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Cenkner DP, Held P, Zalta AK. A latent profile analysis of moral emotions following moral transgressions. J Clin Psychol 2024. [PMID: 38581701 DOI: 10.1002/jclp.23691] [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: 10/26/2023] [Revised: 03/01/2024] [Accepted: 03/27/2024] [Indexed: 04/08/2024]
Abstract
OBJECTIVE Moral transgressions (MTs), events that violate one's moral code, are associated with the moral emotions of guilt and shame. However, there may be different patterns by which people experience guilt and shame that affect distress following MTs. METHOD Undergraduates (N = 1371) exposed to an MT completed self-report assessments. This study used latent profile analysis (LPA) to examine profiles based on guilt cognitions, internalized shame, and distress in relation to a reported MT. Cognitive flexibility, years since the MT, and deliberate and intrusive rumination were examined as variables to determine how these factors predicted profile membership. RESULTS Results from the LPA revealed a three-profile solution: a low moral distress profile (n = 1002), a moderate moral distress profile (n = 262), and a shame prominent profile (n = 107). Results indicated that higher levels of deliberate and intrusive rumination and lower levels of cognitive flexibility significantly increased the likelihood of belonging to the moderate moral distress or shame prominent profiles compared to the low moral distress profile. Higher levels of intrusive rumination and lower levels of cognitive flexibility also significantly increased the likelihood of belonging to the shame prominent profile over the moderate distress profile. CONCLUSION Three different profiles emerged, with the shame prominent profile being driven primarily by internalized shame. Results suggest that intrusive rumination and cognitive inflexibility are risk factors to experiencing adverse responses to MTs.
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Affiliation(s)
- David P Cenkner
- Department of Psychological Science, University of California, Irvine, Irvine, California, USA
| | - Philip Held
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Alyson K Zalta
- Department of Psychological Science, University of California, Irvine, Irvine, California, USA
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Acevedo León NF, Jaramillo PL, Gabela CD, Boren-Alpízar A, Andrukonis A, Schmidt M, McGlone J, Garcia A. Hispanic worker attitudes toward pig euthanasia on U.S. farms. Front Vet Sci 2024; 11:1281102. [PMID: 38628943 PMCID: PMC11019433 DOI: 10.3389/fvets.2024.1281102] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 03/08/2024] [Indexed: 04/19/2024] Open
Abstract
Introduction On-farm pig euthanasia considers aspects of animal welfare and industry economics. Guidelines are available about the euthanasia process, but the agricultural workforce is highly diverse and guidelines do not consider cultural barriers. Euthanasia requires the ability to identify compromised pigs, technical skills, and willingness to euthanize pigs. In addition, timely euthanasia is part of the Common Swine Industry Audit (CSIA) and, thus, can lead to failed audits if not performed as required by the audit standards. The United States (US) swine industry employs a high percentage of Latin American workers, some US residents/citizens, and others through non-immigrant North American Free Trade Agreement (NAFTA) visas. These workers vary in their level of education and swine industry experience. Proper training of this workforce and identification of the barriers associated with performing timely euthanasia are critical to promote improved welfare practices. The objectives of this study were to: (1) develop a survey instrument to identify Hispanic caretaker attitudes toward pig euthanasia, (2) assess and describe swine caretakers' attitudes toward pig euthanasia using the developed survey instrument, and (3) determine the demographic and psychological barriers associated with performing pig euthanasia. Methods Participants (n = 163) were surveyed from 16 farms across the State of Iowa. The on-farm survey was administered for two days in a period of 60 min per day. Results The results for demographics and the swine management survey data indicated that employees with less time working on the farm showed less knowledge of the CSIA, lower perceived ability to identify compromised pigs that needed to be euthanized, lower willingness to pecrform euthanasia on their own, and preferred not to have the responsibility of telling others when to euthanize pigs (p < 0.001). Secondary traumatic stress and transgressions were significantly correlated scales, associated with burnout, betrayals, and worker satisfaction (p = 0.022). Furthermore, individuals identifying as female had higher secondary traumatic stress scores (p = 0.026) and lower compassion satisfaction scores (p = 0.015). Discussion This data suggest that there are demographic, psychometric, and training-related factors correlated with Hispanic caretakers' feelings about pig euthanasia. The results of this study could be used to further improve and develop targeted training programs for Hispanic caretakers for early identification of compromised pigs and timely euthanasia, which could benefit human well-being, animal welfare, and the swine industry audit performance.
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Affiliation(s)
- Nancy F. Acevedo León
- School of Veterinary Medicine, Texas Tech University, Amarillo, TX, United States
- Animal and Food Sciences Department, Texas Tech University, Lubbock, TX, United States
| | - Pablo Lamino Jaramillo
- Department of Agricultural Education and Communication, University of Florida, Gainesville, TX, United States
| | - Carlos Durán Gabela
- Agricultural Education and Communications Department, Texas Tech University, Lubbock, TX, United States
| | - Amy Boren-Alpízar
- Agricultural Education and Communications Department, Texas Tech University, Lubbock, TX, United States
| | | | - Marcelo Schmidt
- School of Veterinary Medicine, Texas Tech University, Amarillo, TX, United States
| | - John McGlone
- Animal and Food Sciences Department, Texas Tech University, Lubbock, TX, United States
| | - Arlene Garcia
- School of Veterinary Medicine, Texas Tech University, Amarillo, TX, United States
- Animal and Food Sciences Department, Texas Tech University, Lubbock, TX, United States
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Webb EL, Ireland JL, Lewis M, Morris D. Potential Sources of Moral Injury for Healthcare Workers in Forensic and Psychiatric Settings: A Systematic Review and Meta-ethnography. Trauma Violence Abuse 2024; 25:918-934. [PMID: 37083056 PMCID: PMC10913356 DOI: 10.1177/15248380231167390] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
The current research examines potentially morally injurious events (PMIEs) faced by healthcare professionals working in forensic and psychiatric environments. A systematic literature review was conducted to identify peer-reviewed articles reporting on sources of moral injury or similar concepts (e.g., moral distress) for healthcare workers in such settings. Thirty articles were included and analyzed using a meta-ethnographic approach. Synthesis yielded three third-order factors, each reflecting a moral dichotomy: (a) "between profession and system," (b) "between relations with patients and relations with others," and (c) "between principles and practices." Findings illustrated the hierarchical relationships between dichotomies, with discordance between values of the healthcare profession and features of the healthcare system providing the conditions for PMIEs to occur. The review advances conceptual understandings of PMIEs in forensic and psychiatric settings, illustrating the multilayered dimensions within which morally injurious events are experienced. Theoretical and practical implications are offered that may support the early detection and prevention of moral injury in healthcare professionals.
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Affiliation(s)
- Elanor Lucy Webb
- Centre for Developmental and Complex Trauma, St Andrew’s Healthcare, Northampton, UK
| | - Jane L. Ireland
- University of Central Lancashire, Preston, UK
- Ashworth Research Centre, Mersey Care NHS Foundation Trust, Liverpool, UK
| | - Michael Lewis
- University of Central Lancashire, Preston, UK
- Ashworth Research Centre, Mersey Care NHS Foundation Trust, Liverpool, UK
| | - Deborah Morris
- Centre for Developmental and Complex Trauma, St Andrew’s Healthcare, Northampton, UK
- University of Buckingham, UK
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Houle SA, Ashbaugh AR. Predictors of negative moral appraisals and their association with symptoms of post-traumatic stress and depression in the context of COVID-19 related stressors. Stress Health 2024; 40:e3296. [PMID: 37526521 DOI: 10.1002/smi.3296] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 05/17/2023] [Accepted: 07/10/2023] [Indexed: 08/02/2023]
Abstract
Research on moral injury (MI) suggests that negative moral appraisals of stressful events can impact mental health in high-stakes occupational contexts (e.g., military). Few studies have examined these associations in the general population, limiting the generalisability of findings. Furthermore, factors that may predispose an individual to adverse outcomes in the context of moral stressors remain largely unknown. The objectives of this study were to (1) explore the applicability of the MI construct to stressors experienced by the general public during the COVID-19 pandemic; (2) explore how trait differences in sense of duty, religiosity/spirituality, anxiety sensitivity, and guilt, shame, and anger, predict negative moral appraisals of COVID-19 stressors. Participants (n = 355) completed an online survey assessing exposure to and appraisals of COVID-19 stressors, mental health symptoms, and dispositional characteristics (i.e., trait emotions, anxiety sensitivity, sense of duty, religiosity/spirituality). Path analysis revealed specific indirect associations between self-based moral appraisals and posttraumatic stress disorder (PTSD) and depression through guilt, and between both self- and other-based moral appraisals and PTSD and depression through anger. Number of COVID-19 stressors had no influence on associations. Sense of duty, reparative guilt, and anxiety sensitivity best predicted negative moral appraisals. Findings partially support the applicability of the MI construct outside the occupational context.
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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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Anito MF, Desalegn M, Novotny NM, Hansen EN. Moral injury in healthcare: A low-and-middle-income perspective. World J Surg 2024. [PMID: 38558222 DOI: 10.1002/wjs.12148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 02/10/2024] [Indexed: 04/04/2024]
Affiliation(s)
| | | | - Nathan M Novotny
- Corewell Children's, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, USA
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Nazarov A, Forchuk CA, Houle SA, Hansen KT, Plouffe RA, Liu JJW, Dempster KS, Le T, Kocha I, Hosseiny F, Heesters A, Richardson JD. Exposure to moral stressors and associated outcomes in healthcare workers: prevalence, correlates, and impact on job attrition. Eur J Psychotraumatol 2024; 15:2306102. [PMID: 38334695 PMCID: PMC10860421 DOI: 10.1080/20008066.2024.2306102] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/14/2023] [Indexed: 02/10/2024] Open
Abstract
Introduction: Healthcare workers (HCWs) often experience morally challenging situations in their workplaces that may contribute to job turnover and compromised well-being. This study aimed to characterize the nature and frequency of moral stressors experienced by HCWs during the COVID-19 pandemic, examine their influence on psychosocial-spiritual factors, and capture the impact of such factors and related moral stressors on HCWs' self-reported job attrition intentions.Methods: A sample of 1204 Canadian HCWs were included in the analysis through a web-based survey platform whereby work-related factors (e.g. years spent working as HCW, providing care to COVID-19 patients), moral distress (captured by MMD-HP), moral injury (captured by MIOS), mental health symptomatology, and job turnover due to moral distress were assessed.Results: Moral stressors with the highest reported frequency and distress ratings included patient care requirements that exceeded the capacity HCWs felt safe/comfortable managing, reported lack of resource availability, and belief that administration was not addressing issues that compromised patient care. Participants who considered leaving their jobs (44%; N = 517) demonstrated greater moral distress and injury scores. Logistic regression highlighted burnout (AOR = 1.59; p < .001), moral distress (AOR = 1.83; p < .001), and moral injury due to trust violation (AOR = 1.30; p = .022) as significant predictors of the intention to leave one's job.Conclusion: While it is impossible to fully eliminate moral stressors from healthcare, especially during exceptional and critical scenarios like a global pandemic, it is crucial to recognize the detrimental impacts on HCWs. This underscores the urgent need for additional research to identify protective factors that can mitigate the impact of these stressors.
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Affiliation(s)
- Anthony Nazarov
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
- Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, Canada
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Canada
| | - Callista A. Forchuk
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
| | - Stephanie A. Houle
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
- Research Directorate, Veteran Affairs Canada, Charlottetown, Canada
| | - Kevin T. Hansen
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
- Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Rachel A. Plouffe
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
- Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Jenny J. W. Liu
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
- Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Kylie S. Dempster
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
| | - Tri Le
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
| | - Ilyana Kocha
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
| | | | - Ann Heesters
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, Canada
- The Institute for Education Research, University Health Network, Toronto, Canada
- Joint Centre for Bioethics, University of Toronto, Toronto, Canada
- The Michener Institute, University Health Network, Toronto, Canada
- The Wilson Centre, University Health Network, Toronto, Canada
| | - J. Don Richardson
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Canada
- Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, Canada
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Canada
- St. Joseph’s Operational Stress Injury Clinic, St. Joseph’s Health Care London, London, Canada
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D’Alessandro-Lowe AM, Patel H, Easterbrook B, Ritchie K, Brown A, Xue Y, Karram M, Millman H, Sullo E, Pichtikova M, Nicholson A, Heber A, Malain A, O’Connor C, Schielke H, Rodrigues S, Hosseiny F, McCabe RE, Lanius RA, McKinnon MC. The independent and combined impact of moral injury and moral distress on post-traumatic stress disorder symptoms among healthcare workers during the COVID-19 pandemic. Eur J Psychotraumatol 2024; 15:2299661. [PMID: 38334706 PMCID: PMC10860446 DOI: 10.1080/20008066.2023.2299661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 12/04/2023] [Indexed: 02/10/2024] Open
Abstract
Background: Healthcare workers (HCWs) across the globe have reported symptoms of Post-Traumatic Stress Disorder (PTSD) during the COVID-19 pandemic. Moral Injury (MI) has been associated with PTSD in military populations, but is not well studied in healthcare contexts. Moral Distress (MD), a related concept, may enhance understandings of MI and its relation to PTSD among HCWs. This study examined the independent and combined impact of MI and MD on PTSD symptoms in Canadian HCWs during the pandemic.Methods: HCWs participated in an online survey between February and December 2021, with questions regarding sociodemographics, mental health and trauma history (e.g. MI, MD, PTSD, dissociation, depression, anxiety, stress, childhood adversity). Structural equation modelling was used to analyze the independent and combined impact of MI and MD on PTSD symptoms (including dissociation) among the sample when controlling for sex, age, depression, anxiety, stress, and childhood adversity.Results: A structural equation model independently regressing both MI and MD onto PTSD accounted for 74.4% of the variance in PTSD symptoms. Here, MI was strongly and significantly associated with PTSD symptoms (β = .412, p < .0001) to a higher degree than MD (β = .187, p < .0001), after controlling for age, sex, depression, anxiety, stress and childhood adversity. A model regressing a combined MD and MI construct onto PTSD predicted approximately 87% of the variance in PTSD symptoms (r2 = .87, p < .0001), with MD/MI strongly and significantly associated with PTSD (β = .813, p < .0001), after controlling for age, sex, depression, anxiety, stress, and childhood adversity.Conclusion: Our results support a relation between MI and PTSD among HCWs and suggest that a combined MD and MI construct is most strongly associated with PTSD symptoms. Further research is needed better understand the mechanisms through which MD/MI are associated with PTSD.
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Affiliation(s)
| | - Herry Patel
- McMaster University, Hamilton, Ontario, Canada
| | | | - Kim Ritchie
- McMaster University, Hamilton, Ontario, Canada
- Trent University, Peterborough, Ontario, Canada
| | | | - Yuanxin Xue
- McMaster University, Hamilton, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Mauda Karram
- McMaster University, Hamilton, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | | | - Emily Sullo
- McMaster University, Hamilton, Ontario, Canada
| | - Mina Pichtikova
- McMaster University, Hamilton, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Andrew Nicholson
- McMaster University, Hamilton, Ontario, Canada
- University of Ottawa, Ottawa, Ontario, Canada
- Atlas Institute for Veterans and Families, Ottawa, Ontario, Canada
- University of Western Ontario, London, Ontario, Canada
| | - Alex Heber
- McMaster University, Hamilton, Ontario, Canada
- Canadian Institute for Pandemic Health Education and Response, Regina, Saskatchewan, Canada
| | - Ann Malain
- Homewood Health Centre, Guelph, Ontario, Canada
| | | | | | - Sarah Rodrigues
- University of Ottawa, Ottawa, Ontario, Canada
- Atlas Institute for Veterans and Families, Ottawa, Ontario, Canada
| | - Fardous Hosseiny
- University of Ottawa, Ottawa, Ontario, Canada
- Atlas Institute for Veterans and Families, Ottawa, Ontario, Canada
| | - Randi E. McCabe
- McMaster University, Hamilton, Ontario, Canada
- St. Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Ruth A. Lanius
- University of Western Ontario, London, Ontario, Canada
- Homewood Research Institute, Guelph, Ontario, Canada
| | - Margaret C. McKinnon
- McMaster University, Hamilton, Ontario, Canada
- St. Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
- Homewood Research Institute, Guelph, Ontario, Canada
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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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Fogarty S, Hay P, Calleri F, Fiddes L, Barnett R, Baskwill A. Explaining the Impact of the COVID-19 Pandemic on Massage Therapists in Australia and Canada: A Mixed Methods Study. J Integr Complement Med 2024; 30:157-164. [PMID: 37585621 DOI: 10.1089/jicm.2023.0125] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background: The COVID-19 pandemic was a time of rapid change and uncertainty, with individual jurisdictions within countries implementing a variety of preventative measures. At the onset of the pandemic, as little was known about how COVID-19 was transmitted, restrictions, such as lockdowns, were implemented to prevent further spread of this virus. In many jurisdictions, massage therapists were deemed as nonessential for a period. This disruption to their livelihood, as a professional group and without autonomy to decide, was unprecedented. This prompted the question as to whether this experience had impacted massage therapists' professional identity. Methods: A sequential explanatory mixed methods design was used and massage therapists in Australia and Canada were recruited to participate. Results from a quantitative questionnaire completed by 649 respondents and from 31 semistructured interviews from a subset of the questionnaire participants were used in the mixed analysis. Results: Massage therapists, impacted by the pandemic, experienced a discord between what it means to be a massage therapist, providing patient-centered care and the public health initiatives implemented during the pandemic. This discord occurred in multiple situations and the type of discord was influenced by a number of factors, including how therapists identified themselves within the workforce (i.e., as a health care provider or a service provider). Conclusion: This study sought to understand how the COVID-19 pandemic impacted massage therapists' professional identity. Massage therapists reported that the pandemic impacted their professional identity through a lack of congruence and discord between their identity-constituting beliefs and what it means to be a massage therapist. The sequela to this discord was therapists experiencing different types of moral distress and or moral injury. Future research is needed to determine the longer-term impacts of COVID-19 on massage therapists.
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Affiliation(s)
- Sarah Fogarty
- School of Medicine, Western Sydney University, Penrith, Australia
| | - Phillipa Hay
- Translational Health Research Institute, School of Medicine, Western Sydney University, Penrith South DC, Australia
- Camden and Campbelltown Hospitals, South Western Sydney Local Health District, Campbelltown, Australia
| | - Felicia Calleri
- Faculty of Health Sciences and Wellness, Humber College, Toronto, Canada
| | | | | | - Amanda Baskwill
- Faculty of Health Sciences and Wellness, Humber College, Toronto, Canada
- School of Health, Human and Justice Studies, Loyalist College, Belleville, Canada
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Warren J. Routine. Acad Emerg Med 2024; 31:198-199. [PMID: 37656896 DOI: 10.1111/acem.14801] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 09/03/2023]
Abstract
Written a year and a half into the pandemic during a particularly difficult week, this poem explores the moral injury and emotional distress that emergency physicians encounter and must process daily. These repeated microtraumas throughout our day frequently contribute to depersonalization and it is important to recognize those factors that "break the routine" and help to improve physician well-being.
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Affiliation(s)
- Jonathan Warren
- Department of Emergency Medicine, Harbor-UCLA, Torrance, California, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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13
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Espinola CW, Nguyen B, Torres A, Sim W, Rueda A, Beavers L, Campbell DM, Jung H, Lou W, Kapralos B, Peter E, Dubrowski A, Krishnan S, Bhat V. Digital Interventions for Stress Among Frontline Health Care Workers: Results From a Pilot Feasibility Cohort Trial. JMIR Serious Games 2024; 12:e42813. [PMID: 38194247 PMCID: PMC10783335 DOI: 10.2196/42813] [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: 09/21/2022] [Revised: 08/03/2023] [Accepted: 09/30/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic has challenged the mental health of health care workers, increasing the rates of stress, moral distress (MD), and moral injury (MI). Virtual reality (VR) is a useful tool for studying MD and MI because it can effectively elicit psychophysiological responses, is customizable, and permits the controlled study of participants in real time. OBJECTIVE This study aims to investigate the feasibility of using an intervention comprising a VR scenario and an educational video to examine MD among health care workers during the COVID-19 pandemic and to use our mobile app for longitudinal monitoring of stress, MD, and MI after the intervention. METHODS We recruited 15 participants for a compound intervention consisting of a VR scenario followed by an educational video and a repetition of the VR scenario. The scenario portrayed a morally challenging situation related to a shortage of life-saving equipment. Physiological signals and scores of the Moral Injury Outcome Scale (MIOS) and Perceived Stress Scale (PSS) were collected. Participants underwent a debriefing session to provide their impressions of the intervention, and content analysis was performed on the sessions. Participants were also instructed to use a mobile app for 8 weeks after the intervention to monitor stress, MD, and mental health symptoms. We conducted Wilcoxon signed rank tests on the PSS and MIOS scores to investigate whether the VR scenario could induce stress and MD. We also evaluated user experience and the sense of presence after the intervention through semi-open-ended feedback and the Igroup Presence Questionnaire, respectively. Qualitative feedback was summarized and categorized to offer an experiential perspective. RESULTS All participants completed the intervention. Mean pre- and postintervention scores were respectively 10.4 (SD 9.9) and 13.5 (SD 9.1) for the MIOS and 17.3 (SD 7.5) and 19.1 (SD 8.1) for the PSS. Statistical analyses revealed no significant pre- to postintervention difference in the MIOS and PSS scores (P=.11 and P=.22, respectively), suggesting that the experiment did not acutely induce significant levels of stress or MD. However, content analysis revealed feelings of guilt, shame, and betrayal, which relate to the experience of MD. On the basis of the Igroup Presence Questionnaire results, the VR scenario achieved an above-average degree of overall presence, spatial presence, and involvement, and slightly below-average realism. Of the 15 participants, 8 (53%) did not answer symptom surveys on the mobile app. CONCLUSIONS Our study demonstrated VR to be a feasible method to simulate morally challenging situations and elicit genuine responses associated with MD with high acceptability and tolerability. Future research could better define the efficacy of VR in examining stress, MD, and MI both acutely and in the longer term. An improved participant strategy for mobile data capture is needed for future studies. TRIAL REGISTRATION ClinicalTrails.gov NCT05001542; https://clinicaltrials.gov/study/NCT05001542. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/32240.
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Affiliation(s)
- Caroline W Espinola
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Interventional Psychiatry Program, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Binh Nguyen
- Department of Electrical, Computer, and Biomedical Engineering, Toronto Metropolitan University, Toronto, ON, Canada
| | - Andrei Torres
- maxSIMhealth Group, Ontario Tech University, Oshawa, ON, Canada
| | - Walter Sim
- Interventional Psychiatry Program, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Alice Rueda
- Interventional Psychiatry Program, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Lindsay Beavers
- Allan Waters Family Simulation Program, Unity Health Toronto, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Douglas M Campbell
- Allan Waters Family Simulation Program, Unity Health Toronto, Toronto, ON, Canada
- Neonatal Intensive Care Unit, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Hyejung Jung
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Wendy Lou
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Bill Kapralos
- maxSIMhealth Group, Ontario Tech University, Oshawa, ON, Canada
| | - Elizabeth Peter
- Lawrence S. Bloomberg, Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Adam Dubrowski
- maxSIMhealth Group, Ontario Tech University, Oshawa, ON, Canada
| | - Sridhar Krishnan
- Department of Electrical, Computer, and Biomedical Engineering, Toronto Metropolitan University, Toronto, ON, Canada
| | - Venkat Bhat
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Interventional Psychiatry Program, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
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14
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Underdahl L, Ditri M, Duthely LM. Physician Burnout: Evidence-Based Roadmaps to Prioritizing and Supporting Personal Wellbeing. J Healthc Leadersh 2024; 16:15-27. [PMID: 38192639 PMCID: PMC10773242 DOI: 10.2147/jhl.s389245] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/19/2023] [Indexed: 01/10/2024] Open
Abstract
Current literature validates the magnitude of physician burnout as a complex challenge affecting physicians, patients, and healthcare delivery that mandates science-informed intervention. Physician burnout affects both individual practitioners and patient care delivery. Interventions, defined as roadmaps, to prioritizing and supporting personal wellbeing encompass organizational, individual, and moral injury, with virtually no consensus on optimal approaches. The purpose of this conceptual review is to present evidence-based innovative insights on contributing factors, mitigation, and designing adaptive systems to combat and prevent burnout. Science-informed policy initiatives that support long-term organizational changes endorsed by both leadership and institutional stakeholders are keys to sustaining personal wellbeing and ending burnout.
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Affiliation(s)
- Louise Underdahl
- College of Doctoral Studies, University of Phoenix, Phoenix, AZ, USA
| | - Mary Ditri
- Community Health, New Jersey Hospital Association, Princeton, NJ, USA
| | - Lunthita M Duthely
- Obstetrics, Gynecology and Reproductive Sciences and the Department of Public Health Sciences, University of Miami Health System, Miami, FL, USA
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15
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Cruise CE, Celis S, Lashewicz BM. "I haven't really gone through things like this": Young long-term care workers' experiences of working during the COVID-19 pandemic. Work 2024:WOR230437. [PMID: 38189722 DOI: 10.3233/wor-230437] [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: 01/09/2024] Open
Abstract
BACKGROUND Long-term care (LTC) facilities were hard hit by the COVID-19 pandemic in Canada. Using life course theory concepts, we looked for conditions that led to worker moral distress -i.e. pain or anguish over not being able to take right action - and how life stage may influence experiences. OBJECTIVE To illuminate the experiences of adults under the age of 30 who stepped into, and/or persevered in, working in LTC during the pandemic, recognizing that this emerging workforce represents the future of LTC in Canada. METHODS This secondary analysis uses interview data from a sub-sample of 16 young workers between 18 and 29 years of age who had been working in Canadian LTC facilities for between 8 months and 7 years. RESULTS Young workers expressed feeling guilt about mourning the loss of socially significant milestones as these milestones paled by comparison to the loss of life and consequences of resident isolation they witnessed at work. To manage feelings of moral distress, young workers attempted to maintain high standards of care for LTC residents and engaged in self-care activities. For some workers, this was insufficient and leaving the field of LTC was their strategy to respond to their mental health needs. CONCLUSION The life stage of young LTC workers influenced their experiences of working during the COVID-19 pandemic. Interventions are needed to support young workers' wellbeing and job retention.
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Affiliation(s)
- Cera E Cruise
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Sofia Celis
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Bonnie M Lashewicz
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
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16
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Burback L, Brémault-Phillips S, Nijdam MJ, McFarlane A, Vermetten E. Treatment of Posttraumatic Stress Disorder: A State-of-the-art Review. Curr Neuropharmacol 2024; 22:557-635. [PMID: 37132142 PMCID: PMC10845104 DOI: 10.2174/1570159x21666230428091433] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/19/2023] [Accepted: 02/23/2023] [Indexed: 05/04/2023] Open
Abstract
This narrative state-of-the-art review paper describes the progress in the understanding and treatment of Posttraumatic Stress Disorder (PTSD). Over the last four decades, the scientific landscape has matured, with many interdisciplinary contributions to understanding its diagnosis, etiology, and epidemiology. Advances in genetics, neurobiology, stress pathophysiology, and brain imaging have made it apparent that chronic PTSD is a systemic disorder with high allostatic load. The current state of PTSD treatment includes a wide variety of pharmacological and psychotherapeutic approaches, of which many are evidence-based. However, the myriad challenges inherent in the disorder, such as individual and systemic barriers to good treatment outcome, comorbidity, emotional dysregulation, suicidality, dissociation, substance use, and trauma-related guilt and shame, often render treatment response suboptimal. These challenges are discussed as drivers for emerging novel treatment approaches, including early interventions in the Golden Hours, pharmacological and psychotherapeutic interventions, medication augmentation interventions, the use of psychedelics, as well as interventions targeting the brain and nervous system. All of this aims to improve symptom relief and clinical outcomes. Finally, a phase orientation to treatment is recognized as a tool to strategize treatment of the disorder, and position interventions in step with the progression of the pathophysiology. Revisions to guidelines and systems of care will be needed to incorporate innovative treatments as evidence emerges and they become mainstream. This generation is well-positioned to address the devastating and often chronic disabling impact of traumatic stress events through holistic, cutting-edge clinical efforts and interdisciplinary research.
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Affiliation(s)
- Lisa Burback
- Department of Psychiatry, University of Alberta, Edmonton, Canada
| | | | - Mirjam J. Nijdam
- ARQ National Psychotrauma Center, Diemen, The Netherlands
- Department of Psychiatry, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | | | - Eric Vermetten
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
- Department of Psychiatry, New York University Grossman School of Medicine, New York, USA
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17
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Yilmaz S, LeClaire M, Begnaud A, McKinney W, Boehmer KR, Schaffhausen C, Linzer M. Developing LHS scholars' competency around reducing burnout and moral injury. Learn Health Syst 2024; 8:e10378. [PMID: 38249843 PMCID: PMC10797582 DOI: 10.1002/lrh2.10378] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 05/02/2023] [Accepted: 06/01/2023] [Indexed: 01/23/2024] Open
Abstract
Despite the known benefits of supportive work environments for promoting patient quality and safety and healthcare worker retention, there is no clear mandate for improving work environments within Learning Health Systems (LHS) nor an LHS wellness competency. Striking rises in burnout levels among healthcare workers provide urgency for this topic. Methods We brought three experts on moral injury, burnout prevention, and ethics to a recurring, interactive LHS training program "Design Shop" session, harnessing scholars' ideas prior to the meeting. Generally following SQUIRE 2.0 guidelines, we evaluated the prework and discussion via informal content analysis to develop a set of pathways for developing moral injury and burnout prevention programs. Along these lines, we developed a new competency for moral injury and burnout prevention within LHS training programs. Results In preparation for the session, scholars differentiated moral injury from burnout, highlighted the profound impact of COVID-19 on moral injury, and proposed testable interventions to reduce injury. Scholar and expert input was then merged into developing the new competency in moral injury and burnout prevention. In particular, the competency focuses on preparing scholars to (1) demonstrate knowledge of moral injury and burnout, (2) measure burnout, moral injury, and their remediable predictors, (3) use methods for improving burnout, (4) structure training programs with supportive work environments, and (5) embed burnout and moral injury prevention into LHS structures. Conclusions Burnout and moral injury prevention have been largely omitted in LHS training. A competency related to burnout and moral injury reduction can potentially bring sustainable work lives for scholars and their colleagues, better incorporation of their science into clinical practice, and better outcomes for patients.
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Affiliation(s)
- Sirin Yilmaz
- Clinical Ethics, Hennepin HealthcareMinneapolisMinnesotaUSA
| | - Michele LeClaire
- Department of MedicineMinneapolis VA Health Care SystemMinneapolisMinnesotaUSA
- Department of MedicineUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Abbie Begnaud
- Department of MedicineUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Warren McKinney
- Department of MedicineHennepin Healthcare Research Institute (HHRI)MinneapolisMinnesotaUSA
| | - Kasey R. Boehmer
- Department of Medicine, Division of Health Care Delivery Research and Knowledge and Evaluation Research (KER) UnitMayo ClinicRochesterMinnesotaUSA
| | - Cory Schaffhausen
- Department of MedicineHennepin Healthcare Research Institute (HHRI)MinneapolisMinnesotaUSA
| | - Mark Linzer
- Clinical Ethics, Hennepin HealthcareMinneapolisMinnesotaUSA
- Department of MedicineUniversity of MinnesotaMinneapolisMinnesotaUSA
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18
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David HS, Rosell T, Hughes D. Moral Injury Among Transplant Providers: Evaluating the Effects of Training in End-of-Life Counseling. Kans J Med 2023; 16:324-327. [PMID: 38298384 PMCID: PMC10829853 DOI: 10.17161/kjm.vol16.21171] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 12/11/2023] [Indexed: 02/02/2024] Open
Abstract
Introduction Ethical issues are pervasive in healthcare, but few specialties rival the moral complexity of transplant medicine. Transplant providers must regularly inform patients that they are no longer eligible to receive a potentially life-saving operation and the stress of these conversations poses a high risk of moral injury. Training in end-of-life counseling (EOLC) has proven to significantly reduce provider stress and burnout. The purpose of this study was to determine whether training in EOLC reduces levels of moral injury among transplant providers. Methods This was a mixed methods study. We interviewed 10 patient participants and administered a survey to staff in the solid organ transplant department at the University of Kansas Health System. Respondents indicated whether they had received training in EOLC and completed the standardized Moral Injury Symptom Scale-Healthcare Professionals version (MISS-HP). A two-sample, one-sided t-test compared levels of moral injury between trained and untrained staff. Subsequently, we conducted semi-structured interviews with transplant providers, then performed inductive coding followed by thematic network analysis. Results Thirty-seven percent (14/38) of respondents reported a moral injury score at or above the threshold for psychosocial dysfunction associated with moral injury. Analysis revealed no difference in moral injury scores between the trained and untrained groups (p = 0.362, power (1-β) = 0.842). Thematic network analysis demonstrated high-level themes of "challenges", "training", and "stress relief". Conclusions Our study demonstrated a concerning prevalence of moral injury among transplant staff and suggested that EOLC training did not significantly mitigate the threat of moral injury.
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Affiliation(s)
- Hannah S David
- University of Kansas School of Medicine, Kansas City, KS
| | - Tarris Rosell
- University of Kansas School of Medicine, Kansas City, KS
- Department of History and Philosophy of Medicine
| | - Dorothy Hughes
- University of Kansas School of Medicine-Salina, Salina, KS
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19
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Heston TF, Pahang JA. Moral injury and the four pillars of bioethics. F1000Res 2023; 8:1193. [PMID: 38435121 PMCID: PMC10904936 DOI: 10.12688/f1000research.19754.4] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/27/2023] [Indexed: 03/05/2024] Open
Abstract
Healthcare providers experience moral injury when their internal ethics are violated. The routine and direct exposure to ethical violations makes clinicians vulnerable to harm. The fundamental ethics in health care typically fall into the four broad categories of patient autonomy, beneficence, nonmaleficence, and social justice. Patients have a moral right to determine their own goals of medical care, that is, they have autonomy. When this principle is violated, moral injury occurs. Beneficence is the desire to help people, so when the delivery of proper medical care is obstructed for any reason, moral injury is the result. Nonmaleficence, meaning do no harm, has been a primary principle of medical ethics throughout recorded history. Yet today, even the most advanced and safest medical treatments are associated with unavoidable, harmful side effects. When an inevitable side effect occurs, the patient is harmed, and the clinician is also at risk of moral injury. Social injustice results when patients experience suboptimal treatment due to their race, gender, religion, or other demographic variables. While minor ethical dilemmas and violations routinely occur in medical care and cannot be eliminated, clinicians can decrease the prevalence of a significant moral injury by advocating for the ethical treatment of patients, not only at the bedside but also by addressing the ethics of political influence, governmental mandates, and administrative burdens on the delivery of optimal medical care. Although clinicians can strengthen their resistance to moral injury by deepening their own spiritual foundation, that is not enough. Improvements in the ethics of the entire healthcare system are necessary to improve medical care and decrease moral injury.
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Affiliation(s)
- Thomas F Heston
- Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, 99210-1495, USA
| | - Joshuel A Pahang
- Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, 99210-1495, USA
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20
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Bryant VE, Sorna MJ, Dana A, Leon KG, Guastello AD, Sambuco N, Huxhold A, Allen B, Cuffe SP, Mathews CA, Dale LP. Protective and risk factors associated with substance use coping among healthcare workers during the COVID-19 pandemic. Front Psychol 2023; 14:1228517. [PMID: 38173849 PMCID: PMC10761529 DOI: 10.3389/fpsyg.2023.1228517] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 11/27/2023] [Indexed: 01/05/2024] Open
Abstract
Background Healthcare workers (HCWs) experienced high levels of stress and mental health consequences associated with the COVID-19 pandemic, which may have contributed to unhealthy coping behaviors, such as substance use coping (SUC). This study aimed to understand the extent of and predictors of SUC. Methods The sample consisted of 263 HCWs in North Central Florida. Univariable and multivariable logistic regression analyses investigated whether moral injury and other work risk factors, protective factors, and clinically relevant symptoms (i.e., work exhaustion, interpersonal disengagement, depression, anxiety, and/or PTSD) were associated with likelihood of SUC. Results Clinically relevant levels of interpersonal disengagement and anxiety increased the likelihood of SUC. Mediational analyses found that interpersonal disengagement and anxiety explained 54.3% of the relationship between Self Moral Injury and SUC and explained 80.4% of the relationship between professional fulfillment and SUC. Conclusion Healthcare supervisors should be aware that providers who are experiencing moral injury and less professional fulfillment may be experiencing significant interpersonal disengagement and anxiety, which could lead to SUC. Future studies should examine the effects of implementing targeted prevention and treatment interventions, along with longitudinal outcomes related to SUC behaviors.
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Affiliation(s)
- Vaughn E. Bryant
- Department of Psychiatry, College of Medicine – Jacksonville, University of Florida, Jacksonville, FL, United States
| | - Michael J. Sorna
- Department of Psychiatry, College of Medicine – Jacksonville, University of Florida, Jacksonville, FL, United States
| | - Audrey Dana
- Department of Psychology, University of North Florida, Jacksonville, FL, United States
| | - Kalie G. Leon
- Department of Psychology, University of North Florida, Jacksonville, FL, United States
| | - Andrea D. Guastello
- Department of Psychiatry, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Nicola Sambuco
- Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States
| | - Ashley Huxhold
- Department of Psychiatry, College of Medicine – Jacksonville, University of Florida, Jacksonville, FL, United States
| | - Brandon Allen
- Department of Emergency Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Steven P. Cuffe
- Department of Psychiatry, College of Medicine – Jacksonville, University of Florida, Jacksonville, FL, United States
| | - Carol A. Mathews
- Department of Psychiatry, Center for OCD, Anxiety and Related Disorders, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Lourdes P. Dale
- Department of Psychiatry, College of Medicine – Jacksonville, University of Florida, Jacksonville, FL, United States
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21
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Grimell J. Moral injury: understanding Swedish veterans who are assessed but not diagnosed with PTSD. Front Psychiatry 2023; 14:1200869. [PMID: 38111618 PMCID: PMC10725915 DOI: 10.3389/fpsyt.2023.1200869] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 11/13/2023] [Indexed: 12/20/2023] Open
Abstract
This article is based on an interview study of 24 Swedish veterans who experienced deteriorating mental health and increased suffering without meeting the criteria for a PTSD diagnosis. With no clinical answers as to the cause of their deteriorating mental health, they have been thrown into a veteran's health limbo. The analysis was based on an inductive logic. A key finding of the analysis was a kind of deep-seated permanent moral conflict that could be conceptualized as moral injury. Such an injury can give rise to intense guilt, shame, anxiety, anger, dejection, bitterness, identity issues and more. The results section of the article details five different yet for the sample representative cases of moral injury and their implications. The notion of moral injury is linked to Mead's division of the self into an I and me, where me is the socially constructed part of the self that is charged with the morality of a group. Thus, a moral me played a key role in the development of moral injury. The conceptual apparatus illustrates a new way of understanding experiences that can create suffering and negatively impact a veteran's mental health. Future research is encouraged that examines this topic, national designs for addressing moral injury, screening for moral injury, and methods for healing included.
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Affiliation(s)
- Jan Grimell
- Department of Sociology, Faculty of Social Sciences, Uppsala University, Uppsala, Sweden
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22
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Ford JD, Seedat S. On the path to recovery: traumatic stress research during the COVID-19 pandemic 2021-2023. Eur J Psychotraumatol 2023; 14:2281988. [PMID: 38038964 PMCID: PMC10990445 DOI: 10.1080/20008066.2023.2281988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/17/2023] [Indexed: 12/02/2023] Open
Abstract
This Special Issue of the European Journal of Psychotraumatology (EJPT) presents 51 articles published between 2021 and 2023 and follows the Special Issue on pandemic-related traumatic stress research published in 2021 (O'Donnell, M. L., & Greene, T. [2021]. Understanding the mental health impacts of COVID-19 through a trauma lens. European Journal of Psychotraumatology, 12(1), 1982502). Research on traumatic stress during the pandemic has cast the spotlight on vulnerable populations and groups, notably front-line healthcare workers; people faced with major losses including the deaths of loved ones; those who personally survived debilitating and often life-threatening viral infection; and students who were isolated and experienced profound delays in their education, relationships, and emerging independence. The papers in this collection underscore the associations between COVID-19 related stressors and a plethora of adverse mental health sequelae, including posttraumatic stress reactions, and draw attention to the ubiquity of grief and moral injury and their wide-ranging and detrimental impact. Currently, there is a paucity of evidence on interventions to enhance resources, self-efficacy, and hope for affected groups and individuals through societal, organisational, and healthcare systems; however early research on the prevention of COVID-related traumatic stress disorders provides a basis for both hope and preparedness for the future.
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Affiliation(s)
- Julian D. Ford
- Department of Psychiatry, University of Connecticut Health Center, Farmington, CT, USA
| | - Soraya Seedat
- South African Medical Research Council Unit on the Genomics of Brain Disorders, Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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24
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Currie GP, Laing RB. Moral distress in healthcare professionals: Time to reflect. J R Coll Physicians Edinb 2023; 53:237-238. [PMID: 37997844 DOI: 10.1177/14782715231215409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023] Open
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Denham F, Varese F, Hurley M, Allsopp K. Exploring experiences of moral injury and distress among health care workers during the Covid-19 pandemic. Psychol Psychother 2023; 96:833-848. [PMID: 37203424 DOI: 10.1111/papt.12471] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE Health care workers have been exposed to a variety of practical and emotional challenges because of the Covid-19 pandemic, leaving them vulnerable to experiencing moral injury and distress. However, there is currently sparse research which directly explores such experiences. This study aimed to explore and characterise the experiences and impacts of moral injury and distress among health care workers during the pandemic. METHODS Twenty semi-structured interviews were conducted with health care workers employed across both mental and physical health care services. Interviews were analysed from a critical realist perspective using thematic analysis. RESULTS Three key themes were identified: attitudes towards moral injury, experiences of moral injury and consequences of moral injury. Participants appeared to identify with the idea of acting against their morals to varying extents based on their job roles. Participants experienced a range of potentially morally injurious and distressing events throughout the pandemic and many ultimately felt that they provided sub-standard levels of care due to extreme pressures on services. Detrimental impacts upon wellbeing were commonly reported, including high levels of emotional distress and feelings of guilt and shame. Some reported a loss of enthusiasm for their job and a desire to leave the profession entirely. CONCLUSION Moral injury and distress presents a real concern for staff wellbeing and retention within the profession. During and beyond the Covid-19 pandemic, there is an urgent need for health care providers to implement wider strategies to target moral injury and distress, and support staff within health care settings.
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Affiliation(s)
- Faye Denham
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Filippo Varese
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- Complex Trauma and Resilience Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Mitchell Hurley
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Kate Allsopp
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- Complex Trauma and Resilience Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Dehkordi MK, Shamsi A, Shakhi S. Online Balint Groups in Iran during the Covid-19 Pandemic. Psychodyn Psychiatry 2023; 51:397-400. [PMID: 38047666 DOI: 10.1521/pdps.2023.51.4.397] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
When Covid-19 was declared a pandemic, most people felt helpless, fearful, and demoralized while health care workers put their own lives at risk to support and heal others. The uncertainties expressed by experts and the ambiguous and protracted nature of the pandemic compounded the sense of frustration caused by the scarcity of protective equipment and effective medications. This combination of factors led to exhaustion, burnout, and moral injury. As a result, mental health practitioners worldwide realized that health care staff needed to stay motivated and resilient. Our contribution in this regard was to start Balint groups throughout Iran, online, for a full year. We learned some lessons worth sharing. Our insights were wrapped around challenges but proved helpful to preserve the integrity of delivering medical services in times of crisis.
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Affiliation(s)
- Mansoureh Kiani Dehkordi
- Department of Psychiatry, Psychosis Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Amirhossein Shamsi
- Department of Physiotherapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahin Shakhi
- Psychiatrist, Department of Psychiatry, UCLA Semel Institute for Neuroscience and Behavior, Los Angeles, California, USA
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Goldberg DG, Soylu T, Hoffman CF, Kishton RE, Cronholm PF. "Anxiety, COVID, Burnout and Now Depression": a Qualitative Study of Primary Care Clinicians' Perceptions of Burnout. J Gen Intern Med 2023:10.1007/s11606-023-08536-2. [PMID: 38010463 DOI: 10.1007/s11606-023-08536-2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Clinician burnout has become a major issue in the USA, contributing to increased mental health challenges and problems with quality of care, productivity, and retention. OBJECTIVE The objective of this study was to understand primary care clinicians' perspectives on burnout during the COVID-19 pandemic as well as their perspectives on the causes of burnout and strategies to improve clinician well-being. APPROACH This qualitative research involved in-depth interviews with 27 primary care clinicians practicing in a range of settings across the USA. Semi-structured interviews lasted between 60 and 90 min and were conducted using Zoom video conferencing software between July 2021 and February 2023. Transcripts were analyzed in NVivo software using multiple cycles of coding. KEY RESULTS Clinicians shared their experiences with burnout and mental health challenges during the COVID-19 pandemic. Contributors to burnout included high levels of documentation, inefficiencies of electronic health record (EHR) systems, high patient volume, staffing shortages, and expectations for responding to patient emails and telephone calls. The majority of participants described the need to work after clinic hours to complete documentation. Many clinicians also discussed the need for health system leaders to make sincere efforts to enhance work-life balance and create a culture of health and well-being for health professionals. Suggested strategies to address these issues included supportive leadership, accessible mental health services, and additional administrative time to complete documentation. CONCLUSIONS The results of this study provide an in-depth view of participating primary care clinicians' experiences and perceptions of burnout and other mental health challenges. These viewpoints can improve awareness of the issues and strategies to improve the health and well-being of our clinician workforce. Strategies include aligning payment models with the best approaches for delivering quality patient care, reducing administrative burden related to documentation, and redesigning EHR systems with a human factors approach.
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Affiliation(s)
- Debora Goetz Goldberg
- Department of Health Administration and Policy, College of Public Health, George Mason University, 4400 University Drive MS IJ3, Fairfax, VA, 22030, USA.
- Center for Evidence-Based Behavioral Health, George Mason University, Fairfax County, USA.
| | - Tulay Soylu
- Department of Health Services Administration and Policy, Temple University, Philadelphia, USA
| | - Carolyn Faith Hoffman
- Department of Health Administration and Policy, College of Public Health, George Mason University, 4400 University Drive MS IJ3, Fairfax, VA, 22030, USA
| | - Rachel E Kishton
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, USA
| | - Peter F Cronholm
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, USA
- Center for Public Health, University of Pennsylvania, Philadelphia, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
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Levi-Belz Y, Groweiss Y, Blank C. Moral injury and its mental health consequences among protesters: findings from Israel's civil protest against the government's judicial reform. Eur J Psychotraumatol 2023; 14:2283306. [PMID: 37994789 PMCID: PMC10993812 DOI: 10.1080/20008066.2023.2283306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/02/2023] [Indexed: 11/24/2023] Open
Abstract
Background: Government actions and participating in protracted-duration protests against it affect protesters' mental health, leading to high distress levels, such as posttraumatic and depressive symptoms. Aside from exposure to violence and other issues, protest participation can pose unique challenges to the protesters as they may be exposed to potentially morally injurious events (PMIEs), such as the betrayal of leaders they once trusted. This study's primary objective was to examine the extent of psychological difficulties among civilians participating in long-duration protests in Israel. More specifically, the study aimed to understand the contribution of exposure to protest-related PMIEs to psychological difficulties such as posttraumatic and depressive symptoms.Method: Participants comprised 4036 Israelis who were actively involved in the unfolding civil protest movement against the government-led judicial overhaul between January 2023 and August 2023. The protesters completed validated self-report questionnaires that included measures of PMIE exposure, PTSD and depressive symptoms.Results: About half (44.3%) of the sample met the criteria for self-report diagnosis of major depression and 10.6% for PTSD. Most of the protesters indicated their exposure to at least one moral injury event, with 63.9% reporting exposure to PMIE-Betrayal. Protesters exposed to PMIEs reported significantly higher levels of both PTSD and depression than non-PMIE-exposed protesters. Hierarchical regression analyses revealed that, beyond demographics and protest-related characteristics such as exposure to violence, PMIE dimensions significantly contributed to both PTSD and depression levels.Conclusions: The findings highlight the mental burden of protesters during the civil protests against the judicial overhaul in Israel. More central to the present research, the findings highlight the critical contribution of PMIEs exposure to this burden. Clinicians treating protesters coping with depression and PTSD following the civil actions should attend to their exposure to PMIEs, which may relate to the deleterious psychological effects among protesters.
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Affiliation(s)
- Yossi Levi-Belz
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
- Department of Behavioral Sciences, Ruppin Academic Center, Emek Hefer, Israel
| | - Yoav Groweiss
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
| | - Carmel Blank
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
- Department of Behavioral Sciences, Ruppin Academic Center, Emek Hefer, Israel
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Teng Y, Dehghan M, Hossini Rafsanjanipoor SM, Altwalbeh D, Riyahi Z, Farahmandnia H, Zeidabadi A, Zakeri MA. Is nurses' clinical competence associated with their moral identity and injury? Nurs Ethics 2023:9697330231209284. [PMID: 37937424 DOI: 10.1177/09697330231209284] [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: 11/09/2023]
Abstract
BACKGROUND The enhancement of nursing care quality is closely related to the clinical competence of nurses, making it a crucial component within health systems. OBJECTIVE The present study investigated the relationship between nurses' clinical competence, moral identity, and moral injury during the COVID-19 outbreak. RESEARCH DESIGN This cross-sectional study was carried out among frontline nurses, using the Moral Identity Questionnaire (MIQ), the Moral Injury Symptom Scale-Healthcare Professionals version (MISS-HP), and the Competency Inventory for Registered Nurse (CIRN) as data collection tools. PARTICIPANTS and research context: The research population for this study consisted of all frontline nurses (n = 251) employed in a hospital in southern Iran. Sampling was conducted between May 1, 2021 and September 30, 2021, during the COVID-19 outbreak. ETHICAL CONSIDERATIONS The present study received approval from the research ethics committee of Rafsanjan University of Medical Sciences, with project No. 99267 and code of ethics ID No. IR. RUMS.REC.1399.262, dated 15.02.2021. RESULTS According to the study findings, 42.2% of the nurses demonstrated high clinical competence, while 51.4% exhibited moderate clinical competence. The results indicated a positive correlation between moral identity and clinical competence but a negative correlation between moral injury and clinical competence. Furthermore, the variables of moral identity and moral injury were found to predict 10% of the variance in clinical competence. CONCLUSION According to the results, moral identity and moral injury had an impact on the clinical competence of nurses. Therefore, implementing a program aimed at enhancing moral identity and providing training strategies to address moral injury during crises like the COVID-19 pandemic can lead to improvements in nurses' clinical competence and the overall quality of care they provide.
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Nazarov A, Fikretoglu D, Liu A, Born J, Michaud K, Hendriks T, Bélanger SA, Do MT, Lam Q, Brooks B, King K, Sudom K, Jetly R, Garber B, Thompson M. Moral Distress, Mental Health, and Risk and Resilience Factors Among Military Personnel Deployed to Long-Term Care Facilities During the COVID-19 Pandemic: Research Protocol and Participation Metrics. JMIR Res Protoc 2023; 12:e44299. [PMID: 37676877 PMCID: PMC10629501 DOI: 10.2196/44299] [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: 11/16/2022] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND The earliest days of the COVID-19 pandemic in Canada were marked by a significant surge in COVID-19 cases and COVID-19-related deaths among residents of long-term care facilities (LTCFs). As part of Canada's response to the COVID-19 pandemic, Canadian Armed Forces (CAF) personnel were mobilized for an initial emergency domestic deployment to the hardest-hit LTCFs (Operation LASER LTCF) to support the remaining civilian staff in ensuring the continued delivery of care to residents. Akin to what was observed following past CAF international humanitarian missions, there was an expected increased risk of exposure to multiple stressors that may be psychologically traumatic and potentially morally injurious in nature (ie, related to core values, eg, witnessing human suffering). Emerging data from health care workers exposed to the unprecedented medical challenges and dilemmas of the early pandemic stages also indicated that such experiences were associated with increased risk of adverse mental health outcomes. OBJECTIVE This study aims to identify and quantify the individual-, group-, and organizational-level risk and resilience factors associated with moral distress, moral injury, and traditional mental health and well-being outcomes of Operation LASER LTCF CAF personnel. This paper aimed to document the methodology, implementation procedures, and participation metrics. METHODS A multimethod research initiative was conducted consisting of 2 primary data collection studies (a quantitative survey and qualitative interviews). The quantitative arm was a complete enumeration survey with web-based, self-report questionnaires administered at 3 time points (3, 6, and 12 mo after deployment). The qualitative arm consisted of individual, web-based interviews with a focus on understanding the nuanced lived experiences of individuals participating in the Operation LASER LTCF deployment. RESULTS CAF personnel deployed to Operation LASER LTCF (N=2595) were invited to participate in the study. Data collection is now complete. Overall, of the 2595 deployed personnel, 1088 (41.93%), 582 (22.43%), and 497 (19.15%) responded to the survey at time point 1 (3 mo), time point 2 (6 mo), and time point 3 (12 mo) after deployment, respectively. The target sample size for the qualitative interviews was set at approximately 50 considering resourcing and data saturation. Interest in participating in qualitative interviews surpassed expectations, with >200 individuals expressing interest; this allowed for purposive sampling across key characteristics, including gender, rank, Operation LASER LTCF role, and province. In total, 53 interviews were conducted. CONCLUSIONS The data generated through this research have the potential to inform and promote better understanding of the well-being and mental health of Operation LASER LTCF personnel over time; identify general and Operation LASER LTCF-specific risk and protective factors; provide necessary support to the military personnel who served in this mission; and inform preparation and interventions for future missions, especially those more domestic and humanitarian in nature. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/44299.
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Affiliation(s)
- Anthony Nazarov
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, ON, Canada
- Department of Psychiatry, Western University, London, ON, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
- HumanSystems Inc, Guelph, ON, Canada
| | - Deniz Fikretoglu
- Defence Research and Development Canada, Department of National Defence, Toronto, ON, Canada
| | - Aihua Liu
- HumanSystems Inc, Guelph, ON, Canada
| | - Jennifer Born
- Director General Military Personnel Research and Analysis, Department of National Defence, Ottawa, ON, Canada
| | - Kathy Michaud
- Director General Military Personnel Research and Analysis, Department of National Defence, Ottawa, ON, Canada
| | - Tonya Hendriks
- Defence Research and Development Canada, Department of National Defence, Toronto, ON, Canada
| | | | - Minh T Do
- Directorate of Mental Health, Canadian Forces Health Services, Department of National Defence, Ottawa, ON, Canada
- Department of Health Sciences, Carleton University, Ottawa, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Quan Lam
- Defence Research and Development Canada, Department of National Defence, Toronto, ON, Canada
| | - Brenda Brooks
- Defence Research and Development Canada, Department of National Defence, Toronto, ON, Canada
| | - Kristen King
- Defence Research and Development Canada, Department of National Defence, Toronto, ON, Canada
| | - Kerry Sudom
- Director General Military Personnel Research and Analysis, Department of National Defence, Ottawa, ON, Canada
| | - Rakesh Jetly
- Directorate of Mental Health, Canadian Forces Health Services, Department of National Defence, Ottawa, ON, Canada
| | - Bryan Garber
- Directorate of Mental Health, Canadian Forces Health Services, Department of National Defence, Ottawa, ON, Canada
| | - Megan Thompson
- Defence Research and Development Canada, Department of National Defence, Toronto, ON, Canada
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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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Andrews K, Lloyd CS, Densmore M, Kearney BE, Harricharan S, McKinnon MC, Théberge J, Jetly R, Lanius RA. 'I am afraid you will see the stain on my soul': Direct gaze neural processing in individuals with PTSD after moral injury recall. Soc Cogn Affect Neurosci 2023; 18:nsad053. [PMID: 37897804 PMCID: PMC10612569 DOI: 10.1093/scan/nsad053] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/20/2023] [Accepted: 10/19/2023] [Indexed: 10/30/2023] Open
Abstract
Direct eye contact is essential to understanding others' thoughts and feelings in social interactions. However, those with post-traumatic stress disorder (PTSD) and exposure to moral injury (MI) may exhibit altered theory-of-mind (ToM)/mentalizing processes and experience shame which precludes one's capacity for direct eye contact. We investigated blood oxygenation level-dependent (BOLD) responses associated with direct vs averted gaze using a virtual reality paradigm in individuals with PTSD (n = 28) relative to healthy controls (n = 18) following recall of a MI vs a neutral memory. Associations between BOLD responses and clinical symptomatology were also assessed. After MI recall, individuals with PTSD showed greater activation in the right temporoparietal junction as compared to controls (T = 4.83; pFDR < 0.001; k = 237) during direct gaze. No significant activation occurred during direct gaze after neutral memory recall. Further, a significant positive correlation was found between feelings of distress and right medial superior frontal gyrus activation in individuals with PTSD (T = 5.03; pFDR = 0.049; k = 123). These findings suggest that direct gaze after MI recall prompts compensatory ToM/mentalizing processing. Implications for future interventions aimed at mitigating the effects of PTSD on social functioning are discussed.
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Affiliation(s)
- Krysta Andrews
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L8N 3K7, Canada
- Homewood Research Institute, Guelph, ON N1E 6K9, Canada
| | - Chantelle S Lloyd
- Homewood Research Institute, Guelph, ON N1E 6K9, Canada
- Department of Psychiatry, Western University, London, ON N6C 0A7, Canada
- Department of Psychology, Neuroscience, and Behaviour, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Maria Densmore
- Department of Psychiatry, Western University, London, ON N6C 0A7, Canada
- Imaging Division, Lawson Health Research Institute, London, ON N6A 4V2, Canada
| | - Breanne E Kearney
- Department of Neuroscience, Western University, London, ON N6A 3K7, Canada
| | - Sherain Harricharan
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L8N 3K7, Canada
| | - Margaret C McKinnon
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L8N 3K7, Canada
- Homewood Research Institute, Guelph, ON N1E 6K9, Canada
- Mood Disorders Program, St. Joseph’s Healthcare Hamilton, Hamilton, ON L8N 3K7, Canada
| | - Jean Théberge
- Department of Psychiatry, Western University, London, ON N6C 0A7, Canada
- Imaging Division, Lawson Health Research Institute, London, ON N6A 4V2, Canada
- Department of Medical Biophysics, Western University, London, ON N6A 5C1, Canada
| | - Rakesh Jetly
- Canadian Forces, Health Services, Ottawa, ON K1A 0S2, Canada
- Department of Psychiatry, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Ruth A Lanius
- Homewood Research Institute, Guelph, ON N1E 6K9, Canada
- Department of Psychiatry, Western University, London, ON N6C 0A7, Canada
- Imaging Division, Lawson Health Research Institute, London, ON N6A 4V2, Canada
- Department of Neuroscience, Western University, London, ON N6A 3K7, Canada
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Campbell BM, Knipp MA, Anwar SS, Hoopsick RA. Moral injury and substance use among United States healthcare workers. Stress Health 2023. [PMID: 37786303 DOI: 10.1002/smi.3321] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/08/2023] [Accepted: 09/18/2023] [Indexed: 10/04/2023]
Abstract
Moral injury (i.e., perpetrating, witnessing, failing to prevent, or being a victim of acts that transgress one's moral beliefs, values, or ethics) has largely been studied in military-connected populations and is associated with a range of adverse psychological sequelae. Emerging literature suggests that healthcare workers also experience moral injury, particularly in the context of the ongoing COVID-19 pandemic. However, it is not known if moral injury contributes to substance use among healthcare workers or whether these effects might differ by gender, race/ethnicity, or occupational level. In March 2022, we collected self-reported pilot data from a diverse sample of US healthcare workers (N = 200) We examined the cross-sectional relationships between moral injury and several measures of substance use (i.e., current non-medical use of prescription drugs [NMUPD], current cannabis use, current use of other illicit drugs, and hazardous drinking) using separate logistic regression models. Next, we used separate interaction models to examine if any of these relations differed by gender, race/ethnicity, or occupational level. In main effects models, healthcare workers reporting greater moral injury had greater odds of current NMUPD (adjusted odds ratio (aOR) = 1.07; p < 0.001), current use of other illicit drugs (aOR = 1.09; p < 0.01), and hazardous drinking (aOR = 1.07; p < 0.01). These relations did not differ by race/ethnicity or occupational level (ps > 0.05); however, men were more likely to report current NMUPD and hazardous drinking (ps < 0.05) in the presence of high moral injury than women healthcare workers. Our findings suggest that healthcare workers experience substantial distress related to morally injurious events, which may affect their likelihood of NMUPD, cannabis use, use of other illicit drugs, and hazardous drinking, and that men in healthcare may be particularly at risk. Healthcare organizations should address systemic issues driving moral injury (e.g., resource shortages, lack of psychosocial support) to prevent substance-related harms among healthcare workers.
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Affiliation(s)
- Benjamin M Campbell
- Department of Kinesiology and Community Health, University of Illinois Urbana-Champaign, Champaign, Illinois, USA
| | - Michael A Knipp
- Department of Kinesiology and Community Health, University of Illinois Urbana-Champaign, Champaign, Illinois, USA
| | - Sinan S Anwar
- Department of Kinesiology and Community Health, University of Illinois Urbana-Champaign, Champaign, Illinois, USA
| | - Rachel A Hoopsick
- Department of Kinesiology and Community Health, University of Illinois Urbana-Champaign, Champaign, Illinois, USA
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Serfioti D, Murphy D, Greenberg N, Williamson V. Professionals' perspectives on relevant approaches to psychological care in moral injury: A qualitative study. J Clin Psychol 2023; 79:2404-2421. [PMID: 37310171 DOI: 10.1002/jclp.23556] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 04/12/2023] [Accepted: 05/31/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Despite the increasing consensus that moral injury (MI) is a unique type of psychological stressor, there is an ongoing debate about best practices for psychological care. This qualitative study explored the perceptions of UK and US professionals in the field of MI investigating advances and challenges in treatment or support delivery and issues relating to treatment/support feasibility and acceptability. METHODS 15 professionals were recruited. Semi-structured, telephone/online interviews were carried out, and transcripts were analyzed using thematic analysis. RESULTS Two interconnected themes emerged: perceived barriers to appropriate care for MI cases and recommendations for providing effective care to MI patients. Professionals highlighted the challenges that occur due to the lack of empirical experience with MI, the negligence of patients' unique individual needs and the inflexibility in existing manualised treatments. CONCLUSIONS These findings illustrate the need to evaluate the effectiveness of current approaches and explore alternative pathways, which will effectively support MI patients in the long-term. Key recommendations include the use of therapeutic techniques which lead to a personalised and flexible support plan to meet patients' needs, increase self-compassion and encourage patients to reconnect with their social networks. Interdisciplinary collaborations (e.g., religious/spiritual figures), could be a valuable addition following patients' agreement.
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Affiliation(s)
- Danai Serfioti
- Department of Psychology, School of Social Sciences, Nottingham Trent University, Nottingham, UK
| | - Dominic Murphy
- Department of Psychological Medicine, King's Centre for Military Health Research, King's College London, London, UK
- Research Department, Combat Stress, Surrey, UK
| | - Neil Greenberg
- Department of Psychological Medicine, King's Centre for Military Health Research, King's College London, London, UK
| | - Victoria Williamson
- Department of Psychological Medicine, King's Centre for Military Health Research, King's College London, London, UK
- Department of Experimental Psychology, Anna Watts Building, University of Oxford, Oxford, UK
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D’Alessandro-Lowe AM, Karram M, Ritchie K, Brown A, Millman H, Sullo E, Xue Y, Pichtikova M, Schielke H, Malain A, O’Connor C, Lanius R, McCabe RE, McKinnon MC. Coping, Supports and Moral Injury: Spiritual Well-Being and Organizational Support Are Associated with Reduced Moral Injury in Canadian Healthcare Providers during the COVID-19 Pandemic. Int J Environ Res Public Health 2023; 20:6812. [PMID: 37835082 PMCID: PMC10572244 DOI: 10.3390/ijerph20196812] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023]
Abstract
Healthcare providers (HCPs) have described the onset of shame- and trust-violation-related moral injuries (MI) throughout the COVID-19 pandemic. Previous research suggests that HCPs may turn to various coping methods and supports, such as spirituality/religiosity, substance use, friends/family or organizational support, to manage workplace stress. It remains unknown, however, if similar coping methods and supports are associated with MI among this population. We explored associations between MI (including the shame and trust-violation presentations individually) and coping methods and supports. Canadian HCPs completed an online survey about their mental health and experiences during the COVID-19 pandemic, including demographic indices (e.g., sex, age, mental health history) and measures of MI, organizational support, social support, spiritual well-being, self-compassion, alcohol use, cannabis use and childhood adversity. Three hierarchical multiple linear regressions were conducted to assess the associations between coping methods/supports and (i) MI, (ii) shame-related MI and (iii) trust-violation-related MI, when controlling for age, mental health history and childhood adversity. One hundred and seventy-six (N = 176) HCPs were included in the data analysis. Spiritual well-being and organizational support were each significantly associated with reduced total MI (p's < 0.001), shame-related MI (p = 0.03 and p = 0.02, respectively) and trust-violation-related MI (p's < 0.001). Notably, comparison of the standardized beta coefficients suggests that the association between trust-violation-related MI and both spiritual well-being and organizational support was more than twice as great as the associations between these variables and shame-related MI, emphasizing the importance of these supports and the trust-violation outcomes particularly. Mental health history (p = 0.02) and self-compassion (p = 0.01) were additionally related to shame-related MI only. Our findings indicate that heightened levels of spiritual well-being and organizational support were associated with reduced MI among HCPs during the COVID-19 pandemic. Rather than placing sole responsibility for mental health outcomes on HCPs individually, organizations can instead play a significant role in mitigating MI among staff by implementing evidence-informed organizational policies and interventions and by considering how supports for spiritual well-being may be implemented into existing models of care where relevant for employees.
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Affiliation(s)
- Andrea M. D’Alessandro-Lowe
- Department of Psychology Neuroscience and Behaviour, McMaster University, Hamilton, ON L8S 4L6, Canada;
- Homewood Research Institute, Guelph, ON N13 6K9, Canada
| | - Mauda Karram
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada
| | - Kim Ritchie
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada
- Trent/Fleming School of Nursing, Trent University, Peterborough, ON K9L 0G2, Canada
| | - Andrea Brown
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada
| | - Heather Millman
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada
| | - Emily Sullo
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada
| | - Yuanxin Xue
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada
- Temetry Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Mina Pichtikova
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada
- Department of Applied Psychology and Human Development, University of Toronto, Toronto, ON M5S 1V6, Canada
| | | | - Ann Malain
- Homewood Health Centre, Guelph, ON NIE 6K9, Canada
| | | | - Ruth Lanius
- Homewood Research Institute, Guelph, ON N13 6K9, Canada
- Lawson Health Research Institute, University of Western Ontario, London, ON N6C 2R5, Canada
| | - Randi E. McCabe
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada
- St. Joseph’s Healthcare Hamilton, Hamilton, ON L8N 4A6, Canada
| | - Margaret C. McKinnon
- Homewood Research Institute, Guelph, ON N13 6K9, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada
- St. Joseph’s Healthcare Hamilton, Hamilton, ON L8N 4A6, Canada
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Williamson V, Murphy D, Bonson A, Aldridge V, Serfioti D, Greenberg N. Restore and Rebuild (R&R) - a feasibility pilot study of a co-designed intervention for moral injury-related mental health difficulties. Eur J Psychotraumatol 2023; 14:2256204. [PMID: 37732994 PMCID: PMC10515691 DOI: 10.1080/20008066.2023.2256204] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/27/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Moral injury can significantly negatively impact mental health, but currently no validated treatment for moral injury-related mental health difficulties exists in a UK context. This study aimed to examine whether the Restore and Rebuild (R&R) treatment was feasible to deliver, acceptable and well tolerated by UK military veterans with moral injury related mental health difficulties. METHOD The R&R treatment was delivered to 20 patients who reported distress related to exposure to a morally injurious event(s) during military service. R&R is a 20-session psychotherapy with key themes of processing the event, self compassion, connecting with others and core values. Treatment was delivered online, weekly, one-to-one by a single therapist. Qualitative interviews with patients and the therapist who delivered R&R were conducted to explore acceptability and analysed using thematic analysis. RESULTS Following treatment, patients experienced a significant reduction in symptoms of post-traumatic stress disorder, depression, alcohol misuse and moral injury related distress. R&R was found to be well tolerated by patients and improved their perceived wellbeing. CONCLUSIONS These results provide preliminary evidence that veterans struggling with moral injury related mental ill health can benefit from R&R treatment.
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Affiliation(s)
- Victoria Williamson
- Department of Experimental Psychology, Anna Watts Building, University of Oxford, Oxford, UK
- Institute of Psychiatry, Psychology and Neuroscience, King’s Centre for Military Health Research, King’s College London, London, UK
| | | | | | | | - Danai Serfioti
- Institute of Psychiatry, Psychology and Neuroscience, King’s Centre for Military Health Research, King’s College London, London, UK
- Department of Psychology, School of Social Sciences, Nottingham Trent University, Nottingham, UK
| | - Neil Greenberg
- Institute of Psychiatry, Psychology and Neuroscience, King’s Centre for Military Health Research, King’s 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] [What about the content of this article? (0)] [Affiliation(s)] [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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O’Mathúna D. Ethics and frontline nursing during COVID-19: A qualitative analysis. Nurs Ethics 2023; 30:803-821. [PMID: 36971185 PMCID: PMC10051012 DOI: 10.1177/09697330221143150] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
BACKGROUND Nurses experienced intense ethical and moral challenges during the COVID-19 pandemic. Our 2020 qualitative parent study of frontline nurses' experiences during the COVID-19 pandemic identified ethics as a cross-cutting theme with six subthemes: moral dilemmas, moral uncertainty, moral distress, moral injury, moral outrage, and moral courage. We re-analyzed ethics-related findings in light of refined definitions of ethics concepts. RESEARCH AIM To analyze frontline U.S. nurses' experiences of ethics during the COVID-19 pandemic. RESEARCH DESIGN Qualitative analysis using a directed content methodology. PARTICIPANTS AND RESEARCH CONTEXT The study included 43 nurses from three major metropolitan academic medical centers and one community hospital in the northeastern, mid-Atlantic, midwestern, and western United States. ETHICAL CONSIDERATIONS Participant privacy and data confidentiality were addressed. FINDINGS Moral dilemmas arose from many situations, most frequently related to balancing safety and patient care. Moral uncertainty commonly arose from lacking health information or evidence about options. Moral distress occurred when nurses knew the right thing to do, but were prevented from doing so, including with end-of-life issues. Moral injury (accompanied by suffering, shame, or guilt) occurred after doing, seeing, or experiencing wrongdoing, often involving authority figures. Nurses expressed moral outrage at events and people within and outside healthcare. Despite difficult ethical situations, some nurses exemplified moral courage, sometimes by resisting policies they perceived as preventing compassionate care, guided by thinking about what was best for patients. DISCUSSION This content analysis of ethics-related subthemes revealed conceptual characteristics and clarified distinctions with corresponding exemplars. Conceptual clarity may inform responses and interventions to address ethical quandaries in nursing practice. CONCLUSIONS Ethics education in nursing must address the moral dilemmas of pandemics, disasters, and other crises. Nurses need time and resources to heal from trying to provide the best care when no ideal option was available.
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Affiliation(s)
- Dónal O’Mathúna
- The Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, College of Nursing, The Ohio State University, Columbus, OH, USA; Center for Bioethics and Medical Humanities, The Ohio State University, Columbus, OH, USA
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Ritter M, Vance M, Iskander J. Moral Injury Among US Public Health Service First Responders During the COVID-19 Pandemic. Public Health Rep 2023; 138:732-735. [PMID: 37300285 PMCID: PMC10261941 DOI: 10.1177/00333549231176294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023] Open
Affiliation(s)
- Mark Ritter
- United States Public Health Service Commissioned Corps, Rockville, MD, USA
- United States Coast Guard, Washington, DC, USA
| | - Mary Vance
- United States Public Health Service Commissioned Corps, Rockville, MD, USA
- United States Coast Guard, Washington, DC, USA
| | - John Iskander
- United States Public Health Service Commissioned Corps, Rockville, MD, USA
- United States Coast Guard, Washington, DC, USA
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40
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Russell B, Mussap AJ. Rumination and threat-biased interpretation mediate posttraumatic stress and growth responses to military stressors. Mil Psychol 2023; 35:451-466. [PMID: 37615560 PMCID: PMC10453989 DOI: 10.1080/08995605.2022.2127618] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/14/2022] [Indexed: 10/14/2022]
Abstract
We examined the role of rumination and threat-biased interpretation in stress and growth responses to military stressors. Two online surveys were completed by 183 (survey 1) and 393 (survey 2) currently serving or retired military personnel. The surveys measured exposure to potential military stressors (exposure to combat, witnessing the consequences of war, and perceived moral injury), posttraumatic stress symptomatology (PTSS), posttraumatic growth (PTG), and personal wellbeing, with survey 1 including measures of rumination, and survey 2 including a measure of threat-biased interpretation. Path analyses revealed that indirect paths from both witnessing the consequences of war and experiencing betrayal to PTSS were mediated by intrusive rumination and threat-biased interpretation, and that indirect paths from both betrayal and transgressions by others to PTG were mediated by deliberate rumination and threat-biased interpretation. The results reveal the idiosyncratic nature of military stressors, their differential involvement with cognitions that underpin rumination about past events and interpretation of current events, and their relevance to posttraumatic stress and growth in military personnel.
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Affiliation(s)
- Brenton Russell
- School of Psychology, Deakin University, Melbourne, Australia
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DeBeer BB, Mignogna J, Nance M, Bahraini N, Penzenik M, Brenner LA. COVID-19 and Lifetime Experiences of Trauma, Moral Injury, and Institutional Betrayal Among Healthcare Providers. J Occup Environ Med 2023; 65:745-750. [PMID: 37254232 PMCID: PMC10694842 DOI: 10.1097/jom.0000000000002891] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE The aim of the study is to increase understanding regarding healthcare provider experiences with psychological trauma, moral injury, and institutional betrayal, both over the lifetime and during the COVID-19 pandemic. METHODS The study employed a cross-sectional design to understand traumatic experiences, moral injury, and institutional betrayal among medical and mental health providers. Participants were asked to identify an index trauma, and experiences were coded qualitatively using categories for traumatic events, moral injury, and institutional betrayal. RESULTS Results revealed that experiences of trauma, moral injury, and institutional betrayal were common in relation to the pandemic, as were prepandemic histories of traumatic exposures. Findings indicate that trauma exposure was a work hazard for healthcare providers during the pandemic, which could result in negative long-term mental health outcomes. CONCLUSIONS Future research is needed to explore potential long-term negative outcomes among healthcare providers.
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Affiliation(s)
- Bryann B. DeBeer
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO
- Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado, Aurora, CO
| | - Joseph Mignogna
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO
- Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado, Aurora, CO
| | - Morgan Nance
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO
- Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado, Aurora, CO
| | - Nazanin Bahraini
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO
- Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado, Aurora, CO
- Department of Psychiatry, Anschutz Medical Campus, University of Colorado, Aurora, CO
| | - Molly Penzenik
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO
| | - Lisa A. Brenner
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO
- Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado, Aurora, CO
- Department of Psychiatry, Anschutz Medical Campus, University of Colorado, Aurora, CO
- Department of Neurology, Anschutz Medical Campus, University of Colorado, Aurora, CO
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Rabin S, Kika N, Lamb D, Murphy D, AM Stevelink S, Williamson V, Wessely S, Greenberg N. Moral Injuries in Healthcare Workers: What Causes Them and What to Do About Them? J Healthc Leadersh 2023; 15:153-160. [PMID: 37605753 PMCID: PMC10440078 DOI: 10.2147/jhl.s396659] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 04/28/2023] [Accepted: 07/26/2023] [Indexed: 08/23/2023] Open
Abstract
Moral injury (MI) refers to the persisting distress which may occur following exposure to potentially morally injurious events (PMIEs). The COVID-19 pandemic has drawn attention to MI in healthcare workers, who have been found to experience more frequent PMIEs in their day-to-day work than those in other occupational groups such as the military. These events may occur on an individual, team, organizational or system level and have been associated with increased clinician burnout and distress, and poor psychological wellbeing. This paper focuses on healthcare workers' experiences of MI, including potential causes and ways to reduce them. There are myriad challenges that influence the development of MI, such as chronic understaffing and the pressure to treat high numbers of patients with limited resources. There are also multiple impacts of MI: at the individual-level, MI can lead to increased staff absences and understaffing, and prolonged patient contact with limited decision-making power. COVID-19 exacerbated such impacts, with a lack of organizational support during a time of increased patient mortality, and uncertainty and heightened pressure on the clinical frontline associated with scarce resources and understaffing. Potential methods for reduction of MI in healthcare workers include pre-exposure mitigation, such as fostering work environments which treat PMIEs in the same way as other occupational hazards and post-exposure mitigation, such as facilitating healthcare workers to process their experiences of PMIEs in peer support groups or with spiritual advisors and, if MI is associated with mental ill-health, talking therapies using trauma-focused and compassion-oriented frameworks.
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Affiliation(s)
- Sarah Rabin
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Natalia Kika
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Danielle Lamb
- Department of Applied Health Research, University College London, London, UK
| | - Dominic Murphy
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Research Department, Combat Stress, Leatherhead, UK
| | - Sharon AM Stevelink
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Victoria Williamson
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Simon Wessely
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Neil Greenberg
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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Ben-Shalom U, Reizer A, Connelly V, Rickover I. The adaptation of soldiers to post-service life - the mediating impact of political views on the relationship between violence and adaptation. Front Psychol 2023; 14:1131316. [PMID: 37645069 PMCID: PMC10461056 DOI: 10.3389/fpsyg.2023.1131316] [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: 12/24/2022] [Accepted: 07/28/2023] [Indexed: 08/31/2023] Open
Abstract
Introduction The current research explores the association between political views, combat experiences, and the adaptation of soldiers to post-service life. Violent experiences in military service were explored as contributors to both positive and negative dimensions of adaptation, while political views served as possible mediators. Methods Three hundred and twenty Israeli veterans participated in the study. Results Political views were correlated with adaptation, especially left-to-right voting and anti-militarism. The results support the mediating role of political beliefs (left-right voting and militarism) in the relationship between combat experience and adaptation to post-service life. Discussion We contend that political perceptions affect adaptation through sense-making of the combat experiences and the individual processing of these experiences, and the willingness to continue in reserve service, which allows social support and recognition. In addition, they are linked to a sense of bitterness following the reduction of public participation in military and reserve service.
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Affiliation(s)
- Uzi Ben-Shalom
- Department of Sociology and Anthropology, Ariel University, Ariel, Israel
- Department of Psychology, Health and Professional Development, Oxford Brookes University, Oxford, United Kingdom
| | - Abira Reizer
- Department of Psychology, Ariel University, Ariel, Israel
| | - Vincent Connelly
- Department of Psychology, Health and Professional Development, Oxford Brookes University, Oxford, United Kingdom
| | - Itamar Rickover
- Department of Sociology and Anthropology, Ariel University, Ariel, Israel
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Zerach G, Ben-Yehuda A, Levi-Belz Y. A prospective investigation of protective factors for moral injury and psychiatric symptomatology among Israeli combatants: A Latent Class Analysis approach. Int J Soc Psychiatry 2023; 69:1134-1144. [PMID: 36734242 DOI: 10.1177/00207640231152211] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND In this prospective study, we examined pre-enlistment characteristics and pre-deployment protective factors of exposure to potentially morally injurious events (PMIEs) among Israeli active-duty combatants, as well as psychiatric symptomatology outcomes of exposure. METHODS A sample of 335 active-duty Israeli combatants participated in a 2.5-year prospective study with three waves of measurements (T1: 12 months before enlistment, T2: 6 months following enlistment- pre deployment, and T3: 18 months following enlistment- post deployment). Participants' characteristics were assessed via semi-structured interviews (T1) and validated self-report measures (T2-T3) between 2019 and 2021. RESULTS Latent Class Analysis (LCA) was used to identify three classes characterized by unique patterns of exposure to PMIEs (T2): Minimal Exposure (56.6%), Betrayal-Only (25.5%), and High Exposure (17.8%). Higher levels of pre-deployment psychological flexibility (T1) were associated with higher odds for inclusion in the high exposure class (T2). As compared to the minimal exposure class, both high exposure and betrayal-only classes were associated with higher levels of mental health symptoms and MI-related psychological outcomes (T2). CONCLUSIONS This is the first prospective study of antecedents and outcomes of exposure to PMIEs among active-duty combatants. Clinicians treating combatants should be aware of the different types of exposure to PMIEs and their possible psychiatric outcomes.
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Affiliation(s)
- Gadi Zerach
- Department of Psychology, Ariel University, Ariel, Israel
| | - Ariel Ben-Yehuda
- Department of Health and Well-being, Medical Corps, IDF, Tel Aviv, Israel
| | - Yossi Levi-Belz
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
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Békés V, Szabó D, Lévay EE, Salgó E, Unoka Z. Moral Injury and Shame Mediate the Relationship Between Childhood Trauma and Borderline Personality Disorder, PTSD, and Complex PTSD Symptoms in Psychiatric Inpatients. J Pers Disord 2023; 37:406-423. [PMID: 37721777 DOI: 10.1521/pedi.2023.37.4.406] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Moral injury (MI) has received increased research attention in the past decades. However, despite its detrimental mental health consequences, MI has not been studied in psychiatric patients. We aimed to establish the relationship between childhood trauma, MI, and borderline personality disorder (BPD), posttraumatic stress disorder (PTSD), and disturbances in self-organization symptoms (DSO), a core diagnostic criterion of complex PTSD besides PTSD symptoms, and shame as a moral emotion in an inpatient psychiatric sample (N = 240). We found that the impact of childhood trauma on present BPD, PTSD, and DSO symptoms was mediated by MI and shame; the models accounted for up to 31% of variance in symptomatology. To our knowledge, this study is the first to investigate MI in a psychiatric sample, and our results highlight the importance of considering MI as a critical factor of patient experiences in relation to childhood trauma that potentially contributes to the development of psychiatric symptoms.
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Affiliation(s)
- Vera Békés
- From Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York, USA
| | - Dominik Szabó
- Doctoral School of Mental Health Sciences, Semmelweis University, Budapest, Hungary
| | - Erika Evelyn Lévay
- Doctoral School of Mental Health Sciences, Semmelweis University, Budapest, Hungary
| | - Ella Salgó
- Doctoral School of Mental Health Sciences, Semmelweis University, Budapest, Hungary
| | - Zsolt Unoka
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
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Lathan EC, Powers A, Kottakis A, Guelfo A, Siegle GJ, Turner JA, Turner MD, Yakkanti V, Jain J, Mekawi Y, Teer AP, Currier JM, Fani N. Civilian moral injury: associations with trauma type and high-frequency heart rate variability in two trauma-exposed community-based samples. Psychol Med 2023; 53:5136-5145. [PMID: 37650341 PMCID: PMC10476056 DOI: 10.1017/s003329172200215x] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 06/13/2022] [Accepted: 06/22/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Moral injury exposure (MIE) and distress (MID) may indirectly affect the relationship between trauma exposure and alterations in autonomic regulation [assessed via high-frequency heart rate variability (hfHRV)] in civilians, but this has not been tested in prior research. We conducted two exploratory studies to examine trauma types' associations with MIE and MID among civilian medical patients (Study 1) and explore how these facets may indirectly affect the relationship between trauma type and hfHRV among civilians seeking mental health services (Study 2). METHODS Participants recruited from a public hospital and/or community advertisements (Study 1, n = 72, 87.5% Black, 83.3% women; Study 2, n = 46, 71.7% Black, 97.8% women) completed measures assessing trauma type, MIE, and MID. In Study 1, trauma types that emerged as significant correlates of MIE and MID were entered into separate linear regression analyses. Trauma types identified were included as predictors in indirect effects models with MIE or MID as the mediator and resting hfHRV (assayed via electrocardiography) as the outcome. RESULTS Childhood sexual abuse emerged as the only significant predictor of MIE, b = 0.38, p < 0.001; childhood sexual abuse, b = 0.26, p < 0.05, and adulthood sexual assault, b = 0.23, p < 0.05 were significant predictors of MID. Participants with greater MIE and MID demonstrated lower hfHRV. Adulthood sexual assault showed an indirect effect on hfHRV through MID, B = -0.10, s.e. = 0.06, 95%CI (-0.232 to -0.005). CONCLUSIONS Moral injury was uniquely associated with sexual violence and lower hfHRV in civilians. Data highlight moral injury as a pathway through which autonomic dysregulation may emerge and its salience for trauma treatment selection.
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Affiliation(s)
- Emma C. Lathan
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Abigail Powers
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Anna Kottakis
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Alfonsina Guelfo
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Greg J. Siegle
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jessica A. Turner
- Department of Psychology, Georgia State University, Atlanta, GA, USA
| | - Matthew D. Turner
- Department of Psychology, Georgia State University, Atlanta, GA, USA
| | - Vijwala Yakkanti
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Jahnvi Jain
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Yara Mekawi
- Department of Psychological and Brain Sciences, University of Louisville, Louisville, KY, USA
| | - Andrew P. Teer
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Joseph M. Currier
- Department of Psychology, University of South Alabama, Mobile, AL, USA
| | - Negar Fani
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
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Diekmann C, Issels L, Alliger-Horn C, Rau H, Fischer C, Thiel T, Willmund G, Zimmermann P. Traumatized German soldiers with moral injury - value-based cognitive-behavioral group therapy to treat war-related shame. Front Psychiatry 2023; 14:1173466. [PMID: 37533887 PMCID: PMC10390695 DOI: 10.3389/fpsyt.2023.1173466] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/03/2023] [Indexed: 08/04/2023] Open
Abstract
Introduction During deployment, soldiers are confronted with potentially morally injurious events. In many cases, these events violate their personal values and belief systems, resulting in feelings of anger, alienation, guilt, and shame. The psychological distress caused by such transgressions is defined as moral injury. It remains unclear to date, which therapeutic interventions are most appropriate for addressing this specific psychological condition. This study examines the effectiveness of value-based cognitive-behavioral group therapy combining elements of cognitive-behavioral therapy, acceptance and commitment therapy, spiritual care, and adaptive disclosure therapy. Materials and methods This controlled study uses the Compass of Shame Scale to assess symptom severity among participants both before and after a three-week inpatient group therapy regimen for moral injury. An intervention group (n = 45) was compared to a waiting-list control group (n = 40). A one-way between subjects ANOVA was conducted to determine the differences between the two measurement points in the intervention group compared to the control group. A positive ethics vote from the Humboldt University Berlin (Charité) was available (No.EA1/092/15). Results A significant difference was found on the shame-associated maladaptive strategies subscales of attack self (F (1, 83) = 5.942, p = 0.017, Cohen's f = 0,27), withdrawal (F (1, 83) = 8.263, p = 0.005, Cohen's f = 0,32), and attack others (F (1, 83) = 10.552, p = 0.002, Cohen's f = 0,36) of the Compass of Shame Scale between the intervention group and the control group at the p < 0.05 level in the pre- and post-treatment (t1-t2) comparison. Conclusion This study suggests that the special therapeutic focus in cognitive-behavioral group therapy can alter shame-based maladaptive coping behaviors in response to war-related moral injury. This study provides further evidence that therapeutic approaches - through fostering a reconciliatory, compassionate, and forgiving approach toward oneself and others - target the underlying mechanisms of moral injury. Therefore, value-based cognitive-behavioral interventions should be considered as a standard element of trauma care in a military setting. Future studies should further examine such interventions in randomized control trials. It would also be particularly valuable for future studies to include a follow-up time point.
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Affiliation(s)
- Caroline Diekmann
- Department of Psychiatry, Psychotherapy and Psychotraumatology, Military Hospital Berlin, Berlin, Germany
- Charité - Berlin University of Medicine, Humboldt University of Berlin, Berlin, Germany
| | - Leonie Issels
- Department of Psychiatry, Psychotherapy and Psychotraumatology, Military Hospital Berlin, Berlin, Germany
| | - Christina Alliger-Horn
- Department of Psychiatry, Psychotherapy and Psychotraumatology, Military Hospital Berlin, Berlin, Germany
| | - Heinrich Rau
- Department of Psychiatry, Psychotherapy and Psychotraumatology, Military Hospital Berlin, Berlin, Germany
| | | | - Thomas Thiel
- Military Chaplaincy Central Office, Berlin, Germany
| | - Gerd Willmund
- Department of Psychiatry, Psychotherapy and Psychotraumatology, Military Hospital Berlin, Berlin, Germany
| | - Peter Zimmermann
- Department of Psychiatry, Psychotherapy and Psychotraumatology, Military Hospital Berlin, Berlin, Germany
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Benfer N, Grunthal B, Dondanville KA, Young-McCaughan S, Blankenship A, Abdallah CG, Back SE, Flanagan J, Foa EB, Fox PT, Krystal JH, Marx BP, McGeary DD, McLean CP, Pruiksma KE, Resick PA, Roache JD, Shiroma P, Sloan DM, Taylor DJ, Wachen JS, López-Roca AL, Nicholson KL, Schobitz RP, Schrader CC, Sharrieff AFM, Yarvis JS, Mintz J, Keane TM, Peterson AL, Litz BT. DSM-5 criterion-a-based trauma types in service members and veterans seeking treatment for posttraumatic stress disorder. Psychol Trauma 2023:2023-86330-001. [PMID: 37410416 PMCID: PMC10770283 DOI: 10.1037/tra0001537] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
OBJECTIVE In posttraumatic stress disorder (PTSD), the assumption of the equipotentiality of traumas ignores potentially unique contexts and consequences of different traumas. Accordingly, Stein et al. (2012) developed a reliable typing scheme in which assessors categorized descriptions of traumatic events into six "types": life threat to self (LTS), life threat to other, aftermath of violence (AV), traumatic loss, moral injury by self (MIS), and moral injury by other (MIO). We extended this research by validating the typing scheme using participant endorsements of type, rather than assesor-based types. We examined the concordance of participant and assesor types, frequency, and validity of participant-based trauma types by examining associations with baseline mental and behavioral health problems. METHOD Interviewers enrolled military personnel and veterans (N = 1,443) in clinical trials of PTSD and helped them select the most currently distressing Criterion-A trauma. Participants and, archivally, assessors typed the distressing aspect(s) of this experience. RESULTS AV was the most frequently participant-endorsed type, but LTS was the most frequently rated worst part of an event. Although participants endorsed MIS and MIO the least frequently, these were associated with worse mental and behavioral health problems. The agreement between participants and assessors regarding the worst part of the event was poor. CONCLUSION Because of discrepancies between participant and assessor typologies, clinical researchers should use participants' ratings, and these should trump assessor judgment. Differences in pretreatment behavioral and mental health problems across some participant-endorsed trauma types partially support the validity of the participant ratings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Natasha Benfer
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts, United States
| | - Breanna Grunthal
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts, United States
| | - Katherine A. Dondanville
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, United States
| | - Abby Blankenship
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
| | | | - Sudie E. Back
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina
- Ralph H. Johnson VA Medical Center, Charleston, South Carolina, United States
| | - Julianne Flanagan
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina
- Ralph H. Johnson VA Medical Center, Charleston, South Carolina, United States
| | - Edna B. Foa
- Department of Psychiatry, University of Pennsylvania
| | - Peter T. Fox
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, United States
- Research Imaging Institute, Department of Radiology, Department of Psychiatry and Behavioral Sciences, and Department of Neurology, University of Texas Health Science Center at San Antonio
| | - John H. Krystal
- Clinical Neurosciences Division, National Center for PTSD, VA Connecticut Healthcare System, West Haven, Connecticut, United States
- Department of Psychiatry, Yale University School of Medicine
| | - Brian P. Marx
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, United States
- Department of Psychiatry, Boston University School of Medicine
| | - Donald D. McGeary
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, United States
| | - Carmen P. McLean
- Dissemination and Training Division, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University
| | - Kristi E. Pruiksma
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
| | | | - John D. Roache
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, United States
| | - Paulo Shiroma
- Minneapolis VA Medical Center, Minneapolis, Minnesota, United States
- Department of Psychiatry, University of Minnesota
| | - Denise M. Sloan
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, United States
- Department of Psychiatry, Boston University School of Medicine
| | | | - Jennifer Schuster Wachen
- Department of Psychiatry, Boston University School of Medicine
- Women’s Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, United States
| | - Argelio L. López-Roca
- Department of Behavioral Health, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas, United States
| | - Karin L. Nicholson
- Department of Medicine, Carl R. Darnall Army Medical Center, Fort Hood, Texas, United States
| | - Richard P. Schobitz
- Department of Behavioral Health, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas, United States
| | - Christian C. Schrader
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, Texas
| | | | - Jeffrey S. Yarvis
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, Texas
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, United States
| | - Terence M. Keane
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, United States
- Department of Psychiatry, Boston University School of Medicine
| | - Alan L. Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, United States
- Department of Psychology, University of Texas at San Antonio
| | - Brett T. Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts, United States
- Department of Psychiatry, Boston University School of Medicine
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Thibodeau PS, Nash A, Greenfield JC, Bellamy JL. The Association of Moral Injury and Healthcare Clinicians' Wellbeing: A Systematic Review. Int J Environ Res 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] [What about the content of this article? (0)] [Affiliation(s)] [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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50
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Van Voorhees EE, Dillon KH, Crombach A, Beaver T, Kelton K, Wortmann JH, Visn-Mid-Atlantic Mirecc Workgroup, Nieuwsma J. Enjoying the violence of war: Association with posttraumatic symptomatology in U.S. combat veterans. Psychol Trauma 2023:2023-84472-001. [PMID: 37384480 PMCID: PMC10755059 DOI: 10.1037/tra0001530] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
OBJECTIVE Engaging in war-related violence can have a devastating impact on military personnel, with research suggesting that injuring or killing others can contribute to posttraumatic stress disorder (PTSD), depression, and moral injury. However, there is also evidence that perpetrating violence in war can become pleasurable to a substantial number of combatants and that developing this "appetitive" form of aggression can diminish PTSD severity. Secondary analyses were conducted on data from a study of moral injury in U.S., Iraq, and Afghanistan combat veterans, to examine the impact of recognizing that one enjoyed war-related violence on outcomes of PTSD, depression, and trauma-related guilt. METHOD Three multiple regression models evaluated the impact of endorsing the item, "I came to realize during the war that I enjoyed violence" on PTSD, depression, and trauma-related guilt, after controlling for age, gender, and combat exposure. RESULTS Results indicated that enjoying violence was positively associated with PTSD, β (SE) = 15.86 (3.02), p < .001, depression, β (SE) = 5.41 (0.98), p < .001, and guilt, β (SE) = 0.20 (0.08), p < .05. Enjoying violence moderated the relationship between combat exposure and PTSD symptoms, β (SE) = -0.28 (0.15), p < .05, such that there was a decrease in the strength of the relationship between combat exposure and PTSD in the presence of endorsing having enjoyed violence. CONCLUSIONS Implications for understanding the impact of combat experiences on postdeployment adjustment, and for applying this understanding to effectively treating posttraumatic symptomatology, are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
| | | | | | | | | | - Jennifer H Wortmann
- Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC)
| | | | - Jason Nieuwsma
- Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC)
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