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Psychological Trauma: Theory, Research,
Practice, and Policy
Morally Injurious Experiences and Meaning in
Salvadorian Teachers Exposed to Violence
Joseph M. Currier, Jason M. Holland, Lisseth Rojas-Flores, Sofia Herrera, and David Foy
Online First Publication, October 14, 2013. doi: 10.1037/a0034092
CITATION
Currier, J. M., Holland, J. M., Rojas-Flores, L., Herrera, S., & Foy, D. (2013, October 14).
Morally Injurious Experiences and Meaning in Salvadorian Teachers Exposed to Violence.
Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication.
doi: 10.1037/a0034092
Morally Injurious Experiences and Meaning
in Salvadorian Teachers Exposed to Violence
Joseph M. Currier
University of South Alabama and Fuller Theological Seminary
Jason M. Holland
University of Nevada, Las Vegas
Lisseth Rojas-Flores and Sofia Herrera
Fuller Theological Seminary
David Foy
Pepperdine University
Helping professionals working to alleviate the effects of violence and injustice can confront morally
injurious experiences (MIE) that violate deeply held moral values/beliefs, placing them at risk for burnout
and trauma-related problems (e.g., posttraumatic stress disorder [PTSD]). Focusing on 257 teachers from
educational departments throughout El Salvador, we incorporated structural equation modeling (SEM) to
examine (1) whether exposure to MIEs for this population (e.g., betrayal, witnessing harm to an innocent
student) are directly linked with higher PTSD symptomatology and work-related burnout and (2) whether
MIEs contribute to these outcomes via meaning made of trauma. SEM results revealed that MIEs were
in fact uniquely linked with PTSD symptoms and burnout, above and beyond rates of direct victimization
and demographic factors. In addition, greater MIEs were indirectly linked with study outcomes via the
extent to which teachers were able to make meaning of their identified stressors. These findings support
the importance of screening for MIEs among helping professionals and also suggest that meaning making
could serve as a central mediating factor for how MIEs contribute to trauma-related problems among
persons working to promote peace and justice in the world.
Keywords: moral injury, meaning, trauma, violence, teacher
Teachers in El Salvador and other less developed nations can
play an integral role in promoting social justice and mitigating the
consequences of trauma in their communities. They not only
facilitate academic development in the classroom, but often serve
as mentors, counselors, advocates, and role models for students
and families. However, in so doing they may place themselves in
close proximity to violence and confront morally injurious expe-
riences (MIEs) that undermine their basic sense of humanity and
understanding of how the world operates. Evidence from meta-
analytic reviews indicates that violence is a salient predictor of
trauma-related distress such as posttraumatic stress disorder
(PTSD; Brewin, Andrews, & Valentine, 2000; Ozer, Best, Lipsey,
& Weisz, 2008), and research also has documented that greater
violence exposure can increase the risk for mental health problems
among helping professionals, such as humanitarian aid workers
(Putman et al., 2009) and urban development workers (Walling,
Eriksson, Putman, & Foy, 2011). However, the nature of these
associations is not entirely clear, and it has recently been suggested
that certain types of occupational stressors are especially trouble-
some to the extent they challenge one’s deeply held moral beliefs
and values as well as possibly threatening death or injury (e.g., Litz
et al., 2009). Drawing on a sample of violence-exposed Salvador-
ian teachers from a number of educational contexts, we incorporate
structural equation modeling (SEM) to examine (1) the extent to
which possible MIEs in this population are directly linked with
PTSD symptoms and work-related burnout, and (2) to what extent
these types of stressors are indirectly associated with the two study
outcomes via teachers’ capacity to make meaning of their identi-
fied stressors.
Violence in El Salvador
El Salvador has been one of the most violent places in the world
over recent decades. After years of militarization and political
violence, the country had a brutal civil war from 1980 to 1992 that
culminated in approximately 75,000 deaths. Violations of interna-
tional war regulations were commonly observed as part of this
conflict, including repeated massacres and assassinations of civil-
ians, killings of wounded and sick in hospitals, and executions of
prisoners (Ugalde et al., 2000). In spite of a peace accord that
promised renewal, estimates suggest that more than 50,000 Salva-
dorians have been killed since the end of the war (Richani, 2010).
The World Bank (2011) also documented that the homicide rate in
El Salvador has been the highest in Latin America over recent
years (58 per 100,000 inhabitants in 2008). In addition, 2010 data
Joseph M. Currier, Psychology Department, University of South Ala-
bama, and Graduate School of Psychology, Fuller Theological Seminary;
Jason M. Holland, Department of Psychology, University of Nevada, Las
Vegas; Lisseth Rojas-Flores and Sofia Herrera, Graduate School of Psy-
chology, Fuller Theological Seminary; David Foy, Graduate School of
Psychology, Pepperdine University.
Correspondence concerning this article should be addressed to Joseph
M. Currier, Psychology Department, University of South Alabama, AL
36608. E-mail: jcurrier@southalabama.edu
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Psychological Trauma: Theory, Research, Practice, and Policy © 2013 American Psychological Association
2013, Vol. 5, No. 5, 000 1942-9681/13/$12.00 http://dx.doi.org/10.1037/a0034092
1
from the Latin American Public Opinion Project (LAPOP) placed
El Salvador near the top for violent crime victimization (e.g.,
assault, armed robbery), with a quarter (24.2%) of the 1,550
persons surveyed being the direct victim of a violent crime and
40% having someone in their household victimized in the previous
year (Macías, Cruz, & Seligson, 2010). Given these statistics, it is
not surprising that nearly half (44%) of the Salvadorians who
participated in the LAPOP reported feeling unsafe in their com-
munities (Macías et al., 2010).
Factors contributing to violence in El Salvador are certainly
complex and wide-ranging (for detailed reviews, see Farah, 2011;
Richani, 2012). Beyond the challenges of a postwar culture, pov-
erty, social inequality and exclusion, rapid urbanization, and ex-
pansion of marginal “colonias” (or barrios) have weakened the
state’s capacity to promote security for its citizens. Rates of
violence have also been exacerbated by high rates of unemploy-
ment and an increase in gang activity and drug trafficking among
younger persons over the past decade (Farah, 2011; Richani, 2010;
World Bank, 2011). In addition, policy changes in the United
States led to the deportation of an estimated 43,000 immigrants
with a criminal record after the civil war in El Salvador (Richani,
2010). Some of these criminals were Salvadorians who were
entrenched in gangs in United States cities with an in-depth knowl-
edge about the crime trade, use of weapons, and the production and
distribution of illicit drugs (e.g., crack cocaine). Many lacked the
resources to legally meet the demands of life in El Salvador (e.g.,
education, familial ties, Spanish language ability), and pursued
security in the country by reproducing gang structures and main-
taining alliances with their U.S. counterparts.
The interplay of these types of issues has contributed to a system
of violence in El Salvador that teachers and other helping profes-
sionals must negotiate on a daily basis. Although trauma research
has not focused on teachers in Central America or violent contexts
in general, initial results from this sample revealed that the teach-
ers had on average experienced three to four types of potentially
traumatic events during adulthood (Rojas-Flores et al., 2013). The
most common of these events included war-related stressors (e.g.,
witnessing fighting, injured people, and dead bodies; 55%), large-
scale natural disasters that have also occurred over recent years in
the country (e.g., floods, hurricanes, and earthquakes; 40%), wit-
nessing someone commit suicide (45%), or being raped or sexually
assaulted (31%), stabbed or attacked with a knife (28%), or in a
life-threatening accident (21%). Consistent with findings from
similar professional groups (e.g., Putman et al., 2009; Walling et
al., 2011), we also found that teachers with exposure to higher
numbers of these possible traumas reported worse PTSD symp-
toms and more challenges staying meaningfully engaged in their
work (i.e., work-related burnout). We attempted to expand on
these findings in the current investigation by testing the contribu-
tion of MIEs on these mental health outcomes and whether diffi-
culties with meaning making may in part account for the probable
links in the structural equation model.
Morally Injurious Experiences Among Salvadorian
Teachers
Beyond the general risk for violence in El Salvador and possible
added occupational hazards of working in the teaching profession,
teachers in this country may confront a range of MIEs that could
factor prominently in the etiology of PTSD symptomatology and
problems with burnout. These stressors could arise from teachers’
own acts of commission or omission, harmful acts perpetrated by
others, or from witnessing human suffering and the consequences
of violence and injustice in their professional role. MIEs can occur
in the context of life threat stressors that provide the basis for the
current diagnostic criteria for PTSD (American Psychiatric Asso-
ciation, 1994; e.g., gang shooting, physical assault on school
grounds) or play a complementary role in shaping teachers’ re-
sponses to these types of traumatic events as well. For example,
Salvadorian teachers might need to cope with specific incidents of
violence in their schools (e.g., acts of revenge or retribution among
students), betrayal by educational leaders, mistreatment of stu-
dents, inability to prevent the suffering of students, and various
ethical dilemmas and/or moral uncertainties in the job. The accu-
mulation of these MIEs might be quite distressing for many
teachers and hinder their occupational effectiveness (e.g., fatigue,
cognitive weariness, and emotional exhaustion; Shirom, 2002).
Moral Injury and Mental Health
Research on the mental health consequences of MIEs is just
beginning. To this point, studies have been qualitative in nature
and largely focused on nurses in critical care or acute care settings
(for reviews, see McCarthy & Deady, 2008; Rittenmeyer & Huff-
man, 2012). Drawing on Jameton’s (1984) work, this research has
largely addressed moral distress or the painful feelings and sense
of psychological disequilibrium that can occur when nurses are
aware of the appropriate action but cannot carry it out because of
institutional obstacles (e.g., lack of time, policy). Example stres-
sors that might cause moral distress among nurses include aggres-
sive treatment with terminally ill patients, unnecessary medical
tests, incompetent treatment by colleagues, power imbalances in
the medical setting, and lack of support from one’s institution.
Although this literature has not focused on PTSD or other mental
health outcomes per se, findings suggest that these types of MIEs
can lead to psychological difficulties among nurses, such as the
loss of cherished values, wounding of one’s moral conscience, and
disconnection from self and others (McCarthy & Deady, 2008). In
another study of moral distress with 16 humanitarian aid and
rescue workers, Nilsson and colleagues (2011) identified four
general domains of MIEs for this population—insufficiency, pow-
erlessness, meaninglessness, and frustration. They also mainly
focused on organizational constraints and found that moral distress
was strongly characterized by a violation in workers’ moral beliefs
or the inability to justify their actions during a deployment
(Nilsson et al., 2011).
In keeping with rich clinical and theoretical accounts of moral
injury among persons who served in military combat (e.g., Shay,
1995), Litz et al. (2009) suggested that MIEs could play a central
role in posttraumatic maladjustment as well. In support of these
claims, Drescher et al. (2011) found consensus (among 23 clinical
professionals with extensive backgrounds working with veterans)
that risk for mental health problems was greater among those who
had experienced war-zone stressors that trangressed their values
and moral beliefs. Common MIEs identified in this qualitative
study included betrayal (e.g., leadership failures), acts of dispro-
portionate violence (e.g., revenge/retribution), incidents involving
civilians (e.g., destruction of property), and acts of within-rank
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2
CURRIER, HOLLAND, ROJAS-FLORES, HERRERA, AND FOY
violence (e.g., sexual assault; Drescher et al., 2011). When ac-
counting for general life threat stressors that might also occur
during a war-zone deployment (e.g., engaging in a fire fight,
completing dangerous operation), other research has also docu-
mented that two relatively extreme examples of MIEs— killing
(Maguen et al., 2009) and abusive violence (e.g., mistreating
civilians, torturing prisoners; Currier, Holland, Jones, & Sheu, in
press)—are associated with worse PTSD symptoms and other
mental health problems among many veterans. Although the per-
petration of these types of violent acts can be a distinctive element
of war-zone service, the moral injury construct is likely broader in
scope and MIEs could also have wide-ranging effects among other
professional groups who similarly contend with pervasive violence
and injustice in their work.
Moral Injury and Meaning Making
One way MIEs might influence the mental health of Salvadorian
teachers is through a breakdown in global meaning (i.e., beliefs,
goals, cohesiveness and purpose; for description of the meaning
making model, see Park, 2010). Being able to make meaning of
stressful events has been shown to be important for one’s psycho-
logical health (Currier, Holland, Chisty, & Allen, 2011; Holland,
Currier, Colemen, & Neimeyer, 2010), and these findings may be
particularly relevant for helping professionals working in situa-
tions with recurrent violence and existential threat. According to
Park (2010), challenges in coping arise in part from the degree that
the reality of stressors cannot be integrated into one’s global
meaning and/or the person cannot accommodate aspects of their
worldviews to make sense or (situationally) construct meaning out
of stressful life experiences. Litz et al. (2009) also postulated that
MIEs may contribute to mental health problems as a result of
conflicts between the appraisal of these types of experiences and
one’s guiding moral beliefs about themselves, others, and the
larger world. From a meaning making perspective, repairing this
type of violation is considered successful if one’s stressful expe-
riences are either adaptively assimilated into their global meaning
system or if the trauma survivor revises his or her beliefs and/or
goals in a benign way to better match their appraisal of the
stressors. However, as may occur for persons living and working
in violent conditions, some may not be able to overcome this
violation of meaning and achieve a sense of safety and stability in
the world.
Although research has yet to examine the link between meaning
making and burnout among violence-exposed professionals (to our
knowledge), recent studies have demonstrated that such a break-
down in global meaning can be associated with severity of PTSD
symptomatology (Currier, Holland, Chisty, & Allen, 2011; Park,
Mills, & Edmondson, 2012). In a study of 130 college students
exposed to a range of potentially traumatic events, Park et al.
(2012) found that reports of personal belief violation of goal
violation were each correlated with greater PTSD symptoms.
Drawing on the Integration of Stressful Experiences Scale (ISLES;
Holland et al., 2010), Currier et al. (2011) also found that meaning
made of trauma (i.e., synchrony between situational appraisal of
traumatic event and global meaning) was uniquely linked with
PTSD symptomatolgy among 169 veterans of the Iraq and Af-
ghanistan wars presenting for care in the Veterans Administration
system. Along with conceptions of moral injury from the military
trauma literature (e.g., Drescher et al., 2011; Litz et al., 2009;
Shay, 1994), these findings suggest the importance of the subjec-
tive meaning made of trauma as a possible mediating factor in
mental health symptoms after stressful events of various types.
Study Aims and Hypotheses
The overarching aim of this study was to examine the role of
MIEs in the psychological and occupational functioning of Salva-
dorian teachers with reported histories of victimization and expo-
sure to other potentially traumatic events. In view of available
empirical and theoretical work on the moral injury construct, we
had two hypotheses about how the accumulation of possible MIEs
among the teachers would contribute to PTSD symptomatology
and burnout:
1) With levels of direct exposure to violence events and demo-
graphic factors controlled, a significant direct link would emerge
between teachers’ MIEs and the two outcomes assessed in the
study (PTSD and burnout).
2) MIEs would also be significantly linked with teachers’ mean-
ing made of their identified stressors, which would partly account
for associations between MIEs and PTSD symptomatology and
burnout in the model.
Method
Participants and Procedures
This study was conducted in March 2012 in collaboration with
the Ministry of Education and Diocese of the Anglican-Episcopal
Church in El Salvador. Following institutional review and ap-
proval by Fuller Seminary, 257 teachers were recruited through
advertisements from the Office of the Minister of Education across
the different educational departments in the country. Participants
completed research procedures before attending a free, 2-hr
psycho-educational workshop on coping with trauma and stress led
by the first author (J.M.C.). Upon each person’s arrival, all re-
search procedures were explained in Spanish, including the general
purpose and voluntary nature of the study. Participants were in-
formed from the outset that they could attend the workshop even
if they declined to participate in the study. The survey lasted
approximately 45 minutes, and research assistants were available
to answer questions and debrief participants in Spanish after com-
pletion of the study questionnaire. Persons who attended the work-
shop were also offered a light meal and $7.00 to defer travel costs,
regardless of their involvement in the study. Of those teachers who
attended the workshop, fewer than 5% declined to participate in
the present study.
The sample predominantly comprised women (68.6%), and the
average age was 42.02 years (SD ⫽ 13.12). Nearly half were
married (45.2%), 32.4% % were single, 11.9% were separated or
divorced, 8.5% were in committed relationships and living with a
partner, and 1.9% were widowed at the time of the study. The
majority resided in urban areas (86.9%; e.g., San Salvador). On
average, participants had worked in the Salvadorian educational
system for 15.44 years (SD ⫽ 10.29) and the majority worked in
urban schools (79.3%). Participants were largely employed as
classroom teachers at the time of the study (83.7%). However,
13.7% worked as administrators (e.g., principal), and 2.7% func-
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3
MORAL INJURY AND MEANING
tioned as both a classroom teacher and school administrator in
their respective schools. Consistent with sample characteristics
from an earlier study with this population (Rojas-Flores et al.,
2013), there was again an overrepresentation of public schools
(83.9%), with 15% of participants working in private institutions
and 1% having positions in both public and private schools at the
time of the study.
Each participant completed a self-report questionnaire assessing
demographic and professional background information, exposure
to violence events and possible MIEs, meaning made of a salient
stressor, and mental health symptoms (PTSD and burnout). In
developing the questionnaire for this study, we assessed for vio-
lence exposure and PTSD with Spanish language versions of
measures that had established psychometric properties from other
Central American samples (Putman et al., 2009; Rojas-Flores et
al., 2013). So as to meet the current study aims, we needed to (1)
develop instrumentation for examining MIEs and (2) translate two
English-language measures into Spanish for assessing meaning
made (Integration of Stressful Life Events Scale) and work-related
burnout (Shirom-Melamed Burnout Measure). For those inter-
ested, please contact the corresponding author for copies of the
Spanish versions of the measures used in this study.
Instrumentation
Moral injury. Given the newness of the moral injury con-
struct and general lack of research with teachers in El Salvador or
other impoverished and violent locales, we needed to develop a
means for assessing possible MIEs in the study. Twelve items were
constructed for this Moral Injury Questionnaire – Teacher Version
(MIQ-T) by the first author (J.M.C.) on the basis of available
theory, research, and clinical evidence on MIEs among veterans
and other groups of helping professionals (see Appendix). These
items covered five broad domains of stressors that may occur for
Salvadorian teachers: (1) specific acts of violence, (2) betrayal, (3)
incidents involving the mistreatment of students, (4) being unable
to prevent harm and suffering of students, and (5) ethical dilem-
mas/moral conflicts. Teachers were instructed to endorse the fre-
quency they had experienced each of these 12 items on a 4-point
scale in which 1 ⫽ Never,2⫽ Seldom,3⫽ Sometimes, and 4 ⫽
Often.
Direct violence exposure. We incorporated 22 items from the
direct victimization index of the Survey of Exposure to Commu-
nity Violence (SECV; Richters & Saltzman, 1990) to assess direct
exposure to violence events that had occurred for teachers during
adulthood (since age 18). Example stressors include being in a
life-threatening accident, physically assaulted (i.e., mugged or
beaten up, stabbed or attacked with knife, shot), physical abuse in
one’s family, sexual assault or rape, seeing a dead body in the
community, or witnessing a violent death of some sort (i.e., suicide
or homicide). Given the historical circumstances in El Salvador,
we included additional items for war-related stressors and natural
disasters that occurred over the past decade. For ease of adminis-
tration with the survey, the items were scored dichotomously (0 ⫽
No,1⫽ Yes), and the total number was summed to represent
teachers’ exposure to the different violence events on the measure.
This version of the SECV was implemented successfully in Gua-
temala with indigenous aid workers (Putman et al., 2009), and the
items have been grouped and scored in this simplified manner by
other researchers as well (e.g., Walling et al., 2011).
Meaning made of stress. Meaning made of stress was as-
sessed with the Integration of Stressful Life Events Scale (ISLES;
Holland et al., 2010). In developing the Spanish version of the
measure, the English ISLES was first translated and then indepen-
dently back-translated by native Spanish speakers. Second, the
translation and back-translation were then reviewed by the
ISLES’s primary author (J.M.H.) and a Salvadorian born psychol-
ogist/researcher (S.H.) to examine whether the original meaning of
the items remained intact and the Spanish language reflected the
regionalisms of El Salvador. Third, this version was further re-
viewed by the original translator and back-translator, both of
whom confirmed that the Spanish translation was correct. Please
see Currier et al. (in press) for additional psychometric details of
the Spanish version of this measure.
Consistent with Holland et al.’s (2010) original instructions,
teachers completed the ISLES with respect to the most stressful
life event over their lifetime. These events included the death of a
close family member (21.2%), surviving a natural disaster (8.0%),
domestic violence or sexual abuse (5.7%), being a victim of a
crime (5.2%), witnessing/surviving other types of violent events
(4.7%), and major illness/injury of a close family member (4.7%).
The ISLES can yield an overall score or two subscales that tap
different aspects of global meaning, with a cluster of items gauging
the Comprehensibility of the stressor (e.g., “I have difficulty
integrating this event into my understanding of the world”) and
another assessing one’s sense of Footing in the World (e.g., “My
previous goals and hopes for the future don’t make sense anymore
since this event”). A 5-point response format was used in the
present study, with anchor points of 1 ⫽ Strongly agree to 5 ⫽
Strongly disagree, and items were scored in such a way that higher
scores indicated more adaptive integration of the identified stres-
sor. In the present sample, Cronbach’s alphas were .83 and .93 for
Comprehensibility and Footing in the World subscales, respec-
tively.
Posttraumatic stress symptomatology. We relied on a 17-
item subscale assessing PTSD symptoms from a Spanish version
of the Los Angeles Symptoms Checklist (LASC; King, King,
Leskin, & Foy, 1995) that had also been used successfully in
Central America by Putman et al. (2009). This measure captures
the three domains of current PTSD symptoms: reexperiencing (3
items; e.g., nightmares, intrusive memories), avoidance (6 items;
e.g., emotional numbness, avoidance of reminders), and hyper-
arousal (8 items; e.g., irritability, excessive jumpiness). In keeping
with the original English version of the LASC (King et al., 1995),
teachers reported how much of a problem each symptom had been
during the previous month with possible responses ranging from
0 ⫽ Not a problem to 4 ⫽ An extreme problem. Cronbach’s alphas
ranged from .68 to .87 across the three subscales in the present
sample.
Work-related burnout. The Shirom-Melamed Burnout Mea-
sure (SMBM; Shirom, 2002) is a widely used, 14-item self-report
questionnaire assessing three domains of work-related burnout for
persons working in emotionally demanding professions: physical
fatigue (6 items), cognitive weariness (5 items), and emotional
exhaustion (3 items). In an effort to assess burnout among the
teachers, the SMBM was translated into Spanish with the same
process as described above for the ISLES. The items were first
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4
CURRIER, HOLLAND, ROJAS-FLORES, HERRERA, AND FOY
translated and back-translated by Spanish-speaking graduate assis-
tants, and the fourth author (S.H.) reviewed the translated version
of the items to ensure that the language was consistent with the
regionalisms of El Salvador. As with Shirom’s (2002) original
directions for the SMBM, responses ranged from 0 ⫽ never or
almost never to 6 ⫽ always or almost always. Cronbach’s alphas
for the three subscales ranged from .89 to .92 in the sample.
Plan of Analysis
The MIQ-T contained items that could be considered causes
(e.g., I saw the harm of an innocent student) or effects (e.g., I feel
guilt over failing to protect a student) of MIEs. Although effect
indicators should be intercorrelated (justifying the use of explor-
atory factor analysis and/or tests of internal consistency), causal
indicators show “no necessary relationship” with one another
(Bollen, 1984, p. 377). As a result, causal indicators must be
evaluated by other means, such as considering face validity of the
item, breadth of coverage of the construct, and concurrent validity
with relevant outcomes (Bollen, 1984; Diamantopoulos & Winkl-
hofer, 2001; Fayers & Hand, 1997). Overall, six MIQ-T items
were regarded as effect indicators (items 1, 3, 5, 7, 9, and 11), and
six items were regarded as causal indicators (items 2, 4, 6, 8, 10,
and 12).
Before performing analyses with the MIQ-T, the optimal num-
ber of factors was established by submitting the six effect indica-
tors to the minimum average partial test (MAP; Velicer, 1976).
The MAP test involves examining the item correlation matrix after
extracting increasing numbers of components and selecting the
solution that best minimizes the partial correlations among items
once variability due to the components is partialed out. The MAP
test was performed using an SPSS macro (O’Connor, 2000). A
larger confirmatory factor analysis (CFA) was also performed with
all items in a multiple indicator multiple cause (MIMIC) model.
MIMIC models can simultaneously test for associations between
causal indicators and a latent variable as well as the direct asso-
ciations between causal and effect indicators, in the presence of the
latent variable. Inspection of modification indices was used to
guide the selection of direct paths (from the causal indicators to the
effect indicators) to add to the model.
Following the CFA, structural equation modeling (SEM) was
used to test the MIQ-T’s direct and indirect effects (via teachers’
meaning made of their identified stressors) on work-related burn-
out and PTSD symptoms. Moral injury was represented as a latent
factor that was consistent with the model from the CFA. The other
constructs were treated as latent factors that were assessed with a
variety of indicators, each of which represented an established
subscale for the corresponding measure. Several covariates were
also added to the model, including age, gender, marital status,
whether a teacher lived in a rural or urban environment, and
lifetime violence exposure.
We relied on a variety of fit indices to assess model fit, includ-
ing the
2
goodness-of-fit test, comparative fit index (CFI; Bentler,
1990), the Standardized Root Mean Square Residual (SRMR), and
the Root Mean Square Error of Approximation (RMSEA; Browne
& Cudeck, 1993). CFI values ⬎ .90 as well as SRMR values ⬍ .10
are generally regarded as favorable (Hu & Bentler, 1999; Kline,
2005). Likewise, RMSEA values ⱕ .05 are considered close
approximate fit, values between .05 and .08 suggest reasonable fit,
and values ⱖ .10 are indicative of poor model fit (Browne &
Cudeck, 1993). CFA and SEM analyses were each performed in
MPlus, version 6.11 (Muthén & Muthén, 1998 –2010), and param-
eters were estimated using a maximum likelihood robust (MLR)
procedure, which is robust in the face of non-normality. Missing
data were handled using full information maximum likelihood
(FIML).
Results
Descriptive Analyses for the MIQ-T
Participants’ responses ranged from 0 to 3 on MIQ-T items and
the means and standard deviations were as follows: #1 M ⫽ 1.66,
SD ⫽ 1.11; #2 M ⫽ 1.11, SD ⫽ 0.97; #3 M ⫽ 0.83, SD ⫽ 0.91;
#4 M ⫽ 0.91, SD ⫽ 0.90; #5 M ⫽ 1.11, SD ⫽ 0.92; #6 M ⫽ 1.29,
SD ⫽ 0.89; #7 M ⫽ 1.00, SD ⫽ 0.88; #8 M ⫽ 1.35, SD ⫽ 0.99;
#9 M ⫽ 1.76, SD ⫽ 1.09; #10 M ⫽ 0.75, SD ⫽ 0.84; #11 M ⫽
1.00, SD ⫽ 1.02; #12 M ⫽ 1.14, SD ⫽ 0.97. Examination of item
frequencies revealed that at least 20% of participants had a score
of 2 or 3 on each of the MIQ-T items and one third or more of the
sample reported considerable exposure to items 1, 2, 5, 6, 8, 9, 11,
and 12.
Factor Analytic Findings for the MIQ-T
The MAP test revealed that a 1-factor model provided the best
fit to the data for the six MIQ-T effect indicators. As a result, only
a 1-factor model was tested in the larger CFA. Examination of the
modification indices in the CFA suggested that direct paths should
be added from item 4 to item 3 as well as from item 6 to item 7.
When all 12 MIQ-T indicators were included in the MIMIC model
(with indicators appropriately represented as effects or causes),
including the two direct paths suggested by the modification
indices, this model was found to provide reasonable fit to the data,
2
(37) ⫽ 76.92, p ⬍ .001; CFI ⫽ .90; SRMR ⫽ .04; RMSEA ⫽
.065, 90%, CI ⫽ .045 – .086. As can be seen in Figure 1, all
indicators were significantly associated with the moral injury
latent factor. The statistically significant direct link between item
4(I saw the harm of an innocent student) and item 3 (I feel guilt
over failing to protect a student) indicated that these two items are
positively related, even after accounting for the moral injury fac-
tor. Conversely, after controlling for their mutual positive associ-
ation with the moral injury factor, an inverse direct link between
item 6 (As a teacher, I had to make decisions at times when I didn’t
know the right thing to do) and item 7 (I felt betrayed or let-down
by my colleagues) was found to be statistically significant. Though
subject to multiple interpretations, this finding could stem from a
trend for teachers who have greater seniority and decision-making
power to be less influenced by decisions made by colleagues and
less likely to feel betrayed or let down by their fellow teachers.
Structural Equation Modeling Findings
Please refer to Table 1 for descriptive statistics and intercorre-
lations between the study variables. Bivariate correlations revealed
that teachers’ scores on the MIQ-T (represented by a sum of the 12
items) were associated with poorer outcomes on all indicators in
the SEM model— greater lifetime violence exposure, less meaning
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5
MORAL INJURY AND MEANING
made (Comprehensibility and Footing in the World), greater PTSD
symptomatology (Reexperiencing, Avoidance, and Hyperarousal),
and greater work-related burnout (Physical, Cognitive, and Emo-
tional). Before running the full SEM analysis, a measurement
model was first tested that only included the latent variables (with
corresponding observed indicators loading on each) as correlated
factors. The measurement model was found to fit the data reason-
ably well,
2
(147) ⫽ 265.03, p ⬍ .001; CFI ⫽ .92; SRMR ⫽ .10;
RMSEA ⫽ .056, 90%, CI ⫽ .045 – .067.
In the full SEM analysis, moral injury was treated as the
independent variable; teachers’ meaning made of trauma was the
mediating variable; and PTSD symptoms and burnout served as
correlated dependent variables. This model included paths from
the independent variable to the mediating and dependent variables
as well as paths from the mediating variable to dependent variables
(see Figure 2 for a pictorial representation). Overall, this model
provided good fit to the data,
2
(202) ⫽ 335.38, p ⬍ .001; CFI ⫽
.91; SRMR ⫽ .05; RMSEA ⫽ .051, 90%, CI ⫽ .041 – .061.
As can be seen in Table 2, exposure to MIEs had a positive
indirect effect through meaning made on PTSD symptoms and
burnout. Moral injury also had a statistically significant positive
direct effect, whereby those who reported greater exposure to
MIEs were more likely to report problems with PTSD symptoms
and burnout at the time of the study. This model also showed that
women (Estimate ⫽⫺.16, p ⫽ .02) and those who had less
lifetime violence exposure (Estimate ⫽⫺.15, p ⫽ .04) were
somewhat more likely to report having made meaning of their
identified stressor. However, none of the other covariates in the
structural equation model (age, marital status, urban/rural living
environment) were significantly associated with meaning, PTSD
symptoms, or burnout.
Discussion
Moral injury is an emerging construct for understanding trauma-
related concerns among professionals working to mitigate social
disorder and suffering in communities throughout the world.
Teachers in El Salvador and other less developed countries might
confront a number of possible MIEs in their professional role, and
are at increased risk for PTSD and other problems that may
compromise their ability to meet the demands of their occupation
(Rojas-Flores et al., 2013). At least half of this group of Salva-
dorian teachers reported experiencing betrayals from educational
leaders, witnessing acts of revenge and retribution in their schools,
feeling guilty about the suffering of their students, facing ethical
dilemmas in the job, lacking resources to care for students, per-
ceiving changes from exposure to students’ suffering, becoming
desensitized to violence, and witnessing mistakes that had led to
students’ suffering. The purpose of this study was to examine (1)
whether these types of stressors might contribute to PTSD symp-
toms and burnout, and (2) to what extent MIEs have positive
indirect effects on these outcomes through teachers’ capacity to
make meaning of the most distressing traumas from their lives.
Results of the SEM analysis indicated that exposure to the MIEs
assessed in the study explained a significant portion of differences
in PTSD symptoms and burnout among the teachers. As hypoth-
esized, those who reported more MIEs indicated greater problems
in these areas, above and beyond lifetime exposure to violence and
demographic factors. Consistent with Litz et al.’s (2009) assertions
about the etiology of trauma-related problems, these results sup-
port the need for broader conceptual models of PTSD among
individuals working in close proximity to violence and suffering.
In addition, these findings support suggestions about the strong
moral dimension for many teachers’ sense of professional identity
(Nias, 1999; Santoro, 2011), and how stressors that undermine
one’s moral beliefs and values can contribute to diminished sig-
nificance and purpose in his or her work. By solely attending to
life-threat traumas in this sample, the clinical picture would likely
not be represented adequately for many of the teachers that we
surveyed. Overall, these findings support the possible utility of the
moral injury construct with teachers and other helping profession-
als working in impoverished and violent contexts, and highlight
the possible need to screen for MIEs in mental health assessments
with these populations.
One of the pathways by which MIEs might contribute to trauma-
related distress is via the violation of one’s meaning system and
subsequent failure to reconcile the appraised meaning of the stres-
sor with their overarching beliefs, goals, and sense of purpose in
life (i.e., global meaning; Park, 2010). In keeping with findings
from other violence-exposed groups (Currier et al., 2011; Park et
al., 2012), significant indirect associations emerged between MIEs
and study outcomes via the meaning made of a salient stressor.
These results similarly align with Litz et al.’s (2009) theoretical
suggestions about the nature of trauma-related distress in cases of
moral injury. It appears that among teachers with higher levels of
MIEs, difficulty with making meaning might partly explain the
link between moral injury and poorer psychological and occupa-
tional functioning. Without overlooking the role of culture in
finding meaning after violence and trauma, these results support
the utility of the ISLES and the application of the meaning-making
framework to trauma populations outside of the United States and
in regions with pervasive violence. However, it was also notable
that meaning made only explained the links between MIEs and
study outcomes in part, as the direct paths from MIEs to PTSD and
burnout were statistically significant in the SEM model.
Two explanations can be offered for these particular findings.
First, we had teachers complete the ISLES with respect to the most
MIQ-T 2
MIQ-T 4
MIQ-T 6
MIQ-T 8
MIQ-T 10
MIQ-T 12
MIQ-T 1
MIQ-T 3
MIQ-T 5
MIQ-T 7
MIQ-T 9
MIQ-T 11
Moral
Injury
.44***
.43***
.43***
1.05***
.48***
.35***
.15**
.12*
.49***
.11*
.18**
.25***
-.41**
.23**
Figure 1. Multiple indicators, multiple causes (MIMIC) model for moral
injury with standardized estimates. Direct paths are also added from item
4 to item 3 as well as from item 6 to item 7.
ⴱ
p ⱕ .05,
ⴱⴱ
p ⱕ .01,
ⴱⴱⴱ
p ⱕ
.001.
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6
CURRIER, HOLLAND, ROJAS-FLORES, HERRERA, AND FOY
distressing event over their lifetimes, which may or may not have
occurred in their professional role or necessarily represented a
stressor that transgressed their moral beliefs/values (i.e., was not
morally injurious). Without overlooking the association between
MIEs and meaning made, the magnitude of this indirect effect
might have been greater had we restricted teachers to complete the
ISLES according to the predetermined set of MIEs developed for
this study. Another explanation is that there are other intervening
factors for MIEs and trauma-related distress that were not included
in this study, such as shame, self-forgiveness, and other possible
experiential aspects of moral injury that have been proposed in the
literature (Drescher et al., 2011; Litz et al., 2009). In addition, the
ISLES provides a general assessment of meaning made of an
identified stressor, and there could be specific domains of global
meaning that might differentially bear on PTSD and burnout
among many Salvadorian teachers. Given the general importance
Table 1
Bivariate Correlations Between Study Variables
12 345678910
1) Moral injury (MIQ-T) — .31
ⴱⴱⴱ
⫺.22
ⴱⴱⴱ
⫺.19
ⴱⴱ
.26
ⴱⴱⴱ
.25
ⴱⴱⴱ
.28
ⴱⴱⴱ
.32
ⴱⴱⴱ
.34
ⴱⴱⴱ
.34
ⴱⴱⴱ
2) Violence exposure (SECV) — ⫺.19
ⴱⴱ
⫺.16
ⴱⴱ
.23
ⴱⴱⴱ
.17
ⴱⴱ
.20
ⴱⴱ
.18
ⴱⴱ
.15
ⴱ
.21
ⴱⴱ
3) ISLES – Comprehensibility — .71
ⴱⴱⴱ
⫺.40
ⴱⴱⴱ
⫺.40
ⴱⴱⴱ
⫺.37
ⴱⴱⴱ
⫺.28
ⴱⴱⴱ
⫺.31
ⴱⴱⴱ
⫺.22
ⴱⴱⴱ
4) ISLES – Footing in the World — ⫺.32
ⴱⴱⴱ
⫺.31
ⴱⴱⴱ
⫺.32
ⴱⴱⴱ
⫺.25
ⴱⴱⴱ
⫺.31
ⴱⴱⴱ
⫺.27
ⴱⴱⴱ
5) LASC – Reexperiencing — .62
ⴱⴱⴱ
.80
ⴱⴱⴱ
.36
ⴱⴱⴱ
.44
ⴱⴱⴱ
.27
ⴱⴱⴱ
6) LASC – Avoidance — .75
ⴱⴱⴱ
.47
ⴱⴱⴱ
.55
ⴱⴱⴱ
.37
ⴱⴱⴱ
7) LASC – Hyperarousal — .45
ⴱⴱⴱ
.55
ⴱⴱⴱ
.30
ⴱⴱⴱ
8) SMBM – Physical — .68
ⴱⴱⴱ
.40
ⴱⴱⴱ
9) SMBM – Cognitive — .57
ⴱⴱⴱ
10) SMBM – Emotional —
M 13.92 10.48 14.26 33.75 2.55 5.32 6.64 7.90 5.50 2.41
SD 6.71 8.10 4.39 8.07 2.14 4.20 5.13 4.47 4.16 2.57
Note. MIQ–T⫽ Moral Injury Questionnaire – Teacher Version; ISLES ⫽ Integration of Stressful Life Events Scale; LASC ⫽ Los Angeles Symptom
Checklist; SECV ⫽ Survey of Exposure to Community Violence; SMBM ⫽ Shirom-Melamed Burnout Measure.
ⴱ
p ⬍ .05.
ⴱⴱ
p ⬍ .01.
ⴱⴱⴱ
p ⬍ .001.
Meaning
Made of
Trauma
Post-
traumatic
Stress
Burnout
Hyperarousal
Reexperiencing Avoidance
Physical Cognitive
Emotional
Comprehensibility
Footing in the
World
.96***
.83***
.79***
.74***
.92***
.62***
.88***
.82***
-.33***
-.39***
.33***
.19**
-.23***
.52***
Moral
Injury
Figure 2. Pictorial representation of the structural equation model with standardized estimates. In this larger
SEM analysis, the moral injury factor was modeled as shown in Figure 1. Several covariates were also added
to the model, including age, gender, marital status, rural/urban living environment, and lifetime violence
exposure, which are not shown here.
ⴱ
p ⱕ .05,
ⴱⴱ
p ⱕ .01,
ⴱⴱⴱ
p ⱕ .001.
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7
MORAL INJURY AND MEANING
of religion in Central America, the loss of faith might represent a
particularly challenging type of crisis for these teachers. Future
research will do well to incorporate alternate measurement strate-
gies and focus in more detail on the types of violations in global
meaning that most strongly contribute to posttraumatic maladjust-
ment across different cultural contexts.
Several additional limitations also merit some discussion. First,
use of a cross-sectional study design means that temporal or causal
inferences cannot be made for results of this study. Also, study
findings may not apply to teachers in other contexts or for other
professional groups. There was also an overrepresentation of
women and the sample was predominantly composed of highly
experienced and middle-aged participants. As a result, these find-
ings may not apply as well to men or younger persons working in
the educational system in El Salvador. Findings would also have
been enhanced if we had been able to incorporate a random
sampling procedure. This group of teachers was self-selected to
attend a workshop on managing the effects of trauma and stress.
As such, this strategy may have led to an overrepresentation of
distressed teachers or those teachers with greater problems might
have elected not to come and we cannot infer that this sample is
representative of the population of teachers in El Salvador. Future
research with this population will do well to incorporate more
sophisticated sampling and measurement strategies that can ex-
pand on these findings.
Despite these limitations, this investigation yielded several im-
portant contributions to the empirical literature on MIEs and
furthers our understanding of trauma-related concerns among
teachers in El Salvador and possible other violent areas. In partic-
ular, findings support the utility of the moral injury construct with
this population in that the teachers’ exposure to the MIEs assessed
in the study uniquely predicted PTSD symptoms and burnout when
controlling for demographic factors and lifetime rates of exposure
to commonly assessed forms of violence. Finally, other results
from the SEM analysis indicated that meaning making could serve
as a central mediating factor for how MIEs may be related to
PTSD and other trauma-related problems among those persons
working to promote peace and justice in the world.
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Table 2
Direct and Indirect Effects in the Structural Equation
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Note. PTSD ⫽ Posttraumatic Stress Disorder.
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(Appendix follows)
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9
MORAL INJURY AND MEANING
Appendix
Moral Injury Questionnaire–Teacher Version (MIQ-T)
Received January 15, 2013
Accepted July 10, 2013 䡲
Considering your experiences as a teacher, mark the box that indicates how frequently you experienced each of the following:
Response
(0)
Never
(1)
Seldom
(2)
Sometimes
(3)
Often
1) Things I saw/experienced things that left me feeling betrayed or let-down by educational leaders.
2) I saw people taking revenge/retribution for things that happened.
3) I feel guilt over failing to protect a student.
4) I saw the harm of an innocent student.
5) I feel guilt for being able to return to safety at the end of the work day when many students
cannot.
6) As a teacher, I had to make decisions at times when I didn’t know the right thing to do.
7) I felt betrayed or let-down by my colleagues.
8) As a teacher, I did not have access to the resources or materials I needed to care for my
students.
9) Seeing so much suffering in the students has changed me.
10) I saw students suffer because of incident(s) involving teachers or other school personnel.
11) I came to realize that I am no longer affected by violence.
12) I saw mistakes made by teachers or other school personnel that led to the suffering of students.
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CURRIER, HOLLAND, ROJAS-FLORES, HERRERA, AND FOY
