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McNeill K, Vaillancourt S, Choe S, Yang I, Sonnadara R. "I don't know if I can keep doing this": a qualitative investigation of surgeon burnout and opportunities for organization-level improvement. Front Public Health 2024; 12:1379280. [PMID: 38799682 PMCID: PMC11116672 DOI: 10.3389/fpubh.2024.1379280] [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: 01/30/2024] [Accepted: 04/23/2024] [Indexed: 05/29/2024] Open
Abstract
Introduction Burnout is a pressing issue within surgical environments, bearing considerable consequences for both patients and surgeons alike. Given its prevalence and the unique contextual factors within academic surgical departments, it is critical that efforts are dedicated to understanding this issue. Moreover, active involvement of surgeons in these investigations is critical to ensure viability and uptake of potential strategies in their local setting. Thus, the purpose of this study was to explore surgeons' experiences with burnout and identify strategies to mitigate its drivers at the level of the organization. Methods A qualitative case study was conducted by recruiting surgeons for participation in a cross-sectional survey and semi-structured interviews. Data collected were analyzed using reflexive thematic analysis, which was informed by the Areas of Worklife Model. Results Overall, 28 unique surgeons participated in this study; 11 surgeons participated in interviews and 22 provided responses through the survey. Significant contributors to burnout identified included difficulties providing adequate care to patients due to limited resources and time available in academic medical centers and the moral injury associated with these challenges. The inequitable remuneration associated with education, administration, and leadership roles as a result of the Fee-For-Service model, as well as issues of gender inequity and the individualistic culture prevalent in surgical specialties were also described as contributing factors. Participants suggested increasing engagement between hospital leadership and staff to ensure surgeons are able to access resources to care for their patients, reforming payment plans and workplace polities to address issues of inequity, and improving workplace social dynamics as strategies for addressing burnout. Discussion The high prevalence and negative sequalae of burnout in surgery necessitates the formation of targeted interventions to address this issue. A collaborative approach to developing interventions to improve burnout among surgeons may lead to feasible and sustainable solutions.
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Affiliation(s)
- Kestrel McNeill
- Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, ON, Canada
| | - Sierra Vaillancourt
- Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, ON, Canada
- Department of Biology, McMaster University, Hamilton, ON, Canada
| | - Stella Choe
- Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, ON, Canada
| | - Ilun Yang
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Ranil Sonnadara
- Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, ON, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Vector Institute for Artificial Intelligence, Toronto, ON, Canada
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Callis AB, Saul T, Bindler RJ. The Impact of Moral Injury on Self-reported Work Performance in Hospital Nurses Following the Global Pandemic Surge. J Nurs Adm 2024; 54:177-183. [PMID: 38381573 DOI: 10.1097/nna.0000000000001404] [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: 02/23/2024]
Abstract
OBJECTIVE The aim of this study was to determine relationships between moral injury (MI) and self-reported nurse work performance (NWP) among hospital nurses after the COVID-19 pandemic surges. BACKGROUND Previously studied in the military, nurse MI became evident due to the pandemic. No previous studies have examined the impact of MI on NWP. Few studies have attended to how MI in nurses can be addressed by nursing leadership. METHODS A convenience sample of 191 nurses from 7 hospitals in Southern California participated in a multisite correlational survey-design study. RESULTS Significant levels of MI occurred in 57% (n = 114) of participants. Increased levels of MI were a significant predictor of decreased levels of self-reported NWP. Younger and less experienced nurses reported greater levels of MI. CONCLUSIONS This study relates MI in nurses to NWP. There is a need for further research to assist nursing administrators in ameliorating MI in nurses and in preparing for the impact of MI on the nursing workforce in future emergent situations.
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Affiliation(s)
- Annette Browning Callis
- Author Affiliations: Professor and Director of Graduate Nursing (Dr Callis), Vanguard University, Costa Mesa; Director of Research (Dr Saul), Providence Southern California Region, Irvine; and Biostatistician (Dr Bindler), Independent Contractor, Providence Southern California Region, Irvine, California; and Research Investigator (Dr Bindler), College of Nursing, Washington State University-Spokane
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Houle SA, Ein N, Gervasio J, Plouffe RA, Litz BT, Carleton RN, Hansen KT, Liu JJW, Ashbaugh AR, Callaghan W, Thompson MM, Easterbrook B, Smith-MacDonald L, Rodrigues S, Bélanger SAH, Bright K, Lanius RA, Baker C, Younger W, Bremault-Phillips S, Hosseiny F, Richardson JD, Nazarov A. Measuring moral distress and moral injury: A systematic review and content analysis of existing scales. Clin Psychol Rev 2024; 108:102377. [PMID: 38218124 DOI: 10.1016/j.cpr.2023.102377] [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: 08/31/2023] [Revised: 11/03/2023] [Accepted: 12/21/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Moral distress (MD) and moral injury (MI) are related constructs describing the negative consequences of morally challenging stressors. Despite growing support for the clinical relevance of these constructs, ongoing challenges regarding measurement quality risk limiting research and clinical advances. This study summarizes the nature, quality, and utility of existing MD and MI scales, and provides recommendations for future use. METHOD We identified psychometric studies describing the development or validation of MD or MI scales and extracted information on methodological and psychometric qualities. Content analyses identified specific outcomes measured by each scale. RESULTS We reviewed 77 studies representing 42 unique scales. The quality of psychometric approaches varied greatly across studies, and most failed to examine convergent and divergent validity. Content analyses indicated most scales measure exposures to potential moral stressors and outcomes together, with relatively few measuring only exposures (n = 3) or outcomes (n = 7). Scales using the term MD typically assess general distress. Scales using the term MI typically assess several specific outcomes. CONCLUSIONS Results show how the terms MD and MI are applied in research. Several scales were identified as appropriate for research and clinical use. Recommendations for the application, development, and validation of MD and MI scales are provided.
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Affiliation(s)
- Stephanie A Houle
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Research Directorate, Veterans Affairs Canada, Charlottetown, Canada
| | - Natalie Ein
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada
| | - Julia Gervasio
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada
| | - Rachel A Plouffe
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychology, University of Dundee, Dundee, UK
| | - Brett T Litz
- Department of Psychiatry, Boston University, Boston, USA; Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, USA; Department of Psychological and Brain Sciences, Boston University, Boston, USA
| | | | - Kevin T Hansen
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada
| | - Jenny J W Liu
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada
| | | | - Walter Callaghan
- Department of Anthropology, University of Toronto, Toronto, Canada
| | | | - Bethany Easterbrook
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, Canada
| | | | - Sara Rodrigues
- The Atlas Institute for Veterans and Families, Ottawa, Canada
| | | | | | - Ruth A Lanius
- Department of Psychiatry, Western University, London, Canada
| | - Clara Baker
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada
| | - William Younger
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada
| | | | | | - J Don Richardson
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada; St. Joseph's Operational Stress Injury Clinic, St. Joseph's Health Care London, London, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
| | - Anthony Nazarov
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada.
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Bushuven S, Trifunovic-Koenig M, Bunz M, Weinmann-Linne P, Klemm V, Strametz R, Müller BS. Applicability and Validity of Second Victim Assessment Instruments among General Practitioners and Healthcare Assistants (SEVID-IX Study). Healthcare (Basel) 2024; 12:351. [PMID: 38338236 PMCID: PMC10855668 DOI: 10.3390/healthcare12030351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND The second victim phenomenon and moral injury are acknowledged entities of psychological harm for healthcare providers. Both pose risks to patients, healthcare workers, and medical institutions, leading to further adverse events, economic burden, and dysfunctionality. Preceding studies in Germany and Austria showed a prevalence of second victim phenomena exceeding 53 percent among physicians, nurses, emergency physicians, and pediatricians. Using two German instruments for assessing moral injury and second victim phenomena, this study aimed to evaluate their feasibility for general practitioners and healthcare assistants. METHODS We conducted a nationwide anonymous online survey in Germany among general practitioners and healthcare assistants utilizing the SeViD (Second Victims in Deutschland) questionnaire, the German version of the Second Victim Experience and Support Tool Revised Version (G-SVESTR), and the German version of the Moral Injury Symptom and Support Scale for Health Professionals (G-MISS-HP). RESULTS Out of 108 participants, 67 completed the survey. In G-SVESTR, the collegial support items exhibited lower internal consistency than in prior studies, while all other scales showed good-quality properties. Personality traits, especially neuroticism, negatively correlated to age, seem to play a significant role in symptom count and warrant further evaluation. Multiple linear regression indicated that neuroticism, agreeableness, G-SVESTR, and G-MISS-HP were significant predictors of symptom count. Furthermore, moral injury partially mediated the relationship between second victim experience and symptom count. DISCUSSION The results demonstrate the feasible use of the questionnaires, except for collegial support. With respect to selection bias and the cross-sectional design of the study, moral injury may be subsequent to the second victim phenomenon, strongly influencing symptom count in retrospect. This aspect should be thoroughly evaluated in future studies.
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Affiliation(s)
- Stefan Bushuven
- Training Center for Emergency Medicine (NOTIS e.V), 78234 Engen, Germany;
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, 79106 Freiburg, Germany
- Institute for Medical Education, University Hospital, LMU Munich, 80539 Munich, Germany
| | - Milena Trifunovic-Koenig
- Training Center for Emergency Medicine (NOTIS e.V), 78234 Engen, Germany;
- Wiesbaden Institute for Healthcare Economics and Patient Safety (WiHelP), Wiesbaden Business School, RheinMain University of Applied Sciences, 65183 Wiesbaden, Germany; (V.K.); (R.S.)
| | - Maxie Bunz
- Institute of General Practice, University of Cologne, 50937 Cologne, Germany; (M.B.); (P.W.-L.); (B.S.M.)
| | - Patrick Weinmann-Linne
- Institute of General Practice, University of Cologne, 50937 Cologne, Germany; (M.B.); (P.W.-L.); (B.S.M.)
| | - Victoria Klemm
- Wiesbaden Institute for Healthcare Economics and Patient Safety (WiHelP), Wiesbaden Business School, RheinMain University of Applied Sciences, 65183 Wiesbaden, Germany; (V.K.); (R.S.)
| | - Reinhard Strametz
- Wiesbaden Institute for Healthcare Economics and Patient Safety (WiHelP), Wiesbaden Business School, RheinMain University of Applied Sciences, 65183 Wiesbaden, Germany; (V.K.); (R.S.)
| | - Beate Sigrid Müller
- Institute of General Practice, University of Cologne, 50937 Cologne, Germany; (M.B.); (P.W.-L.); (B.S.M.)
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Liu G, Tong Y, Li J, Sun X, Chen L, Zheng X, Zhang X, Lv J, Wang J, Wei B, Wei J, Cheng R, Wang Z. Burnout, moral injury, and suicidal/self-harm ideation among healthcare professionals in Mainland China: Insights from an online survey during the COVID-19 pandemic. Int J Psychiatry Med 2023:912174231219041. [PMID: 38047438 DOI: 10.1177/00912174231219041] [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] [Indexed: 12/05/2023]
Abstract
OBJECTIVE This survey aimed to explore the relationships between burnout, moral injury, and suicidal/self-harm ideation among Chinese health professionals to provide a reference for protecting their mental health. METHOD Health professionals were surveyed online using the Maslach Burnout Inventory-Human Services Survey for Medical Personnel, Patient Health Questionnaire-9, and the Moral Injury Symptoms Scale-Health Professional. RESULTS In the analysis, 6146 eligible respondents were included in the study. The average participant age was 34.9 ± 8.5 years, and suicidal/self-harm ideation was detected in 2338 participants (38.0%). The prevalence of suicidal/self-harm ideation among those with severe burnout in the dimensions of emotional exhaustion, depersonalisation, and decreased personal accomplishment was significantly higher than those with mild burnout. The prevalence of suicidal/self-harm ideation among those with significant moral injury symptoms was higher than those without moral injury. Unconditional logistic regression analysis showed that those with moderate or severe emotional exhaustion, moderate or severe reduced sense of professional accomplishment and moderate or severe depersonalisation had increased risks of suicidal/self-harm ideation. CONCLUSIONS Structural equation modelling demonstrated that burnout significantly mediated the relationship between moral injury and suicidal/self-harm ideation. The proportion of mediation (PM) by burnout was 43.0%. Burnout and moral injury were potential predictors of suicidal/self-harm ideation among health professionals. Both moral injury and burnout had positive and direct effects on suicidal/self-harm ideation, and burnout was a mediator in this relationship among Chinese health professionals. Therefore, to alleviate the moral injury and subsequent burnout of healthcare workers and enhance their mental qualities, active interventions should be developed in the future.
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Affiliation(s)
- Guangtian Liu
- Department of Infectious Disease, The No.4 Hospital of Ningxia Hui Autonomous Region, Yinchuan, China
| | - Yan Tong
- Department of Social Medicine, School of Public Health, Shanxi Medical University, Taiyuan, China
| | - Jinghong Li
- Department of Social Medicine, School of Public Health, Shanxi Medical University, Taiyuan, China
| | - Xiaoya Sun
- Department of Clinical Psychology, Futian Center for Chronic Disease Control, Shenzhen, China
| | - Linlin Chen
- Department of Epidemiology and Health Statistics, School of Public Health, Ningxia Medical University, Yinchuan, China
| | - Xiwei Zheng
- Department of Respiratory and Critical Care, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Xinhui Zhang
- Department of Infectious Disease, The No.4 Hospital of Ningxia Hui Autonomous Region, Yinchuan, China
| | - Jufen Lv
- Department of Epidemiology and Health Statistics, School of Public Health, Ningxia Medical University, Yinchuan, China
| | - Jinyan Wang
- Department of Rehabilitation and Nursing, Ningxia Vocational and Technical College for Minorities, Wuzhong, China
| | - Bingfen Wei
- Department of Rehabilitation and Nursing, Ningxia Vocational and Technical College for Minorities, Wuzhong, China
| | - Jianhua Wei
- Department of Infectious Disease, The No.4 Hospital of Ningxia Hui Autonomous Region, Yinchuan, China
| | - Ruixia Cheng
- Department of Infectious Disease, The No.4 Hospital of Ningxia Hui Autonomous Region, Yinchuan, China
| | - Zhizhong Wang
- Department of Epidemiology and Health Statistics, School of Public Health, Ningxia Medical University, Yinchuan, China
- Department of Epidemiology and Health Statistics, School of Public Health, Guangdong Medical University, Dongguan, China
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Sharma ME, Cousins R. Understanding Moral Injury in Frontline Health Care Professionals 2 Years After the Onset of COVID-19. J Nerv Ment Dis 2023; 211:934-939. [PMID: 37192009 DOI: 10.1097/nmd.0000000000001665] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
ABSTRACT Throughout the COVID-19 pandemic, health care professionals have worked in morally challenging situations. The aim of this research was to investigate the predictors of moral injury in United Kingdom frontline health care professionals working in a variety of roles 2 years after the onset of the pandemic. A cross-sectional survey was conducted January 25-February 28, 2022. A total of 235 participants answered sociodemographic, employment, health, COVID-19-related questions, and the 10-item Moral Injury Symptom Scale-Healthcare Professional version. Nearly three quarters had experienced moral injury. Twelve significant predictors of moral injury were entered into a backward elimination binominal logistic regression. The final model included five independent predictors that explained 25.4% variance in moral injury (χ 2 [5, N = 235] = 45.7, p < 0.001). Odds of moral injury were significantly raised in young health care professionals (<31 years), smokers, and those reporting low workplace confidence, not feeling appreciated, and feeling burned out. The findings support interventions to relieve moral injury in frontline health care professionals.
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Abstract
Healthcare workers experience moral injury (MI), a violation of their moral code due to circumstances beyond their control. MI threatens the healthcare workforce in all settings and leads to medical errors, depression/anxiety, and personal and occupational dysfunction, significantly affecting job satisfaction and retention. This article aims to differentiate concepts and define causes surrounding MI in healthcare. A narrative literature review was performed using SCOPUS, CINAHL, and PubMed for peer-reviewed journal articles published in English between 2017 and 2023. Search terms included "moral injury" and "moral distress," identifying 249 records. While individual risk factors predispose healthcare workers to MI, root causes stem from healthcare systems. Accumulation of moral stressors and potentially morally injurious events (PMIEs) (from administrative burden, institutional betrayal, lack of autonomy, corporatization of healthcare, and inadequate resources) result in MI. Individuals with MI develop moral resilience or residue, leading to burnout, job abandonment, and post-traumatic stress. Healthcare institutions should focus on administrative and climate interventions to prevent and address MI. Management should ensure autonomy, provide tangible support, reduce administrative burden, advocate for diversity of clinical healthcare roles in positions of interdisciplinary leadership, and communicate effectively. Strategies also exist for individuals to increase moral resilience, reducing the impact of moral stressors and PMIEs.
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Affiliation(s)
- Emily K Mewborn
- The University of Tennessee Health Science Center, Memphis, TN, USA
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Whitehead PB, Haisch CE, Hankey MS, Mutcheson RB, Dewitt SA, Stewart CA, Stewart JD, Bath JL, Boone SM, Jileaeva I, Faulks ER, Musick DW. Studying moral distress (MD) and moral injury (MI) among inpatient and outpatient healthcare professionals during the COVID-19 pandemic. Int J Psychiatry Med 2023:912174231205660. [PMID: 37807925 DOI: 10.1177/00912174231205660] [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] [Indexed: 10/10/2023]
Abstract
BACKGROUND COVID-19 increased moral distress (MD) and moral injury (MI) among healthcare professionals (HCPs). MD and MI were studied among inpatient and outpatient HCPs during March 2022. OBJECTIVES We sought to examine (1) the relationship between MD and MI; (2) the relationship between MD/MI and pandemic-related burnout and resilience; and (3) the degree to which HCPs experienced pandemic-related MD and MI based on their background. METHODS A survey was conducted to measure MD, MI, burnout, resilience, and intent to leave healthcare at 2 academic medical centers during a 4-week period. A convenience sample of 184 participants (physicians, nurses, residents, respiratory therapists, advanced practice providers) completed the survey. In this mixed-methods approach, researchers analyzed both quantitative and qualitative survey data and triangulated the findings. RESULTS There was a moderate association between MD and MI (r = .47, P < .001). Regression results indicated that burnout was significantly associated with both MD and MI (P = .02 and P < .001, respectively), while intent to leave was associated only with MD (P < .001). Qualitative results yielded 8 sources of MD and MI: workload, distrust, lack of teamwork/collaboration, loss of connection, lack of leadership, futile care, outside stressors, and vulnerability. CONCLUSIONS While interrelated conceptually, MD and MI should be viewed as distinct constructs. HCPs were significantly impacted by the COVID-19 pandemic, with MD and MI being experienced by all HCP categories. Understanding the sources of MD and MI among HCPs could help to improve well-being and work satisfaction.
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Affiliation(s)
| | | | | | - Ryan B Mutcheson
- Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | | | | | | | | | | | - Ilona Jileaeva
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | | | - David W Musick
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
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Zasiekina L, Zasiekin S, Kuperman V. Post-traumatic Stress Disorder and Moral Injury Among Ukrainian Civilians During the Ongoing War. J Community Health 2023; 48:784-792. [PMID: 37119352 PMCID: PMC10148618 DOI: 10.1007/s10900-023-01225-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/01/2023]
Abstract
While severity of post-traumatic stress disorder (PTSD) symptoms and moral injury among civilians affected by armed conflicts is generally understudied, even less research exists on civilian populations during an active war. This paper reports a large-scale study that administered standard assessments of PTSD and moral injury severity, as well as rich demographic questionnaires, to nearly 1300 Ukrainian civilians during the ongoing Russian invasion. Analyses revealed an extremely high prevalence of severe PTSD symptoms and moral injury, relative to both proposed clinical cut-offs and to earlier measurements from a similar population. Further regression analyses identified risk factors and protective factors. Greater severity of PTSD symptoms was observed among women, older and forcibly displaced individuals, and individuals from geographic regions under Russian occupation. Higher education correlated with milder PTSD symptoms. Moral injury was particularly strong in younger individuals. The present study is one of the first to report a large scale set of psychological data collected from the civilian population of Ukraine during the ongoing Russian invasion. It is obvious from the scope and long-term nature of the atrocities that psychological treatment of the civilian population will be required both presently, while the hostilities are ongoing, and in the future. This data contributes to a detailed understanding of the psychological response to traumatic stress, including its overall prevalence and presence in specific demographically and geographically defined civilian groups.
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Affiliation(s)
- Larysa Zasiekina
- Lesya Ukrainka Volyn National University, Lutsk, Ukraine.
- University of Cambridge, Cambridge, UK.
| | - Serhii Zasiekin
- Lesya Ukrainka Volyn National University, Lutsk, Ukraine
- University College London, London, UK
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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.
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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
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Johanson LS, Hughes V, Fingerhood ML, Mewborn E. Addressing moral injury in nursing education. J Prof Nurs 2023; 48:194-199. [PMID: 37775235 DOI: 10.1016/j.profnurs.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 07/14/2023] [Accepted: 07/25/2023] [Indexed: 10/01/2023]
Affiliation(s)
- Linda S Johanson
- 2078 East Winds Ave., Morganton, NC 28655, United States of America; Walden University (virtual university), 100 Washington Ave. S. Suite 900, Minneapolis, MN 55401, United States of America.
| | - Victoria Hughes
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD 21205, United States of America.
| | | | - Emily Mewborn
- The University of Tennessee Health Science Center, United States of America
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12
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O'Garo KGN, Koenig HG. Spiritually Integrated Cognitive Processing Therapy for Moral Injury in the Setting of PTSD: Initial Evidence of Therapeutic Efficacy. J Nerv Ment Dis 2023; 211:656-663. [PMID: 37381149 DOI: 10.1097/nmd.0000000000001686] [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] [Indexed: 06/30/2023]
Abstract
ABSTRACT After defining the syndrome of moral injury (MI), reviewing its relationship to posttraumatic stress disorder (PTSD), and examining its psychological consequences and impact on functioning, we describe a new psychotherapeutic treatment for MI called spiritually integrated cognitive processing therapy (SICPT). SICPT builds on cognitive processing therapy (CPT), a commonly used trauma-focused treatment for PTSD. To our knowledge, SICPT is the first one-on-one individualized psychotherapeutic treatment that integrates a person's spiritual and religious beliefs into the treatment for MI, using the latter to work through and process the psychological, spiritual, and religious symptoms of this condition. Here, we describe the initial results obtained from a single-group experimental study examining the treatment of three patients with significant symptoms of both MI and PTSD. Given the effects of SICPT on reducing both MI and PTSD symptoms, we have decided to report these early results before study completion to alert the scientific community about this potentially effective new treatment.
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Affiliation(s)
- Keisha-Gaye N O'Garo
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
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Whitehead IO, Moffatt S, Warwick S, Spiers GF, Kunonga TP, Tang E, Hanratty B. Systematic review of the relationship between burn-out and spiritual health in doctors. BMJ Open 2023; 13:e068402. [PMID: 37553194 PMCID: PMC10414094 DOI: 10.1136/bmjopen-2022-068402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 05/03/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVE To investigate the relationship between burn-out and spiritual health among medical doctors. DESIGN Systematic literature review and narrative synthesis of cross-sectional studies. SETTING Any setting, worldwide. DATA SOURCES Five databases were searched from inception to March 2022, including Medline, Embase, PsycINFO, Scopus and Web of Science. ELIGIBILITY CRITERIA Any study design that involved medical doctors (and other healthcare staff if assessed alongside medical doctors), that measured (in any way) both burn-out (or similar) and spiritual health (or similar) medical doctors. DATA EXTRACTION AND SYNTHESIS All records were double screened. Data extraction was performed by one reviewer and a proportion (10%) checked by a second reviewer. Quality was assessed using the Appraisal of Cross-sectional Studies tool. Due to the heterogeneity of the included studies, a narrative review was undertaken without a meta-analysis. RESULTS Searches yielded 1049 studies. 40 studies met eligibility criteria and were included in this review. Low reported levels of spirituality were associated with high burn-out scores and vice versa. Religion was not significantly associated with lower levels of burn-out. Few studies reported statistically significant findings, few used validated spiritual scores and most were vulnerable to sampling bias. CONCLUSIONS Published research suggests that burn-out is linked to spiritual health in medical doctors but not to religion. Robust research is needed to confirm these findings and develop effective interventions. PROSPERO REGISTRATION NUMBER CRD42020200145.
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Affiliation(s)
| | - Suzanne Moffatt
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Stephanie Warwick
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Gemma F Spiers
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Eugene Tang
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Barbara Hanratty
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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14
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Wilkinson R, Huxley-Reicher Z, Fox GC, Feuerbach A, Tong M, Blum J, Pai A, Karani R, Muller D. Leveraging Clerkship Experiences to Address Segregated Care: A Survey-Based Approach to Student-Led Advocacy. TEACHING AND LEARNING IN MEDICINE 2023; 35:381-388. [PMID: 35770380 DOI: 10.1080/10401334.2022.2088538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 04/20/2022] [Indexed: 06/15/2023]
Abstract
Phenomenon: Many academic medical centers (AMCs) have a history of separating patients on the basis of insurance status. In New York State, where Black and Latino patients are more than twice as likely to have Medicaid as white patients, this practice leads to de facto racial segregation in healthcare. Emerging evidence suggests that this segregation of care is detrimental to both patient care and medical education. Medical students are uniquely positioned to be change makers in this space but face significant barriers to speaking out about these disparities and successfully advocating for institutional change. Approach: The authors designed, piloted, and distributed a 16-item survey on segregated care to third-year medical students at a large academic medical center in New York City. Students were asked both open- and close-ended questions about witnessing separation and differences in patient care on the basis of insurance during their clinical rotations. The survey was shared with 140 students in March 2019 with a response rate of 46.4% (n = 65). Preliminary findings were presented to school and hospital administrators. Findings: More than half of survey respondents reported witnessing separation of patient care or differences in patient care on the basis of insurance (56.3%, n = 36 and 51.6%, n = 33 respectively). Many students reported that these experiences contributed to cynicism and burnout. The authors leveraged these results to advocate for quality improvement measures. In Ob-Gyn, department leadership launched a clinical transformation taskforce and recruited a new Vice Chair of Clinical Transformation/Chief Patient Experience Officer, whose role includes addressing segregated care and disparities in health outcomes. The hospital committed to establishing integrated practices in new clinical spaces and launching a similar survey among house staff. Insights: Many medical students experience and participate in segregated care during their clerkships and this has the potential to impact their education. Medical students are well-positioned to recognize segregated care across health systems and leverage their experiences for advocacy. A survey-based approach can be a powerful tool enabling students to collect these experiences to address segregated care and other health equity issues.
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Affiliation(s)
- Rachel Wilkinson
- Department of Pediatrics, Kravis Children's Hospital at Mount Sinai, New York, New York, USA
| | - Zina Huxley-Reicher
- Department of Internal Medicine at Yale, New Haven Hospital, New Haven, Connecticut, USA
| | - Gw Conner Fox
- Department of Internal Medicine-Pediatrics at the University of Southern California Medical Center, Los Angeles, California, USA
| | - Alec Feuerbach
- Emergency Medicine at SUNY Downstate Kings County, New York, New York, USA
| | - Michelle Tong
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - James Blum
- Department of Emergency Medicine at Boston Medical Center, Boston, Massachusetts, USA
| | - Akila Pai
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Reena Karani
- Institute for Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David Muller
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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15
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Thibodeau PS, Nash A, Greenfield JC, Bellamy JL. The Association of Moral Injury and Healthcare Clinicians' Wellbeing: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6300. [PMID: 37444147 PMCID: PMC10341511 DOI: 10.3390/ijerph20136300] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/06/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023]
Abstract
Research focused on elucidating moral injury amongst healthcare workers (HCWs) is essential due to the deep connection with morality and individuals' overall wellbeing. Examining moral injury provides an avenue through which researchers can connect individual experiences with systemic level causes (i.e., structural power imbalances between clinicians and health systems) to better study workplace wellbeing. The omnipresence of the COVID-19 pandemic has amplified the need to study moral injury. This paper describes a systematic review conducted using PRISMA-P guidelines to answer the question, "what is the association between moral injury and professional wellbeing and mental health amongst healthcare workers." Twelve databases were searched to identify specified studies. This study's criteria included: (1) articles published through December 2022; (2) qualitative and quantitative empirical studies; (3) articles written in English; (4) articles including moral injury; and (5) articles including at minimum one other measure of professional or personal wellbeing. The initial search produced 248 articles, and 18 articles were ultimately included in the final review. To confirm that no articles were left out of this study, the first author of each included article was contacted to inquire about any additional works that met the inclusion criteria of this study. The elements of the 18 included articles described in this review are discussed. The results indicate that moral injury is associated with both professional wellbeing factors and mental health outcomes. Further theoretical development, including (professional- and identity-based) exploratory research on moral injury, and evidenced-based interventions for moral injury are needed.
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Affiliation(s)
- Pari Shah Thibodeau
- Graduate School of Social Work, University of Denver, 2148 S. High Street, Denver, CO 80210, USA
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16
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King EL, Hawkins LE. Identifying and mitigating moral injury risks in military behavioral health providers. MILITARY PSYCHOLOGY 2022; 35:169-179. [PMID: 37133488 DOI: 10.1080/08995605.2022.2093599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The term "moral injury" was initially used to describe the multifaceted pain that service members feel after perpetrating, witnessing, or failing to prevent acts that conflict with their moral codes. More recently the term has been used to describe healthcare providers' pain stemming from their experiences serving on the frontlines of the healthcare system when: a medical error causes serious harm to patients, systems continuously impede their abilities to provide proper care, or providers assess that they have acted in ways that conflict with their professional ethics or oaths to "do no harm." This article explores moral injury risk at the intersection of military service and healthcare by examining challenges that military behavioral healthcare providers face. Leveraging moral injury definitions previously applied to service members (personal or witnessed transgressions) and in two healthcare contexts ("second victim" to adverse client outcomes and system-driven moral distress), as well as literature on ethical challenges in military behavioral health, this paper uncovers situations that may amplify military behavioral health providers' risks for moral injury. It concludes by offering policy and practice recommendations germane to military medicine aimed at alleviating pressures military behavioral healthcare providers face and mitigating moral injuries' potential ripple effects on provider wellness, retention and care quality.
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Affiliation(s)
- Erika L. King
- Army-University of Kentucky Master of Social Work Program, University of Kentucky, Joint Base San Antonio-Fort Sam Houston, TX, USA
| | - Lataya E. Hawkins
- Army-University of Kentucky Master of Social Work Program, University of Kentucky, Joint Base San Antonio-Fort Sam Houston, TX, USA
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17
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Ngo SB, Clark PJ, Parr SE, Thomas AR, Dayal A, Sanker R, Hess BW, Stull DC. Moral Injury during the COVID-19 pandemic: A delphi model survey of family medicine residents. Int J Psychiatry Med 2022; 57:293-308. [PMID: 34961337 PMCID: PMC9209884 DOI: 10.1177/00912174211054385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The objective is to investigate the primary factors that created experiences leading to moral injury in family medicine residents during the COVID-19 pandemic and also to identify any barriers keeping these residents from seeking or receiving help when they experienced moral injury. METHOD A DELPHI model study utilizing three rounds of surveys was conducted at four family medicine residency programs in the United States. Resident responses to Survey 1 generated factors perceived to be causing them moral injury or constituting barriers to their seeking help. Thematic analysis identified common themes which were presented to residents in Survey 2 for rating and justification. Results and feedback from Survey 2 were shared with residents in Survey 3, where residents were prompted to reevaluate their ratings for factors and barriers for the purpose of generating consensus among themselves. A ranked list of factors and barriers was thereby created for the participating sites. RESULTS Residents shared several stories about the factors that most pressured them to violate their moral values. The most severe and frequent factors contributing to moral injury involved disruptions to doctor-patient relationships, patient-family relationships, and relationships with other healthcare professionals. Time was the major barrier to residents seeking help. CONCLUSION During times of crisis, moral injury among residents may be minimized by protecting and promoting important clinical and professional relationships with patients, colleagues, and other medical professionals. While residents report that lack of time was the most significant barrier to seeking help, it is unclear how this complicated and ubiquitous problem would be resolved or mitigated.
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Affiliation(s)
- Sean B Ngo
- Office of PreHealth Studies, Baylor University, Waco, TX, USA,Sean B Ngo, Baylor University, One Bear Place #97108, Waco, TX 76798, USA.
| | - Payson J Clark
- Office of PreHealth Studies, Baylor University, Waco, TX, USA
| | - Sarah E Parr
- Office of PreHealth Studies, Baylor University, Waco, TX, USA
| | - Abel R Thomas
- Office of PreHealth Studies, Baylor University, Waco, TX, USA
| | - Akshat Dayal
- Office of PreHealth Studies, Baylor University, Waco, TX, USA
| | - Richard Sanker
- Office of PreHealth Studies, Baylor University, Waco, TX, USA
| | | | - Dillon C Stull
- Stanford University School of Medicine, Stanford, CA, USA
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18
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Validation of the German Version of the Moral Injury Symptom and Support Scale for Health Professionals (G-MISS-HP) and Its Correlation to the Second Victim Phenomenon. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084857. [PMID: 35457724 PMCID: PMC9029354 DOI: 10.3390/ijerph19084857] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Comparable to second victim phenomenon (SVP), moral injury (MI) affects health professionals (HP) working in stressful environments. Information on how MI and SVP intercorrelate and their part in a psychological trauma complex is limited. We tested and validated a German version of the Moral Injury Symptom and Support Scale for Health Professionals (G-MISS-HP) instrument, screening for MI and correlated it with the recently developed German version of the Second Victim Experience and Support Tool (G-SVESTR) instrument, testing for SVP. METHODS After translating Moral Injury Symptom and Support Scale for Health Professionals (MISS-HP), we conducted a cross-sectional online survey providing G-MISS-HP and G-SVEST-R to HP. Statistics included Pearson's interitem correlation, reliability analysis, principal axis factoring and principal components analysis with Promax rotation, confirmatory factor and ROC analyses. RESULTS A total of 244 persons responded, of whom 156 completed the survey (33% nurses, 16% physicians, 9% geriatric nurses, 7.1% speech and language therapists). Interitem and corrected item-scale correlations did not measure for one item sufficiently. It was, therefore, excluded from further analyses. The nine-item score revealed good reliability (Guttman's lambda 2 = 0.80; Cronbach's alpha = 0.79). Factor validity was demonstrated, indicating that a three-factor model from the original study might better represent the data compared with our two-factor model. Positive correlations between G-MISS-HP and G-SVESTR subscales demonstrated convergent validity. ROC revealed sensitivity of 89% and specificity of 63% for G-MISS-HP using a nine-item scale with cutoff value of 28.5 points. Positive and negative predictive values were 62% and 69%, respectively. Subgroup analyses did not reveal any differences. CONCLUSION G-MISS-HP with nine items is a valid and reliable testing instrument for moral injury. However, strong intercorrelations of MI and SVP indicate the need for further research on the distinction of these phenomena.
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19
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20
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Guy C, Kunonga E, Kennedy A, Patel P. Moral injury and well-being in essential workers during the COVID-19 pandemic: local survey findings. BMJ LEADER 2022; 6:237-239. [DOI: 10.1136/leader-2021-000518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 12/15/2021] [Indexed: 11/03/2022]
Abstract
BackgroundEssential workers have faced many difficult situations working during the pandemic. Staff may feel that they, or other people, have acted wrongly and be distressed by this. This represents moral injury, which has been linked with significant mental ill health.MethodsThis survey asked essential workers in County Durham and Darlington about their experiences during the first wave of the pandemic and anything they felt would help. Well-being and moral injury were rated using sliders.ResultsThere were 566 responses. A majority of respondents reported feeling troubled by other people’s actions they felt were wrong (60% scored over 40, where 0 is ‘not at all troubled’ and 100 ‘very troubled’, median score=52.5). Respondents were generally less troubled by their own actions (median score=3). Well-being and moral injury scores varied by employment sector (eg, National Health Service (NHS) staff were more troubled by the actions of others than non-NHS staff).Staff suggestions included regular supervisor check-ins, ensuring kindness from everyone, fair rules and enforcement and improving communication and processes. Respondents offered simple, practical actions that could be taken by leaders at team, organisation, societal and governmental levels to tackle moral injury and the underlying causes of moral injurious environments.ConclusionUsing these findings to develop a strategy to address moral injury is important, not only for staff well-being, but staff retention and continued delivery of vital services in these challenging times. Working together, we can seek to reduce and mitigate ‘moral injury’ the same way we do for other physical workplace ‘injuries’.
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21
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Secondary Qualitative Analysis of Moral Injury in Obstetric and Neonatal Nurses. J Obstet Gynecol Neonatal Nurs 2022; 51:166-176. [DOI: 10.1016/j.jogn.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 11/19/2022] Open
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22
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Mensink B, van Schagen A, van der Aa N, Ter Heide FJJ. Moral Injury in Trauma-Exposed, Treatment-Seeking Police Officers and Military Veterans: Latent Class Analysis. Front Psychiatry 2022; 13:904659. [PMID: 35898627 PMCID: PMC9311258 DOI: 10.3389/fpsyt.2022.904659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/15/2022] [Indexed: 11/21/2022] Open
Abstract
Exposure to morally injurious events may have a severe, prolonged negative impact on psychosocial functioning, known as moral injury (MI). Research into the prevalence of MI has mostly focused on event exposure rather than on psychosocial impact. Also, the relationship between MI and post-traumatic stress disorder (PTSD) remains a matter of interest. The aim of this study was to identify MI and PTSD symptom profiles among trauma-exposed, treatment-seeking police officers and military veterans, and to explore demographic and clinical differences between symptom profiles. Latent class and multinomial regression analyses were conducted in a sample of 1,703 participants, using the Clinician-Administered PTSD Scale for DSM-5 and the Brief Symptom Inventory. Four classes of participants were identified, labeled as a MI class (n = 192; 11.27%), a MI-PTSD class (n = 565; 33.18%), a PTSD class (n = 644; 37.82%), and a Neither MI-nor PTSD class (n = 302; 17.73%), resulting in 44.45% (n = 757) of participants who met an MI symptom profile with or without PTSD. There were significant differences between the classes in terms of gender as well as PTSD and comorbid psychopathology symptom severity, the latter of which was highest in the MI-PTSD class. In conclusion, a substantial subgroup of trauma-exposed, treatment-seeking police officers and military veterans could be classified as suffering from MI. Routinely screening for MI in treatment-seeking police officers and military veterans is recommended, and interventions aimed at relieving MI in these populations may be indicated.
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Affiliation(s)
- Beijka Mensink
- ARQ Nationaal Psychotrauma Centrum, ARQ Centrum'45, Oegstgeest, Netherlands
| | | | - Niels van der Aa
- ARQ Nationaal Psychotrauma Centrum, ARQ Centrum'45, Oegstgeest, Netherlands
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23
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Song YK, Mantri S, Lawson JM, Berger EJ, Koenig HG. Morally Injurious Experiences and Emotions of Health Care Professionals During the COVID-19 Pandemic Before Vaccine Availability. JAMA Netw Open 2021; 4:e2136150. [PMID: 34817579 PMCID: PMC8613593 DOI: 10.1001/jamanetworkopen.2021.36150] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
IMPORTANCE Moral injury in health care professionals (HPs) has worsened over the course of the COVID-19 pandemic. The trauma and burnout associated with moral injury has profound implications for the mental health of HPs. OBJECTIVE To explore the potential factors associated with moral injury for HPs who were involved in patient care during the COVID-19 pandemic in 2020, prior to the availability of vaccines. DESIGN, SETTING, AND PARTICIPANTS In this qualitative study, HPs were actively recruited to participate in a survey via snowball sampling via email and social media in 2 phases of 5 weeks each: April 24 to May 30, 2020 (phase 1), and October 24 to November 30, 2020 (phase 2). Overall, 1831 respondents answered demographic questions and assessments for moral injury, intrinsic religiosity, and burnout. Of those, 1344 responded to the open-ended questions. Responses to open-ended questions were coded iteratively and thematically analyzed within the framework of moral injury. EXPOSURES Working in a patient care setting during the COVID-19 pandemic prior to the availability of vaccines. MAIN OUTCOMES AND MEASURES Inductive thematic analysis of open-response survey answers identified dominant emotions and common stressors associated with moral injury. RESULTS There were 335 individuals (109 [32.6%] aged 35-44 years; 288 [86.0%] women; 294 [87.8%] White) in phase 1 and 1009 individuals (384 [38.1%] aged 35-44 years; 913 [90.5%] women; 945 [93.7%] White) in phase 2. In phase 1, the respondents were predominantly nurses (100 [29.9%]), physicians (78 [23.3%]), advanced practice practitioners (APPs) (70 [20.9%]), and chaplains (55 [16.4%]). In phase 2, the respondents were predominantly nurses (589 [58.4%]), physicians (114 [11.3%]), and APPs (104 [10.3%]). HPs faced numerous stressors, such as fear of contagion, stigmatization, short-staffing, and inadequate personal protective equipment. The emotions experienced were (1) fear in phase 1, then fatigue in phase 2; (2) isolation and alienation; and (3) betrayal. CONCLUSIONS AND RELEVANCE These findings suggest that HPs experienced moral injury during the COVID-19 pandemic. Moral injury was not only experienced after a single moral dilemma but also from working in morally injurious environments. These experiences can serve as potential starting points for organizations to engender and enhance organizational and individual recovery, team building, and trust. System-level solutions that address shortages in staffing and personal protective equipment are needed to promote HP well-being.
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Affiliation(s)
- Ye Kyung Song
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Sneha Mantri
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
- Trent Center for Bioethics, Humanities, and History of Medicine, Duke University, Durham, North Carolina
| | - Jennifer M. Lawson
- Trent Center for Bioethics, Humanities, and History of Medicine, Duke University, Durham, North Carolina
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Elizabeth J. Berger
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Harold G. Koenig
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Koenig HG, Al Zaben F. Moral Injury: An Increasingly Recognized and Widespread Syndrome. JOURNAL OF RELIGION AND HEALTH 2021; 60:2989-3011. [PMID: 34245433 PMCID: PMC8270769 DOI: 10.1007/s10943-021-01328-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 05/05/2023]
Abstract
Moral injury (MI), originally discussed in relationship to transgressing moral beliefs and values during wartime among military personnel, has expanded beyond this context to include similar emotions experienced by healthcare professionals, first responders, and others experiencing moral emotions resulting from actions taken or observations made during traumatic events or circumstances. In this article, we review the history, definition, measurement, prevalence, distinctiveness, psychological consequences, manifestations (in and outside of military settings), and correlates of MI in different settings. We also review secular psychological treatments, spiritually integrated therapies, and pastoral care approaches (specific for clergy and chaplains) used to treat MI and the evidence documenting their efficacy. Finally, we examine directions for future research needed to fill the many gaps in our knowledge about MI, how it develops, and how to help those suffering from it.
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Affiliation(s)
- Harold G Koenig
- Departments of Psychiatry and Medicine, Duke University Health System, Durham, NC, 27705, USA.
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
- School of Public Health, Ningxia Medical University, Yinchuan, People's Republic of China.
- Department of Psychiatry, Shiraz University of Medical Sciences, Shiraz, Iran.
- Department of Psychiatry, Duke University Medical Center, Box 3400, Durham, NC, 27710, USA.
| | - Faten Al Zaben
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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25
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Affiliation(s)
- Charles H Griffith
- Department of Internal Medicine, University of Kentucky College of Medicine, Lexington
- Department of Pediatrics, University of Kentucky College of Medicine, Lexington
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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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27
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Wang Z, Al Zaben F, Koenig HG, Ding Y. Spirituality, moral injury and mental health among Chinese health professionals. BJPsych Open 2021; 7:e135. [PMID: 36043686 PMCID: PMC8329767 DOI: 10.1192/bjo.2021.972] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 05/27/2021] [Accepted: 06/29/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Moral injury has been found to be prevalent among healthcare professionals during the COVID-19 public health crisis. AIMS The present study examines the relationship between spirituality, moral injury, and mental health among physicians and nurses in mainland China during the COVID-19 pandemic. METHOD An online cross-sectional study was conducted involving 3006 physicians and nurses in mainland China, where the COVID-19 pandemic has caused high rates of hospital admission and death. The Moral Injury Symptoms Scale-Health Professional was administered, along with measures of mental health and spirituality. Hierarchical linear regression modelling was used to examine the mediating and moderating role of moral injury in the relationship between spirituality and mental health. RESULTS Spirituality was positively correlated with moral injury (β = 2.41, P < 0.01), depressive symptoms (β = 0.74, P < 0.01) and anxiety symptoms (β = 0.65, P < 0.01) after controlling sociodemographic variables. Moral injury significantly mediated the relationship between spirituality and both depression and anxiety, explaining 60% (0.46/0.76) of the total association between spirituality and depression and 58% (0.38/0.65) of the association with anxiety. No moderating effect of moral injury was found on the spirituality-mental health relationship. CONCLUSIONS Although they were the findings of a cross-sectional study, these results suggest that concern over transgressing moral values during the pandemic may have been a driving factor for negative mental health symptoms among Chinese health professionals for whom spirituality was somewhat important. Future longitudinal studies are needed to determine the causal nature of these relationships.
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Affiliation(s)
- Zhizhong Wang
- Department of Epidemiology and Statistic, School of Public Health at Guangdong Medical University, Dongguan, Guangdong, China
| | - Faten Al Zaben
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Harold G. Koenig
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia, and Departments of Psychiatry and Medicine, Duke University Medical Center, Durham, NC, USA
| | - Yuanlin Ding
- Department of Epidemiology and Statistic, School of Public Health at Guangdong Medical University, Dongguan560001, Guangdong, China
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Mantri S, Lawson JM, Wang Z, Koenig HG. Identifying Moral Injury in Healthcare Professionals: The Moral Injury Symptom Scale-HP. JOURNAL OF RELIGION AND HEALTH 2020; 59:2323-2340. [PMID: 32681398 PMCID: PMC7366883 DOI: 10.1007/s10943-020-01065-w] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
This study aims to develop and assess the psychometric properties of a measure of moral injury (MI) symptoms for identifying clinically significant MI in health professionals (HPs), one that might be useful in the current COVID-19 pandemic and beyond. A total of 181 HPs (71% physicians) were recruited from Duke University Health Systems in Durham, North Carolina. Internal reliability of the Moral Injury Symptom Scale-Healthcare Professionals version (MISS-HP) was examined, along with factor analytic, discriminant, and convergent validity. A cutoff score was identified from a receiver operator curve (ROC) that best identified individuals with significant impairment in social or occupational functioning. The 10-item MISS-HP measures 10 theoretically grounded dimensions of MI assessing betrayal, guilt, shame, moral concerns, religious struggle, loss of religious/spiritual faith, loss of meaning/purpose, difficulty forgiving, loss of trust, and self-condemnation (score range 10-100). Internal reliability of the MISS-HP was 0.75. PCA identified three factors, which was confirmed by CFA, explaining 56.8% of the variance. Discriminant validity was demonstrated by modest correlations (r's = 0.25-0.37) with low religiosity, depression, and anxiety symptoms, whereas convergent validity was evident by strong correlations with clinician burnout (r = 0.57) and with another multi-item measure of MI symptoms (r = 0.65). ROC characteristics indicated that a score of 36 or higher was 84% sensitive and 93% specific for identifying MI symptoms causing moderate to extreme problems with family, social, and occupational functioning. The MISS-HP is a reliable and valid measure of moral injury symptoms in health professionals that can be used in clinical practice to screen for MI and monitor response to treatment, as well as when conducting research that evaluates interventions to treat MI in HPs.
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Affiliation(s)
- Sneha Mantri
- Duke University Movement Disorders Center, and Trent Center for Bioethics, Humanities, and History of Medicine, Duke University Medical Center, Durham, NC USA
| | - Jennifer Mah Lawson
- Faculty Associate, Trent Center for Bioethics, Humanities, and History of Medicine, and Associate of the Duke Initiative for Science and Society, Duke University Medical Center, Durham, NC USA
| | - ZhiZhong Wang
- Department of Epidemiology, School of Public Health, Zunyi Medical University, Zunyi, Guizhou People’s Republic of China
| | - Harold G. Koenig
- Department of Psychiatry & Behavioral Sciences, and Department of Medicine, Duke University Medical Center, Box 3400, Durham, NC USA
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- School of Public Health, Ningxia Medical University, Yinchuan, People’s Republic of China
- Department of Psychiatry, Shiraz University of Medical Sciences, Shiraz, Iran
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