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Cahill JM, Kinghorn W, Dugdale L. Repairing moral injury takes a team: what clinicians can learn from combat veterans. JOURNAL OF MEDICAL ETHICS 2023; 49:361-366. [PMID: 35705446 DOI: 10.1136/medethics-2022-108163] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/31/2022] [Indexed: 06/15/2023]
Abstract
Moral injury results from the violation of deeply held moral commitments leading to emotional and existential distress. The phenomenon was initially described by psychologists and psychiatrists associated with the US Departments of Defense and Veterans Affairs but has since been applied more broadly. Although its application to healthcare preceded COVID-19, healthcare professionals have taken greater interest in moral injury since the pandemic's advent. They have much to learn from combat veterans, who have substantial experience in identifying and addressing moral injury-particularly its social dimensions. Veterans recognise that complex social factors lead to moral injury, and therefore a community approach is necessary for healing. We argue that similar attention must be given in healthcare, where a team-oriented and multidimensional approach is essential both for ameliorating the suffering faced by health professionals and for addressing the underlying causes that give rise to moral injury.
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Affiliation(s)
- Jonathan M Cahill
- Center for Clinical Medical Ethics, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, New York, USA
| | - Warren Kinghorn
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Divinity School, Durham, North Carolina, USA
| | - Lydia Dugdale
- Center for Clinical Medical Ethics, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, New York, USA
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2
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Nieuwsma JA, O'Brien EC, Xu H, Smigelsky MA, Meador KG. Patterns of Potential Moral Injury in Post-9/11 Combat Veterans and COVID-19 Healthcare Workers. J Gen Intern Med 2022; 37:2033-2040. [PMID: 35381899 PMCID: PMC8982664 DOI: 10.1007/s11606-022-07487-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/09/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Moral injury has primarily been studied in combat veterans but might also affect healthcare workers (HCWs) due to the COVID-19 pandemic. OBJECTIVE To compare patterns of potential moral injury (PMI) between post-9/11 military combat veterans and healthcare workers (HCWs) surveyed during the COVID-19 pandemic. DESIGN Cross-sectional surveys of veterans (2015-2019) and HCWs (2020-2021) in the USA. PARTICIPANTS 618 military veterans who were deployed to a combat zone after September 11, 2001, and 2099 HCWs working in healthcare during the COVID-19 pandemic. MAIN MEASURES Other-induced PMI (disturbed by others' immoral acts) and self-induced PMI (disturbed by having violated own morals) were the primary outcomes. Sociodemographic variables, combat/COVID-19 experience, depression, quality of life, and burnout were measured as correlates. KEY RESULTS 46.1% of post-9/11 veterans and 50.7% of HCWs endorsed other-induced PMI, whereas 24.1% of post-9/11 veterans and 18.2% of HCWs endorsed self-induced PMI. Different types of PMI were significantly associated with gender, race, enlisted vs. officer status, and post-battle traumatic experiences among veterans and with age, race, working in a high COVID-19-risk setting, and reported COVID-19 exposure among HCWs. Endorsing either type of PMI was associated with significantly higher depressive symptoms and worse quality of life in both samples and higher burnout among HCWs. CONCLUSIONS The potential for moral injury is relatively high among combat veterans and COVID-19 HCWs, with deleterious consequences for mental health and burnout. Demographic characteristics suggestive of less social empowerment may increase risk for moral injury. Longitudinal research among COVID-19 HCWs is needed. Moral injury prevention and intervention efforts for HCWs may benefit from consulting models used with veterans.
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Affiliation(s)
- Jason A Nieuwsma
- Integrative Mental Health, Department of Veterans Affairs, Durham, NC, USA. .,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA. .,VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA.
| | | | - Haolin Xu
- Duke Clinical Research Institute, Durham, NC, USA
| | - Melissa A Smigelsky
- Integrative Mental Health, Department of Veterans Affairs, Durham, NC, USA.,VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA
| | | | | | - Keith G Meador
- Integrative Mental Health, Department of Veterans Affairs, Durham, NC, USA.,VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA.,Department of Psychiatry and Preventative Medicine, Center for Biomedical Ethics and Society, & Graduate Department of Religion, Vanderbilt University, Nashville, TN, USA
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Layson MD, Tunks Leach K, Carey LB, Best MC. Factors Influencing Military Personnel Utilizing Chaplains: A Literature Scoping Review. JOURNAL OF RELIGION AND HEALTH 2022; 61:1155-1182. [PMID: 35059963 DOI: 10.1007/s10943-021-01477-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 05/11/2023]
Abstract
Chaplains have been embedded in military settings for over a millennium. In recent years however, the decline in spiritual/religious (S/R) affiliation of military personnel across Western cultures has led to some commentators questioning the utilization of religious chaplains by defence personnel. This scoping review maps the literature on S/R and non-S/R factors that influence utilizing military chaplains-with a particular emphasis on the Australian military context. A systematic scoping review of tertiary literature databases using Arksey and O'Malley (2003) and Joanna Briggs Institute methodologies (JBI, 2021), revealed a total of 33 articles meeting the inclusion criteria. Results fell into three broad categories: (i) how personal religious views influence utilization of military chaplaincy, (ii) barriers and enablers to personnel utilizing military chaplains, and (iii) the impact of chaplaincy. Despite the current reduction in religiosity in Western society, findings from this scoping review suggest there is little evidence that low religiosity among military personnel forms a significant barrier to utilizing chaplaincy services. To the contrary, the literature revealed that chaplains provide trusted, confidential, and holistic support for military personnel that if diminished or compromised would leave a substantial gap in staff well-being services.
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Affiliation(s)
- Mark D Layson
- Faculty of Arts and Education, Charles Sturt University, Bathurst, NSW, Australia.
- St Mark's National Theological Centre, Charles Sturt University, Canberra, ACT, Australia.
| | - Katie Tunks Leach
- University of Technology Sydney, Sydney, NSW, Australia
- New South Wales Ambulance, Sydney, NSW, Australia
| | - Lindsay B Carey
- Palliative Care Unit, La Trobe University, Melbourne, VIC, Australia
- Centre for Spirituality, Theology and Health, Duke University, Durham, NC, USA
| | - Megan C Best
- Institute for Ethics and Society at the University of Notre Dame, Sydney, NSW, Australia
- School of Medicine, University of Sydney, Sydney, NSW, Australia
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5
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Wortmann JH, Nieuwsma JA, King HA, Fernandez P, Jackson GL, Smigelsky MA, Cantrell W, Meador KG. Collaborative spiritual care for moral injury in the veterans Affairs Healthcare System (VA): Results from a national survey of VA chaplains. J Health Care Chaplain 2021; 28:S9-S24. [PMID: 34825859 DOI: 10.1080/08854726.2021.2004847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The psychospiritual nature of moral injury invites consideration regarding how chaplains understand the construct and provide care. To identify how chaplains in the VA Healthcare System conceptualize moral injury, we conducted an anonymous online survey (N = 361; 45% response rate). Chaplains responded to a battery of items and provided free-text definitions of moral injury that generally aligned with key elements in the existing literature, though with different emphases. Over 90% of chaplain respondents indicated that they encounter moral injury in their chaplaincy care, and a similar proportion agreed that chaplains and mental health professionals should collaborate in providing care for moral injury. Over one-third of chaplain respondents reported offering or planning to offer a moral injury group. Separately, nearly one-quarter indicated present or planned collaboration with mental health to provide groups that in some manner address moral injury. Previous training in evidence-based and collaborative care approaches appears to contribute to the likelihood of providing integrated psychosocial-spiritual care. Results and future directions are discussed, including a description of moral injury that may be helpful to understand present areas of emphasis in VA chaplains' care for moral injury.
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Affiliation(s)
- Jennifer H Wortmann
- Integrative Mental Health, Veterans Affairs Healthcare System, Durham, NC, USA.,VA Mid-Atlantic MIRECC, Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - Jason A Nieuwsma
- Integrative Mental Health, Veterans Affairs Healthcare System, Durham, NC, USA.,VA Mid-Atlantic MIRECC, Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Department of Population Health Sciences, Duke University, Durham, NC, USA.,Division of General Internal Medicine, Duke University, Durham, NC, USA
| | - Paola Fernandez
- Integrative Mental Health, Veterans Affairs Healthcare System, Durham, NC, USA.,VA Mid-Atlantic MIRECC, Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Department of Psychology, University of South Alabama, Mobile, AL, USA
| | - George L Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Department of Population Health Sciences, Duke University, Durham, NC, USA.,Division of General Internal Medicine, Duke University, Durham, NC, USA.,Department of Family Medicine and Community Health, Duke University, Durham, NC, USA
| | - Melissa A Smigelsky
- Integrative Mental Health, Veterans Affairs Healthcare System, Durham, NC, USA.,VA Mid-Atlantic MIRECC, Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - William Cantrell
- Integrative Mental Health, Veterans Affairs Healthcare System, Durham, NC, USA.,VA Mid-Atlantic MIRECC, Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - Keith G Meador
- Integrative Mental Health, Veterans Affairs Healthcare System, Durham, NC, USA.,VA Mid-Atlantic MIRECC, Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Vanderbilt University, Nashville, TN, USA.,Center for Biomedical Ethics and Society, Vanderbilt University, Nashville, TN, USA.,Department of Health Policy, Vanderbilt University, Nashville, TN, USA.,Graduate Department of Religion, Vanderbilt University, Nashville, TN, USA
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Day P, Lawson J, Mantri S, Jain A, Rabago D, Lennon R. Physician moral injury in the context of moral, ethical and legal codes. JOURNAL OF MEDICAL ETHICS 2021; 48:medethics-2021-107225. [PMID: 34290114 DOI: 10.1136/medethics-2021-107225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 06/20/2021] [Indexed: 06/13/2023]
Abstract
After 40 years of attributing high rates of physician career dissatisfaction, attrition, alcoholism, divorce and suicide to 'burnout', there is growing recognition that these outcomes may instead be caused by moral injury. This has led to a debate about the relative diagnostic merits of these two terms, a recognition that interventions designed to treat burnout may be ineffective, and much perplexity about how-if at all-this changes anything.The current research seeks to develop the construct of moral injury outside military contexts, generate more robust validity tests and more fully describe and measure the experiences of persons exposed to moral harms. Absent from the literature is a mechanism through which to move from the collective moral injury experience of physicians to a systematic change in the structure of medical practice. To address this, after providing a brief history, definitions and contrasts between burnout, moral distress and moral injury, we review the interplay of moral and ethical codes in the context of moral injury. We conclude by suggesting that professional associations can potentially prevent moral injury by providing protections for physicians within their codes of ethics.
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Affiliation(s)
- Philip Day
- Department of Family and Community Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jennifer Lawson
- Department of Pediatrics and Trent Center for Bioethics, Humanities, and History of Medicine, Duke University of School Medicine, Durham, North Carolina, USA
| | - Sneha Mantri
- Department of Neurology and Trent Center for Bioethics, Humanities, and History of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Abhi Jain
- St Mark's School of Texas, Dallas, Texas, USA
| | - David Rabago
- Department of Family and Community Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Robert Lennon
- Department of Family and Community Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Čartolovni A, Stolt M, Scott PA, Suhonen R. Moral injury in healthcare professionals: A scoping review and discussion. Nurs Ethics 2021; 28:590-602. [PMID: 33427020 PMCID: PMC8366182 DOI: 10.1177/0969733020966776] [Citation(s) in RCA: 126] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Moral injury emerged in the healthcare discussion quite recently because of the difficulties and challenges healthcare workers and healthcare systems face in the context of the COVID-19 pandemic. Moral injury involves a deep emotional wound and is unique to those who bear witness to intense human suffering and cruelty. This article aims to synthesise the very limited evidence from empirical studies on moral injury and to discuss a better understanding of the concept of moral injury, its importance in the healthcare context and its relation to the well-known concept of moral distress. A scoping literature review design was used to support the discussion. Systematic literature searches conducted in April 2020 in two electronic databases, PubMed/Medline and PsychInfo, produced 2044 hits but only a handful of empirical papers, from which seven well-focused articles were identified. The concept of moral injury was considered under other concepts as well such as stress of conscience, regrets for ethical situation, moral distress and ethical suffering, guilt without fault, and existential suffering with inflicting pain. Nurses had witnessed these difficult ethical situations when faced with unnecessary patient suffering and a feeling of not doing enough. Some cases of moral distress may turn into moral residue and end in moral injury with time, and in certain circumstances and contexts. The association between these concepts needs further investigation and confirmation through empirical studies; in particular, where to draw the line as to when moral distress turns into moral injury, leading to severe consequences. Given the very limited research on moral injury, discussion of moral injury in the context of the duty to care, for example, in this pandemic settings and similar situations warrants some consideration.
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Affiliation(s)
- Anto Čartolovni
- 324714Catholic University of Croatia, Croatia; University of Hull, UK
| | | | - P Anne Scott
- 8799National University of Ireland Galway, Ireland
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Kassam AF, Cortez AR, Winer LK, Conzen KD, El-Hinnawi A, Jones CM, Matsuoka L, Watkins AC, Collins KM, Bhati C, Selzner M, Sonnenday CJ, Englesbe MJ, Diwan TS, Dick AAS, Quillin RC. Extinguishing burnout: National analysis of predictors and effects of burnout in abdominal transplant surgery fellows. Am J Transplant 2021; 21:307-313. [PMID: 32463950 DOI: 10.1111/ajt.16075] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 01/25/2023]
Abstract
Burnout among surgeons has been attributed to increased workload and decreased autonomy. Although prior studies have examined burnout among transplant surgeons, no studies have evaluated burnout in abdominal transplant surgery fellows. The objective of our study was to identify predictors of burnout and understand its impact on personal and patient care during fellowship. A survey was sent to all abdominal transplant surgery fellows in an American Society of Transplant Surgeons-accredited fellowship. The response rate was 59.2% (n = 77) and 22.7% (n = 17) of fellows met criteria for burnout. Fellows with lower grit scores were more likely to exhibit burnout compared with fellows with higher scores (3.6 vs 4.0, P = .026). Those with burnout were more likely to work >100 hours per week (58.8% vs 27.6%, P = .023), have severe work-related stress (58.8% vs 22.4%, P = .010), consider quitting fellowship (94.1% vs 20.7%, P < .001), or make a medical error (35.3% vs 5.2%, P = .003). This national analysis of abdominal transplant fellows found that burnout rates are relatively low, but few fellows engage in self-care. Personal and program-related factors attribute to burnout and it has unacceptable effects on patient care. Transplant societies and fellowship programs should develop interventions to give fellows tools to prevent and combat burnout.
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Affiliation(s)
- Al-Faraaz Kassam
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio, USA.,Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alexander R Cortez
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio, USA.,Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Leah K Winer
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio, USA.,Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kendra D Conzen
- Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Ashraf El-Hinnawi
- Department of Surgery, The Ohio State University, Columbus, Ohio, USA
| | | | - Lea Matsuoka
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anthony C Watkins
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Kelly M Collins
- Department of Transplantation and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Chandra Bhati
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Markus Selzner
- Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | | | | | - Tayyab S Diwan
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - André A S Dick
- Department of Surgery, University of Washington, Seattle, Washington, USA.,Seattle Children's Hospital, Seattle, Washington, USA
| | - Ralph C Quillin
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio, USA.,Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
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Implementation of a complex intervention to improve care for patients whose situations are clinically uncertain in hospital settings: A multi-method study using normalisation process theory. PLoS One 2020; 15:e0239181. [PMID: 32936837 PMCID: PMC7494119 DOI: 10.1371/journal.pone.0239181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/02/2020] [Indexed: 12/01/2022] Open
Abstract
Purpose To examine the use of Normalisation Process Theory (NPT) to establish if, and in what ways, the AMBER care bundle can be successfully normalised into acute hospital practice, and to identify necessary modifications to optimise its implementation. Method Multi-method process evaluation embedded within a mixed-method feasibility cluster randomised controlled trial in two district general hospitals in England. Data were collected using (i) focus groups with health professionals (HPs), (ii) semi-structured interviews with patients and/or carers, (iii) non-participant observations of multi-disciplinary team meetings and (iv) patient clinical note review. Thematic analysis and descriptive statistics, with interpretation guided by NPT components (coherence; cognitive participation; collective action; reflexive monitoring). Data triangulated across sources. Results Two focus groups (26 HPs), nine non-participant observations, 12 interviews (two patients, 10 relatives), 29 clinical note reviews were conducted. While coherence was evident, with HPs recognising the value of the AMBER care bundle, cognitive participation and collective action presented challenges. Specifically: (1) HPs were unable and unwilling to operationalise the concept of ‘risk of dying’ intervention eligibility criteria (2) integration relied on a ‘champion’ to drive participation and ensure sustainability; and (3) differing skills and confidence led to variable engagement with difficult conversations with patients and families about, for example, nearness to end of life. Opportunities for reflexive monitoring were not routinely embedded within the intervention. Reflections on the use of the AMBER care bundle from HPs and patients and families, including recommended modifications became evident through this NPT-driven analysis. Conclusion To be successfully normalised, new clinical practices, such as the AMBER care bundle, must be studied within the wider context in which they operate. NPT can be used to the aid identification of practical strategies to assist in normalisation of complex interventions where the focus of care is on clinical uncertainty in acute hospital settings.
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Nieuwsma JA, Brancu M, Wortmann J, Smigelsky MA, King HA, Meador KG. Screening for moral injury and comparatively evaluating moral injury measures in relation to mental illness symptomatology and diagnosis. Clin Psychol Psychother 2020; 28:239-250. [PMID: 32830386 DOI: 10.1002/cpp.2503] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 11/09/2022]
Abstract
Moral injury merits further study to clarify its identification, prevalence, assessment and intersection with psychosocial and psychiatric problems. The present study investigated the screening potential of the Brief Moral Injury Screen (BMIS) in a sample of post-9/11 veterans (N = 315) and comparatively evaluated how this tool, the Moral Injury Events Scale (MIES), and the Moral Injury Questionnaire-Military Version (MIQ-M) relate to psychiatric diagnoses and mental illness symptom severity. Those who endorsed failing to prevent or doing something morally wrong had the highest symptomatology scores on measures of posttraumatic stress disorder, depression, suicidality, alcohol abuse and drug abuse, followed by those who reported solely witnessing a moral injury event. Posttraumatic stress disorder and depressive symptoms correlated most strongly with scores on the MIQ-M; suicidality, alcohol abuse and drug abuse scores correlated most strongly with scores on the BMIS and MIQ-M. Moral injury, as measured by three scales, was robustly correlated with worse outcomes on various symptom measures. The three scales appear to differentially predict mental illness symptomatology and diagnoses, with the BMIS predicting suicidality and alcohol and drug abuse as well as better than other measures.
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Affiliation(s)
- Jason A Nieuwsma
- Department of Veterans Affairs, Mental Health and Chaplaincy, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Mira Brancu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA.,VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina, USA
| | - Jennifer Wortmann
- Department of Veterans Affairs, Mental Health and Chaplaincy, Durham, North Carolina, USA
| | - Melissa A Smigelsky
- Department of Veterans Affairs, Mental Health and Chaplaincy, Durham, North Carolina, USA
| | - Heather A King
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina, USA
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- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina, USA
| | - Keith G Meador
- Department of Veterans Affairs, Mental Health and Chaplaincy, Durham, North Carolina, USA.,Department of Psychiatry and Preventative Medicine, Center for Biomedical Ethics and Society, & Graduate Department of Religion, Vanderbilt University, Nashville, Tennessee, USA
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Laventhal NT, Basak RB, Dell ML, Elster N, Geis G, Macauley RC, Mercurio MR, Opel DJ, Shalowitz DI, Statter MB, Diekema DS. Professional Obligations of Clinicians and Institutions in Pediatric Care Settings during a Public Health Crisis: A Review. J Pediatr 2020; 224:10-15. [PMID: 32585238 PMCID: PMC7308757 DOI: 10.1016/j.jpeds.2020.06.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/18/2020] [Indexed: 11/24/2022]
Affiliation(s)
| | - Ratna B Basak
- Brookdale University Hospital Medical Center, Brooklyn, New York
| | - Mary Lynn Dell
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Nanette Elster
- Loyola University Stritch School of Medicine, Chicago, Illinois
| | - Gina Geis
- Albany Medical College, Albany, New York
| | | | | | - Douglas J Opel
- University of Washington School of Medicine, Seattle, Washington
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Barnes HA, Hurley RA, Taber KH. Moral Injury and PTSD: Often Co-Occurring Yet Mechanistically Different. J Neuropsychiatry Clin Neurosci 2019; 31:A4-103. [PMID: 31012825 DOI: 10.1176/appi.neuropsych.19020036] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Haleigh A Barnes
- Dr. Barnes is affiliated with the Mental Health Service Line at the Salisbury VA Healthcare System in Salisbury, North Carolina. Drs. Hurley and Taber are affiliated with the Veterans Affairs Mid Atlantic Mental Illness Research, Education, and Clinical Center, and the Research and Academic Affairs Service Line at the Salisbury VA Healthcare System. Dr. Hurley is affiliated with the Departments of Psychiatry and Radiology at Wake Forest School of Medicine in Winston-Salem, North Carolina, and the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine in Houston. Dr. Taber is affiliated with the Division of Biomedical Sciences at the Via College of Osteopathic Medicine in Blacksburg, Virginia, and the Department of Physical Medicine and Rehabilitation at Baylor College of Medicine in Houston
| | - Robin A Hurley
- Dr. Barnes is affiliated with the Mental Health Service Line at the Salisbury VA Healthcare System in Salisbury, North Carolina. Drs. Hurley and Taber are affiliated with the Veterans Affairs Mid Atlantic Mental Illness Research, Education, and Clinical Center, and the Research and Academic Affairs Service Line at the Salisbury VA Healthcare System. Dr. Hurley is affiliated with the Departments of Psychiatry and Radiology at Wake Forest School of Medicine in Winston-Salem, North Carolina, and the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine in Houston. Dr. Taber is affiliated with the Division of Biomedical Sciences at the Via College of Osteopathic Medicine in Blacksburg, Virginia, and the Department of Physical Medicine and Rehabilitation at Baylor College of Medicine in Houston
| | - Katherine H Taber
- Dr. Barnes is affiliated with the Mental Health Service Line at the Salisbury VA Healthcare System in Salisbury, North Carolina. Drs. Hurley and Taber are affiliated with the Veterans Affairs Mid Atlantic Mental Illness Research, Education, and Clinical Center, and the Research and Academic Affairs Service Line at the Salisbury VA Healthcare System. Dr. Hurley is affiliated with the Departments of Psychiatry and Radiology at Wake Forest School of Medicine in Winston-Salem, North Carolina, and the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine in Houston. Dr. Taber is affiliated with the Division of Biomedical Sciences at the Via College of Osteopathic Medicine in Blacksburg, Virginia, and the Department of Physical Medicine and Rehabilitation at Baylor College of Medicine in Houston
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Griffin BJ, Purcell N, Burkman K, Litz BT, Bryan CJ, Schmitz M, Villierme C, Walsh J, Maguen S. Moral Injury: An Integrative Review. J Trauma Stress 2019; 32:350-362. [PMID: 30688367 DOI: 10.1002/jts.22362] [Citation(s) in RCA: 246] [Impact Index Per Article: 49.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 07/13/2018] [Accepted: 07/14/2018] [Indexed: 12/18/2022]
Abstract
Individuals who are exposed to traumatic events that violate their moral values may experience severe distress and functional impairments known as "moral injuries." Over the last decade, moral injury has captured the attention of mental health care providers, spiritual and faith communities, media outlets, and the general public. Research about moral injury, especially among military personnel and veterans, has also proliferated. For this article, we reviewed scientific research about moral injury. We identified 116 relevant epidemiological and clinical studies. Epidemiological studies described a wide range of biological, psychological/behavioral, social, and religious/spiritual sequelae associated with exposure to potentially morally injurious events. Although a dearth of empirical clinical literature exists, some authors debated how moral injury might and might not respond to evidence-based treatments for posttraumatic stress disorder (PTSD) whereas others identified new treatment models to directly address moral repair. Limitations of the literature included variable definitions of potentially morally injurious events, the absence of a consensus definition and gold-standard measure of moral injury as an outcome, scant study of moral injury outside of military-related contexts, and clinical investigations limited by small sample sizes and unclear mechanisms of therapeutic effect. We conclude our review by summarizing lessons from the literature and offering recommendations for future research.
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Affiliation(s)
- Brandon J Griffin
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry, University of California-San Francisco, San Francisco, CA, USA
| | - Natalie Purcell
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Social and Behavioral Sciences, University of California-San Francisco, San Francisco, CA, USA
| | - Kristine Burkman
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry, University of California-San Francisco, San Francisco, CA, USA
| | - Brett T Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA, USA.,Departments of Psychiatry and Psychology, Boston University, Boston, MA, USA
| | - Craig J Bryan
- National Center for Veterans Studies, The University of Utah, Salt Lake City, UT, USA.,Department of Psychology, The University of Utah, Salt Lake City, UT, USA
| | - Martha Schmitz
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry, University of California-San Francisco, San Francisco, CA, USA
| | - Claudia Villierme
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Jessica Walsh
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychology, Palo Alto University, Palo Alto, CA, USA
| | - Shira Maguen
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry, University of California-San Francisco, San Francisco, CA, USA
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14
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English DP, Huang M. Highlights from the Society of Gynecologic Oncology's 50th Annual Meeting on Women's Cancer. Gynecol Oncol 2019; 153:467-470. [PMID: 31023555 DOI: 10.1016/j.ygyno.2019.04.652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
| | - Marilyn Huang
- Department of Obstetrics and Gynecology, Sylvester Cancer Center/University of Miami, United States of America
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15
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Koenig HG, Youssef NA, Pearce M. Assessment of Moral Injury in Veterans and Active Duty Military Personnel With PTSD: A Review. Front Psychiatry 2019; 10:443. [PMID: 31316405 PMCID: PMC6611155 DOI: 10.3389/fpsyt.2019.00443] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/04/2019] [Indexed: 11/17/2022] Open
Abstract
Background: Moral injury (MI) involves distress over having transgressed or violated core moral boundaries, accompanied by feelings of guilt, shame, self-condemnation, loss of trust, loss of meaning, and spiritual struggles. MI is often found in Veterans and Active Duty Military personnel with posttraumatic stress disorder (PTSD). MI is widespread among those with PTSD symptoms, adversely affects mental health, and may increase risk of suicide; however, MI is often ignored and neglected by mental health professionals who focus their attention on PTSD only. Methods: A review of the literature between 1980 and 2018 conducted in 2018 is presented here to identify scales used to assess MI. Databases used in this review were PsychInfo, PubMed (Medline), and Google Scholar. Search terms were "moral injury," "measuring," "screening," "Veterans," and "Active Duty Military." Inclusion criteria were quantitative measurement of MI and health outcomes, Veteran or Active Duty Military status, and peer-review publication. Excluded were literature reviews, dissertations, book chapters, case reports, and qualitative studies. Results: Of the 730 studies identified, most did not meet eligibility criteria, leaving 118 full text articles that were reviewed, of which 42 did not meet eligibility criteria. Of the remaining 76 studies, 34 were duplicates leaving 42 studies, most published in 2013 or later. Of 22 studies that assessed MI, five used scales assessing multiple dimensions, and 17 assessed only one or two aspects (e.g., guilt, shame, or forgiveness). The remaining 20 studies used one of the scales reported in the first 22. Of the five scales assessing multiple dimensions of MI, two assess both morally injurious events and symptoms and the remaining three assess symptoms only. All studies were cross-sectional, except three that tested interventions. Conclusions: MI in the military setting is widespread and associated with PTSD symptom severity, anxiety, depression, and risk of suicide in current or former military personnel. Numerous measures exist to assess various dimensions of MI, including five multidimensional scales, although future research is needed to identify cutoff scores and clinically significant change scores. Three multidimensional measures assess MI symptoms alone (not events) and may be useful for determining if treatments directed at MI may both reduce symptoms and impact other mental health outcomes including PTSD.
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Affiliation(s)
- Harold G Koenig
- Duke University Medical Center, Durham, NC, United States.,King Abdulaziz University, Jeddah, Saudi Arabia.,Ningxia Medical University, Yinchuan, China
| | - Nagy A Youssef
- Medical College of Georgia, Augusta University, Charlie Norwood VA Medical Center, Augusta, GA, United States
| | - Michelle Pearce
- Department of Family and Community Medicine, Center for Integrative Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
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