Moral injuries (MIs) may result from individuals being exposed to potentially morally injurious events (PMIEs). PMIEs have been a feature of work within much of the National Health Service (NHS) for many years, and the understanding of MI is now more commonplace, having been highlighted during the COVID-19 pandemic; however, understanding of how such events affect workers over the long term is lacking.

To understand the development of healthcare workers’ (HCWs) experiences of PMIEs over a period of 3 years.

We carried out follow-up semistructured qualitative interviews with 15 NHS staff who were previously interviewed on the same topic in 2021. All interviews were recorded, transcribed and analysed using reflexive thematic analysis following an inductive approach.

Three main themes and six subthemes were identified: (1) internal context and subjective experiences, (1.i) control in a rigid system, (1.ii) psychosocial dynamics, (2) external context and the moral cost of culture, (2.i) organisational culture, (2.ii) sources of MI, (3) responses to PMIEs, (3.i) maladaptive responses, (3.ii) adaptive responses. Key issues identified included perceptions of insufficient control over their work and work environment, low psychological safety and perceived misunderstanding of the value of their work from patients and colleagues, leading to a challenging organisational culture. We found that in the 3 years between the interviews many staff reported developing ‘secondary’ feelings of betrayal as a result of perceived ongoing governmental neglect of recognition for HCWs’ sacrifices during the pandemic and a lack of acknowledgement of governmental mistakes made in the acute period.

Findings show an interplay between individual and organisational factors that HCWs faced while working in the NHS, underlining the need for wide-ranging intervention strategies. Since the HCWs’ original interviews in 2021, a secondary betrayal has developed, emphasising the need for interventions that can restore trust in the system.

Coercive control is a complex behavioural phenomenon where severity, frequency and patterns need to be examined collectively. However, approaches to measuring coercive control to date have demonstrated limited understanding of these patterns of behaviour by a partner or ex-partner that reflect an individual woman’s experience. The aim of this study was to develop a holistic contemporary valid self-report measure of coercive control by partners.

Standard instrument development, with academic and lived experience feedback and psychometric testing, using secondary data analysis, to develop the Coercive-Composite Abuse Scale (C-CAS).

Australian survey of women: feedback from experts.

Data for scale development from 854 adult women in Australia, where items assessed 5-year and 12-month abuse frequency. Feedback from five survivors and eight expert researchers.

Scale reliability and validity; robustness of subscales; association with fear of a partner.

Developed from existing scales and informed by academic and lived-experience expertise, the C-CAS factor analysis revealed a four-factor structure accounting for 57% of variance – Psychological Control (13 items, α=0.928), Sexual and Reproductive Coercion (6 items, α=0.887), Severe Coercive Control (8 items, α=0.820) and Technology-Facilitated Threats (3 items, α=0.754), showing excellent internal consistency. Evidence of the scale’s face, content and construct validity was demonstrated, with further testing needed to confirm these findings. The factors combined into four key patterns- three of combined abuse and psychological control, which were experienced alone by some women. Our hypotheses asserting distinct patterns of abuse types for individuals, with severe combined patterns eliciting greater fear of a partner/ex-partner, were confirmed.

The C-CAS, a self-report measure of coercive control experiences among women, has demonstrated initial reliability and validity and is suitable for use in population or clinical studies. Additional validation with diverse samples is required.