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Wilson MA, Shay A, Harris JI, Faller N, Usset TJ, Simmons A. Moral Distress and Moral Injury in Military Healthcare Clinicians: A Scoping Review. AJPM Focus 2024; 3:100173. [PMID: 38304024 PMCID: PMC10832382 DOI: 10.1016/j.focus.2023.100173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Introduction Healthcare clinicians are often at risk of psychological distress due to the nature of their occupation. Military healthcare providers are at risk for additional psychological suffering related to unique moral and ethical situations encountered in military service. This scoping review identifies key characteristics of moral distress and moral injury and how these concepts relate to the military healthcare clinician who is both a care provider and service member. Methods A scoping review of moral distress and moral injury literature as relates to the military healthcare clinician was conducted on the basis of the Joanna Briggs Institute scoping review framework. Databases searched included CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE (Ovid), Embase (Ovid), PsycInfo, 2 U.S. Defense Department sources, conference papers index, and dissertation abstracts. Reference lists of all identified reports and articles were searched for additional studies. Results A total of 573 articles, published between the years 2009 and 2021, were retrieved to include a portion of the COVID-19 pandemic period. One hundred articles met the inclusion criteria for the final full-text review and analysis. Discussion This scoping review identified moral distress and moral injury literature to examine similarities, differences, and overlaps in the defining characteristics of the concepts and the associated implications for patients, healthcare clinicians, and organizations. This review included the unfolding influence of the COVID-19 pandemic on moral experiences in health care and the blurring of those lines between civilian and military healthcare clinicians. Future directions of moral injury and moral distress research, practice, and care are discussed.
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Affiliation(s)
- Melissa A. Wilson
- U.S. Air Force Research Laboratory, Dayton, Ohio
- College of Health, Education and Human Services Department of Nursing, Wright State University, Dayton, Ohio
| | - Amy Shay
- School of Nursing, Indiana University, Indianapolis, Indiana
| | | | | | - Timothy J. Usset
- Division of Health Policy & Management, University of Minnesota, Minneapolis, Minnesota
| | - Angela Simmons
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Harris JI, Dunlap S, Xanthos D, Pyne JM, Hermes E, Griffin BJ, Kondrath SR, Kim SY, Golden KB, Cooney NJ, Usset TJ. Implementing a Multi-Disciplinary, Evidence-Based Resilience Intervention for Moral Injury Syndrome: Systemic Barriers and Facilitators. Behav Sci (Basel) 2024; 14:281. [PMID: 38667079 PMCID: PMC11047717 DOI: 10.3390/bs14040281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/11/2024] [Accepted: 03/14/2024] [Indexed: 04/29/2024] Open
Abstract
Moral injury syndrome (MIS) is a mental health (MH) problem that substantially affects resilience; the presence of MIS reduces responsiveness to psychotherapy and increases suicide risk. Evidence-based treatment for MIS is available; however, it often goes untreated. This project uses principles of the Consolidated Framework for Implementation Research (CFIR) to assess barriers and facilitators to the implementation of Building Spiritual Strength (BSS), a multi-disciplinary treatment for MIS. Interviews were conducted with chaplains and mental health providers who had completed BSS facilitator training at six sites in the VA. Data were analyzed using the Hamilton Rapid Turnaround method. Findings included multiple facilitators to the implementation of BSS, including its accessibility and appeal to VA chaplains; leadership by VA chaplains trained in the intervention; and effective collaboration between the chaplains and mental health providers. Barriers to the implementation of BSS included challenges in engaging mental health providers and incorporating them as group leaders, veterans' lack of familiarity with the group format of BSS, and the impact of the COVID-19 pandemic. Results highlight the need for increased trust and collaboration between VA chaplains and mental health providers in the implementation of BSS and treatment of MIS.
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Affiliation(s)
- J. Irene Harris
- VA Maine Healthcare System, Augusta, ME 04330, USA; (S.R.K.); (N.J.C.); (T.J.U.)
- Department of Psychology, University of Maine, Orono, ME 04469, USA
| | - Shawn Dunlap
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA; (S.D.); (K.B.G.)
| | | | - Jeffrey M. Pyne
- Center for Mental Health Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR 72114, USA; (J.M.P.)
- Psychiatric Research Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Eric Hermes
- Veterans Affairs Northeast Program Evaluation Center, Orange, CT 06516, USA
| | - Brandon J. Griffin
- Center for Mental Health Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR 72114, USA; (J.M.P.)
- Psychiatric Research Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Susannah Robb Kondrath
- VA Maine Healthcare System, Augusta, ME 04330, USA; (S.R.K.); (N.J.C.); (T.J.U.)
- Department of Psychology, University of Maine, Orono, ME 04469, USA
| | - Se Yun Kim
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA; (S.D.); (K.B.G.)
| | - Kristin B. Golden
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA; (S.D.); (K.B.G.)
| | - Nathaniel J. Cooney
- VA Maine Healthcare System, Augusta, ME 04330, USA; (S.R.K.); (N.J.C.); (T.J.U.)
| | - Timothy J. Usset
- VA Maine Healthcare System, Augusta, ME 04330, USA; (S.R.K.); (N.J.C.); (T.J.U.)
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN 55455, USA
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Fantus S, Cole R, Usset TJ, Hawkins LE. Multi-professional perspectives to reduce moral distress: A qualitative investigation. Nurs Ethics 2024:9697330241230519. [PMID: 38317421 DOI: 10.1177/09697330241230519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND Encounters of moral distress have long-term consequences on healthcare workers' physical and mental health, leading to job dissatisfaction, reduced patient care, and high levels of burnout, exhaustion, and intentions to quit. Yet, research on approaches to ameliorate moral distress across the health workforce is limited. RESEARCH OBJECTIVE The aim of our study was to qualitatively explore multi-professional perspectives of healthcare social workers, chaplains, and patient liaisons on ways to reduce moral distress and heighten well-being at a southern U.S. academic medical center. PARTICIPANTS & RESEARCH CONTEXT Purposive sampling and chain-referral methods assisted with recruitment through hospital listservs, staff meetings, and newsletters. Interested participants contacted the principal investigator and all interviews were conducted in-person. Consent was attained prior to interviews. All interviews were recorded and transcribed verbatim. RESEARCH DESIGN Directed content analysis was used to deductively organize codes and to develop themes in conjunction with the National Academy of Medicine's National Plan for Health Workforce Well-Being. Rigor was attained through peer-debriefing, data triangulation methods, and frequent research team meetings. ETHICAL CONSIDERATIONS Ethics approval was obtained from the university and medical center institutional review boards. FINDINGS Themes demonstrate that rather than offering interventions in the aftermath of moral distress, multilevel daily practices ought to be considered that pre-emptively identify and reduce morally distressing encounters through (1) the care team, (2) management and leadership, and (3) the health care industry. Strategies include interdisciplinary decision-making, trusting managerial relationships, and organizational policies and practices that explicitly invest in mental health promotion and diverse leadership opportunities. CONCLUSION Moral distress interventions ought to target short-term stress reactions while also addressing the long-term impacts of moral residue. Health systems must financially commit to an ethical workplace culture that explicitly values mental health and well-being.
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Usset TJ, Stratton RG, Knapp S, Schwartzman G, Yadav SK, Schaefer BJ, Harris JI, Fitchett G. Factors Associated With Healthcare Clinician Stress and Resilience: A Scoping Review. J Healthc Manag 2024; 69:12-28. [PMID: 38175533 DOI: 10.1097/jhm-d-23-00020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
GOAL Clinician stress and resilience have been the subjects of significant research and interest in the past several decades. We aimed to understand the factors that contribute to clinician stress and resilience in order to appropriately guide potential interventions. METHODS We conducted a scoping review (n = 42) of published reviews of research on clinician distress and resilience using the methodology of Peters and colleagues (2020). Our team examined these reviews using the National Academy of Medicine's framework for clinician well-being and resilience. PRINCIPAL FINDINGS We found that organizational factors, learning/practice environment, and healthcare responsibilities were three of the top four factors identified in the reviews as contributing to clinician distress. Learning/practice environment and organizational factors were two of the top four factors identified in the reviews as contributing to their resilience. PRACTICAL APPLICATIONS Clinicians continue to face numerous external challenges that complicate their work. Further research, practice, and policy changes are indicated to improve practice environments for healthcare clinicians. Healthcare leaders need to promote resources for organizational and system-level changes to improve clinician well-being.
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Affiliation(s)
- Timothy J Usset
- Division of Health Policy and Management, University of Minnesota, Minneapolis, Minnesota, and VA Maine Health Care System, Augusta, Maine
| | | | - Sarah Knapp
- Ascension St. Vincent Hospital, Indianapolis, Indiana
| | - Gabrielle Schwartzman
- The School of Medicine and Health Sciences, George Washington University, Washington, DC
| | | | | | - J Irene Harris
- VA Maine Health Care System, Augusta, Maine, and Department of Psychology, University of Maine, Orono, Maine
| | - George Fitchett
- Department of Religion, Health and Human Values, Rush University Medical Center, Chicago, Illinois
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Weber MC, Smith AJ, Jones RT, Holmes GA, Johnson AL, Patrick RNC, Alexander MD, Miyazaki Y, Wright H, Ehman AC, Langenecker SA, Benight CC, Pyne JM, Harris JI, Usset TJ, Maguen S, Griffin BJ. Moral injury and psychosocial functioning in health care workers during the COVID-19 pandemic. Psychol Serv 2023; 20:19-29. [PMID: 36355661 DOI: 10.1037/ser0000718] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Studies of moral injury among nonmilitary samples are scarce despite repeated calls to examine the prevalence and outcomes of moral injury among civilian frontline workers. The purpose of this study was to describe the prevalence of moral injury and to examine its association with psychosocial functioning among health care workers during the COVID-19 pandemic. We surveyed health care workers (N = 480), assessing exposure to potentially morally injurious events (PMIEs) and psychosocial functioning. Data were analyzed using latent class analysis (LCA) to explore patterns of PMIE exposure (i.e., classes) and corresponding psychosocial functioning. The minimal exposure class, who denied PMIE exposure, accounted for 22% of health care workers. The moral injury-other class included those who had witnessed PMIEs for which others were responsible and felt betrayed (26%). The moral injury-self class comprised those who felt they transgressed their own values in addition to witnessing others' transgressions and feeling betrayed (11%). The betrayal-only class included those who felt betrayed by government and community members but otherwise denied PMIE exposure (41%). Those assigned to the moral injury-self class were the most impaired on a psychosocial functioning composite, followed by those assigned to the moral injury-other and betrayal-only classes, and finally the minimal exposure class. Moral injury is prevalent and impairing for health care workers, which establishes a need for interventions with health care workers in organized care settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Marcela C Weber
- South Central Mental Illness Research, Education, and Clinical Center
| | - Andrew J Smith
- Department of Psychiatry, Geisel School of Medicine, Dartmouth University
| | - Russell T Jones
- Department of Psychology, Virginia Polytechnic Institute and State University
| | - Glen A Holmes
- Department of Education, Virginia Polytechnic Institute and State University
| | - Alicia L Johnson
- Department of Education, Virginia Polytechnic Institute and State University
| | - Rafael N C Patrick
- Department of Engineering, Virginia Polytechnic Institute and State University
| | - M David Alexander
- Department of Education, Virginia Polytechnic Institute and State University
| | - Yasuo Miyazaki
- Department of Education, Virginia Polytechnic Institute and State University
| | - Hannah Wright
- Department of Psychiatry, Huntsman Mental Health Institute, University of Utah
| | - Anandi C Ehman
- Central Arkansas Veterans Healthcare System, Center for Mental Healthcare and Outcomes Research
| | - Scott A Langenecker
- Department of Psychiatry, Huntsman Mental Health Institute, University of Utah
| | - Charles C Benight
- Department of Psychology, Lyda Hill Institute for Human Resilience, University of Colorado-Colorado Springs
| | - Jeffrey M Pyne
- South Central Mental Illness Research, Education, and Clinical Center
| | | | - Timothy J Usset
- Division of Health Policy and Management, University of Minnesota
| | | | - Brandon J Griffin
- Central Arkansas Veterans Healthcare System, Center for Mental Healthcare and Outcomes Research
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Wilson MA, Simmons A, Harris JI, Thomas S, Shay A, Usset TJ, Cook W, Bevington D, Hurley AC, Epstein E. Adaptation and Testing of a Military Version of the Measure of Moral Distress for Healthcare Professionals. Am J Crit Care 2022; 31:392-401. [PMID: 36045043 DOI: 10.4037/ajcc2022177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Moral distress is well-documented among civilian critical care nurses and adversely affects patient outcomes, care delivery, and retention of health care providers. Despite its recognized significance, few studies have addressed moral distress in military critical care nurses. OBJECTIVES To refine and validate an instrument to assess moral distress in military critical care nurses. METHODS This study examined moral distress in military critical care nurses (N = 245) using a new instrument, the Measure of Moral Distress for Healthcare Professionals-Military (MMD-HP-M). The psychometric properties of the refined scale were assessed by use of descriptive statistics, tests of reliability and validity, exploratory factor analysis, correlations, and qualitative analysis of open-ended responses. RESULTS Initial testing showed promising evidence of instrument performance. The Cronbach α (0.94) suggested good internal consistency of the instrument for the overall sample. Scores for the MMD-HP items and the MMD-HP-M items showed a strong, significant correlation (α= 0.78, P < .001). Unique attributes of military nursing that contribute to moral distress included resource access, futile care, and austere conditions. Exploratory factor analysis established a new military-centric factor for question items associated with inadequate training for patient care, providing care in resource-limited settings, and personal exhaustion. CONCLUSIONS These results will help guide specific, targeted interventions to reduce the negative effects of moral distress on our military health care providers, especially in terms of readiness for the next global pandemic and retention of these invaluable personnel.
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Affiliation(s)
- Melissa A Wilson
- Melissa A. Wilson is a nurse scientist, US Air Force Research Laboratory, 711th Human Performance Wing, Wright-Patterson Air Force Base, Ohio
| | - Angela Simmons
- Angela Simmons is assistant dean for student affairs at the Uniformed Services University of the Health Sciences, Graduate School of Nursing, Bethesda, Maryland
| | - J Irene Harris
- J. Irene Harris is a clinician/ investigator, VA Maine Healthcare System, Lewiston, Maine
| | - Sheila Thomas
- Sheila Thomas is an epidemiological statistician, Airmen Biosciences, Product Development, En Route Care, 711th Human Performance Wing, Wright-Patterson Air Force Base, Ohio
| | - Amy Shay
- Amy Shay is a clinical assistant professor, Indiana University, School of Nursing, Indianapolis
| | - Timothy J Usset
- Timothy J. Usset is executive director, Division of Health Policy and Management, University of Minnesota, Minneapolis
| | - Wendy Cook
- Wendy Cook is associate director for professional education, the US Navy/Naval Medical Center San Diego, California
| | - Daniel Bevington
- Daniel Bevington is a nurse educator at the Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Ann C Hurley
- Ann C. Hurley is a senior nurse scientist, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elizabeth Epstein
- Elizabeth Epstein is an associate professor and associate dean of academic programs, University of Virginia School of Nursing, Charlottesville, Virginia
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Shiroma PR, Velasquez T, Usset TJ, Wilhelm JH, Thuras P, Baltutis E. Antidepressant Effect of the VA Weight Management Program (MOVE) Among Veterans With Severe Obesity. Mil Med 2020; 185:e586-e591. [PMID: 32077960 DOI: 10.1093/milmed/usz475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/26/2019] [Accepted: 12/20/2019] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Obesity is prevalent among users of Veteran's Health Administration services, where it is comorbid with depression, post-traumatic stress disorder, type 2 diabetes, cardiovascular disease, colon, and breast cancer. Among obese subjects, severe obesity represents a subpopulation with the highest risk of depression. We investigate the antidepressant effect of a local VA weight management program (Managing Overweight Veterans Everywhere - MOVE) among depressed veterans with severe obesity. MATERIAL AND METHODS In a 10-week prospective pilot study, 14 clinically depressed veterans with severe obesity were recruited from: (1) the 2-week residential based intense MOVE program (IMP) (N = 7) and (2) the 10-week educational module of self-management MOVE program (SMP) (N = 7). Subjects had a Beck Depression Inventory, 2nd edition (BDI-II) score > 12 and BMI > 40 or BMI > 35 with associated to comorbid conditions. Concurrent treatment for depression such as medications or psychotherapy was excluded. The primary efficacy endpoint was the change in BDI-II score form baseline to week 10. Analysis consisted of linear mixed model with baseline BDI-II score as a covariate, and level of MOVE intervention (IMP vs. SMP), time, and time by treatment interaction as fixed effects, and random patient effect. Pearson's correlation examined the relationships between clinical and demographic variables and change in severity of depression by BDI-II scores. Secondary outcomes include weight loss and energy expenditure. RESULTS The sample was composed by 14 subjects (IMP = 7; SMP = 7) mostly unemployed (N = 9), married (N = 10), mid-aged (mean = 58.2, SD = 8.4), Caucasian (N = 13), male (N = 12), with recurrent depression (N = 11), and a mean overall duration of current depressive episode of 13.5 months (SD = 10.2). Out of 14 participants; seven had a family history of mood disorder, two had previous psychiatric hospitalization, three had a previous suicidal attempt, and eight had a history of substance use disorder. There was a significant decrease in severity of depression among all 14 (F3,36.77 = 5.28; P < 0.01); antidepressant effect favored the IMP compared to SMP at day 12 (F1,15.10 = 9.37, P = 0.01) and week 6 (F2,27.34 = 4.26, P = 0.03), but effect fell short of significance at week 10. The change in severity of depression measured by BDI-II score significantly correlated with total weight loss (r = -0.60; P = 0.04) and daily energy expenditure at 12 days (r = -0.67; P = 0.01), week 6 (r = -0.59; P = 0.03), and week 10 (r = -0.71; P = 0.01). CONCLUSIONS Depressed veterans with severe obesity improved their depressive symptoms by participating in the MOVE program. Veterans in the IMP had greater but short-term antidepressant effect as compared to educational intervention for obesity. Future studies with larger sample size may elucidate the underlying mechanisms of weight reduction to improve depression and, more importantly, sustain response among veterans with severe obesity.
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Affiliation(s)
- Paulo R Shiroma
- Mental Health Service Line, Minneapolis VA Medical Center, One Veterans Drive, Minneapolis, MN 55417.,Department of Psychiatry, University of Minnesota Medical School, 2450 Riverside Avenue Minneapolis, MN 55454
| | - Tina Velasquez
- United Health Group, Research and Development, P.O. Box 1459, Minneapolis, MN 55440-1459
| | - Timothy J Usset
- Mental Health Service Line, Minneapolis VA Medical Center, One Veterans Drive, Minneapolis, MN 55417
| | - John H Wilhelm
- University of Central Florida College of Medicine, 4000 Central Florida Blvd, Orlando, FL 32816
| | - Paul Thuras
- Mental Health Service Line, Minneapolis VA Medical Center, One Veterans Drive, Minneapolis, MN 55417.,Department of Psychiatry, University of Minnesota Medical School, 2450 Riverside Avenue Minneapolis, MN 55454
| | - Eric Baltutis
- Mental Health Service Line, Minneapolis VA Medical Center, One Veterans Drive, Minneapolis, MN 55417
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Harris JI, Park CL, Currier JM, Usset TJ, Voecks CD. Moral injury and psycho-spiritual development: Considering the developmental context. Spirituality in Clinical Practice 2015. [DOI: 10.1037/scp0000045] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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