Psychological hardiness, resilience, and moral injury outcomes among pre-hospital emergency medical services personnel in Iran: a cross-sectional study

Pre-hospital emergency medical services (EMS) personnel are routinely exposed to ethically challenging situations that may lead to moral injury. Psychological hardiness and resilience are related but distinct personal resources. This study examined the associations of psychological hardiness and resilience with moral injury outcomes among pre-hospital EMS personnel. This cross-sectional study, reported according to the STROBE statement, was conducted among all eligible pre-hospital EMS personnel in Chaharmahal and Bakhtiari Province, Iran, between July and September 2026 (census; 400 invited, 366 completed, response rate 91.5%). Data were collected with the Abbreviated Moral Injury Outcome Scale (AMIOS), the Connor–Davidson Resilience Scale (CD-RISC-25), and the 20-item Kobasa Psychological Hardiness Questionnaire. Analyses used Spearman correlations, Mann–Whitney U and Kruskal–Wallis tests, and multiple linear regression, unadjusted and adjusted for sociodemographic and occupational characteristics. Mean age was 37.43 ± 8.60 years and mean work experience 11.89 ± 6.81 years. Mean total scores were 55.14 ± 23.71 for resilience (0–100), 50.77 ± 14.13 for hardiness (20–80), and 24.86 ± 12.93 for moral injury outcomes (0–56). Moral injury outcomes correlated inversely with hardiness (rs = − 0.47, P < 0.001) and resilience (rs = − 0.26, P < 0.001); hardiness and resilience were positively correlated (rs = 0.49). In the unadjusted regression model (R² = 0.234, P < 0.001), hardiness was inversely associated with moral injury outcomes (B = − 0.43, 95% CI − 0.53 to − 0.33; β = −0.47, P < 0.001), whereas resilience was not (B = − 0.01, 95% CI − 0.07 to 0.04; P = 0.608). Results were similar after adjustment for sex, education, academic discipline, marital status, employment status, workplace, and work experience (hardiness β = −0.46, P < 0.001; resilience P = 0.436). Moral injury outcome scores did not differ significantly by any sociodemographic or occupational characteristic (all P > 0.05). In the regression model, higher hardiness scores were associated with lower moral injury outcome scores, including after accounting for resilience and for sociodemographic and occupational characteristics, whereas resilience was not significantly associated with moral injury outcomes once hardiness was included. Because of the cross-sectional design, these findings describe statistical associations only and do not establish causal or protective effects; longitudinal studies are needed.