A Study of Moral Distress, Moral Injury and Post-Traumatic Stress for Nurses (MDMIPTS)

March 18, 2026 updated by: Melissa A. Wilson, Mayo Clinic

Moral Distress, Moral Injury and Post-Traumatic Stress Among Mayo Clinic Nurses

The goal of this descriptive study is to examine levels of moral distress (MD), moral injury (MI), & post-traumatic stress (PTS) levels among nursing staff at Mayo Clinic. The main questions this study aims to answer are:

  1. Determine the levels of MD, MI, and PTS symptoms experienced by nurses who participate in the study.
  2. Evaluate differences in MD, MI, and PTS symptoms by setting, specialties, and geographic locations.
  3. Examine demographic and professional characteristics that are associated with high levels of MD, MI and PTS.

Study Overview

Status

Enrolling by invitation

Conditions

Intervention / Treatment

Study Type

Observational

Enrollment (Estimated)

21300

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • United States
    • Arizona
      • Phoenix, Arizona, United States, 85054
        • Mayo Clinic
    • Florida
      • Jacksonville, Florida, United States, 32250
        • Mayo Clinic
    • Minnesota
      • Rochester, Minnesota, United States, 55905
        • Mayo Clinic

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Child
  • Adult
  • Older Adult

Accepts Healthy Volunteers

No

Sampling Method

Non-Probability Sample

Study Population

Mayo Clinic Department of Nursing Staff across all Mayo Clinic sites, including: Mayo Clinic in Rochester, Minnesota; Mayo Clinic in Arizona; Mayo Clinic in Florida; and Mayo Clinic Health System sites in the midwest.

Description

Inclusion Criteria:

• Mayo Clinic Department of Nursing Staff including:

  • Registered nurses
  • Licensed practical nurses
  • Nursing support staff (including roles such as patient care assistants, patient care specialists, medical assistants, and nurse technicians)

Exclusion Criteria:

  • Social workers
  • Chaplains
  • Unit coordinators
  • Other staff who do not support direct patient care but are within the nursing department
  • Other employees outside the Department of Nursing

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

Cohorts and Interventions

Group / Cohort
Intervention / Treatment
Mayo Clinic Nurses
Mayo Clinic Department of Nursing staff across the enterprise including advanced practice nurses, registered nurses, licensed practical nurses, and nursing support/unlicensed staff.
Other: Surveys
Participants will complete an electronic survey containing the Measure of Moral Distress- Healthcare Professionals (MMD-HP), Moral Injury Outcome Scale (MIOS) including functional outcome measures adapted from the Brief Inventory of Psychosocial Functioning, The PCL-5 Checklist for DSM-5 (Post-Traumatic Stress Disorder (PSTD) Checklist for the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5)) (PCL-5), and the Well-Being Index (WBI), additionally including a demographic questionnaire with wellbeing questions.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Measure of Moral Distress-Healthcare Professionals (MMD-HP) Score
Time Frame: Baseline
The MMD-HP (Measure of Moral Distress-Healthcare Professionals) is a 27-item moral distress scale. A composite score is computed for items 1 - 25 and is obtained by multiplying the frequency scores (0 = Never to 4 = Very Frequently scale) and the distress scores (0 = None to 4 = Very Distressing scale) for each item; the products of these can range from 0 - 16. Higher scores indicate a greater deal of moral distress.
Baseline
Moral Injury Outcome Scale (MIOS) score
Time Frame: Baseline
The Moral Injury Outcome Scale (MIOS) is a 14-item self-reported survey divided into two subscales-shame-related and trust-violation related. Both the shame and trust-violated subscales are seven items per subscale. Respondents are asked to indicate how strongly they agree with each statement in the past month using a 5 point Likert scale where 0 = Strongly Disagree and 4 = Strongly Agree. The total score range for each subscale is 0 - 28, and the overall score range is 0 - 56. Symptom severity is categorized as follows: 14 - 28 indicates mild moral injury, 29 - 42 indicates moderate moral injury, and 35 - 56 indicates severe moral injury.
Baseline
Post-Traumatic Stress Disorder (PCL-5) score
Time Frame: Baseline
The PCL - 5 (Post-Traumatic Stress Disorder (PSTD) Checklist) is a 20-item self-reported survey that assesses the 20 DSM-5 symptoms of PTSD. Respondents are asked to indicate the frequency that each item occurs on a 5 point Likert scale where 0 = Not at All and 4 = Extremely. The total score is the sum of all 20 questions, with higher scores indicating a greater likelihood of PTSD.
Baseline

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Mayo Clinic

Collaborators

Mayo Clinic Center for Clinical and Translational Science (CCaTS)

Investigators

  • Principal Investigator: Cindy Tofthagen, PhD, Mayo Clinic
  • Principal Investigator: Melissa A Wilson, PhD, Mayo Clinic

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

  • Dyrbye, L. N., Johnson, P. O., Johnson, L. M., Satele, D. V., & Shanafelt, T. D. (2018). Efficacy of the Well-Being Index to Identify Distress and Well-Being in U.S. Nurses. Nurs Res, 67(6), 447-455. https://doi.org/10.1097/nnr.0000000000000313
  • Wortmann JH, Jordan AH, Weathers FW, Resick PA, Dondanville KA, Hall-Clark B, et al. Psychometric analysis of the PTSD Checklist-5 (PCL-5) among treatment-seeking military service members. Psychol Assess. 2016;28(11):1392-403.
  • Houle, S. A., Ein, N., Gervasio, J., Plouffe, R. A., Litz, B. T., Carleton, R. N., Hansen, K. T., Liu, J. J. W., Ashbaugh, A. R., Callaghan, W., Thompson, M. M., Easterbrook, B., Smith-MacDonald, L., Rodrigues, S., Bélanger, S. A. H., Bright, K., Lanius, R. A., Baker, C., Younger, W.,…Nazarov, A. (2024). Measuring moral distress and moral injury: A systematic review and content analysis of existing scales. Clin Psychol Rev, 108, 102377. https://doi.org/10.1016/j.cpr.2023.102377
  • Booth, A. T., & Robinson, K. L. System-wide assessment using the Measure of Moral Distress - Healthcare professionals. Nursing Ethics, 0(0), 09697330251324296. https://doi.org/10.1177/09697330251324296
  • D'Alessandro-Lowe AM, Patel H, Easterbrook B, Ritchie K, Brown A, Xue Y, et al. The independent and combined impact of moral injury and moral distress on post-traumatic stress disorder symptoms among healthcare workers during the COVID-19 pandemic. Eur J Psychotraumatol. 2024;15(1):2299661.
  • Austin CL, Saylor R, Finley PJ. Moral distress in physicians and nurses: Impact on professional quality of life and turnover. Psychol Trauma. 2017;9(4):399-406.
  • Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and Initial Psychometric Evaluation. J Trauma Stress. 2015;28(6):489-98.
  • Schuster M, Dwyer PA. Post-traumatic stress disorder in nurses: An integrative review. J Clin Nurs. 2020;29(15-16):2769-87.
  • Brennan CJ, Roberts C, Cole JC. Prevalence of occupational moral injury and post-traumatic embitterment disorder: a systematic review and meta-analysis. BMJ Open. 2024;14(2):e071776.
  • Weber MC, Smith AJ, Jones RT, Holmes GA, Johnson AL, Patrick RNC, et al. Moral injury and psychosocial functioning in health care workers during the COVID-19 pandemic. Psychol Serv. 2023;20(1):19-29.
  • Ehman AC, Smith AJ, Wright H, Langenecker SA, Benight CC, Maguen S, et al. Exposure to potentially morally injurious events and mental health outcomes among frontline workers affected by the coronavirus pandemic. Psychol Trauma. 2023;15(3):524-35.
  • Hines SE, Chin KH, Glick DR, Wickwire EM. Trends in Moral Injury, Distress, and Resilience Factors among Healthcare Workers at the Beginning of the COVID-19 Pandemic. Int J Environ Res Public Health. 2021;18(2).
  • Papazoglou K, Chopko B. The Role of Moral Suffering (Moral Distress and Moral Injury) in Police Compassion Fatigue and PTSD: An Unexplored Topic. Front Psychol. 2017;8:1999.
  • Maguen S, Litz BT. Moral Injury in Veterans of War. PTSD Research Quarterly (RQ). 2012;23(1):1-3.
  • Gibbons SW, Shafer M, Hickling EJ, Ramsey G. How do deployed health care providers experience moral injury? Narrat Inq Bioeth. 2013;3(3):247-59.
  • Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, Maguen S. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695-706.
  • Shay J. Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York, NY: Scribner; 1994. 246 p.
  • Yan GW. The Invisible Wound: Moral Injury and Its Impact on the Health of Operation Enduring Freedom/Operation Iraqi Freedom Veterans. Mil Med. 2016;181(5):451-8.
  • Horesh D, Brown AD. Traumatic stress in the age of COVID-19: A call to close critical gaps and adapt to new realities. Psychol Trauma. 2020;12(4):331-5.
  • Wingfield T, Taegtmeyer M. Healthcare workers and Coronavirus: Behind the stiff upper lip we are highly vulnerable Waltham, MA: The Conversation; 2020 [Available from: https://theconversation.com/healthcare-workers-and-coronavirus-behind-the-stiff-upper-lip-we-are-highly-vulnerable-133864.
  • Agazio J, Goodman P. Making the hard decisions: Ethical care decisions in wartime nursing practice. Nurs Outlook. 2017;65(5s):S92-s9.
  • Gibbons SW, Shafer MA, Hickling L, Edward J, Benedeck DM. Combat health care providers and resiliency: Adaptive coping mechanisms during and after deployment. Psychol Serv. 2014;11(2):192-9.
  • American Association of Critical Care Nurses. AACN Public Policy Position Statement 2001. Aliso Viejo, CA: American Association of Critical Care Nurses; 2001.
  • 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 Empir Bioeth. 2019;10(2):113-24.
  • American Association of Critical Care Nurses. Moral distress public policy position statement. Aliso Viejo, CA: American Association of Critical Care Nurses; 2008.
  • Adia, 2023: Brennan, C. J., Roberts, C., & Cole, J. C. (2024). Prevalence of occupational moral injury and post-traumatic embitterment disorder: a systematic review and meta-analysis. BMJ Open, 14(2), e071776. https://doi.org/10.1136/bmjopen-2023-071776

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

March 3, 2026

Primary Completion (Estimated)

May 1, 2026

Study Completion (Estimated)

August 1, 2026

Study Registration Dates

First Submitted

February 23, 2026

First Submitted That Met QC Criteria

March 2, 2026

First Posted (Actual)

March 6, 2026

Study Record Updates

Last Update Posted (Actual)

March 20, 2026

Last Update Submitted That Met QC Criteria

March 18, 2026

Last Verified

March 1, 2026

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 25-008396
  • Mayo Clinic CTSA (Other Identifier: Mayo Clinic)

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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