The research, led by Fatemeh Alidadi of Shahid Beheshti University of Medical Sciences and colleagues, tested a six-session supportive-educational intervention grounded in the moral resilience framework developed by nurse-scientist Cynda Rushton. That framework identifies six core capacities: personal integrity, relational integrity, buoyancy, self-regulation, self-stewardship, and moral efficacy. Rather than simply teaching nurses to cope with distress after it arises, the programme aims to cultivate the internal resources that allow clinicians to recognize ethical challenges, preserve their integrity, and respond to difficult situations with deliberate skill rather than reflexive anguish.

The study was conducted between March and September 2024 in the emergency departments of two teaching hospitals in Borujerd, Iran. All eligible emergency nurses were invited to participate through census sampling, and inclusion required a bachelor’s degree in nursing and at least six months of emergency nursing experience. Sixty-eight nurses enrolled and were divided into two groups of thirty-four. Instead of randomizing individuals, the researchers allocated entire hospitals to conditions with a single coin toss after confirming that the two groups were statistically equivalent at baseline. One hospital received the moral resilience programme; the other received communication-skills training of identical duration, delivered by the same facilitator, serving as an active control designed to account for the benefits of simply receiving attention and group education.

The primary outcome was moral distress, measured with the Persian version of Corley’s Moral Distress Scale at three time points: baseline, two weeks after the programme concluded, and three months later. The researchers analyzed the data using a mixed 2 × 3 repeated-measures analysis of variance, a statistical approach that evaluates how scores change over time within each group and whether those trajectories differ between groups. This design allowed the team to distinguish genuine intervention effects from the natural passage of time or the mere experience of participating in a training programme.

The results were striking. Mean moral distress scores fell by 43.58 points in the intervention group from baseline to the immediate post-intervention assessment, compared with a decline of only 5.45 points in the control group. The between-group difference at post-intervention was large, with a Cohen’s d effect size of 0.95 and a p-value below 0.001, indicating a difference that is both statistically robust and practically meaningful. Importantly, the improvement was not fleeting: at the three-month follow-up, the between-group difference remained large at d = 0.83, suggesting that the gains from the moral resilience programme endured well beyond the end of formal training.

A critical benchmark for interpreting these findings is the minimal clinically important difference, or MCID, the smallest change in a score that patients or clinicians would consider meaningful rather than statistical noise. The researchers used a 20-point MCID for the moral distress scale, and the observed within-group change in the intervention arm exceeded this threshold by a wide margin. In other words, the reduction in distress was not merely detectable by statistical tests; it represented a change large enough to matter in the daily working lives of emergency nurses.

The choice of an active control group strengthens the study’s design considerably. Many intervention trials compare a new programme against no treatment at all, which makes it impossible to determine whether benefits arise from the specific content of the intervention or from the generic experience of receiving attention, social support, and structured time away from clinical duties. By giving the control group communication-skills training of equivalent duration from the same facilitator, the researchers ensured that both groups received comparable doses of professional development, making the observed difference more likely attributable to the moral resilience content itself.

Nevertheless, the authors are careful to emphasize the limitations of their design. Because each condition was delivered in only one hospital, the study cannot fully separate the effects of the programme from unmeasured hospital-level factors such as management style, staffing ratios, departmental culture, or patient mix. A hospital that happened to have a particularly supportive environment might have amplified the intervention’s benefits, or one with a more toxic culture might have dampened them. The quasi-experimental allocation, while pragmatic, also lacks the protection against selection bias that true cluster randomization would provide. These constraints mean the findings should be regarded as promising but preliminary rather than definitive proof of effectiveness.

The theoretical grounding in Rushton’s framework is what distinguishes this intervention from generic stress-management or wellness programmes. Personal integrity work helps nurses clarify and articulate their core values; relational integrity focuses on honest communication and maintaining trust within teams; buoyancy addresses the capacity to recover from morally adverse events; self-regulation teaches physiological and emotional regulation techniques; self-stewardship emphasizes sustainable self-care; and moral efficacy builds the confidence and skills to act on ethical convictions. By addressing distress at its roots rather than its symptoms, the programme aims to produce durable change in how nurses relate to the ethical demands of their work.

The implications extend well beyond the two hospitals studied. Emergency departments worldwide are grappling with unprecedented pressures, from pandemic aftershocks to rising patient volumes and persistent staffing shortages. Moral distress has been linked to intentions to leave the profession, and retaining experienced emergency nurses has become a strategic priority for health systems everywhere. If a relatively brief, six-session programme can produce a large and sustained reduction in moral distress, the potential return on investment is substantial. The authors call for multi-site cluster-randomized trials that measure moral resilience directly and disentangle programme effects from organizational context, a necessary step before routine implementation can be recommended. Until then, this study offers a compelling early signal that building moral resilience may be one of the most practical and scalable tools available for protecting the psychological wellbeing of the nurses who hold emergency medicine’s front line.

Subject of Research: Effectiveness of a moral resilience-based educational intervention on moral distress in emergency nurses

Article Title: Effectiveness of a moral resilience-based supportive-educational intervention on moral distress among emergency nurses: a quasi- experimental study

Article References: Alidadi, F., Zamanzadeh, V., Monjazebi, F., & Ghadirian, F. (2026). Effectiveness of a moral resilience-based supportive-educational intervention on moral distress among emergency nurses: a quasi- experimental study. BMC Nursing. https://doi.org/10.1186/s12912-026-05537-4

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05537-4

Keywords: moral distress, moral resilience, emergency nursing, nursing ethics, quasi-experimental study, educational intervention, Iran, Rushton framework, burnout, nurse wellbeing, BMC Nursing, Effectiveness

The study rests on a qualitative survey administered in March 2025 to 50 military chaplains during their annual training days at the Swedish Armed Forces Headquarters in Stockholm. Because electronic devices are barred inside the facility, chaplains filled out paper questionnaires, capturing handwritten reflections from chaplains serving home guard battalions, regiments, air bases, naval stations, garrisons, and military regions. Grimell, who conducted the research as part of a project commissioned by the chief of chaplains, analyzed the responses using inductive and abductive thematic analysis, allowing themes to emerge from the data while iteratively testing them against the concepts embedded in the ACCES framework.

Understanding the Swedish case requires a cultural detour. In Sweden, the support offered by priests and deacons is officially termed soul care, or själavård, the formal designation for the spiritual, existential, and religious care provided by clergy of the Church of Sweden. Unlike many countries where pastoral care was reshaped by the psychologizing currents of the clinical pastoral education movement that swept North America and parts of Europe after World War II, Sweden resisted that shift. Soul care there remains anchored in the conviction that every human being possesses a soul—a unique inner dimension that can be wounded by trauma, moral conflict, and existential strain. This culturally embedded concept survived intact and was carried into the military sphere, where it now operates under a distinctly functional logic: strengthening resilience in crisis and war, and sustaining the will to defend.

The Swedish military chaplaincy is widely considered the oldest continuously operating chaplaincy in the world, with clergy serving the armed forces in an unbroken tradition since the sixteenth century. What makes the modern system distinctive is its formalization through ACCES, a five-function framework with no direct equivalent in other sectors of Swedish society. Within military doctrine, soul care sits under the pillar of moral factors—alongside determination, courage, endurance, esprit de corps, and ethical conduct—which are treated as essential to operational capability. Crucially, the service is explicitly inclusive: it is available to all personnel regardless of religious affiliation or worldview, functioning as an existential rather than a religious offering by default, though faith-specific needs are addressed when raised.

The survey’s clearest finding is that military soul care is broadly valued, often described as ranging from moderately important to indispensable. Chaplains reported that commanders and personnel alike regarded their presence as meaningful, particularly in units whose members had carried deployment experiences home. One home guard chaplain recorded the sentiment bluntly: important, very important—even non-believers appreciate the presence of the chaplain. Another described arriving at a battalion that had been without a chaplain for years and being welcomed with expressions of respect and trust. But the data also surfaced a persistent ambiguity: while the institution is esteemed, commanders do not always grasp how to concretely integrate it into training, exercises, and operations. A minority of chaplains, especially in home guard battalions where limited contract days compress planning around weapons and tactical training, reported having to secure their own opportunities to serve.

By far the most requested aspect of the framework is the soul-care conversation. These conversations, grounded in absolute confidentiality—a legal guarantee that chaplains may not disclose anything shared, regardless of content—occur everywhere from formal appointments to spontaneous exchanges in mess halls, guard posts, and over coffee. Military service generates a dense stream of morally and existentially charged experiences: preparing to use lethal force, coping with wounded or fallen comrades, enduring family separation, navigating the consequences of leadership. Personnel frequently cannot discuss these matters with commanders, medical staff, or even family without fear of career consequences or mandated reporting. The chaplain becomes a pressure-release valve, someone who understands military life yet stands entirely outside the chain of command. Chaplains in the study described their role as exactly that: a safety valve, a trusted confidant who passes nothing on.

Support during crises and death emerged as the second cornerstone of demand. When injury, trauma, or death occurs within a military context, commanders consistently seek the presence of a priest. This expectation is rooted in the structure of Swedish society itself: the Church of Sweden, on behalf of the state, holds formal responsibility for funerals in most municipalities, meaning its clergy are routinely trained in grief support, bereavement groups, and death rituals. No other profession in the military possesses comparable expertise in death and bereavement. Chaplains reported that grief conversations were among their most recurring duties, and that requests for education about death—including war grave service—were increasing. Grimell notes that in the event of full-scale war, death would become a constant dimension of operations, and preparing commanders and personnel for that reality, including the dignified handling of battlefield fatalities that may not be recoverable due to drone threats, must be planned in peacetime.

Ceremonies, traditions, and rituals form the third consistently requested dimension. Field sermons, Christmas vespers, end-of-year ceremonies, and commemorative services connect today’s soldiers to nearly five centuries of continuity, fostering collective identity and belonging across generations. Chaplains emphasized that field services contribute to recovery and resilience-building, and that the rituals carry symbolic weight beyond their religious content—hope, faith in something greater, and a transcendent dimension beyond military life. Yet here, too, the study found tension: some chaplains longed for more field sermons, while other units considered training objectives more pressing and left worship off the schedule.

The least utilized functions proved to be advisory and educational support. Although the ACCES framework formally includes advising commanders on ethical and moral matters—ranging from unit morale assessments to serving as an ethical sounding board for junior officers—and teaching subjects such as the laws of armed conflict and values-based exercises, these roles were not intuitively associated with priests. Commanders, the data suggests, find it easier to deploy chaplains in tasks traditionally bound to the priestly role. Grimell argues that clearer information to commanders, forthcoming regulations on military soul care, and pedagogical professional development for chaplains could close this gap and unlock the framework’s latent capacity.

Perhaps the study’s most consequential conclusion concerns the chaplains’ dual employment model. Swedish military chaplains combine parish ministry with military service, ensuring that their core competencies—accompanying the dying, supporting the bereaved, leading funerals, holding crises—are continuously exercised in civilian life. Grimell warns that full-time military employment, as practiced in many other nations, could gradually erode these skills. For now, the model sustains exactly what the armed forces most request: priests who can stand beside soldiers in the darkest moments, speak confidentially outside the chain of command, and anchor troops in rituals older than the modern state. As Europe’s security environment darkens, this fusion of theology, tradition, and operational readiness may prove to be one of Sweden’s most quietly strategic assets.

The theoretical grounding of the study offers readers outside Sweden a useful lens for interpreting its findings. Drawing on pastoral theology, the article frames the soul as an integrating centre of awareness, meaning, and value—a repository of accumulated experiences of pain, joy, and pleasure that also houses a person’s moral compass. On this account, trauma is never an isolated event; it becomes woven into an enduring substructure of the self, affecting body and soul together. Related concepts such as William James’s early notion of the sick soul and Edward Tick’s later idea of the soul wound echo this understanding, positioning moral injury not merely as a psychological symptom but as an affliction of a person’s deepest spiritual core.

This framing helps explain why Swedish chaplains gravitate toward priestly competencies rather than advisory or teaching roles. If the soul is where suffering, moral conflict, and meaning-making converge, then rituals, confidential conversations, and presence at death are not peripheral extras but direct interventions at the point of greatest need. The study’s emphasis on conversations held outside the chain of command also aligns with international research on moral injury, which suggests that personnel burdened by ethically fraught experiences benefit from confidants who carry no evaluative power over their careers.

The Swedish case also illuminates broader comparative questions. In nations where chaplaincy has been heavily psychologized or folded into clinical frameworks, the boundary between spiritual care and mental health care can blur, sometimes leaving chaplains uncertain about their distinct professional identity. Sweden’s resistance to that trajectory—rooted in the absence of the clinical pastoral education movement—has preserved a clearly delineated role: clergy who care for souls through tradition, ritual, and confidential counsel. Whether this distinctiveness translates into measurable differences in resilience, retention, or moral functioning among personnel remains an open empirical question, and one that future quantitative studies could productively pursue across allied armed forces.

Subject of Research: Perceived needs for military soul care among commanders and personnel in the Swedish Armed Forces

Article Title: Perceived Needs for Military Soul Care Among Commanders and Military Personnel in the Swedish Armed Forces

Article References: Grimell, J. (2026). Perceived Needs for Military Soul Care Among Commanders and Military Personnel in the Swedish Armed Forces. Pastoral Psychology. https://doi.org/10.1007/s11089-026-01364-1

Image Credits: AI Generated

DOI: 10.1007/s11089-026-01364-1

Keywords: military chaplaincy, Swedish Armed Forces, military soul care, soul care, ACCES framework, pastoral care, existential health, confidentiality, crisis support, military rituals, moral resilience, Church of Sweden