Serving on multiple fronts: A grounded theory model of complex decision-making in military mental health care

"Juggle the different hats we wear": enacted strategies for negotiating boundaries in overlapping relationships

Despite agreement that teaching on professional boundaries is needed, the design of health profession curricula is challenged by a lack of research on how boundaries are maintained and disagreement on where boundaries should be drawn. Curricula constrained by these challenges can leave graduates without formal preparation for practice conditions. Dual role or overlapping relationships are an example: they continue to be taught as boundary crossings amidst mounting evidence that they must be routinely navigated in small, interconnected communities. In this study, we examined how physicians are navigating overlapping personal (non-sexual) and professional relationships with the goal to inform teaching and curricula on professional boundaries. Following constructivist grounded theory methodology, 22 physicians who had returned to their rural, northern and/or remote hometown in British Columbia, Canada or who had lived and practised in a such a community for decades were interviewed in iterative cycles informed by analysis. We identified four strategies described by physicians for regulating multiple roles within overlapping relationships: (a) signalling the appropriate role for the current context; (b) separating roles by redirecting an interaction to an appropriate context; (c) switching roles by pushing the appropriate role forward into the context and pulling other roles into the background; and (d) suspending an interfering role by ending a relationship. Negotiating boundaries within overlapping relationships may involve monitoring role clarity and role alignment, while avoiding role conflict. The enacted role regulation strategies could be critically assessed within teaching discussions on professional boundaries and also analyzed through further ethics research.

Identifying and mitigating moral injury risks in military behavioral health providers

The term "moral injury" was initially used to describe the multifaceted pain that service members feel after perpetrating, witnessing, or failing to prevent acts that conflict with their moral codes. More recently the term has been used to describe healthcare providers' pain stemming from their experiences serving on the frontlines of the healthcare system when: a medical error causes serious harm to patients, systems continuously impede their abilities to provide proper care, or providers assess that they have acted in ways that conflict with their professional ethics or oaths to "do no harm." This article explores moral injury risk at the intersection of military service and healthcare by examining challenges that military behavioral healthcare providers face. Leveraging moral injury definitions previously applied to service members (personal or witnessed transgressions) and in two healthcare contexts ("second victim" to adverse client outcomes and system-driven moral distress), as well as literature on ethical challenges in military behavioral health, this paper uncovers situations that may amplify military behavioral health providers' risks for moral injury. It concludes by offering policy and practice recommendations germane to military medicine aimed at alleviating pressures military behavioral healthcare providers face and mitigating moral injuries' potential ripple effects on provider wellness, retention and care quality.

Framework for Incorporating Artificial Somatic Markers in the Decision-Making of Autonomous Agents

The somatic marker hypothesis proposes that when a person faces a decision scenario, many thoughts arise and different “physical consequences” are fleetingly observable. It is generally accepted that affective dimension influences cognitive capacities. Several proposals for including affectivity within artificial systems have been presented. However, to the best of our knowledge, a proposal that considers the incorporation of artificial somatic markers in a disaggregated and specialized way for the different phases that make up a decision-making process has not been observed yet. Thus, this research work proposes a framework that considers the incorporation of artificial somatic markers in different phases of the decision-making of autonomous agents: recognition of decision point; determination of the courses of action; analysis of decision options; decision selection and performing; memory management. Additionally, a unified decision-making process and a general architecture for autonomous agents are presented. This proposal offers a qualitative perspective following an approach of grounded theory, which is suggested when existing theories or models cannot fully explain or understand a phenomenon or circumstance under study. This research work represents a novel contribution to the body of knowledge in guiding the incorporation of this biological concept in artificial terms within autonomous agents.