The role of guilt-shame proneness and locus of control in predicting moral injury among healthcare professionals

Abstract

Despite the advances in studies conducted among healthcare professionals to explore the impact of the pandemic on their mental health, a large population still continues to display COVID-19 related psychological complaints. There has been recent awareness of moral injury related guilt and shame among doctors and nurses. However, the factors associated with moral injury have not received much attention, due to which the issue still persists. This study aims to explore the role of guilt-shame proneness, and locus of control in predicting moral injury among healthcare professionals. MISS-HP, PGI Locus of Control, and GASP scales were administered to a sample of 806 healthcare professionals. Pearson correlation coefficient indicated a significant positive relationship between moral injury and guilt-shame proneness, as well as the locus of control. Regression analysis indicated a significant role of guilt-shame proneness and locus of control in predicting moral injury. In conclusion, while studying moral injury, it becomes equally important to consider these factors to understand the concept better.

Keywords:

• moral conflict
• frontline workers
• ethical dilemma
• pandemic
• healthcare professionals

1. Introduction

The COVID-19 pandemic caused havoc in the healthcare industry. This unprecedented situation led to a staggering toll, with more than 100 million documented infections and an unfortunate loss of over 2 million lives worldwide (Fukushima et al., 2023). The volume of people getting infected and dying due to the virus led to clinician distress, despair, suffering, and burnout coupled with moral dilemmas (Williamson et al., 2023). Given their proximity to people suffering in grief, and an overwhelming number of deaths, doctors and nurses have suffered a cumulative effect of these challenges on their mental health. Studies suggest an alarming exposure to morally conflicting events during the pandemic which has posed the threat of increased vicarious traumatization, anxiety, and depressive symptoms (Akram, 2021; D’Alessandro-Lowe et al., 2022; Rosen et al., 2022). The number of people experiencing depression doubled during the pandemic, going from 11% in the beginning to 22% later on. This change happened because of more stress, which explains about half of the difference, while the impact of COVID-19 deaths contributed to 15%, and being in contact with COVID-19 patients was linked to 14% of the difference (Cermakova et al., 2023). In Northeastern India, healthcare workers (HCWs) faced substantial challenges, with 74.5% encountering depression, 42% dealing with anxiety, and 32% struggling with insomnia. Notably, those with a prior history of psychological issues were at an eight-fold, seven-fold, and three-fold higher risk of developing depression, anxiety, and insomnia, respectively (Visi et al., 2022). There is evidence of extreme emotional and psychological responses including guilt and shame that have posed a risk of moral injury to them (Cavalera, 2020). The concept of moral injury was restricted to the military experiences of combat trauma for over a decade. Recently studies started exploring its relevance outside the battlefield (Zahiriharsini et al., 2022). The pandemic redirected the investigation and studies began addressing the consequences of morally injurious events experienced by healthcare workers.

Moral injury among healthcare professionals is a significant issue that has been brought to the forefront during the pandemic. Moral injury is a term used to describe the emotional and psychological harm that can occur as a result of actions or inaction that violate an individual’s moral or ethical beliefs (Čartolovni et al., 2021). This pandemic has highlighted the moral and ethical challenges that healthcare professionals face on a daily basis, as well as the emotional and psychological toll that these challenges can take (Robert et al., 2020). However, moral injury among healthcare professionals is not limited to the pandemic, and is a longstanding issue that has been present in the healthcare field for many years (Howe et al., 2012). Moral injury can be described as a long-lasting psychological, emotional, and behavioural impact of a transgression encompassing feelings of guilt and shame. These transgressions lead to a feeling of hopelessness, helplessness, and a breach of trust in the goodness of humanity. The term was coined by Shay in Shay (1994) but was expanded by many after that. Litz et al. (2009) first developed a preliminary causal framework to study moral injury. A significant role of guilt-shame proneness and attribution of the transgression was highlighted in the model. If the attribution is global, stable, and internal, the aversive emotional and psychological experiences will be elevated (Levi-Belz et al., 2020). Such pessimistic attributions with an internal locus of control can lead to self-condemnation and withdrawal from the community.

2. Moral injury, guilt-shame proneness, and locus of control

In the healthcare domain, moral injury can occur as a result of a variety of factors. Guilt-shame proneness is the tendency to experience feelings of guilt and shame as a result of moral or ethical violations, which is one factor that may play a role in the development of moral injury among healthcare professionals. The central role of shame and hence, shame proneness in moral injury was highlighted by Delima-Tokarz (2016) in the study on veterans. It was suggested that dispositional tendencies like shame proneness have the potential to increase the probability of moral injury. Recently, the role of shame proneness in the increased likelihood of moral injury has been explored (Vella & Pai, 2023; Zalta & Held, 2020). An individual with high shame proneness has more chances of internally attributing the moral violation, and an individual with low shame proneness has more chances of externally attributing the moral violation (Tangney et al., 2007). This is because people who are high in guilt-shame proneness are more likely to internalize the negative consequences of their actions and blame themselves for any harm that may have occurred. These studies discuss the role of guilt and shame proneness in determining moral injury (Delima-Tokarz, 2016; Litz et al., 2009; Zalta & Held, 2020). However, there are a few studies that report contradictory findings. A study was conducted by Aldridge et al. (2019), which aimed to explore the relationship between guilt-shame proneness and moral injury. The study highlighted that no significant relationship exists between guilt-shame proneness and exposure to morally injurious events. Similarly, another study done by Houle and Ashbaugh (2023) found that dispositional shame proneness was not associated with negative moral appraisals. Due to insufficient literature on the relationship between guilt-shame proneness and moral injury, tailoring interventions has become an unresolved challenge.

Another factor that may play a role in the development of moral injury among healthcare professionals is locus of control. Locus of control can be defined as the degree to which people believe they can exert control over the outcomes of their life events (Nowicki et al., 2021). Research suggests that people who have an internal locus of control are more likely to experience moral injury. As a consequence of their actions or inaction, they are more likely to blame themselves for any harm that may have occurred. This internalization of blame may lead to feelings of guilt and shame, and ultimately to the development of moral injury. It is also important to highlight that these factors may not operate in isolation and that there may be other factors that contribute to moral injury among healthcare professionals.

One of the primary causes of moral injury among healthcare professionals is exposure to violence and trauma (Čartolovni et al., 2021). Healthcare professionals, particularly those working in emergency departments or in conflict zones, may be exposed to traumatic events on a regular basis (Hooper et al., 2010). This can include caring for patients who have been victims of violence and experiencing violence themselves. The constant exposure to trauma can lead to feelings of guilt, helplessness, and moral distress, as well as the development of conditions including moral injury, and post-traumatic stress disorder (PTSD).

Another plausible cause of moral injury among doctors and nurses is conflicts between personal values and organizational policies (Nelson et al., 2022). Healthcare professionals may find themselves in situations where they are asked to carry out actions or make decisions that violate their personal moral or ethical beliefs. A healthcare professional may be asked to participate in a medical procedure that they believe is morally or ethically wrong, or they may be asked to withhold care from a patient due to a lack of resources (Choe et al., 2015). These types of conflicts can lead to feelings of guilt and shame. It can further lead to a loss of trust in the healthcare system, and cause moral distress. Healthcare professionals may be faced with difficult decisions about who should receive care, and who should be left without treatment due to the scarcity of resources. This can be particularly difficult for healthcare professionals, as they have taken an oath to serve their patients with the best possible care, but are faced with the reality that they do not have the resources to meet the needs of everyone who comes through their doors. Thus, it is crucial to explore the mechanisms by which guilt-shame proneness and locus of control may contribute to moral injury. This understanding can inform the development of interventions to mitigate moral injury among healthcare professionals.

As we move ahead in the future of the pandemic, it becomes necessary to assess moral injury to prevent further damage to the well-being of healthcare workers. The prevalence of moral injury among healthcare workers (HCWs) responding to the pandemic shows considerable variation. In the US, it’s approximately 32%, whereas in China, estimates range from 20% to 41%. A global study revealed that 27% of HCWs experienced a certain degree of impairment in social or professional functioning due to moral injury symptoms. Subsequently, during a later phase of the study conducted six months later, this percentage increased to 46% in a separate and larger sample (Hegarty et al., 2022). If these issues are left unaddressed, there can be long-term mental health consequences for doctors and nurses (Riedel et al., 2022). Due to a lack of empirical studies done to particularly study the factors associated with moral injury among healthcare workers, the development of interventions has still not gauged much attention. Hence, in order to devise a moral injury-specific intervention program for healthcare workers, there is a dire need to study the role of cognitive factors like guilt-shame proneness and locus of control in predicting moral injury.

3. Moral injury among healthcare professionals and the COVID-19 pandemic

During the COVID-19 pandemic, healthcare professionals have been on the front lines of the fight against the virus, and many have experienced moral injury as a result of the overwhelming demands placed on them (Weber et al., 2023). One of the main causes of moral injury among healthcare professionals during the pandemic was the shortage of resources (Kumar & Rodney, 2021). Many hospitals and clinics were overwhelmed with patients, and healthcare workers had to make difficult decisions about whom to treat and whom to triage. This has led to feelings of guilt and helplessness; as healthcare professionals were forced to choose between saving one patient or another. Another cause of moral injury among healthcare professionals during the pandemic was the emotional toll of dealing with so much suffering and loss (Gupta & Sahoo, 2020; Kumar & Rodney, 2021). The pandemic resulted in a high number of deaths, and healthcare workers had to care for patients who were dying alone, without the support of their loved ones. Moreover, it highlighted existing inequalities in the healthcare system (Bambra et al., 2020). This created a moral conflict for healthcare professionals, who had to reconcile their desire to help others with the reality that they were unable to provide adequate care to everyone. Furthermore, the pandemic brought to light the lack of support and recognition for healthcare workers. Many healthcare professionals have reported feeling undervalued and unappreciated for their efforts during the pandemic (Billings et al., 2021). This contributed to feelings of burnout and compassion fatigue and further exacerbated the moral injury that many healthcare professionals are experiencing.

The second wave of the COVID-19 pandemic worsened these issues, as healthcare professionals faced a surge of patients, scarcity of critical care equipment, and a lack of clear guidance on how to best care for patients (Hines et al., 2021). This led to difficult decisions as well as a sense of moral distress among healthcare professionals who were unable to provide the care that they believed their patients deserved. The psychological impact of moral injury among healthcare professionals can be significant (Gilbert-Ouimet et al., 2022). It can lead to a loss of motivation and a decrease in job satisfaction among healthcare professionals. This can ultimately lead to a decrease in the overall quality of care provided. Despite the prevalence of moral injury among healthcare professionals, there is a lack of research on this topic (Čartolovni et al., 2021). In the wake of the limited and unequal distribution of resources, healthcare workers have dealt with unparalleled challenges during the pandemic. Healthcare workers were forced to adjust to the sudden shift in their ethics as they were working in a risk-prone environment with an increased possibility of harm to their health, in addition to the ethically difficult decisions they had to make (Čartolovni et al., 2021). Studies have been conducted to analyze the prevalence and impact of moral injury among healthcare professionals (Hines et al., 2021; Rushton et al., 2022; Spilg et al., 2022). However, only a few have empirically examined the cognitive predictors of moral injury. Furthermore, there is a lack of data on the effectiveness of interventions to mitigate this type of injury. Therefore, the present study aims to explore the role of guilt-shame proneness, and locus of control in predicting moral injury among healthcare professionals.

4. Method

4.1. Participants

The study was carried out among 806 healthcare professionals from various healthcare sectors. Data was collected by the authors using online Google Forms. An a priori power analysis was done with a specified power level of 0.80. Responses were collected from 406 doctors and 400 nurses from the North and South regions of India using a purposive sampling method. Due to the fear of contracting the infection and lockdown restrictions, there was a drop in patient footfall in private clinics and non-COVID OPDs (Atreya et al., 2020). Hence, healthcare professionals who worked in private clinics or visited the hospital only for severe cases were excluded from the study. Moral Injury is often understood as an experience of profound grief and loss with individual and systemic consequences in the broader context (Ramsay, 2019). Hence, those who had suffered a loss of life in their family due to COVID-19 were also excluded, so that their grief due to personal loss does not alter their responses on the Moral Injury Symptom Scale (MISS-HP). Healthcare professionals from general wards, emergency wards, intensive care units, surgical wards, maternity wards, pediatric and psychiatric wards among others were included in the study However, only those who had worked rotational shifts in hospitals during the COVID-19 pandemic were considered. Based on these criteria, responses from a total of 806 health professionals including 406 doctors and 400 nurses were considered for the final analysis.

4.2. Measures

All the study participants were administered the Moral Injury Symptom Scale (MISS-HP), PGI Locus of control scale, and Guilt and Shame Proneness (GASP) Scale. In addition, the demographic characteristics of the participants were also studied. This included information about their age, gender, and profession. In addition, whether they witnessed a COVID-related death and got infected by COVID-19 was also studied. Moral Injury Symptom Scale- Health Professionals (MISS-HP) was developed by Mantri et al. (2020). It is a 10-item scale where the responses for each item range from 1 to 10 based on agreement and disagreement with the statements. 10 dimensions that are measured by the MISS-HP include guilt, shame, betrayal, self-condemnation, moral concerns, and loss of trust. In addition, it also measures the loss of meaning, difficulty forgiving, religious struggle, as well as loss of religious faith. Internal consistency of the MISS-HP (Cronbach’s alpha) was 0.73. The 10-item Moral Injury Symptom Scale- Health Professionals (MISS-HP) has been developed specifically for health professionals to measure the specific type of moral injury they may experience in their profession. The scale allows for a more precise measurement of this type of injury by assessing different dimensions of moral injury that are specific to health professionals. The scale can also be used to study the factors that contribute to moral injury. This can inform the development of interventions that target these factors, and help to create a more supportive environment for health professionals. For the present study, responses were coded from 1 to 10 where one denoted strongly disagree and ten denoted strongly agree.

PGI Locus of Control Scale was a seven-item scale in Hindi, originally developed by Menon et al. in the 1980s. Later it was modified and translated into English by Sharma et al. (2018), based on the present Indian conditions. It is a short, forced-choice nine-item scale that measures internal/external locus of control in the Indian population. The test-retest reliability was found to be .812 and inter-score reliability was found to be .89. It is a well-validated and reliable measure of locus of control (Sharma et al., 2018). Locus of control is a concept that pertains to people’s belief about the extent to which they can exert control over the outcomes of their life events (Tyler et al., 2020). People who have an internal locus of control have this belief that the events in their lives can be influenced by their actions and active efforts, while people who have an external locus of control believe that the events in their lives are controlled by factors including fate, luck, or powerful others. The PGI Locus of Control Scale measures the extent to which people perceive themselves as having internal or external control over their lives. The scale is divided into two types of items, internal as well as external. Internal items assess the degree to which people believe that they can exert control over events in their lives through their efforts, while external items assess the degree to which people believe that events that are happening in their lives are controlled by factors outside of their control. In this study, the responses were coded as 0,1,2 as per the scores for the three options given for each item. The PGI Locus of Control Scale has been widely used in research and practice in India to study the concept of locus of control as well as its relationship with various outcomes.

The Guilt and Shame Proneness Scale (GASP) is a 16-item scale developed by Cohen et al. (2011). It is a reliable and valid scale that consists of 2 guilt subscales measuring negative-behavior evaluation (Guilt- NBE) and repair action tendencies. In addition, it has 2 shame subscales measuring negative self-evaluation (Shame- NSE) and withdrawal action tendencies (Cohen et al., 2011). Guilt NBE refers to the belief that one’s actions are unacceptable or wrong, and this sub-scale has a Cronbach’s alpha of 0.68. Repair action tendencies are the inclination to take steps to make amends or rectify one’s actions, and this sub-scale has Cronbach’s alpha of 0.61. Shame NSE refers to feelings of worthlessness or inadequacy. This subscale has a Cronbach’s alpha of 0.70. Lastly, withdrawal action tendencies refer to the inclination to avoid or withdraw from social interactions or relationships. This sub-scale has a Cronbach’s alpha of 0.62. Studies have found that the scale has good internal consistency and test-retest reliability. It is positively associated with other measures of guilt and shame, providing evidence for its construct validity. The responses gathered for the present study were systematically coded on a scale ranging from 1 to 7, where one corresponded to “very unlikely,” and seven corresponded to “very likely.”

4.3. Data analysis

SPSS version 20 was used for data analysis in order to study the demographic characteristics of the participants, and frequencies and percentages of responses were calculated. All the responses were utilized for analysis as there were no missing values for any of the variables. The normality of the data was checked and the histogram depicted an approximately bell-shaped graph, symmetric about the mean. In addition, the skewness and kurtosis values were close to 0 for all the variables. The relationship of moral injury with guilt-shame proneness and locus of control was examined using Pearson correlation and regression analysis. For testing whether guilt-shame proneness predicts moral injury, linear regression analysis was done for all the sub-scales separately (Cohen et al., 2011). A multiple linear regression model was developed with one dependent variable, that is moral injury, and two independent variables, that are guilt-shame proneness and locus of control.

5. Results

Among the 806 respondents, 46.5% were of the age group 20–30 years, 40.2% belonged to the age group 30–40 years, 11.8% were of the age group 40–50 years, and 1.5% were of the age group 50–60 years. Of these, 35.6% were males, 64.1% were females, and 0.2% belonged to the other categories. As indicated in Table 1, 71.6% of the participants witnessed a COVID-related death in their workplace and 41.1% of them were themselves infected.

Table 1. Demographic profile of the participants

Variables	Categories	Frequency	Percentage
Gender	Male	287	35.6%
	Female	517	64.1%
	Other	2	.2%
Age	20–30	375	46.5%
	30–40	324	4.2%
	40–50	95	11.8%
	50–60	12	1.5%
Witnessed a COVID-related death in the workplace	Yes	577	71.6%
	No	229	28.4%
Infected by COVID-19	Yes	331	41.1%
	No	475	58.9%

As indicated in Table 2, the mean score for moral injury is 62.36, signifying a significant presence of moral injury. Additionally, the mean score for locus of control is 11.29, demonstrating a moderate belief in an internal locus of control. Furthermore, the scores exhibit a propensity for guilt and shame proneness, with a mean score of 17.97 on guilt NBE and 18.07 for guilt repair. Moreover, the mean score for shame NSE is 18.26, while for shame withdraw is 16.73.

Table 2. Mean statistics

Variables	MISS	Guilt NBE	Repair Action Tendencies	Shame NSE	Withdrawal Action Tendencies	Locus of control
Mean	62.36	17.97	18.07	18.26	16.73	11.29

Pearson correlation coefficient indicated a significant, but weak positive relationship of moral injury with guilt-shame proneness and locus of control. Data presented in Table 3 indicates a weak positive correlation between moral injury and guilt NBE (r = 0.123, p = 0.01) as well as repair action tendencies (r = 0.180, p = 0.01). Similarly, a significant, but weak positive correlation was observed between moral injury and shame NSE (r = 0.129, p = 0.01)), as well as withdrawal action tendencies (r = 0.163, p = 0.01). In addition, there was also a weak positive correlation noticed between moral injury and locus of control (r = 0.093, p = 0.01).

Table 3. Pearson correlation coefficients

Variables	Guilt NBE	Repair Action Tendencies	Shame NSE	Withdrawal Action Tendencies	Locus of control
MISS-HP	.123	.180	.129	.163	.093

Significant at the 0.01 level.

As indicated in Table 4, guilt NBE significantly predicted moral injury (B = 0.443, p = 0.001). Moreover, repair action tendencies also significantly predicted moral injury (B = 0.694, p = 0.00). In addition, shame NSE (B = 0.506, p = 0.00) and withdrawal action tendencies (B = 0.654, p = 0.00) too significantly predicted moral injury. Moreover, for testing whether the locus of control predicts moral injury, linear regression analysis was conducted. As indicated in Table 5, internal locus of control significantly predicted moral injury (B = 0.674, p = 0.007).

Table 4. Linear regression for moral injury and guilt shame proneness

Variables	Unstandardized Beta (B)	F	R	R Square	Sig.
Guilt NBE	0.443	12.37	0.123	0.015	0.001
Repair Action Tendencies	0.694	26.989	0.180	0.013	0.000
Shame NSE	0.506	13.642	0.129	0.017	0.000
Withdrawal Action Tendencies	0.654	21.141	0.163	0.027	0.000

Dependent variable: MISS.

Table 5. Linear regression for moral injury and locus of control

Variables	Unstandardized Beta (B)	F	R	R Square	Sig.
Locus of Control	0.674	7.004	0.093	0.009	0.007

Dependent variable: MISS.

6. Discussion

The present study aimed to analyze the role of guilt-shame proneness and locus of control in predicting moral injury among healthcare workers. The analysis of mean scores reveals significant insights into the psychological experiences of healthcare professionals. It is evident that they face a substantial level of moral injury, reflecting the common exposure to morally distressing situations in healthcare (Hegarty et al., 2022). The moderate belief in an internal locus of control indicates that they perceive themselves as having some influence over their life circumstances (Padmanabhan, 2021). Additionally, their guilt-proneness situations lacking personal benefit, for situations requiring repair and repentance, suggest a strong sense of responsibility and a willingness to make amends. Furthermore, their shame proneness, indicates sensitivity to situations challenging their self-worth and a tendency to withdraw socially in response to shame (Dolezal & Rose, 2022). These findings collectively offer a comprehensive understanding of the emotional and psychological dynamics within this specific group of healthcare professionals. The Pearson correlation analysis suggested a significant relationship between moral injury and locus of control. A higher score on the PGI locus of control scale means that the belief in internal control is also higher (Cohen et al., 2011). This in turn suggests that the higher the belief in internal control over events, the higher the moral injury. Thus, the positive correlation between moral injury and locus of control suggests that individuals who experience moral injury tend to have a higher internal locus of control.

An external locus of control could potentially lead to increased concerns about how one is perceived by others, resulting in a tendency to avoid situations that might result in negative evaluations. Conversely, an internal locus of control could direct attributions of failure to oneself for not meeting personal standards, contributing to a decrease in self-esteem (Duncan‐Plummer et al., 2023). Shame-proneness predicted different dimensions of burnout, with a notably strong correlation between demoralization and shame-proneness among NICU nurses (Barr, 2022).

The relationship between moral injury and locus of control is of great importance as it can have a significant impact on an individual’s recovery process from moral injury. Individuals who have a higher internal locus of control tend to believe that they can control the events in their lives through their efforts (Darshani, 2014). They may have a greater sense of agency and believe that they have the ability to change or improve the situation. This sense of control can be empowering at times. However, this high belief in personal control over events in life may be shattered when they are not able to exercise control in high-stress situations like the pandemic and are unable to prevent mishappenings. This incongruence can make them vulnerable to moral injury. Individuals who experience moral injury may feel a sense of powerlessness and a lack of control over the situation, which can lead to feelings of distress and impede their recovery. They may feel that they have no control over the events that led to their moral injury and that they are unable to change or improve the situation. This can lead to feelings of hopelessness and helplessness, making the recovery process more difficult.

The relationship between moral injury and locus of control is also important to understand in the context of interventions for moral injury. Interventions that focus on increasing a person’s sense of control and self-efficacy may be particularly effective in helping individuals recover from moral injury (Koenig & Al Zaben, 2021). This may include interventions that teach individuals coping skills and strategies for managing stress (Ter Heide & Olff, 2023). However, it is also important to note that locus of control can be influenced by a variety of factors, including an individual’s overall personality, upbringing, and life experiences. People who have experienced any sort of trauma or abuse in their past may be more likely to have an external locus of control, while individuals who have had positive life experiences may be more likely to have an internal locus of control (Tyler et al., 2020).

The positive correlation of moral injury with guilt NBE, repair action tendencies, shame NSE, and withdrawal action tendencies highlights the complex nature of moral injury and the various ways in which it can manifest. Guilt and shame are common emotions experienced by individuals who have been through traumatic events, particularly those involving moral or ethical violations. These emotions can be particularly intense and long-lasting in cases of moral injury (Murray & Ehlers, 2021). The correlation between moral injury and guilt NBE suggests that individuals with higher levels of moral injury may experience more intense feelings of guilt and a greater tendency to engage in repair actions, such as seeking forgiveness or making amends for their actions. This can be seen as an attempt to restore a sense of morality and repair the harm caused by the traumatic event. Similarly, the correlation between moral injury and shame NSE suggests that individuals with higher levels of moral injury may experience more intense feelings of shame, and a greater tendency to withdraw from social situations and avoid others (Koenig & Al Zaben, 2021). This can be seen as a coping mechanism, as individuals may feel a sense of guilt and shame and want to avoid social interactions where these emotions may be triggered. However, this coping mechanism can be detrimental to one’s mental health and relationships, as it can lead to isolation and a lack of social support. It is important to note that these are just some of the ways in which moral injury can manifest. The specific symptoms and behaviors experienced by an individual will depend on a variety of factors, including their previous trauma, personality, and coping mechanisms.

In addition, the regression analysis indicates a significant role locus of control and guilt-shame proneness in predicting moral injury. The findings of the present study are consistent with the preliminary model of moral injury developed by Litz et al. (2009). The framework suggested the role of internal attributions and guilt-shame proneness in increasing the risk for moral injury. When individuals make internal attributions and experience high levels of guilt-shame proneness, they may be more likely to develop moral injury. This may occur because internal attributions and guilt-shame proneness can lead to feelings of self-blame and a belief that one has acted in an immoral way. These feelings can be particularly intense when the individual perceives that they have violated their own moral code or the moral code of their community. Moral injury is a complex and multidimensional construct that includes psychological, moral, and spiritual dimensions. Litz et al. (2009) proposed that moral injury is a psychological trauma that occurs as a result of perpetrating or failing to prevent acts that transgress deeply held moral beliefs and expectations. It may also include bearing a witness to such transgressing acts. Therefore, the finding that guilt-shame proneness is a significant predictor of moral injury is consistent with the idea that internal attributions and guilt-shame proneness can increase the risk for moral injury. In addition, the significant role of locus of control in predicting moral injury suggests that people with a higher internal locus of control are more likely to experience moral injury. This may be because people with an internal locus of control feel more responsible for their actions and the outcomes of those actions, and thus may experience more guilt or shame when their actions violate their moral or ethical beliefs (Detert et al., 2008).

In the present study, due to a purposive sample and the exclusion of other causal factors related to moral injury, the applicability of the results may have certain limitations. It is also important to consider that moral injury is a multidimensional construct. The correlation and linear regression analysis has only looked at the associations of some of the aspects of moral injury such as locus of control, guilt, shame, and action tendencies. It is possible that other variables or aspects of moral injury may be related to the independent variables in a different way or not related at all. Moreover, this study is only one part of a larger research effort, and more research is needed to fully understand the relationship between locus of control and moral injury. An additional limitation of the study stems from the absence of longitudinal data, particularly concerning constructs that demonstrate variability over time due to the nature of individual work experiences. Therefore, it is important to consider the limitations of this study, and further research is needed to gain a more comprehensive understanding of the predictors of moral injury.

Despite the drawbacks, the results of the present study are consistent with the previous studies and can be utilised for enhancing the existing literature on moral injury for healthcare professionals. In today’s profit-driven and business-oriented environment, healthcare workers have to consider plenty of factors while making a decision on the right course of action for their patients (Palabindala et al., 2016). All the treatment-related decisions encompass the financial consideration of the healthcare system, insurance policies, and administrative protocols of that institution (Menachemi & Collum, 2011). A constant dilemma between the Hippocratic oath and the profit-making reality makes unreasonable and untenable demands from healthcare workers (Balak et al., 2020). They are often faced with ethical challenges in their daily work, and it is essential that they are equipped with the skills and knowledge to navigate these challenges in an ethical and compassionate manner. By providing access to information related to the predictors of moral injury, healthcare organizations can help their employees to understand and make sense of their experiences, as well as to develop new coping strategies. Findings of a significant relationship between moral injury and guilt-shame proneness as well as locus of control also contribute to the development of more nuanced and multi-faceted approach to devise interventions and mitigate moral injury.

7. Conclusion

In conclusion, assessing guilt-shame proneness and locus of control to study moral injury among healthcare professionals will be essential for effective coping strategies. Like other psychiatric illnesses, a gap is expected in the experience of morally injurious events and their consequences. This time-lapse can become an opportunity to devise a framework for the effective management of moral injury among healthcare professionals. Further studies on the factors like guilt-shame proneness and locus of control that are associated with moral injury will help in a better understanding of the construct.

Ethics declaration

The authors hereby declare that this research involving human participants adheres to the ICMJE guidelines on the Protection of Research Participants. Formal and prospective approval from The Research Conduct and Ethics Committee, Center for Research CHRIST (Deemed to be University), Bengaluru, was obtained. All the participants have provided appropriate informed consent through google forms as a pre-requisite to the main questionnaires.

Acknowledgment

The authors would like to acknowledge the contribution of all the healthcare professionals who participated in the study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data not available due to ethical restrictions.

Additional information

Notes on contributors

Kirti Singhal

Kirti Singhal is a doctoral student in the Department of Psychology, CHRIST (Deemed to be) University, Delhi, NCR campus. She has published a Scopus-indexed journal article on moral injury among Indian healthcare professionals.

Surekha Chukkali

Surekha Chukkali is a professor and Head in the Department of Psychology, CHRIST (Deemed to be) University, Delhi, NCR campus. She has many publications to her credit and has developed psychometric assessments on Grit and superstitious beliefs.