1
|
Simms A, Leightley D, Lamb D. Caring for the carers: an evaluation of the recovery, readjustment and reintegration programme (R3P). BMJ Mil Health 2024; 170:384-389. [PMID: 37487658 DOI: 10.1136/military-2023-002359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 07/03/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION The challenges faced by healthcare workers, not least during the response to the COVID-19 pandemic, have been extensively studied, and concerns continue to be highlighted in relation to their long-term mental health. Identifying the need to support their personnel, a leader-led structured programme of reflection: the recovery, readjustment and reintegration programme (R3P) was designed by the UK Defence Medical Services to mitigate the potential stressors associated with this outbreak and enhance the resilience of the workforce. METHODS 128 military personnel completed an evaluation of R3P. A survey included measures of anxiety before and after the intervention, perceptions of the discussion themes and whether these brought a sense of closure to areas of distress, and attitudes to help-seeking. RESULTS Most respondents (86%-92%) rated the five discussion themes either 'helpful' or 'very helpful', 51% of respondents reported a sense of closure about an issue that had been causing distress and 72% of respondents felt better able to seek help should it be necessary. Evaluating the effect R3P had on anxiety, a Wilcoxon signed rank test elicited a statistically significant difference in anxiety pre-R3P and post-R3P; Z=-3.54, p<0.001. The median anxiety rating was 3.5 (IQR 4.75, 95% CI 1.25 to 6.00) before undertaking R3P, which decreased to 3 (IQR 4.75, 95% CI 1.00 to 5.75) after undertaking R3P. 39.1% of participants reported decreased anxiety, 18.8% reported increased anxiety and 42.2% reported no change. CONCLUSION This evaluation has identified several positive aspects to R3P with many personnel reporting a reduction in anxiety, a sense of closure and increased likelihood of help-seeking. Several participants did report an increase in anxiety and the long-term impact of R3P on mental health and well-being is unclear. Further mixed-methods evaluation incorporating a longer follow-up is required.
Collapse
Affiliation(s)
- Amos Simms
- Academic Department of Military Mental Health, King's College London, London, UK
| | - D Leightley
- King's Centre for Military Health Research, King's College London, London, UK
| | - D Lamb
- RCDM (Research and Academia), MOD, Birmingham, UK
| |
Collapse
|
2
|
Schnyder U. What Is Moral Injury? PSYCHOTHERAPY AND PSYCHOSOMATICS 2024:1-5. [PMID: 39208779 DOI: 10.1159/000540679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2024] [Accepted: 07/30/2024] [Indexed: 09/04/2024]
Affiliation(s)
- Ulrich Schnyder
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| |
Collapse
|
3
|
Rivlin K, Bornstein M, Wascher J, Norris Turner A, Norris AH, Howard D. State Abortion Policy and Moral Distress Among Clinicians Providing Abortion After the Dobbs Decision. JAMA Netw Open 2024; 7:e2426248. [PMID: 39088213 PMCID: PMC11294965 DOI: 10.1001/jamanetworkopen.2024.26248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 06/10/2024] [Indexed: 08/02/2024] Open
Abstract
Importance Moral distress occurs when individuals feel powerless to do what they think is right, including when clinicians are prevented from providing health care they deem necessary. The loss of federal protections for abortion following the Dobbs v Jackson Women's Health Organization Supreme Court decision may place clinicians providing abortion at risk of experiencing moral distress, as many could face new legal and civil penalties for providing care in line with professional standards and that they perceive as necessary. Objective To assess self-reported moral distress scores among abortion-providing clinicians following the Dobbs decision overall and by state-level abortion policy. Design, Setting, and Participants This survey study, conducted from May to December 2023, included US abortion-providing clinicians (physicians, advanced practice clinicians, and nurses). A purposive electronic survey was disseminated nationally through professional listservs and snowball sampling. Exposure Abortion policy in each respondent's state of practice (restrictive vs protective using classifications from the Guttmacher Institute). Main Outcomes and Measures Using descriptive statistics and unadjusted and adjusted negative binomial regression models, the association between self-reported moral distress on the Moral Distress Thermometer (MDT), a validated psychometric tool that scores moral distress from 0 (none) to 10 (worst possible), and state abortion policy was examined. Results Overall, 310 clinicians (271 [87.7%] women; mean [SD] age, 41.4 [9.7] years) completed 352 MDTs, with 206 responses (58.5%) from protective states and 146 (41.5%) from restrictive states. Reported moral distress scores ranged from 0 to 10 (median, 5) and were more than double for clinicians in restrictive compared with protective states (median, 8 [IQR, 6-9] vs 3 [IQR, 1-6]; P < .001). Respondents with higher moral distress scores included physicians compared with advanced practice clinicians (median, 6 [IQR, 3-8] vs 4 [IQR, 2-7]; P = .005), those practicing in free-standing abortion clinics compared with those practicing in hospitals (median, 6 [IQR, 3-8] vs 4 [IQR, 2-7]; P < .001), those no longer providing abortion care compared with those still providing abortion care (median, 8 [IQR, 4-9] vs 5 [IQR, 2-8]; P = .004), those practicing in loss states (states with the greatest decline in abortion volume since the Dobbs decision) compared with those in stable states (unadjusted incidence rate [IRR], 1.72 [95% CI, 1.55-1.92]; P < .001; adjusted IRR, 1.59 [95% CI, 1.40-1.79]; P < .001), and those practicing in surge states (states with the greatest increase in abortion volume since the Dobbs decision) compared with those in stable states (unadjusted IRR, 1.27 [95% CI, 1.11-1.46]; P < .001; adjusted IRR, 1.24 [95% CI, 1.09-1.41]; P = .001). Conclusions and Relevance In this purposive national survey study of clinicians providing abortion, moral distress was elevated among all clinicians and more than twice as high among those practicing in states that restrict abortion compared with those in states that protect abortion. The findings suggest that structural changes addressing bans on necessary health care, such as federal protections for abortion, are needed at institutional, state, and federal policy levels to combat widespread moral distress.
Collapse
Affiliation(s)
- Katherine Rivlin
- Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, Illinois
| | - Marta Bornstein
- Department of Health Promotion Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia
| | - Jocelyn Wascher
- Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, Illinois
| | | | - Alison H. Norris
- Division of Epidemiology, Colleges of Public Health and Medicine, The Ohio State University, Columbus
| | - Dana Howard
- Division of Bioethics, Department of Biomedical Education and Anatomy, The Ohio State University College of Medicine, Columbus
| |
Collapse
|
4
|
McNicholas F, Twohig A. Trauma and warfare and clinicians' role. Pediatr Res 2024; 96:2-3. [PMID: 38438556 DOI: 10.1038/s41390-024-03124-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/10/2024] [Indexed: 03/06/2024]
Affiliation(s)
- Fiona McNicholas
- Children's Health Ireland, Crumlin, Dublin, Ireland.
- Lucena CAMHS, Dublin, Ireland.
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.
| | - Aoife Twohig
- Children's Health Ireland, Temple St, Dublin, Ireland
- School of Medicine, Trinity College, Dublin, Ireland
| |
Collapse
|
5
|
Campbell BM, Knipp MA, Anwar SS, Hoopsick RA. Moral injury and substance use among United States healthcare workers. Stress Health 2024; 40:e3321. [PMID: 37786303 DOI: 10.1002/smi.3321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/08/2023] [Accepted: 09/18/2023] [Indexed: 10/04/2023]
Abstract
Moral injury (i.e., perpetrating, witnessing, failing to prevent, or being a victim of acts that transgress one's moral beliefs, values, or ethics) has largely been studied in military-connected populations and is associated with a range of adverse psychological sequelae. Emerging literature suggests that healthcare workers also experience moral injury, particularly in the context of the ongoing COVID-19 pandemic. However, it is not known if moral injury contributes to substance use among healthcare workers or whether these effects might differ by gender, race/ethnicity, or occupational level. In March 2022, we collected self-reported pilot data from a diverse sample of US healthcare workers (N = 200) We examined the cross-sectional relationships between moral injury and several measures of substance use (i.e., current non-medical use of prescription drugs [NMUPD], current cannabis use, current use of other illicit drugs, and hazardous drinking) using separate logistic regression models. Next, we used separate interaction models to examine if any of these relations differed by gender, race/ethnicity, or occupational level. In main effects models, healthcare workers reporting greater moral injury had greater odds of current NMUPD (adjusted odds ratio (aOR) = 1.07; p < 0.001), current use of other illicit drugs (aOR = 1.09; p < 0.01), and hazardous drinking (aOR = 1.07; p < 0.01). These relations did not differ by race/ethnicity or occupational level (ps > 0.05); however, men were more likely to report current NMUPD and hazardous drinking (ps < 0.05) in the presence of high moral injury than women healthcare workers. Our findings suggest that healthcare workers experience substantial distress related to morally injurious events, which may affect their likelihood of NMUPD, cannabis use, use of other illicit drugs, and hazardous drinking, and that men in healthcare may be particularly at risk. Healthcare organizations should address systemic issues driving moral injury (e.g., resource shortages, lack of psychosocial support) to prevent substance-related harms among healthcare workers.
Collapse
Affiliation(s)
- Benjamin M Campbell
- Department of Kinesiology and Community Health, University of Illinois Urbana-Champaign, Champaign, Illinois, USA
| | - Michael A Knipp
- Department of Kinesiology and Community Health, University of Illinois Urbana-Champaign, Champaign, Illinois, USA
| | - Sinan S Anwar
- Department of Kinesiology and Community Health, University of Illinois Urbana-Champaign, Champaign, Illinois, USA
| | - Rachel A Hoopsick
- Department of Kinesiology and Community Health, University of Illinois Urbana-Champaign, Champaign, Illinois, USA
| |
Collapse
|
6
|
Kitto C, Lamb D, Billings J. Responding to the call of the NHS Nightingale, but at what cost? An auto-ethnography of a volunteer frontline mental health trainer's experiences during the COVID-19 pandemic. J Health Psychol 2024; 29:534-551. [PMID: 38083867 DOI: 10.1177/13591053231213478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Healthcare workers, globally, volunteered time and skills to the COVID-19 pandemic frontline response. In March 2020, the predicted high demand for extra critical care beds led to the rapid construction of the UK National Health Service (NHS) Nightingale field hospital, London. I volunteered to develop and deliver psychological preparedness training - coined 'Psychological PPE' - to over 2300 frontline staff over an 8-week period. Existing research has identified broad themes of the impact working on the COVID-19 frontline has on healthcare workers but does not capture in-depth accounts of individuals' experiences. Using autoethnographic enquiry, this research explores my frontline experience at the NHS Nightingale during this time, and the personal impact this had on me. Reflexive thematic analysis explored themes of recognition and sacrifice, emotional lability and fragility, and the impact of transitions. Findings inform personal recovery, as well as future research and policy development pertaining to the sustainable recovery of our NHS people.
Collapse
Affiliation(s)
- Chloe Kitto
- UCL, UK
- Royal National Orthopaedic Hospital, UK
| | | | | |
Collapse
|
7
|
Ahmed Pihlgren S, Johansson L, Holmes EA, Kanstrup M. Exploring healthcare workers' experiences of a simple intervention to reduce their intrusive memories of psychological trauma: an interpretative phenomenological analysis. Eur J Psychotraumatol 2024; 15:2328956. [PMID: 38533843 PMCID: PMC10977018 DOI: 10.1080/20008066.2024.2328956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/02/2024] [Indexed: 03/28/2024] Open
Abstract
ABSTRACTBackground: Many healthcare workers (HCWs) endured psychologically traumatic events at work during the coronavirus disease 2019 (COVID-19) pandemic. For some, these events are re-experienced as unwanted, recurrent, and distressing intrusive memories. Simple psychological support measures are needed to reduce such symptoms of post-traumatic stress in this population. A novel intervention to target intrusive memories, called an imagery-competing task intervention (ICTI), has been developed from the laboratory. The intervention includes a brief memory reminder cue, then a visuospatial task (Tetris® gameplay using mental rotation instructions for approximately 20 min) thought to interfere with the traumatic memory image and reduce its intrusiveness. The intervention has been adapted and evaluated in a randomized controlled trial (RCT) with Swedish HCWs (ClinicalTrials.gov identifier: NCT04460014).Objective: We aimed to explore how HCWs who worked during the COVID-19 pandemic experienced the use of a brief intervention to reduce their intrusive memories of work-related trauma.Method: Interpretative phenomenological analysis was used for in-depth understanding of the lived experiences of HCWs who used the intervention. Seven participants from the RCT were interviewed by an independent researcher without prior knowledge of the intervention. Interviews were conducted via telephone and transcribed verbatim.Results: Four general themes were generated: 'Triggers and troublesome images', 'Five Ws regarding support - what, when, why, by/with who, for whom', 'Receiving it, believing it, and doing it' and 'The intervention - a different kind of help'; the last two included two subthemes each. The results reflect participants' similarities and differences in their lived experiences of intrusive memories, support measures, and intervention impressions and effects.Conclusion: HCWs' experiences of the novel ICTI reflect a promising appraisal of the intervention as a potential help measure for reducing intrusive memories after trauma, and gives us a detailed understanding of HCWs' needs, with suggestions for its adaption for future implementation.Trial registration: ClinicalTrials.gov identifier: NCT04460014.
Collapse
Affiliation(s)
- Sara Ahmed Pihlgren
- Department of Psychology, Uppsala University, Uppsala, Sweden
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Lotta Johansson
- The Neurosurgical Intensive Care Unit, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Health and Caring Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Emily A. Holmes
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Marie Kanstrup
- Department of Psychology, Uppsala University, Uppsala, Sweden
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Theme Women’s Health and Allied Health Professionals, Medical Unit for Medical Psychology, Karolinska University Hospital, Solna, Sweden
| |
Collapse
|
8
|
Larsman P, Pousette A, Skyvell Nilsson M, Gadolin C, Törner M. Ethical value conflicts in healthcare and their effects on nurses' health, turnover intent, team effectiveness, and patient safety: a longitudinal questionnaire study. Scand J Work Environ Health 2024; 50:113-121. [PMID: 38232184 DOI: 10.5271/sjweh.4138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVE Moral distress emanating from value conflicts comprising ethical dimensions pose a threat to nurses' health and retention, as well as to the quality of care. The aim of the present study was to investigate the relationships between the frequency of ethical value conflicts (EVC), and the perceived distress when they occur, respectively, and nurses' work-related stress, burnout symptoms, turnover intent, team effectiveness, and patient safety. METHODS A two-wave longitudinal cohort questionnaire study was performed among registered nurses at six hospitals in two Swedish regions. Cross-sectional analyses (T1) were based on 1817 nurses in 228 care units (CU), and longitudinal analyses (T1 - T2) on 965 nurses in 190 CU. Hypothesis testing was performed using multilevel controlled regression modeling. RESULTS The results indicated that nurses who were often exposed to EVC also to a higher extent tended to report these conflicts as stressful. Frequent exposure to EVC induced by insufficient resources, inapt organizational structures or interpersonal staff relations were cross-sectionally associated with work-related stress, burnout symptoms, turnover intent, and team effectiveness. The longitudinal analyses indicated that EVC induced by a lack of resources primarily had negative effects on nurses' health and well-being. At the CU level, such conflicts also impaired team effectiveness. At the individual level, EVC induced by organizational constraints or interpersonal relations negatively affected care effectiveness. CONCLUSIONS EVC are related to negative consequences in healthcare, and such processes take place both on the individual and organizational levels.
Collapse
Affiliation(s)
- Pernilla Larsman
- Department of Psychology, University of Gothenburg, Box 500, SE-405 30 Gothenburg, Sweden.
| | | | | | | | | |
Collapse
|
9
|
Weissinger GM, Swavely D, Holtz H, Brewer KC, Alderfer M, Lynn L, Yoder A, Adil T, Wasser T, Cifra D, Rushton C. Critical Care Nurses' Moral Resilience, Moral Injury, Institutional Betrayal, and Traumatic Stress After COVID-19. Am J Crit Care 2024; 33:105-114. [PMID: 38424022 DOI: 10.4037/ajcc2024481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Traumatic stress and moral injury may contribute to burnout, but their relationship to institutional betrayal and moral resilience is poorly understood, leaving risk and protective factors understudied. OBJECTIVES To examine traumatic stress symptoms, moral injury symptoms, moral resilience, and institutional betrayal experienced by critical care nurses and examine how moral injury and traumatic stress symptoms relate to moral resilience, institutional betrayal, and patient-related burnout. METHODS This cross-sectional study included 121 critical care nurses and used an online survey. Validated instruments were used to measure key variables. Descriptive statistics, regression analyses, and group t tests were used to examine relationships among variables. RESULTS Of participating nurses, 71.5% reported significant moral injury symptoms and/or traumatic stress. Both moral injury symptoms and traumatic stress were associated with burnout. Regression models showed that institutional betrayal was associated with increased likelihood of traumatic stress and moral injury. Increases in scores on Response to Moral Adversity subscale of moral resilience were associated with a lower likelihood of traumatic stress and moral injury symptoms. CONCLUSIONS Moral resilience, especially response to difficult circumstances, may be protective in critical care environments, but system factors (eg, institutional betrayal) must also be addressed systemically rather than relying on individual-level interventions to address nurses' needs.
Collapse
Affiliation(s)
- Guy M Weissinger
- Guy M. Weissinger is the Diane Foley Parrett Endowed Assistant Professor, Fitzpatrick College of Nursing, Villanova University, Villanova, Pennsylvania
| | - Deborah Swavely
- Deborah Swavely is the senior director, Nursing Clinical Inquiry and Research, Reading Hospital, West Reading, Pennsylvania
| | - Heidi Holtz
- Heidi Holtz is an assistant professor, Goldfarb School of Nursing, Barnes-Jewish College, St Louis, Missouri
| | - Katherine C Brewer
- Katherine C. Brewer is an assistant professor, Towson University, Towson, Maryland
| | - Mary Alderfer
- Mary Alderfer is the Johns Hopkins Clinical Research Network liaison, Reading Hospital
| | - Lisa Lynn
- Lisa Lynn is a level 5 staff nurse (medical intensive care unit), Reading Hospital
| | - Angela Yoder
- Angela Yoder is a level 5 staff nurse (medical intensive care unit), Reading Hospital
| | - Thomas Adil
- Thomas Adil is the director of spiritual care, Reading Hospital
| | - Tom Wasser
- Tom Wasser is a consulting statistician, StatBiz, Macungie, Pennsylvania
| | - Danielle Cifra
- Danielle Cifra is a level 3 staff nurse (medical and surgical intensive care units) and the nursing quality improvement coordinator, Phoenixville Hospital, Phoenixville, Pennsylvania
| | - Cynda Rushton
- Cynda Rushton is the Anne and George L. Bunting Professor of Clinical Ethics, Berman Institute of Bioethics and School of Nursing, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
10
|
Brennan CJ, Roberts C, Cole JC. Prevalence of occupational moral injury and post-traumatic embitterment disorder: a systematic review and meta-analysis. BMJ Open 2024; 14:e071776. [PMID: 38382965 PMCID: PMC10882372 DOI: 10.1136/bmjopen-2023-071776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVES Occupational moral injury and post-traumatic embitterment disorder (PTED) describe the psychological distress caused by exposure to injustice at work. This meta-analysis aims to determine the prevalence of occupational moral injury and PTED and establish whether prevalence estimates differ depending on occupation. DESIGN A systematic review and meta-analysis. DATA SOURCES Google Scholar, PubMed, APA PsycINFO, Web of Science Core Collection, Scopus, ScienceDirect and Sage Journals Online were searched in June 2020 and updated in November 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Observational studies that measured prevalence or average scores of moral injury, or PTED in any occupational group and any geographical location. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened and coded eligible studies. Study design, participant demographics, sampling method, location, measurement tool and prevalence or average scores were extracted. Risk of bias was assessed using the Quality Assessment Checklist for Prevalence Studies tool. Meta-analysis was conducted using random effects models. Results that could not be combined were summarised qualitatively in a narrative synthesis using the Guidance for Systematic Reviews. RESULTS In total, 88 studies across armed forces and veterans, healthcare, first responders, educators, journalists, child protection service employees, the unemployed, public-sector employees and mixed occupations were included. Studies included in each separate meta-analysis based on the measure used ranged from 2 to 30. The pooled prevalence of clinically relevant moral injury in healthcare professionals was 45%, and exposure to any potentially morally injurious event (PMIE) across occupations was 67%. Exposure to transgressions by others and betrayal was significantly lower in the armed forces than civilian occupations. Pooled prevalence of PTED across occupations was 26%. CONCLUSION Exposure to PMIEs, moral injury symptoms and PTED are prevalent at work and exposure to transgressions by others and betrayal are more likely in civilian occupations than the armed forces. PROSPERO REGISTRATION NUMBER CRD42020191766.
Collapse
Affiliation(s)
| | - Carl Roberts
- Psychology, University of Liverpool, Liverpool, UK
| | - Jon C Cole
- Psychology, University of Liverpool, Liverpool, UK
| |
Collapse
|
11
|
D’Alessandro-Lowe AM, Patel H, Easterbrook B, Ritchie K, Brown A, Xue Y, Karram M, Millman H, Sullo E, Pichtikova M, Nicholson A, Heber A, Malain A, O’Connor C, Schielke H, Rodrigues S, Hosseiny F, McCabe RE, Lanius RA, McKinnon MC. The independent and combined impact of moral injury and moral distress on post-traumatic stress disorder symptoms among healthcare workers during the COVID-19 pandemic. Eur J Psychotraumatol 2024; 15:2299661. [PMID: 38334706 PMCID: PMC10860446 DOI: 10.1080/20008066.2023.2299661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 12/04/2023] [Indexed: 02/10/2024] Open
Abstract
Background: Healthcare workers (HCWs) across the globe have reported symptoms of Post-Traumatic Stress Disorder (PTSD) during the COVID-19 pandemic. Moral Injury (MI) has been associated with PTSD in military populations, but is not well studied in healthcare contexts. Moral Distress (MD), a related concept, may enhance understandings of MI and its relation to PTSD among HCWs. This study examined the independent and combined impact of MI and MD on PTSD symptoms in Canadian HCWs during the pandemic.Methods: HCWs participated in an online survey between February and December 2021, with questions regarding sociodemographics, mental health and trauma history (e.g. MI, MD, PTSD, dissociation, depression, anxiety, stress, childhood adversity). Structural equation modelling was used to analyze the independent and combined impact of MI and MD on PTSD symptoms (including dissociation) among the sample when controlling for sex, age, depression, anxiety, stress, and childhood adversity.Results: A structural equation model independently regressing both MI and MD onto PTSD accounted for 74.4% of the variance in PTSD symptoms. Here, MI was strongly and significantly associated with PTSD symptoms (β = .412, p < .0001) to a higher degree than MD (β = .187, p < .0001), after controlling for age, sex, depression, anxiety, stress and childhood adversity. A model regressing a combined MD and MI construct onto PTSD predicted approximately 87% of the variance in PTSD symptoms (r2 = .87, p < .0001), with MD/MI strongly and significantly associated with PTSD (β = .813, p < .0001), after controlling for age, sex, depression, anxiety, stress, and childhood adversity.Conclusion: Our results support a relation between MI and PTSD among HCWs and suggest that a combined MD and MI construct is most strongly associated with PTSD symptoms. Further research is needed better understand the mechanisms through which MD/MI are associated with PTSD.
Collapse
Affiliation(s)
| | - Herry Patel
- McMaster University, Hamilton, Ontario, Canada
| | | | - Kim Ritchie
- McMaster University, Hamilton, Ontario, Canada
- Trent University, Peterborough, Ontario, Canada
| | | | - Yuanxin Xue
- McMaster University, Hamilton, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Mauda Karram
- McMaster University, Hamilton, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | | | - Emily Sullo
- McMaster University, Hamilton, Ontario, Canada
| | - Mina Pichtikova
- McMaster University, Hamilton, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Andrew Nicholson
- McMaster University, Hamilton, Ontario, Canada
- University of Ottawa, Ottawa, Ontario, Canada
- Atlas Institute for Veterans and Families, Ottawa, Ontario, Canada
- University of Western Ontario, London, Ontario, Canada
| | - Alex Heber
- McMaster University, Hamilton, Ontario, Canada
- Canadian Institute for Pandemic Health Education and Response, Regina, Saskatchewan, Canada
| | - Ann Malain
- Homewood Health Centre, Guelph, Ontario, Canada
| | | | | | - Sarah Rodrigues
- University of Ottawa, Ottawa, Ontario, Canada
- Atlas Institute for Veterans and Families, Ottawa, Ontario, Canada
| | - Fardous Hosseiny
- University of Ottawa, Ottawa, Ontario, Canada
- Atlas Institute for Veterans and Families, Ottawa, Ontario, Canada
| | - Randi E. McCabe
- McMaster University, Hamilton, Ontario, Canada
- St. Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Ruth A. Lanius
- University of Western Ontario, London, Ontario, Canada
- Homewood Research Institute, Guelph, Ontario, Canada
| | - Margaret C. McKinnon
- McMaster University, Hamilton, Ontario, Canada
- St. Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
- Homewood Research Institute, Guelph, Ontario, Canada
| |
Collapse
|
12
|
Coimbra BM, Zylberstajn C, van Zuiden M, Hoeboer CM, Mello AF, Mello MF, Olff M. Moral injury and mental health among health-care workers during the COVID-19 pandemic: meta-analysis. Eur J Psychotraumatol 2024; 15:2299659. [PMID: 38189775 PMCID: PMC10776063 DOI: 10.1080/20008066.2023.2299659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/11/2023] [Indexed: 01/09/2024] Open
Abstract
Background: During the COVID-19 pandemic, health-care workers (HCWs) may have been confronted with situations that may culminate in moral injury (MI). MI is the psychological distress that may result from perpetrating or witnessing actions that violate one's moral codes. Literature suggests that MI can be associated with mental health problems.Objective: We aimed to meta-analytically review the literature to investigate whether MI is associated with symptoms of posttraumatic stress disorder (PTSD), anxiety, depression, burnout, and suicidal ideation among active HCWs during the COVID-19 pandemic.Method: We searched eight databases for studies conducted after the onset of the COVID-19 pandemic up to 18 July 2023, and performed random-effects meta-analyses to examine the relationship between MI and various mental health outcomes.Results: We retrieved 33 studies from 13 countries, representing 31,849 individuals, and pooled 79 effect sizes. We found a positive association between MI and all investigated mental health problems (rs = .30-.41, all ps < .0001). Between-studies heterogeneity was significant. A higher percentage of nurses in the samples was associated with a stronger relationship between MI and depressive and anxiety symptoms. Samples with a higher percentage of HCWs providing direct care to patients with COVID-19 exhibited a smaller effect between MI and depressive and anxiety symptoms. We observed a stronger effect between MI and PTSD symptoms in US samples compared to non-US samples.Conclusion: We found that higher MI is moderately associated with symptoms of PTSD, anxiety, depression, burnout, and suicidal ideation among HCWs during the COVID-19 pandemic. Our findings carry limitations due to the array of MI scales employed, several of which were not specifically designed for HCWs, but underscore the need to mitigate the effect of potentially morally injurious events on the mental health of HCWs.
Collapse
Affiliation(s)
- Bruno Messina Coimbra
- Programme for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
- Department of Methodology and Statistics, Faculty of Social and Behavioral Sciences, Utrecht University, Utrecht, The Netherlands
- Amsterdam UMC, Department of Psychiatry, Amsterdam Public Health Research Institute and Amsterdam Neuroscience Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Cecilia Zylberstajn
- Programme for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Mirjam van Zuiden
- Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands
| | - Chris Maria Hoeboer
- Amsterdam UMC, Department of Psychiatry, Amsterdam Public Health Research Institute and Amsterdam Neuroscience Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Andrea Feijo Mello
- Programme for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Marcelo Feijo Mello
- Programme for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Albert Einstein, São Paulo, Brazil
| | - Miranda Olff
- Amsterdam UMC, Department of Psychiatry, Amsterdam Public Health Research Institute and Amsterdam Neuroscience Research Institute, University of Amsterdam, Amsterdam, The Netherlands
- ARQ National Psychotrauma Centre, Diemen, The Netherlands
| |
Collapse
|
13
|
Fulton T, Lathan EC, Karkare MC, Guelfo A, Eghbalzad L, Ahluwalia V, Ely TD, Turner JA, Turner MD, Currier JM, Mekawi Y, Fani N. Civilian Moral Injury and Amygdala Functional Connectivity During Attention to Threat. BIOLOGICAL PSYCHIATRY. COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2024; 9:112-120. [PMID: 37487958 PMCID: PMC10803642 DOI: 10.1016/j.bpsc.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/27/2023] [Accepted: 07/06/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Moral injury references emotional and spiritual/existential suffering that may emerge following psychological trauma. Despite being linked to adverse mental health outcomes, little is known about the neurophysiological mechanisms of this phenomenon. In this study, we examined neural correlates of moral injury exposure and distress using the Moral Injury Exposure and Symptom Scale for Civilians. We also examined potential moderation of these effects by race (Black vs. White individuals) given the likely intersection of race-related stress with moral injury. METHODS Forty-eight adults ages 18 to 65 years (mean age = 30.56, SD = 11.93) completed the Moral Injury Exposure and Symptom Scale for Civilians and an affective attentional control measure, the affective Stroop task (AS), during functional magnetic resonance imaging; the AS includes presentation of threat-relevant and neutral distractor stimuli. Voxelwise functional connectivity of the bilateral amygdala was examined in response to threat-relevant versus neutral AS distractor trials. RESULTS Functional connectivity between the right amygdala and left postcentral gyrus/primary somatosensory cortex was positively correlated with the Moral Injury Exposure and Symptom Scale for Civilians exposure score (voxelwise p < .001, cluster false discovery rate-corrected p < .05) in response to threat versus neutral AS distractor trials. Follow-up analyses revealed significant effects of race; Black but not White participants demonstrated this significant pattern of amygdala-left somatosensory cortex connectivity. CONCLUSIONS Increased exposure to potentially morally injurious events may lead to emotion-somatosensory pathway disruptions during attention to threat-relevant stimuli. These effects may be most potent for individuals who have experienced multilayered exposure to morally injurious events, including racial trauma. Moral injury appears to have a distinct neurobiological signature that involves abnormalities in connectivity of emotion-somatosensory paths, which may be amplified by race-related stress.
Collapse
Affiliation(s)
- Travis Fulton
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia; Molecular and Systems Pharmacology PhD Program, Emory University, Atlanta, Georgia
| | - Emma C Lathan
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Maya C Karkare
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Alfonsina Guelfo
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Leyla Eghbalzad
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Vishwadeep Ahluwalia
- Center for Advanced Brain Imaging, Georgia Institute of Technology, Atlanta, Georgia
| | - Timothy D Ely
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | | | | | - Joseph M Currier
- Department of Psychology, University of South Alabama, Mobile, Alabama
| | - Yara Mekawi
- Department of Psychological and Brain Sciences, University of Louisville, Louisville, Kentucky
| | - Negar Fani
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia.
| |
Collapse
|
14
|
Ford JD, Seedat S. On the path to recovery: traumatic stress research during the COVID-19 pandemic 2021-2023. Eur J Psychotraumatol 2023; 14:2281988. [PMID: 38038964 PMCID: PMC10990445 DOI: 10.1080/20008066.2023.2281988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/17/2023] [Indexed: 12/02/2023] Open
Abstract
This Special Issue of the European Journal of Psychotraumatology (EJPT) presents 51 articles published between 2021 and 2023 and follows the Special Issue on pandemic-related traumatic stress research published in 2021 (O'Donnell, M. L., & Greene, T. [2021]. Understanding the mental health impacts of COVID-19 through a trauma lens. European Journal of Psychotraumatology, 12(1), 1982502). Research on traumatic stress during the pandemic has cast the spotlight on vulnerable populations and groups, notably front-line healthcare workers; people faced with major losses including the deaths of loved ones; those who personally survived debilitating and often life-threatening viral infection; and students who were isolated and experienced profound delays in their education, relationships, and emerging independence. The papers in this collection underscore the associations between COVID-19 related stressors and a plethora of adverse mental health sequelae, including posttraumatic stress reactions, and draw attention to the ubiquity of grief and moral injury and their wide-ranging and detrimental impact. Currently, there is a paucity of evidence on interventions to enhance resources, self-efficacy, and hope for affected groups and individuals through societal, organisational, and healthcare systems; however early research on the prevention of COVID-related traumatic stress disorders provides a basis for both hope and preparedness for the future.
Collapse
Affiliation(s)
- Julian D. Ford
- Department of Psychiatry, University of Connecticut Health Center, Farmington, CT, USA
| | - Soraya Seedat
- South African Medical Research Council Unit on the Genomics of Brain Disorders, Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| |
Collapse
|
15
|
Sinskey JL, Chang JM, Lu AC, Pian-Smith MC. Patient Safety and Clinician Well-Being. Anesthesiol Clin 2023; 41:739-753. [PMID: 37838381 DOI: 10.1016/j.anclin.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Clinician well-being and patient safety are intricately linked. We propose that organizational factors (ie, elements of the perioperative work environment and culture) affect both, as opposed to a bidirectional causal relationship. Threats to patient safety and clinician well-being include clinician mental health issues, negative work environments, poor teamwork and communication, and staffing shortages. Opportunities to mitigate these threats include the normalization of mental health care, peer support, psychological safety, just culture, teamwork and communication training, and creative staffing approaches.
Collapse
Affiliation(s)
- Jina L Sinskey
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 521 Parnassus Avenue, 4th Floor, San Francisco, CA, USA.
| | - Joyce M Chang
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 521 Parnassus Avenue, 4th Floor, San Francisco, CA, USA
| | - Amy C Lu
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - May C Pian-Smith
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA
| |
Collapse
|
16
|
Levi-Belz Y, Groweiss Y, Blank C. Moral injury and its mental health consequences among protesters: findings from Israel's civil protest against the government's judicial reform. Eur J Psychotraumatol 2023; 14:2283306. [PMID: 37994789 PMCID: PMC10993812 DOI: 10.1080/20008066.2023.2283306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/02/2023] [Indexed: 11/24/2023] Open
Abstract
Background: Government actions and participating in protracted-duration protests against it affect protesters' mental health, leading to high distress levels, such as posttraumatic and depressive symptoms. Aside from exposure to violence and other issues, protest participation can pose unique challenges to the protesters as they may be exposed to potentially morally injurious events (PMIEs), such as the betrayal of leaders they once trusted. This study's primary objective was to examine the extent of psychological difficulties among civilians participating in long-duration protests in Israel. More specifically, the study aimed to understand the contribution of exposure to protest-related PMIEs to psychological difficulties such as posttraumatic and depressive symptoms.Method: Participants comprised 4036 Israelis who were actively involved in the unfolding civil protest movement against the government-led judicial overhaul between January 2023 and August 2023. The protesters completed validated self-report questionnaires that included measures of PMIE exposure, PTSD and depressive symptoms.Results: About half (44.3%) of the sample met the criteria for self-report diagnosis of major depression and 10.6% for PTSD. Most of the protesters indicated their exposure to at least one moral injury event, with 63.9% reporting exposure to PMIE-Betrayal. Protesters exposed to PMIEs reported significantly higher levels of both PTSD and depression than non-PMIE-exposed protesters. Hierarchical regression analyses revealed that, beyond demographics and protest-related characteristics such as exposure to violence, PMIE dimensions significantly contributed to both PTSD and depression levels.Conclusions: The findings highlight the mental burden of protesters during the civil protests against the judicial overhaul in Israel. More central to the present research, the findings highlight the critical contribution of PMIEs exposure to this burden. Clinicians treating protesters coping with depression and PTSD following the civil actions should attend to their exposure to PMIEs, which may relate to the deleterious psychological effects among protesters.
Collapse
Affiliation(s)
- Yossi Levi-Belz
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
- Department of Behavioral Sciences, Ruppin Academic Center, Emek Hefer, Israel
| | - Yoav Groweiss
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
| | - Carmel Blank
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
- Department of Behavioral Sciences, Ruppin Academic Center, Emek Hefer, Israel
| |
Collapse
|
17
|
Fino E, Daniels JK, Micheli G, Gazineo D, Godino L, Imbriaco G, Antognoli M, Sist L, Regnano D, Decaro R, Guberti M, Mazzetti M. Moral injury in a global health emergency: a validation study of the Italian version of the Moral Injury Events Scale adjusted to the healthcare setting. Eur J Psychotraumatol 2023; 14:2263316. [PMID: 37815082 PMCID: PMC10566389 DOI: 10.1080/20008066.2023.2263316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/11/2023] [Indexed: 10/11/2023] Open
Abstract
Background: When exposed to events that transgress one's moral beliefs, a plethora of negative consequences may follow, which are captured by the concept of moral injury (MI). Despite its relevance to experiences of healthcare workers during a global health emergency, there is lack of validated MI instruments adapted to the healthcare setting.Objective: The present study aims to provide a validation of the Italian version of the Moral Injury Events Scale (MIES) adjusted to the healthcare setting by assessing its factor structure, internal consistency and construct validity.Methods: A sample of 794 healthcare workers (46% nurses, 51% female) engaged in hospital facilities during the COVID-19 pandemic in Italy completed measures of MI, PTSD, anxiety, depression, burnout, meaning in life and positive affect.Results: Using an exploratory structural equation modelling (ESEM) we assessed the scale factor structure for the entire sample and separately for nurse professional and female healthcare worker groups. Findings support a three-factor solution: Factor 1 'perceived transgressions by others'; Factor 2 'perceived transgressions by self'; and Factor 3 'perceived betrayals by others'. Findings also indicate some level of convergence with measures of PTSD, anxiety, depression and burnout.Conclusion: Results suggest that the MIES may be useful in capturing unique experiences of moral injury amongst healthcare workers engaged in a global health emergency. The low range correlations with measures of psychological distress might potentially indicate that MI, which captures cognitive value judgements rather than manifest symptomatology, may uniquely explain a certain amount of variance. Implications for the development of new empirically derived and theoretical guided tools are discussed, highlighting the need for future research to examine the role of individualising and social binding moral principles in gaining a more nuanced understanding of moral injury experiences amongst healthcare professionals across different socio-cultural settings.
Collapse
Affiliation(s)
- Edita Fino
- Department of Psychology “Renzo Cannestrari”, Alma Mater Studiorum - Università di Bologna, Bologna, Italy
| | - Judith K. Daniels
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, the Netherlands
| | - Giulia Micheli
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, the Netherlands
| | - Domenica Gazineo
- Governo Clinico e Qualità, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Lea Godino
- Medical Genetics Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Guglielmo Imbriaco
- UO Centrale Operativa 118 Emilia Est, Ospedale ‘Maggiore’, Bologna, Italy
| | | | - Luisa Sist
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum - Università di Bologna, Bologna, Italy
| | - Domenico Regnano
- Team accessi vascolari, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Roberta Decaro
- UO Deg. Percorso fegato e vie biliari/Medicina interna trattamento gravi insufficienze d’organo/TI post-operatoria/TI trapianti, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Michela Mazzetti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - Università di Bologna, Bologna, Italy
| |
Collapse
|
18
|
Fatima M, Imran N, Aamer I, Iqtadar S, Shabbir B. When healers get wounded! Moral injury in healthcare providers during the COVID-19 pandemic in Pakistan. Front Psychiatry 2023; 14:1244055. [PMID: 37795516 PMCID: PMC10545959 DOI: 10.3389/fpsyt.2023.1244055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/06/2023] [Indexed: 10/06/2023] Open
Abstract
Introduction Moral injury (MI) is a multi-faceted and multidimensional phenomenon. Occupational MI has been studied mainly among military personnel and first responders and is linked to mental health problems. MI encompasses negative moral emotions such as shame, guilt, and anger leading to distress, and impairment in social and occupational functioning. The COVID-19 pandemic predisposed healthcare providers to moral dilemmas, potentially morally injurious events (PMIEs), and MI. We aimed to assess the prevalence and predictors of MI in healthcare providers during the COVID-19 pandemic in Pakistan. Materials and methods This cross-sectional study was conducted in July-October 2021 among physician/clinician staff working at teaching hospitals in Lahore. The Moral Injury Symptoms Scale-Health Professionals (MISS-HP) was used to collect data. SPSS 26 was used for data analysis applying Wilcoxon Mann-Whitney U and Kruskal-Wallis tests on non-normally distributed data at α = 0.05. Predictors of MI were ascertained through Binary Logistic Regression analysis. Results Four hundred and twenty physicians responded to the questionnaires. The Median (IQR) MI scores were 37(28-47). Guilt, moral concerns, and shame were higher-scoring MI dimensions. 40.8% (n = 171) suffered from clinically significant distress and impaired functioning while 14.3% (n = 60) from severe distress. Gender, department, and history of psychiatric illness predicted higher levels of distress which were 1.9 times higher in females than males and 2.5 times higher with a history of psychiatric illness. Working on the front lines did not predict MI. Conclusion Our findings highlight the substantial burden of MI in our sample during COVID-19, having implications for healthcare providers' well-being, healthcare quality, and service delivery. This calls for concerted efforts from all stakeholders to better prepare for future disasters through effective human-resource policies, pre-trauma exposure soft-skills training, effective teamwork and communication strategies; self-stewardship and resilience modules, and mental health support for healthcare providers. The dimensional construct of MI may vary across cultures; hence we recommend further cross-cultural research on MI in healthcare providers, particularly in the context of public health disasters.
Collapse
Affiliation(s)
- Madah Fatima
- Academic Department of Psychiatry and Behavioral Sciences, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
| | - Nazish Imran
- Child and Family Psychiatry Department, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
| | - Irum Aamer
- Academic Department of Psychiatry and Behavioral Sciences, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
| | - Somia Iqtadar
- Department of Medicine, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
| | - Bilquis Shabbir
- Department of Medicine, Sir Ganga Ram Hospital, Fatima Jinnah Medical University, Lahore, Pakistan
| |
Collapse
|
19
|
Zhang X, Johannsson H, Tucker JD, Riyat A, Chiu YLT, Greenberg N, Sharpe R. 'Thrown in at the deep end': a qualitative analysis into the transition from trainee to consultant during the COVID-19 pandemic and lessons for the future. BJA OPEN 2023; 7:100217. [PMID: 37638089 PMCID: PMC10291287 DOI: 10.1016/j.bjao.2023.100217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/21/2023] [Indexed: 08/29/2023]
Abstract
Background Sustained crises such as the COVID-19 pandemic would be expected to impact the transition from trainee to consultant for anaesthetists or intensivists, but limited research exists on this important topic. This study aimed to examine the social context of this crucial career transition during the pandemic and post-pandemic periods. Methods We conducted semi-structured interviews with anaesthetists and intensivists who became consultants after the first UK lockdown. Thematic analysis was used and data saturation was reached at 33 interviews. Results The pandemic substantially impacted the transition to consultant role in various ways, including professional identity, clinical and non-clinical responsibilities, and wellbeing. Participants experienced identity confusion, self-doubt, and moral injury, resulting in intense emotional distress, feelings of guilt and helplessness, which persisted beyond the pandemic. They also felt unprepared for their consultant roles because of disruptions in training. The pandemic exaggerated the vulnerability of those transitioning to consultants, because of increased clinical uncertainties, and pressures of the growing backlog. Additionally, the pandemic impacted on the wellbeing of those transitioning to consultants, intensifying feelings of anxiety and stress. We also identified unique opportunities presented by the pandemic, which accelerated learning and encouraged post-traumatic growth. Our study identified practical solutions that may improve transition experience at individual, organisational, and national levels. Conclusions Persistent crises significantly impact the transition from trainee to consultant. Our findings generated insights into the challenges of this critical career transition and staff wellbeing, and serve to inform approaches of ongoing support for those transitioning to consultants.
Collapse
Affiliation(s)
- Xiaoxi Zhang
- London North West University Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | | | - Joseph D. Tucker
- London School of Hygiene and Tropical Medicine, London, UK
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, NC, USA
| | - Amardeep Riyat
- London North West University Healthcare NHS Trust, London, UK
| | - Yuan-Li Tiffany Chiu
- Centre for Higher Education Research and Scholarship, Imperial College London, London, UK
| | | | - Roger Sharpe
- London North West University Healthcare NHS Trust, London, UK
| |
Collapse
|
20
|
Rabin S, Kika N, Lamb D, Murphy D, AM Stevelink S, Williamson V, Wessely S, Greenberg N. Moral Injuries in Healthcare Workers: What Causes Them and What to Do About Them? J Healthc Leadersh 2023; 15:153-160. [PMID: 37605753 PMCID: PMC10440078 DOI: 10.2147/jhl.s396659] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/26/2023] [Indexed: 08/23/2023] Open
Abstract
Moral injury (MI) refers to the persisting distress which may occur following exposure to potentially morally injurious events (PMIEs). The COVID-19 pandemic has drawn attention to MI in healthcare workers, who have been found to experience more frequent PMIEs in their day-to-day work than those in other occupational groups such as the military. These events may occur on an individual, team, organizational or system level and have been associated with increased clinician burnout and distress, and poor psychological wellbeing. This paper focuses on healthcare workers' experiences of MI, including potential causes and ways to reduce them. There are myriad challenges that influence the development of MI, such as chronic understaffing and the pressure to treat high numbers of patients with limited resources. There are also multiple impacts of MI: at the individual-level, MI can lead to increased staff absences and understaffing, and prolonged patient contact with limited decision-making power. COVID-19 exacerbated such impacts, with a lack of organizational support during a time of increased patient mortality, and uncertainty and heightened pressure on the clinical frontline associated with scarce resources and understaffing. Potential methods for reduction of MI in healthcare workers include pre-exposure mitigation, such as fostering work environments which treat PMIEs in the same way as other occupational hazards and post-exposure mitigation, such as facilitating healthcare workers to process their experiences of PMIEs in peer support groups or with spiritual advisors and, if MI is associated with mental ill-health, talking therapies using trauma-focused and compassion-oriented frameworks.
Collapse
Affiliation(s)
- Sarah Rabin
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Natalia Kika
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Danielle Lamb
- Department of Applied Health Research, University College London, London, UK
| | - Dominic Murphy
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Research Department, Combat Stress, Leatherhead, UK
| | - Sharon AM Stevelink
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Victoria Williamson
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Simon Wessely
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Neil Greenberg
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| |
Collapse
|
21
|
Lamb D, Stevelink SAM, Scott HR, Greenberg N, Wessely S. COVID-19 and the mental health of health-care workers. Lancet Psychiatry 2023; 10:245. [PMID: 36931774 PMCID: PMC10017111 DOI: 10.1016/s2215-0366(23)00062-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 02/21/2023] [Accepted: 02/21/2023] [Indexed: 03/17/2023]
Affiliation(s)
- Danielle Lamb
- NIHR ARC North Thames, University College London, London, UK.
| | - Sharon A M Stevelink
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Hannah R Scott
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Neil Greenberg
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Simon Wessely
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| |
Collapse
|
22
|
Billings J. The effect of the COVID-19 pandemic on health-care workers. Lancet Psychiatry 2023; 10:3-5. [PMID: 36526344 PMCID: PMC9750182 DOI: 10.1016/s2215-0366(22)00410-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Jo Billings
- Division of Psychiatry, University College London, London, UK.
| |
Collapse
|
23
|
Rodrigues S, Mercier JM, McCall A, Nannarone M, Hosseiny F. 'Against everything that got you into the job': experiences of potentially morally injurious events among Canadian public safety personnel. Eur J Psychotraumatol 2023; 14:2205332. [PMID: 37170904 PMCID: PMC10184585 DOI: 10.1080/20008066.2023.2205332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/07/2023] [Accepted: 04/12/2023] [Indexed: 05/13/2023] Open
Abstract
Background: Moral injury (MI) has become a research and organizational priority as frontline personnel have, both during and in the years preceding the COVID-19 pandemic, raised concerns about repeated expectations to make choices that transgress their deeply held morals, values, and beliefs. As awareness of MI grows, so, too, does attention on its presence and impacts in related occupations such as those in public safety, given that codes of conduct, morally and ethically complex decisions, and high-stakes situations are inherent features of such occupations.Objective: This paper shares the results of a study of the presence of potentially morally injurious events (PMIEs) in the lived experiences of 38 public safety personnel (PSP) in Ontario, Canada.Method: Through qualitative interviews, this study explored the types of events PSP identify as PMIEs, how PSP make sense of these events, and the psychological, professional, and interpersonal impacts of these events. Thematic analysis supported the interpretation of PSP descriptions of events and experiences.Results: PMIEs do arise in the context of PSP work, namely during the performance of role-specific responsibilities, within the organizational climate, and because of inadequacies in the broader healthcare system. PMIEs are as such because they violate core beliefs commonly held by PSP and compromise their ability to act in accordance with the principles that motivate them in their work. PSP associate PMIEs, in combination with traumatic experiences and routine stress, with adverse psychological, professional and personal outcomes.Conclusion: The findings provide additional empirical evidence to the growing literature on MI in PSP, offering insight into the contextual dimensions that contribute to the sources and effects of PMIEs in diverse frontline populations as well as support for the continued application and exploration of MI in the PSP context.
Collapse
Affiliation(s)
- Sara Rodrigues
- Research and Policy, Atlas Institute for Veterans and Families, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
- Institute of Mental Health Research, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
| | - Jean-Michel Mercier
- Research and Policy, Atlas Institute for Veterans and Families, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
- Institute of Mental Health Research, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
| | - Adelina McCall
- Research and Policy, Atlas Institute for Veterans and Families, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
- Institute of Mental Health Research, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
| | - Molly Nannarone
- Research and Policy, Atlas Institute for Veterans and Families, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
- Institute of Mental Health Research, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
| | - Fardous Hosseiny
- Research and Policy, Atlas Institute for Veterans and Families, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
- Institute of Mental Health Research, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
| |
Collapse
|