Prevalence of Exposures and Moral Injury in First Responders

Workers in high-stakes occupations, such as first responders, are at risk of exposure to potentially morally injurious events (PMIEs) and moral injury, yet research with first responders has been scarce. This study aimed to assess the frequency of exposure to PMIEs, the prevalence of moral injury, and the correlation between moral injury and other mental health symptoms.

In this cross-sectional study, firefighters, emergency medical technicians (EMTs), and paramedics working for a large urban Fire Department in California were invited to complete an online, confidential survey using validated scales to assess exposure to PMIEs, moral injury symptoms, and symptoms of posttraumatic stress disorder, anxiety, depression, alcohol use, and burnout between February 21, 2024, and April 16, 2024. We calculated item frequencies and correlation and reliability analysis on each scale separately and between the total scores from all measures using Pearson, polyserial, and polychoric methods. Reliability was assessed using Guttman's lambda and Cronbach's alpha.

Participants (N = 292) endorsed a range of PMIEs, including exposure by commission (48.6%), omission (48.6%), and witnessing (80.8%). Among those that reported PMIE exposure and moral injury symptoms (N = 147), 18.4% met the threshold for clinically meaningful moral injury. Moral injury symptoms were strongly correlated with each of the mental health measures (r = 0.49-0.59), with the exception of alcohol use (r = 0.08).

Exposure to PMIEs was common in these professional first responders, and a substantial proportion of participants reported clinically meaningful moral injury symptoms. These data fill an important gap and provide information that can help with moral injury assessment and treatment for first responders.