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Fleming WH, Smigelsky MA. Enhancing the Utility of the Moral Injury Experience Wheel: Manualized Applications for Diverse Contexts. JOURNAL OF RELIGION AND HEALTH 2024:10.1007/s10943-024-02082-9. [PMID: 38992253 DOI: 10.1007/s10943-024-02082-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/20/2024] [Indexed: 07/13/2024]
Abstract
Moral injury has emerged as an important construct for understanding the distress experienced in the aftermath of a moral violation, initially among combat veterans and increasingly among other populations, such as healthcare workers and first responders. While numerous measures have been validated to assess for exposure to potentially morally injurious events and/or sequelae, additional tools are needed to facilitate nuanced discussion of the experience of moral injury in therapeutic encounters. The Moral Injury Experience Wheel (MIEW; Fleming, 2023) is an infographic instrument that is designed to elicit precise language and help differentiate feelings in an effort to process morally perplexing circumstances. This paper describes the contents and potential clinical applications of a newly developed manual to guide the use of the MIEW. The MIEW and manual are designed to be used independently or alongside existing moral injury interventions. A case study featuring the use of the MIEW and manual demonstrates how the tools can be used in a professional healthcare setting. Recommendations for moral injury care practitioners are provided.
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Affiliation(s)
- Wesley H Fleming
- Clinical Chaplain, Syracuse VAMC, 800 Irving Ave, Syracuse, NY, 13210, USA.
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Tunks Leach K, Demant D, Simpson P, Lewis J, Levett-Jones T. Chaplaincy and spiritual care in Australian ambulance services: an exploratory cross-sectional study. J Health Care Chaplain 2024; 30:202-225. [PMID: 38574262 DOI: 10.1080/08854726.2024.2323371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Ambulance staff wellbeing programs aim to support the bio-psycho-social and sometimes spiritual needs of paramedics. While evidence demonstrates strong connections between spirituality and/or religion to wellbeing outcomes, little is known about spiritual care in ambulance services or its impact. The aim of this study was to investigate paramedics' perspectives on the role and value of Australian ambulance chaplains. A cross-sectional online study of registered paramedics in Australia was conducted between November and December 2022. Analysis of the 150 responses identified that paramedics viewed the chaplain's role as one built on professional caring relationships that provided proactive and reactive care in paramedic workplaces. Chaplains were perceived to promote wellbeing by incorporating emotional, psychological, social and spiritual care, and assisting paramedics to access additional support. Perceived religiousness of chaplains and organisational factors were barriers to paramedics accessing chaplains, while pre-existing relationships and shared experiences positively influenced paramedics decision to seek chaplain support.
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Affiliation(s)
- Katie Tunks Leach
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Daniel Demant
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, OLD, Australia
| | - Paul Simpson
- School of Health Sciences, Western Sydney University, Sydney, NSW, Australia
| | | | - Tracy Levett-Jones
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
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Woerner AJ, Greenberg CH, Chick JFB, Monroe EJ, Abad-Santos M, Kim H, Lee E, Makary MS, Hage AN, Covello B, Shin DS. Moral Injury Among Interventional Radiologists. Acad Radiol 2024; 31:1122-1129. [PMID: 37926643 DOI: 10.1016/j.acra.2023.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 09/01/2023] [Accepted: 09/05/2023] [Indexed: 11/07/2023]
Abstract
RATIONALE AND OBJECTIVES To evaluate moral injury (MI) among interventional radiologists using validated assessment tools. MATERIALS AND METHODS An anonymous 29-question online survey was distributed to interventional radiologists using the Society of Interventional Radiology Connect Open Forum website, Twitter, Facebook, LinkedIn, and electronic mail. The survey consisted of demographic and practice environment questions, a global quality of life (QoL) scale (scored 1-100), the MI Symptom Scale‑Healthcare Professional (MISS-HP) (scored 1-100), and two open-ended questions. A MISS-HP score ≥ 36 was indicative of experiencing MI. P < .05 was considered statistically significant for all two-sided tests. RESULTS Beginning on March 30, 2023, 365 surveys were completed over 5 days. Of the respondents, 299 (81.9%) were male, 65 (17.8%) were female, and one preferred not to disclose gender. The respondents included practicing interventional radiologists (299; 81.9%) and interventional radiologists-in-training (66; 18.1%). Practice settings included academic (146; 40.0%), community (121; 33.2%), hybrid (84; 23.0%), or other (14; 3.8%) centers. Mean QoL was 71.1 ± 17.0 (range: 0-100) suggestive of "good" QoL. Mean QoL in the MI subgroup was significantly different from that for the rest of the group (67.6 ± 17.0 vs. 76.6 ± 16.0; P < 0.05). 223 (61.1%) respondents scored ≥ 36 on the MISS-HP, and thus were categorized as having profession-related MI. Mean MISS-HP was 39.9 ± 12.6 (range: 10-83). Mean MISS-HP in the MI subgroup was significantly different from that for the rest of the group (47.4 ± 9.6 vs. 28.0 ± 5.7; P < 0.05). There was a negative correlation between MI and QoL (r = -0.4; P < 0.001). Most common themes for greatest contribution to MI were ineffective leadership, barriers to patient care, corporatization of medicine, non-physician administration, performing futile procedures, turf battles, and reduced resources. Most common themes for ways to reduce MI were more autonomy, less bureaucracy, more administrative support, physician-directed leadership, adequate staffing, changes to the medical system, physician unionization, transparency with insurance companies, more time off, and leaving medicine/retirement. CONCLUSION MI is prevalent among interventional radiologists, and it negatively correlates with QoL. Future work should investigate causative factors and mitigating solutions.
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Affiliation(s)
- Andrew J Woerner
- Section of Vascular and Interventional Radiology, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, Washington, 98195, USA (A.J.W., C.H.G., J.F.B.C., M.A.S., D.S.S.)
| | - Colvin H Greenberg
- Section of Vascular and Interventional Radiology, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, Washington, 98195, USA (A.J.W., C.H.G., J.F.B.C., M.A.S., D.S.S.)
| | - Jeffrey Forris Beecham Chick
- Section of Vascular and Interventional Radiology, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, Washington, 98195, USA (A.J.W., C.H.G., J.F.B.C., M.A.S., D.S.S.)
| | - Eric J Monroe
- Section of Vascular and Interventional Radiology, Department of Radiology, University of Wisconsin, Madison, Wisconsin, USA (E.J.M.)
| | - Matthew Abad-Santos
- Section of Vascular and Interventional Radiology, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, Washington, 98195, USA (A.J.W., C.H.G., J.F.B.C., M.A.S., D.S.S.)
| | - HeeJin Kim
- Department of Information and Statistics, Chungnam National University, Yuseong-gu, Daejeon, South Korea (H.K., E.L.)
| | - Eunjee Lee
- Department of Information and Statistics, Chungnam National University, Yuseong-gu, Daejeon, South Korea (H.K., E.L.)
| | - Mina S Makary
- Department of Radiology, Division of Vascular and Interventional Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA (M.S.M.)
| | - Anthony N Hage
- Department of Radiology, Division of Vascular and Interventional Radiology, Thomas Jefferson Hospital, Philadelphia, Pennsylvania, USA (A.N.H.)
| | - Brian Covello
- Division of Interventional Radiology, Department of Radiology, Aventura Hospital & Medical Center, Aventura, Florida, USA (B. C.)
| | - David S Shin
- Section of Vascular and Interventional Radiology, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, Washington, 98195, USA (A.J.W., C.H.G., J.F.B.C., M.A.S., D.S.S.).
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Lown BA, Collier J, Manning C, Gareis K. The Healing Healthcare Initiative: Guiding leaders to heal a traumatized workforce. Healthc Manage Forum 2024; 37:74-79. [PMID: 37831518 DOI: 10.1177/08404704231204874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
The COVID-19 pandemic amplified burnout and moral distress among healthcare professionals and accentuated the systemic gaps and limitations of current approaches to workforce well-being. The Schwartz Center for Compassionate Healthcare launched the Healing Healthcare Initiative (HHI) in response to these compounded challenges. Aligned with national recommendations, the HHI framework comprises six key principles and eight implementation domains that foster compassionate and trauma-informed organizational cultures. C-suite level executive teams from six diverse healthcare organizations were selected to participate in the year-long pilot. Organizational and executive team surveys identified siloed well-being efforts and gaps in knowledge and awareness that undermine meaningful progress. The HHI pilot offers executive teams a space for reflection and open conversations, fostering trust within the team, and reinforcing the commitment to employee well-being. The program supports leadership teams in creating a strategy to implement the HHI framework that engages frontline workers in co-designing organizational solutions for a thriving workforce.
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Affiliation(s)
- Beth A Lown
- The Schwartz Center for Compassionate Healthcare, Somerville, Massachusetts, United States
| | - Julie Collier
- The Schwartz Center for Compassionate Healthcare, Somerville, Massachusetts, United States
| | - Colleen Manning
- Goodman Research Group, Inc., Cambridge, Massachusetts, United States
| | - Karen Gareis
- Goodman Research Group, Inc., Cambridge, Massachusetts, United States
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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] [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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Berry DM, Adams LM, Vytla SP. Vaccine hesitancy and hesitant adoption among nursing students in Texas. Prev Med Rep 2024; 38:102612. [PMID: 38375178 PMCID: PMC10874835 DOI: 10.1016/j.pmedr.2024.102612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 02/21/2024] Open
Abstract
Background As the state facing the second-largest nursing workforce shortage in the U.S. and low vaccination rates among residents early in the pandemic, Texas provided a unique opportunity to examine vaccine hesitancy and hesitant adoption among nursing students in an environment where state-level executive orders prohibited mandatory vaccinations. Methods The purpose of this study was to describe the level of vaccine hesitancy and hesitant adoption among nursing students in the state of Texas. We used a convenient, opt-in, online survey of nursing students conducted between mid-April and mid-June 2022. The survey was distributed to all pre-licensure nursing programs in Texas. Results The majority of survey respondents (n = 599) were between the ages of 18-28 (68 %), female (88 %) and white (57 %). Most received at least one dose of the COVID-19 vaccination (84 %). Of those receiving the vaccine, a high proportion (82 %) were identified as hesitant adopters. Respondents cited concerns about side effects (57 %) most frequently as the reason for vaccine hesitancy. Conclusion Given the worldwide nursing shortage, factors potentially impacting the future workforce, such as vaccine hesitancy and hesitant adoption, must be closely monitored. More research is needed to understand the concerns of nursing students and the motivations of hesitant and non-hesitant adopters.
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Affiliation(s)
- Devon M. Berry
- 3380 College Park Drive, Suite 400, The Woodlands, TX 77384, USA
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Ippolito M, Noto A, Lakbar I, Chalkias A, Afshari A, Kranke P, Garcia CSR, Myatra SN, Schultz MJ, Giarratano A, Bilotta F, De Robertis E, Einav S, Cortegiani A. Peri-operative night-time work of anaesthesiologists: A qualitative study of critical issues and proposals. Eur J Anaesthesiol 2024; 41:34-42. [PMID: 37972930 DOI: 10.1097/eja.0000000000001930] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND Qualitative data on the opinions of anaesthesiologists regarding the impact of peri-operative night-time working conditions on patient safety are lacking. OBJECTIVES This study aimed to achieve in-depth understanding of anaesthesiologists' perceptions regarding the impact of night-time working conditions on peri-operative patient safety and actions that may be undertaken to mitigate perceived risks. DESIGN Qualitative analysis of responses to two open-ended questions. SETTING Online platform questionnaire promoted by the European Society of Anaesthesiology and Intensive Care (ESAIC). PARTICIPANTS The survey sample consisted of an international cohort of anaesthesiologists. MAIN OUTCOME MEASURES We identified and classified recurrent themes in the responses to questions addressing perceptions regarding (Q1) peri-operative night-time working conditions, which may affect patient safety and (Q2) potential solutions. RESULTS We analysed 2112 and 2113 responses to Q1 and Q2, respectively. The most frequently reported themes in relation to Q1 were a perceived reduction in professional performance accompanied by concerns regarding the possible consequences of work with fatigue (27%), and poor working conditions at night-time (35%). The most frequently proposed solutions in response to Q2 were a reduction of working hours and avoidance of 24-h shifts (21%), an increase in human resources (14%) and performance of only urgent or emergency surgeries at night (14%). CONCLUSION Overall, the surveyed anaesthesiologists believe that workload-to-staff imbalance and excessive working hours were potential bases for increased peri-operative risk for their patients, partly because of fatigue-related medical errors during night-time work. The performance of nonemergency elective surgical cases at night and lack of facilities were among the reported issues and potential targets for improvement measures. Further studies should investigate whether countermeasures can improve patient safety as well as the quality of life of anaesthesia professionals. Regulations to improve homogeneity, safety, and quality of anaesthesia practice at night seem to be urgently needed.
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Affiliation(s)
- Mariachiara Ippolito
- From the Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo (MI, AG, AC), Department of Anaesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo (MI, AG, AC), Division of Anaesthesia and Intensive Care, Department of Human Pathology of the Adult and Evolutive Age 'Gaetano Barresi', University of Messina, Policlinico 'G. Martino', Messina, Italy (AN), Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, 1, Montpellier Cedex 5, Montpellier, France (IL), Institute for Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA (AC), Outcomes Research Consortium, Cleveland, OH, USA (AC), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AA), Institute of Clinical Medicine, University of Copenhagen (AA), Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany (PK), Consorcio Hospital General Universitario de Valencia, Valencia. Methodology research Department, Universidad Europea de Valencia, Spain (CSRG), Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India (SNM), Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands (MJS), Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (MJS), Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK (MJS), Department of Anaesthesiology, Critical Care and Pain Medicine, Policlinico Umberto I Teaching Hospital, Sapienza University of Rome, Rome (FB), Division of Anaesthesia, Analgesia, and Intensive Care, Department of Medicine and surgery. University of Perugia, Italy (EDR) and General Intensive Care Unit of the Shaare Zedek Medical Centre and the Hebrew University Faculty of Medicine, Jerusalem, Israel (SE)
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Onnink B, Correll MC, Correll A, Correll T. Psychotherapy's Role in Evaluating the Invisible Wounds of Moral Injury. INNOVATIONS IN CLINICAL NEUROSCIENCE 2024; 21:36-42. [PMID: 38495605 PMCID: PMC10941865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Moral injury is a relatively new concept with varying definitions that attempts to define a profound and lasting insult to one's conscience caused by perpetration of or directly witnessing harm to another person in a high-pressure situation. This entity is separate from posttraumatic stress disorder (PTSD), but it can coexist with PTSD. This article provides psychotherapeutic examples of the diagnosis of moral injury from a psychodynamic perspective, focusing on morally challenging situations related to warfare and the healthcare system.
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Affiliation(s)
- Ben Onnink
- Dr. Onnink is a resident, Department of Psychiatry, Wright State University Boonshoft School of Medicine in Dayton, Ohio
| | - Matthew C Correll
- Mr. M. Correll is a student at Wright State University Raj Soin School of Business in Dayton, Ohio
| | - Andrew Correll
- Mr. A. Correll is with Wright State University Boonshoft School of Medicine in Dayton, Ohio
| | - Terry Correll
- Dr. T. Correll is Clinical Professor, Department of Psychiatry, Wright State University Boonshoft School of Medicine in Dayton, Ohio
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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] [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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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] [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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Fatima M, Imran N, Aamer I, Iqtadar S, Shabbir B. When healers get wounded! Moral injury in healthcare providers during the COVID-19 pandemic in Pakistan. Front Psychiatry 2023; 14:1244055. [PMID: 37795516 PMCID: PMC10545959 DOI: 10.3389/fpsyt.2023.1244055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/06/2023] [Indexed: 10/06/2023] Open
Abstract
Introduction Moral injury (MI) is a multi-faceted and multidimensional phenomenon. Occupational MI has been studied mainly among military personnel and first responders and is linked to mental health problems. MI encompasses negative moral emotions such as shame, guilt, and anger leading to distress, and impairment in social and occupational functioning. The COVID-19 pandemic predisposed healthcare providers to moral dilemmas, potentially morally injurious events (PMIEs), and MI. We aimed to assess the prevalence and predictors of MI in healthcare providers during the COVID-19 pandemic in Pakistan. Materials and methods This cross-sectional study was conducted in July-October 2021 among physician/clinician staff working at teaching hospitals in Lahore. The Moral Injury Symptoms Scale-Health Professionals (MISS-HP) was used to collect data. SPSS 26 was used for data analysis applying Wilcoxon Mann-Whitney U and Kruskal-Wallis tests on non-normally distributed data at α = 0.05. Predictors of MI were ascertained through Binary Logistic Regression analysis. Results Four hundred and twenty physicians responded to the questionnaires. The Median (IQR) MI scores were 37(28-47). Guilt, moral concerns, and shame were higher-scoring MI dimensions. 40.8% (n = 171) suffered from clinically significant distress and impaired functioning while 14.3% (n = 60) from severe distress. Gender, department, and history of psychiatric illness predicted higher levels of distress which were 1.9 times higher in females than males and 2.5 times higher with a history of psychiatric illness. Working on the front lines did not predict MI. Conclusion Our findings highlight the substantial burden of MI in our sample during COVID-19, having implications for healthcare providers' well-being, healthcare quality, and service delivery. This calls for concerted efforts from all stakeholders to better prepare for future disasters through effective human-resource policies, pre-trauma exposure soft-skills training, effective teamwork and communication strategies; self-stewardship and resilience modules, and mental health support for healthcare providers. The dimensional construct of MI may vary across cultures; hence we recommend further cross-cultural research on MI in healthcare providers, particularly in the context of public health disasters.
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Affiliation(s)
- Madah Fatima
- Academic Department of Psychiatry and Behavioral Sciences, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
| | - Nazish Imran
- Child and Family Psychiatry Department, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
| | - Irum Aamer
- Academic Department of Psychiatry and Behavioral Sciences, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
| | - Somia Iqtadar
- Department of Medicine, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
| | - Bilquis Shabbir
- Department of Medicine, Sir Ganga Ram Hospital, Fatima Jinnah Medical University, Lahore, Pakistan
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Calabrese L, Battafarano DF, Stamatos C, Saag KG. "Burnout" Coupled with Workforce Shortages Spells Trouble: Innovative Solutions Are Essential for More Satisfying Rheumatology Practice. Arthritis Rheumatol 2023; 75:1499-1502. [PMID: 37096452 DOI: 10.1002/art.42537] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 03/14/2023] [Accepted: 04/18/2023] [Indexed: 04/26/2023]
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Rushton CH. Transforming Moral Suffering by Cultivating Moral Resilience and Ethical Practice. Am J Crit Care 2023; 32:238-248. [PMID: 37391375 DOI: 10.4037/ajcc2023207] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
Ethical challenges are inherent in nursing practice. They affect patients, families, teams, organizations, and nurses themselves. These challenges arise when there are competing core values or commitments and diverse views on how to balance or reconcile them. When ethical conflict, confusion, or uncertainty cannot be resolved, moral suffering ensues. The consequences of moral suffering in its many forms undermine safe, high-quality patient care, erode teamwork, and undermine well-being and integrity. My experience as a nurse in the pediatric intensive care unit and later as a clinical nurse specialist in confronting these moral and ethical challenges has been the foundation of my program of research. Together we will explore the evolution of our understanding of moral suffering-its expressions, meanings, and consequences and attempts to measure it. Moral distress, the most described form of moral suffering, took hold within nursing and slowly within other disciplines. After 3 decades of research documenting the existence of moral distress, there were few solutions. It was at this juncture that my work pivoted toward exploring the concept of moral resilience as a means for transforming but not eliminating moral suffering. The evolution of the concept, its components, a scale to measure it, and research findings will be explored. Throughout this journey, the interplay of moral resilience and a culture of ethical practice were highlighted and examined. Moral resilience is continuing to evolve in its application and relevance. Many vital lessons have been learned that can inform future research and guide interventions to harness the inherent capabilities of clinicians to restore or preserve their integrity and to engage in large-scale system transformation.
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Affiliation(s)
- Cynda Hylton Rushton
- Cynda Hylton Rushton is the Anne and George L. Bunting Professor of Clinical Ethics, Berman Institute of Bioethics, and a professor of nursing and pediatrics, Johns Hopkins University School of Nursing, Baltimore, Maryland
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Buchbinder M, Browne A, Berlinger N, Jenkins T, Buchbinder L. Moral Stress and Moral Distress: Confronting Challenges in Healthcare Systems under Pressure. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023:1-15. [PMID: 37347222 PMCID: PMC10758677 DOI: 10.1080/15265161.2023.2224270] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
Stresses on healthcare systems and moral distress among clinicians are urgent, intertwined bioethical problems in contemporary healthcare. Yet conceptualizations of moral distress in bioethical inquiry often overlook a range of routine threats to professional integrity in healthcare work. Using examples from our research on frontline physicians working during the COVID-19 pandemic, this article clarifies conceptual distinctions between moral distress, moral injury, and moral stress and illustrates how these concepts operate together in healthcare work. Drawing from the philosophy of healthcare, we explain how moral stress results from the normal operations of overstressed systems; unlike moral distress and moral injury, it may not involve a sense of powerlessness concerning patient care. The analysis of moral stress directs attention beyond the individual, to stress-generating systemic factors. We conclude by reflecting on how and why this conceptual clarity matters for improving clinicians' professional wellbeing, and offer preliminary pathways for intervention.
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Affiliation(s)
| | | | | | | | - Liza Buchbinder
- Center for Social Medicine and Humanities and Semel Institute, UCLA
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Cahill JM, Moyse AJ, Dugdale LS. "Ruptured selves: moral injury and wounded identity". MEDICINE, HEALTH CARE, AND PHILOSOPHY 2023; 26:225-231. [PMID: 36780060 DOI: 10.1007/s11019-023-10138-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 05/13/2023]
Abstract
Moral injury is the trauma caused by violations of deeply held values and beliefs. This paper draws on relational philosophical anthropologies to develop the connection between moral injury and moral identity and to offer implications for moral repair, focusing particularly on healthcare professionals. We expound on the notion of moral identity as the relational and narrative constitution of the self. Moral identity is formed and forged in the context of communities and narrative and is necessary for providing a moral horizon against which to act. We then explore the relationship between moral injury and damaged moral identities. We describe how moral injury ruptures one's sense of self leading to moral disorientation. The article concludes with implications for moral repair. Since moral identity is relationally formed, moral repair is not primarily an individual task but requires the involvement of others to heal one's identity. The repair of moral injury requires the transformation of a moral identity in community.
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Affiliation(s)
- Jonathan M Cahill
- Center for Clinical Medical Ethics, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA
| | - Ashley J Moyse
- Center for Clinical Medical Ethics, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA
| | - Lydia S Dugdale
- Department of Medicine, Center for Clinical Medical Ethics, Columbia University, Vagelos College of Physicians & Surgeons, 622 W 168th St, PH 8E-105, 10032-3784, New York, NY, USA.
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Moya AN, Owodunni OP, Harrison JL, Shahriari SR, Shetty AK, Borah GL, Schmidt MH, Bowers CA. Preoperative Frailty Risk in Cranioplasty Patients: Risk Analysis Index Predicts Adverse Outcomes. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5059. [PMID: 37351116 PMCID: PMC10284328 DOI: 10.1097/gox.0000000000005059] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 04/19/2023] [Indexed: 06/24/2023]
Abstract
Cranioplasty is a common surgical procedure used to repair cranial defects, and it is associated with significant morbidity and mortality. Although frailty is a strong predictor of poor postoperative outcomes across surgical specialties, little is known about frailty's impact on cranioplasty outcomes. This study examined the association between frailty and cranioplasty by comparing the effect of the Risk Analysis Index-Administrative (RAI-A) and the Modified Frailty Index-5 (mFI-5) on cranioplasty outcomes. Methods The National Surgical Quality Improvement Program was queried for patients undergoing cranioplasty between 2012 and 2020. Receiver operating characteristics and multivariable analyses were used to assess the relationship of postoperative outcomes and the RAI-A, mFI-5, and increasing patient age. Results There were 2864 included study patients with a median age of 57 years (IQR, 44-67), and a higher proportion of patients were women (57.0%) and White (68.5%). The RAI-A had a more robust predictive ability for 30-day mortality (C-Statistic, 0.741; 95% confidence interval (CI), 0.678-0.804) compared with mFI-5 (C-Statistic, 0.574; 95% CI, 0.489-0.659) and increasing patient age (C-Statistic, 0.671; 95% CI, 0.610-0.732). On multivariable analyses, frailty was independently associated with mortality and other poor postoperative outcomes (P < 0.05). Conclusions The RAI-A demonstrated superior discrimination than the mFI-5 and increasing patient age in predicting mortality. Additionally, the RAI-A showed independent associations with nonhome discharge and postoperative complications (CDII, CDIIIb, and CDIV). The high rates of operative morbidity (5.0%-36.5%) and mortality (0.4%-3.2%) after cranioplasty highlight the importance of identifying independent risk factors for poor cranioplasty outcomes.
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Affiliation(s)
- Addi N. Moya
- From the University of New Mexico School of Medicine, Albuquerque, N.M
| | - Oluwafemi P. Owodunni
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, N.M
| | - Joshua L. Harrison
- Department of Surgery, Division of Plastic, Reconstructive, Hand and Burn Surgery, University of New Mexico School of Medicine, Albuquerque, N.M
| | - Shawhin R. Shahriari
- Department of Surgery, Division of Plastic, Reconstructive, Hand and Burn Surgery, University of New Mexico School of Medicine, Albuquerque, N.M
| | - Anil K. Shetty
- Department of Surgery, Division of Plastic, Reconstructive, Hand and Burn Surgery, University of New Mexico School of Medicine, Albuquerque, N.M
| | - Gregory L. Borah
- Department of Surgery, Division of Plastic, Reconstructive, Hand and Burn Surgery, University of New Mexico School of Medicine, Albuquerque, N.M
| | - Meic H. Schmidt
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, N.M
| | - Christian A. Bowers
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, N.M
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Rosenström T, Tuisku K, Suvisaari J, Pukkala E, Junttila K, Haravuori H, Elovainio M, Haapa T, Jylhä P, Laukkala T. Healthcare workers' heterogeneous mental-health responses to prolonging COVID-19 pandemic: a full year of monthly follow up in Finland. BMC Psychiatry 2022; 22:724. [PMID: 36402992 PMCID: PMC9675158 DOI: 10.1186/s12888-022-04389-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 11/11/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic strained healthcare workers but the individual challenges varied in relation to actual work and changes in work. We investigated changes in healthcare workers' mental health under prolonging COVID-19 pandemic conditions, and heterogeneity in the mental-health trajectories. METHODS A monthly survey over a full year was conducted for employees of the HUS Helsinki University Hospital (n = 4804) between 4th June 2020 to 28th May 2021. Pandemic-related potentially traumatic events (PTEs), work characteristics (e.g., contact to COVID-19 patients), local COVID-19 incidence, and demographic covariates were used to predict Mental Health Index-5 (MHI-5) and Insomnia Severity Index (ISI) in generalized multilevel and latent-class mixed model regressions. RESULTS Local COVID-19 log-incidence (odds ratio, OR = 1.21, with 95% CI = 1.10-1.60), directly caring for COVID-19 patients (OR = 1.33, CI = 1.10-1.60) and PTEs (OR = 4.57, CI = 3.85-5.43) were all independently associated with psychological distress, when (additionally) adjusting for age, sex, profession, and calendar time. Effects of COVID-19 incidence on mental health were dissociable from calendar time (i.e., evolved in time) whereas those on sleep were not. Latent mental-health trajectories were characterized by a large class of "stable mental health" (62% of employees) and minority classes for "early shock, improving" (14%) and "early resilience, deteriorating" mental health (24%). The minority classes, especially "early shock, improving", were more likely to live alone and be exposed to PTEs than the others. CONCLUSIONS Healthcare workers faced changing and heterogeneous mental-health challenges as the COVID-19 pandemic prolonged. Adversity and mental ill-being may have accumulated in some employees, and factors like living arrangements may have played a role. Knowledge on employees' demographic and socioeconomic background, as well as further research on the factors affecting employees' resilience, may help in maintaining healthy and efficient workforce in the face of a prolonging pandemic.
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Affiliation(s)
- Tom Rosenström
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, 00014, Helsinki, Finland.
| | - Katinka Tuisku
- grid.7737.40000 0004 0410 2071Department of Psychiatry, University of Helsinki and Acute Psychiatry and Consultations, HUS Helsinki University Hospital, 00029 Helsinki, Finland
| | - Jaana Suvisaari
- grid.14758.3f0000 0001 1013 0499Finnish Institute for Health and Welfare, Mental Health Team, 00271 Helsinki, Finland
| | - Eero Pukkala
- grid.502801.e0000 0001 2314 6254Faculty of Social Sciences, Tampere University, 33100 Tampere, Finland
| | - Kristiina Junttila
- grid.7737.40000 0004 0410 2071Nursing Research Center, HUS Helsinki University Hospital and University of Helsinki, 00029 Helsinki, Finland
| | - Henna Haravuori
- grid.14758.3f0000 0001 1013 0499Finnish Institute for Health and Welfare, Mental Health Team, 00271 Helsinki, Finland
| | - Marko Elovainio
- grid.7737.40000 0004 0410 2071Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, 00014 Helsinki, Finland ,grid.14758.3f0000 0001 1013 0499Finnish Institute for Health and Welfare, Health Services Research, 00271 Helsinki, Finland
| | - Toni Haapa
- grid.7737.40000 0004 0410 2071Nursing Research Center, HUS Helsinki University Hospital and University of Helsinki, 00029 Helsinki, Finland
| | - Pekka Jylhä
- grid.7737.40000 0004 0410 2071Department of Psychiatry, University of Helsinki and Acute Psychiatry and Consultations, HUS Helsinki University Hospital, 00029 Helsinki, Finland
| | - Tanja Laukkala
- grid.7737.40000 0004 0410 2071Department of Psychiatry, University of Helsinki and Acute Psychiatry and Consultations, HUS Helsinki University Hospital, 00029 Helsinki, Finland
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