusters), treatment approaches (eg, therapeutic orientations in psychotherapy and alternative therapies and classifications of drugs in pharmacotherapy), as well as treatment characteristics (eg, length of intervention) on treatment outcomes.

RESULTS

The literature search was completed on April 14, 2021. After the removal of duplicates, a total of 12,002 studies were screened for inclusion. As of July 2021, title and abstract screening has been completed, with 1469 out of 12,002 (12.23%) studies included for full-text review. Full review is expected to be completed in the summer of 2021, with initial results expected for publication by early winter of 2021.

CONCLUSIONS

This meta-analysis will provide information on the current state of evidence on the efficacy and effectiveness of various treatment approaches for military-related PTSD and identify factors that may influence treatment outcomes. The results will inform clinical decision-making for service providers and service users. Finally, the findings will provide insights into future treatment development and practice recommendations to better support the well-being of military and veteran populations.

TRIAL REGISTRATION

PROSPERO CRD42021245754; https://tinyurl.com/y9u57c59.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/33151.

Exploring the Well-being of Health Care Workers During the COVID-19 Pandemic: Protocol for a Prospective Longitudinal Study

BACKGROUND

Health care workers (HCWs) have experienced several stressors associated with the COVID-19 pandemic. Structural stressors, including extended work hours, redeployment, and changes in organizational mandates, often intersect with interpersonal and personal stressors, such as caring for those with COVID-19 infections; worrying about infection of self, family, and loved ones; working despite shortages of personal protective equipment; and encountering various difficult moral-ethical dilemmas.

OBJECTIVE

The paper describes the protocol for a longitudinal study seeking to capture the unique experiences, challenges, and changes faced by HCWs during the COVID-19 pandemic. The study seeks to explore the impact of COVID-19 on the mental well-being of HCWs with a particular focus on moral distress, perceptions of and satisfaction with delivery of care, and how changes in work structure are tolerated among HCWs providing clinical services.

METHODS

A prospective longitudinal design is employed to assess HCWs' experiences across domains of mental health (depression, anxiety, posttraumatic stress, and well-being), moral distress and moral reasoning, work-related changes and telehealth, organizational responses to COVID-19 concerns, and experiences with COVID-19 infections to self and to others. We recruited HCWs from across Canada through convenience snowball sampling to participate in either a short-form or long-form web-based survey at baseline. Respondents to the baseline survey are invited to complete a follow-up survey every 3 months, for a total of 18 months.

RESULTS

A total of 1926 participants completed baseline surveys between June 26 and December 31, 2020, and 1859 participants provided their emails to contact them to participate in follow-up surveys. As of July 2021, data collection is ongoing, with participants nearing the 6- or 9-month follow-up periods depending on their initial time of self-enrollment.

CONCLUSIONS

This protocol describes a study that will provide unique insights into the immediate and longitudinal impact of the COVID-19 pandemic on the dimensions of mental health, moral distress, health care delivery, and workplace environment of HCWs. The feasibility and acceptability of implementing a short-form and long-form survey on participant engagement and data retention will also be discussed.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/32663.

Impacts of morally distressing experiences on the mental health of Canadian health care workers during the COVID-19 pandemic

BACKGROUND

Research is urgently needed to understand health care workers' (HCWs') experiences of moral-ethical dilemmas encountered throughout the COVID-19 pandemic, and their associations with organizational perceptions and personal well-being. This research is important to prevent long-term moral and psychological distress and to ensure that workers can optimally provide health services.

OBJECTIVE

Evaluate associations between workplace experiences during COVID-19, moral distress, and the psychological well-being of Canadian HCWs.

METHOD

A total of 1362 French- and English-speaking Canadian HCWs employed during the COVID-19 pandemic were recruited to participate in an online survey. Participants completed measures reflecting moral distress, perceptions of organizational response to the pandemic, burnout, and symptoms of psychological disorders, including depression, anxiety, and posttraumatic stress disorder (PTSD).

RESULTS

Structural equation modelling showed that when organizational predictors were considered together, resource adequacy, positive work life impact, and ethical work environment negatively predicted severity of moral distress, whereas COVID-19 risk perception positively predicted severity of moral distress. Moral distress also significantly and positively predicted symptoms of depression, anxiety, PTSD, and burnout.

CONCLUSIONS

Our findings highlight an urgent need for HCW organizations to implement strategies designed to prevent long-term moral and psychological distress within the workplace. Ensuring availability of adequate resources, reducing HCW risk of contracting COVID-19, providing organizational support regarding individual priorities, and upholding ethical considerations are crucial to reducing severity of moral distress in HCWs.

Validity and Cross-Cultural Invariance of the Resiliency Scale for Young Adults – Spanish Version

Abstract. Emerging adulthood represents a time of substantial change and unpredictability. Personal resiliency is defined as an ability to adapt and thrive in the face of challenging circumstances. This study evaluated the cross-cultural validity of a new Spanish translation of the Resiliency Scale for Young Adults (RSYA) using samples of 393 young adults (66.2% women) from Spain (ages 18–30 years, Mage = 25.88, SDage = 2.87) and 365 young adults (71.23% women) from Canada (ages 18–30 years, Mage = 18.56, SDage = 1.26). Results showed that scores on the Spanish RSYA demonstrated high internal consistency reliability, convergent validity, a sound three-factor structure, and partial scalar invariance. Overall, the RSYA translation is a promising theory-based measurement tool designed for use in Spanish young adult samples.

Personality Measurement and Profile in a European Sample of Civil Airline Pilots

Abstract. The study examined the psychometric properties of the Revised NEO Personality Inventory (NEO PI-R, UK edition) in a large European sample of civil airline pilots. The NEO PI-R is a comprehensive and robust measure of personality that has been validated across cultures and contexts. Furthermore, the personality profile of the pilot sample was examined and compared to a normative sample representing the UK working population. Data from 591 pilots (95.1% male) were collected. Analyses include the internal reliability and factorial validity (precisely, Exploratory Structural Equation Modeling) to examine the measurement equivalence of the NEO PI-R with reference to UK norms ( N = 1,301). Internal reliability estimates of the NEO PI-R scores were good at the domain level, but generally weak at the facet level. The structural model in the pilot sample was congruent with the general working population sample. Furthermore, there was convincing evidence for a distinct personality profile of civil pilots, although the stability of this profile will require further validation. The NEO PI-R’s validity in the assessment of general personality in civil airline pilots is discussed, along with implications of the results for the utility of personality assessment in civil aviation contexts.

Enthusiastic Acts of Evil: The Assessment of Sadistic Personality in Polish and Italian Populations

Subclinical sadism has received substantial attention in recent research as a trait that predicts a variety of malevolent behaviors. The objective of this study was to assess the 'psychometric robustness and portability' of the Assessment of Sadistic Personality (ASP). We examined the convergent and discriminant validity, and invariance of translated versions of the ASP within community samples of Polish and Italian individuals. The study included 568 individuals (340 women and 228 men) residing in Italy (Mage = 23.57, SDage = 2.55) and 556 individuals (411 women, 144 men, 1 other) residing in Poland (Mage = 23.48, SDage = 4.60). For cultural invariance purposes, data from a Canadian sample comprising 638 students were used. To establish convergent and discriminant validity, participants completed measures of sadism, the Dark Triad, the Big Five, interpersonal reactivity, and maladaptive traits described in the DSM-5. Across both samples, convergent and discriminant validity were supported. Configural and partial metric invariance were satisfied, and following implementation of alignment optimization, latent mean differences were evaluated between countries. Results of the study supported the psychometric qualities of the ASP across different cultures and languages, and the utility of the ASP as a valid measure extending beyond university samples.

The Big Three Perfectionism Scale–Short Form (BTPS-SF): Development of a Brief Self-Report Measure of Multidimensional Perfectionism

The Big Three Perfectionism Scale (BTPS) is a 45-item self-report measure of perfectionism with three overarching factors: rigid, self-critical, and narcissistic perfectionism. Our objective was to create a brief version of the BTPS, the Big Three Perfectionism Scale–Short Form (BTPS-SF). Sixteen items were selected, and confirmatory factor analysis using a large sample of Canadian university students ( N = 607) revealed the BTPS-SF had acceptable model fit. Moreover, the BTPS-SF displayed strong test–retest reliability. The relationships of the BTPS-SF factors with depression, anxiety, stress, emotional intelligence, personality, resiliency, and elements of subjective well-being also suggested adequate criterion validity. Overall, results suggest the BTPS-SF represents an efficient, easily administered, and novel means of assessing multidimensional perfectionism.

Subclinical Sadism and the Dark Triad

Abstract. The Dark Triad is a constellation of three antisocial personality traits: Machiavellianism, narcissism, and psychopathy. Recently, researchers have introduced a “Dark Tetrad” that includes subclinical sadism, although others suggest considerable overlap between psychopathy and sadism. To clarify the position of sadism within the Dark Triad, an online study was conducted with 615 university students. Exploratory factor analysis revealed that a six-factor solution fit the data best, representing Machiavellianism, psychopathy, physical sadism, verbal sadism, narcissism, and vicarious sadism. Furthermore, convergent validity was supported through sadism’s correlations with the HEXACO personality traits. The results support sadism’s inclusion within the Dark Tetrad as a unique construct but with some conceptual overlap with psychopathy.

Do Factors from Admissions and Dental School Predict Performance on National Board Exams? A Multilevel Modeling Study

The aim of this study was to assess the association among admissions variables, dental school performance, and licensing exam performance for six cohorts of graduates of one dental school. Data from all dental school graduates of Schulich School of Medicine & Dentistry, Western University, Canada, from 2009 to 2014 who had matching National Dental Examining Board of Canada (NDEB) data (N=298) were analyzed. In the results, significant differences between cohorts were found on both the NDEB objective structured clinical examination (OSCE) and written scores. Approximately 18% of the variation in OSCE scores was attributable to cohort differences and 82% to student differences. Approximately 10% of the variation in written scores was attributable to cohort differences and 90% to student differences. Several multilevel models were conducted. The final predictive model for NDEB OSCE scores consisted of age, Canadian Dental Aptitude Test (DAT) reading comprehension scores, year 2 average, and year 4 average. For predicting NDEB written exam scores, the final model consisted of DAT chemistry and year 1, 2, and 4 averages. The findings of this study showed that academic performance on admissions variables and in training predicted performance on dental licensing exams, whereas variables that captured noncognitive or interpersonal skills, such as interview scores, were not predictive. This difference may be due to construct mismatch, such that the outcome variables had no theoretical association with the predictors. Additional outcome measures (including noncognitive) are needed that have greater ecological validity in predicting potential for competence in practice.

An Investigation of the Psychometric Properties of the Chinese Trait Emotional Intelligence Questionnaire Short Form (Chinese TEIQue-SF)

The present study examined the psychometric properties of the Chinese version of the Trait Emotional Intelligence Questionnaire Short Form (TEIQue-SF). Analyses were performed using a sample of undergraduates (N = 585) recruited from four universities across China. Confirmatory factor analysis of the Chinese TEIQue-SF supported the one-factor structure of trait emotional intelligence. Measurement invariance analyses were conducted across the Chinese sample and a sample of Canadian undergraduate students (N = 638). Although the two samples demonstrated configural and partial metric invariance, scalar invariance was not found. Cross-cultural implications and explanations of the present findings, as well as suggestions for future research are discussed.

A cross-cultural validation of the Resiliency Scale for Young Adults in Canada and China

The current study reports on a cross-cultural validation of the recently developed Resiliency Scale for Young Adults (RSYA) with two samples consisting of 617 Canadian university students and 651 Chinese university students. Confirmatory factor analysis, tests of cultural invariance, and correlations with relevant individual difference variables were conducted as tests of validity. In the Chinese sample, confirmatory factor analysis supported the factor structure of the RSYA and internal consistency reliabilities for the three factors and 10 facets were good-to-excellent. Cultural and gender invariance were supported. Correlations with depression, anxiety, stress, flourishing, and life satisfaction were also in the expected direction in the Chinese sample. These findings provide additional support for the RSYA as a reliable and valid measure of personal resiliency for Chinese young adults. Findings support the three-factor model of personal resiliency in both Canadian and Chinese young adults, as well as cultural and gender invariance. The robustness of this model has implications for assessing and developing resiliency cross-culturally.

What Matters from Admissions? Identifying Success and Risk Among Canadian Dental Students

The aims of this study were to determine whether different student profiles would emerge in terms of high and low GPA performance in each year of dental school and to investigate the utility of preadmissions variables in predicting performance and performance stability throughout each year of dental school. Data from 11 graduating cohorts (2004-14) at the Schulich School of Medicine & Dentistry, University of Western Ontario, Canada, were collected and analyzed using bivariate correlations, latent profile analysis, and hierarchical generalized linear models (HGLMs). The data analyzed were for 616 students in total (332 males and 284 females). Four models were developed to predict adequate and poor performance throughout each of four dental school years. An additional model was developed to predict student performance stability across time. Two separate student profiles reflecting high and low GPA performance across each year of dental school were identified, and scores on cognitive preadmissions variables differentially predicted the probability of grouping into high and low performance profiles. Students with higher pre-dental GPAs and DAT chemistry were most likely to remain stable in a high-performance group across each year of dental school. Overall, the findings suggest that selection committees should consider pre-dental GPA and DAT chemistry scores as important tools for predicting dental school performance and stability across time. This research is important in determining how to better predict success and failure in various areas of preclinical dentistry courses and to provide low-performing students with adequate academic assistance.

Resiliency Across Cultures: A Validation of the Resiliency Scale for Young Adults

This study presents a cross-cultural validation of the recently developed Resiliency Scale for Young Adults (RSYA) with a sample of 289 Canadian university students and 259 Italian university students. The RSYA demonstrated good internal consistency across the two samples and acceptable retest reliability for the Canadian sample. Confirmatory factor analysis supported the three-factor, 10-facet structure of the RSYA, and comparison of the two country samples found metric invariance. As expected, positive correlations also emerged between resiliency and trait emotional intelligence in both samples. Finally, correlations with personality variables were explored in both samples. The present findings provide further support for the RSYA as a valid and reliable measure of personal resiliency for both Canadian and Italian young adults, and for the cross-cultural generalizability of the three-factor model of personal resiliency upon which it is based.