Moral Injury Outcome Scale (MIOS)
A self-report measure for assessing moral injury outcomes in clinical practice and research.
The Moral Injury Outcome Scale (MIOS) is a 14-item measure of outcomes associated with potentially morally injurious experiences. Developed by the international Moral Injury Outcome Scale Consortium, it can be used with additional modules for exposure classification, PTSD screening and functional outcomes.
How the MIOS works
The MIOS centres on 14 items assessing two domains of moral injury outcomes. Depending on the version, additional components provide information about the potentially morally injurious experience, PTSD symptoms and functional impact.
Shame-Related Outcomes
Self-directed consequences including shame, self-condemnation and changes in how a person sees themselves.
Trust Violation-Related Outcomes
Consequences involving trust, beliefs about other people, anger, disgust and changes in how a person sees the social or moral world.
- Exposure classification
- PTSD screen (optional)
- 14-item MIOS
- Functional outcomes (optional)
All versions include the same 14 core MIOS items. The Full, Clinical and Abbreviated versions differ in the amount of information collected about the experience, PTSD symptoms and functional impact.
MIOS versions
All three versions include the same 14 core items. The surrounding components differ depending on the amount of contextual and functional information needed.
| Component | Full | Clinical | Abbreviated |
|---|---|---|---|
| Exposure classification | Extended classification, including date and optional event description | Classification of the potentially morally injurious experience | Brief exposure screen |
| PTSD screen | Included | Not included | Not included |
| 14-item MIOS | Included | Included | Included |
| Functional outcomes | Included | Included | Not included |
| Typical use | Research or comprehensive assessment | Routine clinical assessment and outcome monitoring | Brief assessment or surveillance |
Administration notes
When to include the PTSD screen
The embedded PC-PTSD-5 is included in the Full version when PTSD screening is useful within the same assessment. If PTSD is already assessed elsewhere, the Clinical or Abbreviated version may reduce respondent burden.
Handling open-text event descriptions
The Full version allows an optional event description. Because open-text responses may contain identifying or operationally sensitive information, organizations may choose to ask respondents not to include identifying details or omit the field in some settings.
Choosing the functional outcomes module
The Full and Clinical versions include the functional outcomes module. It may be particularly useful when the goal is to examine whether changes in moral injury outcomes are accompanied by changes in day-to-day functioning.
Downloads and translations
Download current MIOS forms and administration guidance, or find access information for translations maintained elsewhere.
EnglishFull · Abbreviated · InstructionsOriginalDownloads ↓
- Full versionVersion 1.1Licence: CC BY-NC-ND 4.0Litz, B. T., Plouffe, R. A., Nazarov, A., Murphy, D., Phelps, A., Coady, A., Houle, S. A., Dell, L., Frankfurt, S., Zerach, G., Levi-Belz, Y., The Moral Injury Outcome Scale Consortium, Ashbaugh, A., Yeterian, J., Berke, D., Carney, J., Cummings, M., Chartoff, R., Ellickson-Larew, S., … Murray, K. (2022). Defining and assessing the syndrome of moral injury: Initial findings of the Moral Injury Outcome Scale consortium. Frontiers in Psychiatry / Frontiers Research Foundation, 13. https://doi.org/10.3389/fpsyt.2022.923928
- Abbreviated versionVersion 1.1Licence: CC BY-NC-ND 4.0Litz, B. T., Plouffe, R. A., Nazarov, A., Murphy, D., Phelps, A., Coady, A., Houle, S. A., Dell, L., Frankfurt, S., Zerach, G., Levi-Belz, Y., The Moral Injury Outcome Scale Consortium, Ashbaugh, A., Yeterian, J., Berke, D., Carney, J., Cummings, M., Chartoff, R., Ellickson-Larew, S., … Murray, K. (2022). Defining and assessing the syndrome of moral injury: Initial findings of the Moral Injury Outcome Scale consortium. Frontiers in Psychiatry / Frontiers Research Foundation, 13. https://doi.org/10.3389/fpsyt.2022.923928
- Administrator instructions & scoringVersion 2.2
Litz, B. T., Plouffe, R. A., Nazarov, A., Murphy, D., Phelps, A., Coady, A., Houle, S. A., Dell, L., Frankfurt, S., Zerach, G., Levi-Belz, Y., & The Moral Injury Outcome Scale Consortium. (2022). Defining and assessing the syndrome of moral injury: Initial findings of the Moral Injury Outcome Scale Consortium. Frontiers in Psychiatry, 13, 923928. https://doi.org/10.3389/fpsyt.2022.923928
FrançaisClinicalValidatedDownload ↓
- Clinical versionVersion 1.1Licence: CC BY-NC-ND 4.0Ein, N., Plouffe, R. A., Houle, S. A., Birch, M., Thompson, M., Bélanger, S., Richardson, J. D., & Nazarov, A. (2026). Psychometric validation of the French version of the Moral Injury Outcome Scale (MIOS). Psychological Trauma: Theory, Research, Practice and Policy. https://doi.org/10.1037/tra0002079
Ein, N., Plouffe, R. A., Houle, S. A., Birch, M., Thompson, M., Bélanger, S., Richardson, J. D., & Nazarov, A. (2026). Psychometric validation of the French version of the Moral Injury Outcome Scale (MIOS). Psychological Trauma: Theory, Research, Practice, and Policy. https://doi.org/10.1037/tra0002079
УкраїнськаFull · InstructionsTranslation available; validation study not currently listedDownloads ↓
- Full versionVersion 1.6 · September 2026Licence: CC BY-NC-ND 4.0Nazarov, A., Kudar, K., Nishta, O., Richardson, JD. (2026). Український переклад Шкали наслідків моральної травми (MIOS) [Ukrainian translation of the Moral Injury Outcome Scale]. MacDonald Franklin OSI Research Centre. Версія 1.6: вересень 2026.
- Instructions & scoringVersion 1.3 · September 2026Licence: CC BY-NC-ND 4.0
Nazarov, A., Kudar, K., Nishta, O., Richardson, JD. (2026). Український переклад Шкали наслідків моральної травми (MIOS) [Ukrainian translation of the Moral Injury Outcome Scale]. MacDonald Franklin OSI Research Centre. Version 1.6: September 2026.
PersianPersian MIOSValidatedContact for access →
- Persian MIOSContact: Jamshid JamaliContact for access
Shabanikiya, H., Kokabisaghi, F., Khalilzadeh, F. D., Khorasani, N., & Jamali, J. (2025). Translation and validation for Persian version of Abbreviated Moral Injury Outcome Scale (AMIOS) in emergency health professionals: A comprehensive methodological approach. BMC Health Services Research, 25(1), 850.
HebrewFullTranslation available; validation study not currently listedContact for access →
- Hebrew MIOSContact: Dr. Brett LitzContact for access
Scoring and interpretation
The 14 core MIOS items yield two subscale scores and a total score. Current guidance also provides thresholds for interpretation and benchmarks for measuring change over time.
Scoring the MIOS
Each of the 14 core MIOS items is scored from 0 to 4. There are no reverse-scored items. Higher scores indicate greater severity of moral injury outcomes during the past month.
| Score | Items | Range |
|---|---|---|
| Shame-Related Outcomes | 1, 3, 7, 8, 12, 13, 14 | 0–28 |
| Trust Violation-Related Outcomes | 2, 4, 5, 6, 9, 10, 11 | 0–28 |
| Total MIOS | All 14 items | 0–56 |
Current recommended thresholds
| Score | Moral injury | Moral distress | Below current thresholds |
|---|---|---|---|
| Total MIOS | ≥31 | 26–30 | <26 |
| Shame | ≥15 | 13–14 | <13 |
| Trust violation | ≥18 | 15–17 | <15 |
Moral injury and moral distress thresholds may be met by the total score or either subscale. Scores fall below current caseness thresholds when the total score and both subscales are below their respective thresholds.
Interpret scores in context. MIOS thresholds can support clinical and research interpretation but should be considered alongside the person's history, presentation and other relevant assessment information rather than used in isolation.
Measuring change over time
Current MIOS guidance identifies a 13-point change in the total score as the reliable-change threshold.
- ≥13-point decrease
- Reliable improvement
- ≥13-point increase
- Reliable deterioration
- ≥13-point decrease + post-treatment score ≤9
- Probable recovery under the current change framework
These benchmarks are intended to support outcome monitoring and should be interpreted within the broader clinical or research context.
Functional outcomes
The Full and Clinical versions include a 9-item functional outcomes module examining how the identified experience affects day-to-day functioning.
It covers:
- romantic relationships
- relationships with children and other family members
- friendships and socializing
- work, education or training
- recreation
- religious faith or spirituality
- day-to-day activities
Responses are rated from 0 to 6. Because some domains may not apply to every person, the functional score can be standardized by dividing the total score across completed items by the maximum possible score for those items and multiplying by 100. Higher scores indicate greater functional impairment.
- 0–10
- No impairment
- 11–30
- Mild impairment
- 31–50
- Moderate impairment
- 51–80
- Severe impairment
- 81–100
- Extreme impairment
The functional module can help distinguish changes in moral injury symptoms from changes in day-to-day functioning.
Validation studies
The MIOS has been evaluated in military, Veteran and health care populations, with additional studies examining translations, interpretation thresholds and clinically meaningful change.
| Study | Population / contribution | Action |
|---|---|---|
| Litz et al. (2022) | Original validation · military personnel and Veterans in Canada, the United States, the United Kingdom and Australia | |
| Tao et al. (2023) | Acute care nurses · United States | |
| Plouffe et al. (2025) | Health care workers · Canada | |
| Shabanikiya et al. (2025) | Persian validation · emergency health professionals | |
| Ein et al. (2026) | French validation · Canadian military personnel | |
| Litz et al. (2025) | Moral injury and moral distress thresholds · U.S. Veterans | |
| Litz et al. (2026) | Clinically significant change benchmarks · U.S. Veterans |
Citing the MIOS
When using the MIOS, cite the original validation publication and, where applicable, the specific translated version or validation study used.
Litz, B. T., Plouffe, R. A., Nazarov, A., Murphy, D., Phelps, A., Coady, A., Houle, S. A., Dell, L., Frankfurt, S., Zerach, G., Levi-Belz, Y., & The Moral Injury Outcome Scale Consortium. (2022). Defining and assessing the syndrome of moral injury: Initial findings of the Moral Injury Outcome Scale Consortium. Frontiers in Psychiatry, 13, 923928. https://doi.org/10.3389/fpsyt.2022.923928
Translation-specific citations are provided with the relevant language under Downloads and translations.
Moral Injury Outcome Scale Consortium
The MIOS was developed through an international collaboration of researchers and clinicians working across military, Veteran and related health contexts.
- Andrea Ashbaugh
- Danielle Berke
- Jessica Carney
- Ruth Chartoff
- Alanna Coady
- Mackenzie Cummings
- Lisa Dell
- Stephanie Ellickson-Larew
- David Forbes
- Sheila Frankfurt
- Breanna Grunthal
- Fardous Hosseiny
- Stephanie A. Houle
- Kim Jones
- Lisa King
- Ellie Lawrence-Wood
- Yossi Levi-Belz
- Brett Litz
- Kelsey Madden
- Alexandra McIntyre-Smith
- Dominic Murphy
- Kim Murray
- Anthony Nazarov
- Andrea Phelps
- Rachel A. Plouffe
- J. Don Richardson
- Luke Rusowicz-Orazem
- Patrick Smith
- Maya Bina N. Vannini
- Frank Weathers
- Julie Yeterian
- Gadi Zerach
Use and permissions
Use conditions may vary by version or translation. Check the information provided with the relevant MIOS form before modifying, translating, adapting or integrating the instrument into another product or platform.
Related
Questions about the MIOS?
For questions about implementation, collaboration, translations or access to a version not hosted here, get in touch with our team.