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Harris JI, Dunlap S, Xanthos D, Pyne JM, Hermes E, Griffin BJ, Kondrath SR, Kim SY, Golden KB, Cooney NJ, Usset TJ. Implementing a Multi-Disciplinary, Evidence-Based Resilience Intervention for Moral Injury Syndrome: Systemic Barriers and Facilitators. Behav Sci (Basel) 2024; 14:281. [PMID: 38667079 PMCID: PMC11047717 DOI: 10.3390/bs14040281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/11/2024] [Accepted: 03/14/2024] [Indexed: 04/29/2024] Open
Abstract
Moral injury syndrome (MIS) is a mental health (MH) problem that substantially affects resilience; the presence of MIS reduces responsiveness to psychotherapy and increases suicide risk. Evidence-based treatment for MIS is available; however, it often goes untreated. This project uses principles of the Consolidated Framework for Implementation Research (CFIR) to assess barriers and facilitators to the implementation of Building Spiritual Strength (BSS), a multi-disciplinary treatment for MIS. Interviews were conducted with chaplains and mental health providers who had completed BSS facilitator training at six sites in the VA. Data were analyzed using the Hamilton Rapid Turnaround method. Findings included multiple facilitators to the implementation of BSS, including its accessibility and appeal to VA chaplains; leadership by VA chaplains trained in the intervention; and effective collaboration between the chaplains and mental health providers. Barriers to the implementation of BSS included challenges in engaging mental health providers and incorporating them as group leaders, veterans' lack of familiarity with the group format of BSS, and the impact of the COVID-19 pandemic. Results highlight the need for increased trust and collaboration between VA chaplains and mental health providers in the implementation of BSS and treatment of MIS.
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Affiliation(s)
- J. Irene Harris
- VA Maine Healthcare System, Augusta, ME 04330, USA; (S.R.K.); (N.J.C.); (T.J.U.)
- Department of Psychology, University of Maine, Orono, ME 04469, USA
| | - Shawn Dunlap
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA; (S.D.); (K.B.G.)
| | | | - Jeffrey M. Pyne
- Center for Mental Health Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR 72114, USA; (J.M.P.)
- Psychiatric Research Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Eric Hermes
- Veterans Affairs Northeast Program Evaluation Center, Orange, CT 06516, USA
| | - Brandon J. Griffin
- Center for Mental Health Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR 72114, USA; (J.M.P.)
- Psychiatric Research Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Susannah Robb Kondrath
- VA Maine Healthcare System, Augusta, ME 04330, USA; (S.R.K.); (N.J.C.); (T.J.U.)
- Department of Psychology, University of Maine, Orono, ME 04469, USA
| | - Se Yun Kim
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA; (S.D.); (K.B.G.)
| | - Kristin B. Golden
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA; (S.D.); (K.B.G.)
| | - Nathaniel J. Cooney
- VA Maine Healthcare System, Augusta, ME 04330, USA; (S.R.K.); (N.J.C.); (T.J.U.)
| | - Timothy J. Usset
- VA Maine Healthcare System, Augusta, ME 04330, USA; (S.R.K.); (N.J.C.); (T.J.U.)
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN 55455, USA
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Jamieson N, Carey LB, Jamieson A, Maple M. Examining the Association Between Moral Injury and Suicidal Behavior in Military Populations: A Systematic Review. JOURNAL OF RELIGION AND HEALTH 2023; 62:3904-3925. [PMID: 37592186 DOI: 10.1007/s10943-023-01885-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 08/19/2023]
Abstract
The increasing number of suicides among military populations cannot be fully accounted for by conventional risk factors like Post-Traumatic Stress Disorder (PTSD). As a result, researchers and theorists propose that delving into the concept of Moral Injury could offer a more comprehensive understanding of the phenomenon of suicide. Moral Injury is not currently a recognized mental health disorder but can be associated with PTSD. Moral Injury is a multi-dimensional issue that profoundly affects emotional, psychological, behavioral, social, and spiritual well-being. The objective of this systematic review is to examine the association between Moral Injury and suicidal behavior (suicide ideation, plans and or suicide attempt) within military populations. The review will specifically concentrate on identifying and analyzing studies that have investigated the connection between these variables, with a specific focus on the context of military personnel both serving and former serving members. Of the 2214 articles identified as part of this review, 12 studies satisfied the research criteria with a total participant sample having an average age of 40.7 years. The male population accounted for 78.6% of the overall sample. Two studies were identified as high-quality, while the remaining ten were rated as moderate. The analysis of these twelve studies consistently affirms a connection between Moral Injury and suicidal behavior; most obviously, that exposure to morally injurious events substantially amplify the risk of suicide, with higher levels of potential exposure being linked to increased Moral Injury and heightened levels of suicidal behavior. Our review uncovered noteworthy findings regarding the association between Moral Injury and suicidal behavior, marking a pioneering effort in exploring this association and offering valuable insights into this emerging issue. Several limitations are noted regarding this review and recommendations are made concerning the need to prioritize, expand and employ longitudinal research designs that include non-military populations such as first responders (e.g., police, paramedics, firefighters) and medical, nursing, or allied health professionals-all disciplines known to be impacted by Moral Injury.
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Affiliation(s)
- Nikki Jamieson
- Moral Injury Australia, Brisbane, Queensland, Australia.
| | - Lindsay B Carey
- Palliative Care Unit, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
- Institue of Ethics and Society, The University of Notre Dame, Sydney Campus, New South Wales, Australia
| | | | - Myfanwy Maple
- School of Health, University of New England, Armidale, New South Wales, Australia
- Manna Institute, Faculty of Medicine and Health, University of New England, Armidale, New South Wales, Australia
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McDaniel JT, Redner R, Jayawardene W, Haun J, Clapp J, Che D, Renzaglia K, Abou-Jabal D. Moral Injury is a Risk Factor for Substance Use and Suicidality Among US Military Veterans with and without Traumatic Brain Injury. JOURNAL OF RELIGION AND HEALTH 2023; 62:3926-3941. [PMID: 37679519 DOI: 10.1007/s10943-023-01905-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/09/2023]
Abstract
A national survey of United States veterans was conducted, yielding 252 veterans with Traumatic Brain Injury (TBI) and 1235 veterans without TBI. Participants were asked questions about moral injury, suicidality, substance use, and other sociodemographic variables. Multivariable linear regression analysis was used to examine the previously described relationships. Increasing severity of moral injury was associated with higher scores on the substance use tool (b = 0.02, p = 0.04), although the magnitude of effect was not different from those without TBI (Z = - 0.57, p = 0.72). Increasing severity of moral injury was positively associated with suicidal behavior scores (b = 0.10, p < 0.01). The strength of this relationship was stronger in veterans with TBI than those without TBI (Z = 1.78, p = 0.04). Rehabilitation programs that treat veterans for TBI may need to consider the evaluation of moral injury given its association with adverse events in this population.
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Affiliation(s)
- Justin T McDaniel
- School of Human Sciences, Southern Illinois University, 475 Clocktower Drive, Carbondale, IL, 62901, USA.
| | - Ryan Redner
- School of Psychological and Behavioral Sciences, Southern Illinois University, Carbondale, IL, USA
| | | | - Jolie Haun
- James A. Haley Veterans' Hospital, US Veterans Health Administration, Tampa, FL, USA
| | - John Clapp
- School of Social Work, University of Southern California, Los Angeles, CA, USA
| | - Dunren Che
- School of Computing, Southern Illinois University, Carbondale, IL, USA
| | - Karen Renzaglia
- Department of Plant Biology, Southern Illinois University, Carbondale, IL, USA
| | - Dania Abou-Jabal
- School of Human Sciences, Southern Illinois University, Carbondale, IL, USA
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Santiago S, Yahalom J, Ames D, Kopacz MS, Weinreich HM, Erickson Z, Sakhno S, Van Hoof T, Hamilton AB, Koenig HG, Yarns BC. Faith-Based Organizations' Support of Veteran Congregants at Risk for Mental Health Conditions and Suicide: A Qualitative Study of Clergy Experiences in Los Angeles County. JOURNAL OF RELIGION AND HEALTH 2023; 62:3874-3886. [PMID: 37707768 DOI: 10.1007/s10943-023-01912-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 09/15/2023]
Abstract
Faith-based organizations (FBOs) are often "gatekeepers" to mental health care for congregants at risk of mental illness and suicide, especially U.S. military Veterans, but data to inform better collaboration are needed. We conducted focus groups with clergy in Los Angeles County to understand the mental health support FBOs provide and barriers to collaboration with the mental healthcare system. Clergy detailed strategies used to support the mental health of Veteran congregants. Barriers included stigma, limits in clergy training, and incomplete knowledge about community and VA mental health resources. Results suggest strategies to improve collaboration between FBOs and the mental healthcare system in Los Angeles County.
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Affiliation(s)
- Susana Santiago
- Department of Physical Medicine and Rehabilitation, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Jonathan Yahalom
- Department of Mental Health, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Mail Code 116AE, Bldg. 401, Rm. A236, Los Angeles, CA, 90073, USA
- Department of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Donna Ames
- Department of Mental Health, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Mail Code 116AE, Bldg. 401, Rm. A236, Los Angeles, CA, 90073, USA
- Department of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Heidi M Weinreich
- Department of Social Work, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Zachary Erickson
- Department of Mental Health, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Mail Code 116AE, Bldg. 401, Rm. A236, Los Angeles, CA, 90073, USA
| | - Sergii Sakhno
- Department of Mental Health, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Mail Code 116AE, Bldg. 401, Rm. A236, Los Angeles, CA, 90073, USA
| | - Therese Van Hoof
- Department of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Alison B Hamilton
- Department of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Harold G Koenig
- Departments of Psychiatry & Behavioral Sciences and Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Department of Public Health, Ningxia Medical University, Yinchuan, People's Republic of China
| | - Brandon C Yarns
- Department of Mental Health, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Mail Code 116AE, Bldg. 401, Rm. A236, Los Angeles, CA, 90073, USA.
- Department of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
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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] [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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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] [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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7
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Zasiekina L, Duchyminska T, Bifulco A, Bignardi G. War trauma impacts in Ukrainian combat and civilian populations: Moral injury and associated mental health symptoms. MILITARY PSYCHOLOGY 2023:1-12. [PMID: 37486615 DOI: 10.1080/08995605.2023.2235256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 07/05/2023] [Indexed: 07/25/2023]
Abstract
This is the first study to compare active-duty soldiers and student civilian samples during the first three months of the Ukrainian-Russian war in relation to moral injury and its association with PTSD, anxiety and depression. A total of 350 participants, including 191 active-duty soldiers of the Ukrainian Armed Force (UAF), who were on the frontline during the full-scale invasion of Russian troops in February 2022, and 159 students from different HEIs in Volyn oblast, were recruited into the study through their attendance at the Ukrainian Psychotrauma Center. Prior to the in-person group-intervention program of psychosocial support for military and civil populations at the Ukrainian Psychotrauma Center, moral injury, PTSD, depression, and anxiety were assessed. Results showed significantly higher moral injury, PTSD, depression, and anxiety scores in civilian students, with a two-way ANOVA indicating a significant impact of female gender in civilians only. A hierarchical regression indicated that moral injury is a predictor of PTSD symptoms in both active-duty and civilian student groups. However, previous family trauma of genocide is associated with PTSD symptoms in active soldiers only. The findings of the current study could contribute insights for clinical practice for combatants and civilians during the current war.
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Affiliation(s)
- Larysa Zasiekina
- Department of General and Clinical Psychology, Lesya Ukrainka Volyn National University, Lutsk, Ukraine
- Department of Psychology, University of Cambridge, Cambridge, UK
| | - Tamara Duchyminska
- Department of Applied Psychology and Psychodiagnostics, Lesya Ukrainka Volyn National University, Lutsk, Ukraine
| | - Antonia Bifulco
- The Centre for Abuse and Trauma Centre, Middlesex University, London, UK
| | - Giacomo Bignardi
- Department of Psychology, University of Cambridge, Cambridge, UK
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Kidwell MC, Kerig PK. To Trust is to Survive: Toward a Developmental Model of Moral Injury. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2023; 16:459-475. [PMID: 37234829 PMCID: PMC10205960 DOI: 10.1007/s40653-021-00399-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/03/2021] [Indexed: 05/28/2023]
Abstract
Research on trauma- and stressor-related disorders has recently expanded to consider moral injury, or the harmful psychological impact of profound moral transgressions, betrayals, and acts of perpetration. Largely studied among military populations, this construct has rarely been empirically extended to children and adolescents despite its relevance in the early years, as well as youths' potentially heightened susceptibility to moral injury due to ongoing moral development and limited social resources relative to adults. Application of the construct to young persons, however, requires theoretical reconceptualization from a developmental perspective. The present paper brings together theory and research on developmentally-oriented constructs involving morally injurious events, including attachment trauma, betrayal trauma, and perpetration-induced traumatic stress, and describes how they may be integrated and extended to inform a developmentally-informed model of moral injury. Features of such a model include identification of potentially morally injurious events, maladaptive developmental meaning-making processes that underlie moral injury, as well as behavioral and emotional indicators of moral injury among youth. Thus, this review summarizes the currently available developmental literatures, identifies the major implications of each to a developmentally-informed construct of moral injury, and presents a conceptual developmental model of moral injury for children and adolescents to guide future empirical research.
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Affiliation(s)
- Mallory C. Kidwell
- Department of Psychology, University of Utah, 380 S 1530 E, Salt Lake City, UT 84112 USA
| | - Patricia K. Kerig
- Department of Psychology, University of Utah, 380 S 1530 E, Salt Lake City, UT 84112 USA
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Maguen S, Griffin BJ, Vogt D, Hoffmire CA, Blosnich JR, Bernhard PA, Akhtar FZ, Cypel YS, Schneiderman AI. Moral injury and peri- and post-military suicide attempts among post-9/11 veterans. Psychol Med 2023; 53:3200-3209. [PMID: 35034682 PMCID: PMC10235653 DOI: 10.1017/s0033291721005274] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 11/29/2021] [Accepted: 12/06/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Our goal was to examine the association between moral injury, mental health, and suicide attempts during military service and after separation by gender in post-9/11 veterans. METHODS A nationally representative sample of 14057 veterans completed a cross-sectional survey. To examine associations of exposure to potentially morally injurious events (PMIEs; witnessing, perpetrating, and betrayal) and suicidal self-directed violence, we estimated two series of multivariable logistic regressions stratified by gender, with peri- and post-military suicide attempt as the dependent variables. RESULTS PMIE exposure accounted for additional risk of suicide attempt during and after military service after controlling for demographic and military characteristics, current mental health status, and pre-military history of suicidal ideation and attempt. Men who endorsed PMIE exposure by perpetration were 50% more likely to attempt suicide during service and twice as likely to attempt suicide after separating from service. Men who endorsed betrayal were nearly twice as likely to attempt suicide during service; however, this association attenuated to non-significance after separation in the fully adjusted models. In contrast, women who endorsed betrayal were over 50% more likely to attempt suicide during service and after separation; PMIE exposure by perpetration did not significantly predict suicide attempts before or after service among women in the fully adjusted models. CONCLUSIONS Our findings indicate that suicide assessment and prevention programs should consider the impact of moral injury and attend to gender differences in this risk factor in order to provide the most comprehensive care.
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Affiliation(s)
- Shira Maguen
- San Francisco VA Healthcare System, San Francisco, CA, USA
- University of California – San Francisco, San Francisco, CA, USA
| | - Brandon J. Griffin
- Central Arkansas VA Healthcare System, Little Rock, AR, USA
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Dawne Vogt
- VA Boston Healthcare System, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Claire A. Hoffmire
- VA Eastern Colorado Health Care System, Aurora, Colorado, USA
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - John R. Blosnich
- University of Southern California, Los Angeles, CA, USA
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Paul A. Bernhard
- Health Outcomes of Military Exposures, Epidemiology Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, USA
| | - Fatema Z. Akhtar
- Health Outcomes of Military Exposures, Epidemiology Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, USA
| | - Yasmin S. Cypel
- Health Outcomes of Military Exposures, Epidemiology Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, USA
| | - Aaron I. Schneiderman
- Health Outcomes of Military Exposures, Epidemiology Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, USA
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Development of Moral Injury in ICU Professionals During the COVID-19 Pandemic: A Prospective Serial Interview Study. Crit Care Med 2023; 51:231-240. [PMID: 36661451 PMCID: PMC9847689 DOI: 10.1097/ccm.0000000000005766] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES During the COVID-19 pandemic, ICU professionals have faced moral problems that may cause moral injury. This study explored whether, how, and when moral injury among ICU professionals developed in the course of the COVID-19 pandemic. DESIGN This is a prospective qualitative serial interview study. SETTING Two hospitals among which one university medical center and one teaching hospital in the Netherlands. SUBJECTS Twenty-six ICU professionals who worked during the COVID-19 pandemic. INTERVENTIONS None. MEASUREMENTS MAIN RESULTS In-depth interviews with follow-up after 6 and 12 months. In total, 62 interviews were conducted. ICU professionals narrated about anticipatory worry about life and death decisions, lack of knowledge and prognostic uncertainty about COVID-19, powerlessness and failure, abandonment or betrayal by society, politics, or the healthcare organization, numbness toward patients and families, and disorientation and self-alienation. Centrally, ICU professionals describe longitudinal processes by which they gradually numbed themselves emotionally from patients and families as well as potentially impactful events in their work. For some ICU professionals, organizational, societal, and political responses to the pandemic contributed to numbness, loss of motivation, and self-alienation. CONCLUSIONS ICU professionals exhibit symptoms of moral injury such as feelings of betrayal, detachment, self-alienation, and disorientation. Healthcare organizations and ICU professionals themselves should be cognizant that these feelings may indicate that professionals might have developed moral injury or that it may yet develop in the future. Awareness should be raised about moral injury and should be followed up by asking morally injured professionals what they need, so as to not risk offering unwanted help.
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Szabó D, Békés V, Lévay EE, Salgó E, Unoka ZS. Moral injury in psychiatric patients with personality and other clinical disorders: development, psychometric properties, and validity of the Moral Injury Events Scale-Civilian Version. Eur J Psychotraumatol 2023; 14:2247227. [PMID: 37650250 PMCID: PMC10472878 DOI: 10.1080/20008066.2023.2247227] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 09/01/2023] Open
Abstract
Background: Moral injury emerges when someone perpetrates, fails to prevent, or witnesses acts that violate their own moral or ethical code. Nash et al. [(2013). Psychometric evaluation of the moral injury events scale. Military Medicine, 178(6), 646-652] developed a short measure, the Moral Injury Events Scale (MIES) to facilitate the empirical study of moral injury in the military. Our study aimed to develop a civilian version of the measure (MIES-CV) and examine its psychometric properties in a sample of psychiatric inpatients .Methods: In this cross-sectional study, the sample comprised 240 adult patients (71.7% female) with a mean age of 31.57 (SD = 11.69). The most common diagnoses in the sample were anxiety disorders (58.3%), depressive disorders (53.8%), and borderline personality disorder (39.6%). Participants were diagnosed using structured clinical interviews and filled out psychological questionnaires.Results: Exploratory factor analysis suggested that Nash et al.'s model (Perceived Transgressions, Perceived Betrayals) represents the data well. This two-factor solution showed an excellent fit in the confirmatory factor analysis, as well. Meaningful associations were observed between moral injury and psychopathology dimensions, shame, reflective functioning, well-being, and resilience. The Perceived Betrayals factor was a significant predictor of bipolar disorders, PTSD, paranoid personality disorder, borderline personality disorder, and avoidant personality disorder.Conclusions: Our study demonstrated that this broad version of the MIES is a valid measure of moral injury that can be applied to psychiatric patients.
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Affiliation(s)
- Dominik Szabó
- Doctoral School of Mental Health Sciences, Semmelweis University, Budapest, Hungary
| | - Vera Békés
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, USA
| | - 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 Szabolcs Unoka
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
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12
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Williamson V, Murphy D, Aldridge V, Bonson A, Seforti D, Greenberg N. Development of an intervention for moral injury-related mental health difficulties in UK military veterans: a feasibility pilot study protocol. Eur J Psychotraumatol 2022; 13:2138059. [PMID: 36340009 PMCID: PMC9629100 DOI: 10.1080/20008066.2022.2138059] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 09/27/2022] [Accepted: 10/02/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Experiencing potentially morally injurious events (PMIEs) has been found to be significantly associated with poor mental health outcomes in military personnel/veterans. Currently, no manualised treatment for moral injury-related mental health difficulties for UK veterans exists. This article describes the design, methods and expected data collection of the Restore & Rebuild (R&R) protocol, which aims to develop procedures to treat moral injury related mental ill health informed by a codesign approach. Methods: The study consists of three main stages. First, a systematic review will be conducted to understand the best treatments for the symptoms central to moral injury-related mental ill health (stage 1). Then the R&R manual will be co-designed with the support of UK veteran participants with lived experience of PMIEs as well as key stakeholders who have experience of supporting moral injury affected individuals (stage 2). The final stage of this study is to conduct a pilot study to explore the feasibility and acceptability of the R&R manual (stage 3). Results: Qualitative data will be analysed using thematic analysis. Conclusions: This study was approved by the King's College London's Research Ethics Committee (HR-20/21-20850). The findings will be disseminated in several ways, including publication in academic journals, a free training event and presentation at conferences. By providing information on veteran, stakeholder and clinician experiences, we anticipate that the findings will not only inform the development of an acceptable evidence-based approach for treating moral injury-related mental health problems, but they may also help to inform broader approaches to providing care to trauma exposed military veterans.
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Affiliation(s)
| | - Dominic Murphy
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Research Department, Combat Stress, Surrey, UK
| | | | | | - Danai Seforti
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Neil Greenberg
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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13
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Symons X. Why Conscience Matters: A Theory of Conscience and Its Relevance to Conscientious Objection in Medicine. RES PUBLICA (LIVERPOOL, ENGLAND) 2022; 29:1-21. [PMID: 35789952 PMCID: PMC9244116 DOI: 10.1007/s11158-022-09555-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/12/2022] [Indexed: 06/15/2023]
Abstract
Conscience is an idea that has significant currency in liberal democratic societies. Yet contemporary moral philosophical scholarship on conscience is surprisingly sparse. This paper seeks to offer a rigorous philosophical account of the role of conscience in moral life with a view to informing debates about the ethics of conscientious objection in medicine. I argue that conscience is concerned with a commitment to moral integrity and that restrictions on freedom of conscience prevent agents from living a moral life. In section one I argue that conscience is a principle of moral awareness in rational agents, and that it yields an awareness of the personal nature of moral obligation. Conscience also monitors the coherence between an agent's identity-conferring beliefs and intentions and their practical actions. In section two I consider how human beings are harmed when they are forced to violate their conscience. Restrictions on the exercise of conscience prevent people from living in accord with their own considered understanding of the requirements of morality and undermine one's capacity for moral agency. This article concludes with a consideration of how a robust theory of conscience can inform our understanding of conscientious objection in medicine. I argue that it is in the interest of individual practitioners and the medical profession generally to foster moral agency among doctors. This provides a prima facie justification for permitting at least some kinds of conscientious objection.
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Affiliation(s)
- Xavier Symons
- Plunkett Centre for Ethics, Australian Catholic University, 7 Ice Street, Darlinghurst, NSW 2010 Australia
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14
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Hamrick HC, Ehlke SJ, Davies RL, Higgins JM, Naylor J, Kelley ML. Moral Injury as a Mediator of the Associations Between Sexual Harassment and Mental Health Symptoms and Substance Use Among Women Veterans. JOURNAL OF INTERPERSONAL VIOLENCE 2022; 37:NP10007-NP10035. [PMID: 33435809 DOI: 10.1177/0886260520985485] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Moral injury is an array of symptoms theorized to develop in response to morally injurious events, defined as events that challenge one's core moral beliefs and expectations about the self, others, and world. Recent measures of moral injury have distinguished self-directed moral injury (e.g., moral injury symptoms that emerge following the perpetration of morally injurious events) from other-directed moral injury, the symptoms of which are believed to stem from one's response to actions that others have committed (e.g., within-rank violence, failures of leadership, and acts of betrayal committed by trusted others or institutions). Using a convenience sample of 154 primarily former military women, the present study examined if other-directed moral injury symptoms (e.g., anger, betrayal, and mistrust) associated with military experience would mediate the association between military sexual harassment and mental health and substance abuse symptoms. Results demonstrated that 85.8% (n = 127) of the of this sample of women veterans reported experiencing sexual harassment during their military service. Using a single mediation model, we further demonstrated that other-directed moral injury mediated the association between sexual harassment experience and mental health symptoms. Given the percentage of women veterans who reported sexual harassment, these results suggest that additional training for military members, and particularly, military leaders, is necessary to begin to reduce sexual harassment. In addition, mental health providers who work with current and former military members should consider how other-directed moral injury may be associated with mental health symptoms among women veterans who have experienced sexual harassment while in the military.
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Affiliation(s)
| | - Sarah J Ehlke
- Oklahoma Tobacco Research Center, Oklahoma City, OK, USA
| | - Rachel L Davies
- Virginia Consortium Program in Clinical Psychology, Norfolk, VA, USA
| | | | - Jennifer Naylor
- Durham Veterans Affairs Medical Center, NC, USA
- Duke University Medical Center, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham, NC, USA
| | - Michelle L Kelley
- Virginia Consortium Program in Clinical Psychology, Norfolk, VA, USA
- Old Dominion University, Norfolk, VA, USA
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15
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“Putting Down and Letting Go”: An Exploration of a Community-Based Trauma-Oriented Retreat Program for Military Personnel, Veterans, and RCMP. TRAUMA CARE 2022. [DOI: 10.3390/traumacare2020009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Current military members, veterans, and Royal Canadian Mounted Police (RCMP) experience higher rates of posttraumatic stress disorder (PTSD) and moral injury (MI). Trauma-oriented retreats have been offered as a means of addressing these concerns. This article aims to explore the impact of a non-evidence-based trauma-oriented retreat for the above populations experiencing PTSD or MI; (2) Methods: This qualitative study, nested within the larger mixed-methods pre/post longitudinal follow-up study, examined the experiences of 124 military members, veterans, and RCMP who participated in the retreat. Data were collected from semi-structured interviews and first-hand observations of the organization. Analysis was conducted using thematic analysis while being informed by realist evaluation principles; (3) Results: The results showed that important contextual elements were related to participants being ready, having multiple comorbidities and using the program as a first or last resort. Effectual mechanisms included a home-like setting; immersion; credibility of facilitators; experiential learning; an holistic approach; letting go, and reconnecting to self. Outcomes included: re-finding self, symptom management, social connection, and hope for a meaningful life. The gendered analysis suggested less favorable results; (4) Conclusions: Care is warranted as the evidence-base and effectiveness of trauma-oriented retreats yet needs to be established prior to broad use.
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16
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Exploration of Trauma-Oriented Retreats: Quantitative Changes in Mental Health Measures for Canadian Military Members, Veterans and Royal Canadian Mounted Police with Posttraumatic Stress Disorder and Moral Injury. TRAUMA CARE 2022. [DOI: 10.3390/traumacare2020010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Military members, veterans, and public safety personnel have been noted to have a higher risk of exposure to potentially traumatic events and potentially morally injurious events resulting in operational stress injuries (OSI) such as posttraumatic stress disorder (PTSD) and moral injury (MI). Treatments that can quickly and effectively address these conditions are desperately needed. The purpose of this research was to identify the impact of participation in a non-evidence-based trauma-oriented retreat for the above populations experiencing PTSD and MI. Methods: This study was an embedded mixed-methods longitudinal study with parallel repeated quantitative measures designed to evaluate outcomes at 1, 3, 6, and 12 months after completion of the retreat. Results: Analysis showed a statistically significant reduction in self-reported symptoms of PTSD, anxiety, stress, depression, MI, anger, and emotional dysregulation pre/post-retreat, and an increase in resilience. Self-reported longitudinal results did not see a change in symptom scores, with participants continuing to maintain their clinical diagnoses post-retreat. Conclusions: The results from this study illustrate that trauma-oriented retreats may be a complementary treatment modality for OSI-related conditions but should not be seen as a first-line treatment option. Program evaluation, determination of the evidence-based nature of retreats, and standardization are yet needed.
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17
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Williamson V, Murphy D, Greenberg N. Experiences and impact of moral injury in U.K. veterinary professional wellbeing. Eur J Psychotraumatol 2022; 13:2051351. [PMID: 35432782 PMCID: PMC9009941 DOI: 10.1080/20008198.2022.2051351] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Veterinary professionals (VPs) are often exposed to distressing and ethically challenging events in their line of work, yet little is known about whether they may experience moral injury and the impact potentially morally injurious events (PMIEs) may have on their wellbeing. This cross-sectional study aimed to examine the association between PMIEs and the mental health outcomes of U.K. VPs. METHOD Assessments of PMIE exposure and self-report measures of common mental disorders were administered using an anonymous online questionnaire to 90 U.K. VPs between December 2020 and May 2021. RESULTS Exposure to PMIEs was reported by almost all VPs (89.0%), with acts of omission most frequently reported. Experiences of PMIEs were significantly associated with symptoms of PTSD (p < 0.01) and experiencing a betrayal event was significantly associated with PTSD symptoms (p<0.05). However, there was no significant association found between PMIE exposure and alcohol misuse or CMD (p > 0.05). CONCLUSIONS This study provides some of the first evidence that experiences of moral injury are significantly associated with adverse mental health outcomes in U.K. VPs. Future work is needed to design effective pathways for prevention and intervention for VPs exposed to highly challenging events. HIGHLIGHTS U.K. veterinary professionals were found to experience moral injury.Experiences of moral injury were significantly associated with symptoms of PTSD.
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Affiliation(s)
- Victoria Williamson
- King's Centre for Military Health Research, Institute of Psychology, Psychiatry and Neuroscience, King's College London, London, UK.,Department of Experimental Psychology, Anna Watts Building, University of Oxford, Oxford, UK
| | - Dominic Murphy
- King's Centre for Military Health Research, Institute of Psychology, Psychiatry and Neuroscience, King's College London, London, UK.,Combat Stress, Research Department, Surrey, UK
| | - Neil Greenberg
- King's Centre for Military Health Research, Institute of Psychology, Psychiatry and Neuroscience, King's College London, London, UK
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18
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Reynolds KA, Pankratz L, Jain B, Grocott B, Bonin L, King G, Sommer JL, El-Gabalawy R, Giuliano RJ, Kredentser M, Mota N, Roos LE. Moral Injury Among Frontline Long-Term Care Staff and Management During the COVID-19 Pandemic. FRONTIERS IN HEALTH SERVICES 2022; 2:841244. [PMID: 36925899 PMCID: PMC10012813 DOI: 10.3389/frhs.2022.841244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/07/2022] [Indexed: 11/13/2022]
Abstract
Background A growing body of research highlights the experiences of moral injury among healthcare professionals during the COVID-19 pandemic. Moral injury (i.e., participating in or witnessing acts that violate one's central moral values), is associated with a host of psychological sequelae and corresponding negative psychosocial impacts. There is a lack of research examining the experiences of moral injury among those working in long-term care settings during the COVID-19 pandemic. Given the drastic impact that the COVID-19 pandemic has had on long-term care facilities in Canada, it is important to understand the experiences of moral injury among those working in long-term care settings to inform the development of effective prevention and intervention strategies. Objectives & Method The objectives of this study were to understand the experiences and impact of moral injury among Canadian frontline long-term care workers (staff and management) during the COVID-19 pandemic. Participants (N = 32 long-term care staff and management working in Ottawa and Manitoba) completed in-depth, semi-structured qualitative interviews and clinical diagnostic assessments (Mini International Neuropsychiatric Interviews; MINI; Version 7.0.2) between March 2021-June 2021. Findings The core category of our qualitative grounded theory model of moral injury in long-term care exemplified four shared types of morally injurious experiences, paired with cognitive, affective, and physiological symptom domains. Seven associated main themes emerged, contributing to the experiences and impact of moral injury in long-term care: 1) Beliefs about older adults and long-term care; 2) Interpretation of morally injurious experiences; 3) Management of morally injurious experiences; 4) Long-term care pandemic impacts; 5) Personal pandemic impacts; 6) Structural impacts in long-term care; and 7) Mental health needs and supports. Clinical assessments demonstrated anxiety disorders (n = 4) and feeding and eating disorders (n = 3) were among the most frequently classified current psychiatric disorders among long-term care workers. Conclusions This is the first Canadian study to examine the experiences and impact of moral injury in long-term care during the COVID-19 pandemic using qualitative and clinical diagnostic methodologies. Implications and insights for screening and intervention are offered.
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Affiliation(s)
- Kristin A Reynolds
- Department of Psychology, Faculty of Arts, University of Manitoba, Winnipeg, MB, Canada.,Department of Psychiatry, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Lily Pankratz
- Department of Psychology, Faculty of Arts, University of Manitoba, Winnipeg, MB, Canada
| | - Barbie Jain
- Department of Psychology, Faculty of Arts, University of Manitoba, Winnipeg, MB, Canada
| | - Bronwen Grocott
- Department of Psychology, Faculty of Arts, University of Manitoba, Winnipeg, MB, Canada
| | - Lynette Bonin
- Department of Psychology, Faculty of Arts, University of Manitoba, Winnipeg, MB, Canada
| | | | - Jordana L Sommer
- Department of Psychology, Faculty of Arts, University of Manitoba, Winnipeg, MB, Canada
| | - Renée El-Gabalawy
- Department of Psychology, Faculty of Arts, University of Manitoba, Winnipeg, MB, Canada.,Department of Psychiatry, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Clinical Health Psychology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ryan J Giuliano
- Department of Psychology, Faculty of Arts, University of Manitoba, Winnipeg, MB, Canada
| | - Maia Kredentser
- Department of Clinical Health Psychology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Natalie Mota
- Department of Psychology, Faculty of Arts, University of Manitoba, Winnipeg, MB, Canada.,Department of Psychiatry, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Clinical Health Psychology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Leslie E Roos
- Department of Psychology, Faculty of Arts, University of Manitoba, Winnipeg, MB, Canada.,Department of Pediatrics, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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19
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Meat in a Seat: A Grounded Theory Study Exploring Moral Injury in Canadian Public Safety Communicators, Firefighters, and Paramedics. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182212145. [PMID: 34831899 PMCID: PMC8618733 DOI: 10.3390/ijerph182212145] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 11/16/2022]
Abstract
The work of public safety personnel (PSP) is inherently moral; however, the ability of PSP to do what is good and right can be impeded and frustrated, leading to moral suffering. Left unresolved, moral suffering may develop into moral injury (MI) and potential psychological harm. The current study was designed to examine if MI is relevant to frontline public safety communicators, firefighters, and paramedics. Semi-structured interviews (n = 3) and focus groups (n = 3) were conducted with 19 participants (public safety communicators (n = 2); paramedics (n = 7); and firefighters (n = 10)). Interviews and focus groups were audio-recorded, transcribed, coded, and constantly compared in accordance with the grounded theory method. A conceptual theory of "frustrating moral expectations" emerged, with participants identifying three interrelated properties as being potentially morally injurious: chronic societal problems, impaired systems, and organizational quagmires. Participants navigated their moral frustrations through both integrative and disintegrative pathways, resulting in either needing to escape their moral suffering or transforming ontologically. The current study results support MI as a relevant concept for frontline PSP. Given the seriousness of PSP leaving their profession or committing suicide to escape moral suffering, the importance of the impact of MI on PSP and public safety organizations cannot be ignored or underestimated. Understanding the similarities and differences of morally injurious exposures of frontline PSP may be critical for determining mental health and resilience strategies that effectively protect PSP.
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20
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Mantri S, Song YK, Lawson JM, Berger EJ, Koenig HG. Moral Injury and Burnout in Health Care Professionals During the COVID-19 Pandemic. J Nerv Ment Dis 2021; 209:720-726. [PMID: 34582400 DOI: 10.1097/nmd.0000000000001367] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT The coronavirus pandemic (COVID-19) is predicted to increase burnout in health professionals (HPs), but little is known about moral injury (MI) in this context. We administered the Moral Injury Symptoms Scale for Health Professionals (MISS-HP) and the abbreviated Maslach Burnout Inventory via online survey to a global sample of 1831 HPs in April and October 2020. Mean MISS-HP increased from 27.4 (SD, 11.6) in April to 36.4 (SD, 13.8) in October (p < 0.001), with an accompanying increase in personal accomplishment (April: 4.7; SD, 3.1; October: 9.3; SD, 3.1; p < 0.001) and no change in other burnout subscales. In April, 26.7% of respondents reported at least moderate functional impairment from MI, increasing to 45.7% in October (p < 0.001). Predictors of MISS-HP included younger age and being a nurse. Odds of functional impairment were higher in respondents who were widowed, divorced, never married, or had direct experience caring for patients with COVID-19. COVID-19 has increased MI but not burnout in HPs; younger or unmarried individuals, nurses, and frontline workers may benefit from targeted outreach to reduce downstream effects of MI, depression, and/or posttraumatic stress disorder.
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Affiliation(s)
| | | | | | - Elizabeth J Berger
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, Hempstead, New York
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21
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Boska RL, Dunlap S, Kopacz M, Bishop TM, Harris JI. Understanding Moral Injury Morbidity: A Qualitative Study Examining Chaplain's Perspectives. JOURNAL OF RELIGION AND HEALTH 2021; 60:3090-3099. [PMID: 34480691 PMCID: PMC8418282 DOI: 10.1007/s10943-021-01414-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/25/2021] [Indexed: 06/13/2023]
Abstract
Moral injury tends to be conceptualized through an interplay of psychological and religious concerns. Recent qualitative research has begun utilizing chaplains to bolster the understanding of moral injury within veterans. The current study examined qualitative data regarding how moral injury is viewed through the lens of Chaplain Services within the Veterans Health Administration (VA). Specifically, chaplains were asked to describe how moral injury presents, what kinds of complaints veterans voice with regard to moral injury, and how moral injury impacts social functioning. Chaplains highlighted how moral injury is a pervasive issue affecting veterans across multiple domains. Clinical implications discussed further.
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Affiliation(s)
- Rachel L Boska
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, Canandaigua, NY, 14424, USA.
| | - Shawn Dunlap
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, 01730, USA
| | | | - Todd M Bishop
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, Canandaigua, NY, 14424, USA
- Department of Psychiatry, University of Rochester School of Medicine & Dentistry, Rochester, NY, 14642, USA
| | - J Irene Harris
- VISN 1 MIRECC, VA Bedford Healthcare System, Bedford, MA, 01730, USA
- University of Minnesota Medical School, Minneapolis, MN, 55455, USA
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22
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Koenig HG, Al Zaben F. Moral Injury: An Increasingly Recognized and Widespread Syndrome. JOURNAL OF RELIGION AND HEALTH 2021; 60:2989-3011. [PMID: 34245433 PMCID: PMC8270769 DOI: 10.1007/s10943-021-01328-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 05/05/2023]
Abstract
Moral injury (MI), originally discussed in relationship to transgressing moral beliefs and values during wartime among military personnel, has expanded beyond this context to include similar emotions experienced by healthcare professionals, first responders, and others experiencing moral emotions resulting from actions taken or observations made during traumatic events or circumstances. In this article, we review the history, definition, measurement, prevalence, distinctiveness, psychological consequences, manifestations (in and outside of military settings), and correlates of MI in different settings. We also review secular psychological treatments, spiritually integrated therapies, and pastoral care approaches (specific for clergy and chaplains) used to treat MI and the evidence documenting their efficacy. Finally, we examine directions for future research needed to fill the many gaps in our knowledge about MI, how it develops, and how to help those suffering from it.
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Affiliation(s)
- Harold G Koenig
- Departments of Psychiatry and Medicine, Duke University Health System, Durham, NC, 27705, USA.
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
- School of Public Health, Ningxia Medical University, Yinchuan, People's Republic of China.
- Department of Psychiatry, Shiraz University of Medical Sciences, Shiraz, Iran.
- Department of Psychiatry, Duke University Medical Center, Box 3400, Durham, NC, 27710, USA.
| | - Faten Al Zaben
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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23
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Day P, Lawson J, Mantri S, Jain A, Rabago D, Lennon R. Physician moral injury in the context of moral, ethical and legal codes. JOURNAL OF MEDICAL ETHICS 2021; 48:medethics-2021-107225. [PMID: 34290114 DOI: 10.1136/medethics-2021-107225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 06/20/2021] [Indexed: 06/13/2023]
Abstract
After 40 years of attributing high rates of physician career dissatisfaction, attrition, alcoholism, divorce and suicide to 'burnout', there is growing recognition that these outcomes may instead be caused by moral injury. This has led to a debate about the relative diagnostic merits of these two terms, a recognition that interventions designed to treat burnout may be ineffective, and much perplexity about how-if at all-this changes anything.The current research seeks to develop the construct of moral injury outside military contexts, generate more robust validity tests and more fully describe and measure the experiences of persons exposed to moral harms. Absent from the literature is a mechanism through which to move from the collective moral injury experience of physicians to a systematic change in the structure of medical practice. To address this, after providing a brief history, definitions and contrasts between burnout, moral distress and moral injury, we review the interplay of moral and ethical codes in the context of moral injury. We conclude by suggesting that professional associations can potentially prevent moral injury by providing protections for physicians within their codes of ethics.
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Affiliation(s)
- Philip Day
- Department of Family and Community Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jennifer Lawson
- Department of Pediatrics and Trent Center for Bioethics, Humanities, and History of Medicine, Duke University of School Medicine, Durham, North Carolina, USA
| | - Sneha Mantri
- Department of Neurology and Trent Center for Bioethics, Humanities, and History of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Abhi Jain
- St Mark's School of Texas, Dallas, Texas, USA
| | - David Rabago
- Department of Family and Community Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Robert Lennon
- Department of Family and Community Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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24
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Wang Z, Al Zaben F, Koenig HG, Ding Y. Spirituality, moral injury and mental health among Chinese health professionals. BJPsych Open 2021; 7:e135. [PMID: 36043686 PMCID: PMC8329767 DOI: 10.1192/bjo.2021.972] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 05/27/2021] [Accepted: 06/29/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Moral injury has been found to be prevalent among healthcare professionals during the COVID-19 public health crisis. AIMS The present study examines the relationship between spirituality, moral injury, and mental health among physicians and nurses in mainland China during the COVID-19 pandemic. METHOD An online cross-sectional study was conducted involving 3006 physicians and nurses in mainland China, where the COVID-19 pandemic has caused high rates of hospital admission and death. The Moral Injury Symptoms Scale-Health Professional was administered, along with measures of mental health and spirituality. Hierarchical linear regression modelling was used to examine the mediating and moderating role of moral injury in the relationship between spirituality and mental health. RESULTS Spirituality was positively correlated with moral injury (β = 2.41, P < 0.01), depressive symptoms (β = 0.74, P < 0.01) and anxiety symptoms (β = 0.65, P < 0.01) after controlling sociodemographic variables. Moral injury significantly mediated the relationship between spirituality and both depression and anxiety, explaining 60% (0.46/0.76) of the total association between spirituality and depression and 58% (0.38/0.65) of the association with anxiety. No moderating effect of moral injury was found on the spirituality-mental health relationship. CONCLUSIONS Although they were the findings of a cross-sectional study, these results suggest that concern over transgressing moral values during the pandemic may have been a driving factor for negative mental health symptoms among Chinese health professionals for whom spirituality was somewhat important. Future longitudinal studies are needed to determine the causal nature of these relationships.
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Affiliation(s)
- Zhizhong Wang
- Department of Epidemiology and Statistic, School of Public Health at Guangdong Medical University, Dongguan, Guangdong, China
| | - Faten Al Zaben
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Harold G. Koenig
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia, and Departments of Psychiatry and Medicine, Duke University Medical Center, Durham, NC, USA
| | - Yuanlin Ding
- Department of Epidemiology and Statistic, School of Public Health at Guangdong Medical University, Dongguan560001, Guangdong, China
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25
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Williamson V, Murphy D, Phelps A, Forbes D, Greenberg N. Moral injury: the effect on mental health and implications for treatment. Lancet Psychiatry 2021; 8:453-455. [PMID: 33743196 DOI: 10.1016/s2215-0366(21)00113-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/05/2021] [Accepted: 03/05/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Victoria Williamson
- King's Centre for Military Health Research, Institute of Psychology, Psychiatry and Neuroscience, King's College London, London SE5 9RJ, UK; Department of Experimental Psychology, University of Oxford, Oxford, UK.
| | - Dominic Murphy
- King's Centre for Military Health Research, Institute of Psychology, Psychiatry and Neuroscience, King's College London, London SE5 9RJ, UK; Combat Stress Research Department, Combat Stress, Surrey, UK
| | - Andrea Phelps
- Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, VIC, Australia
| | - David Forbes
- Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, VIC, Australia
| | - Neil Greenberg
- King's Centre for Military Health Research, Institute of Psychology, Psychiatry and Neuroscience, King's College London, London SE5 9RJ, UK
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Jamieson N, Usher K, Ratnarajah D, Maple M. Walking Forwards with Moral Injury: Narratives from Ex-serving Australian Defence Force Members. JOURNAL OF VETERANS STUDIES 2021. [DOI: 10.21061/jvs.v7i1.214] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Hall NA, Everson AT, Billingsley MR, Miller MB. Moral injury, mental health and behavioural health outcomes: A systematic review of the literature. Clin Psychol Psychother 2021; 29:92-110. [PMID: 33931926 DOI: 10.1002/cpp.2607] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/19/2021] [Accepted: 04/16/2021] [Indexed: 01/30/2023]
Abstract
Despite a burgeoning of research on moral injury in the past decade, existing reviews have not explored the breadth of consequences and the multitude of pathways through which moral injury and potentially morally injurious experiences (PMIEs) influence mental and behavioural health outcomes. This study aimed to identify associations between moral injury on mental and behavioural health. Literature searches of psychological and medical databases were conducted through April 2020. Eligible studies measured moral injury or PMIEs, and health outcomes (e.g., depression, substance use and suicidality). Fifty-seven publications representing 49 separate samples were included. Studies examined the impact of moral injury on post-traumatic stress disorder (PTSD) (n = 43); depression (n = 32); anxiety (n = 15); suicide (n = 15); substance use (n = 14); and 'other' health outcomes, including pain, burnout, sleep disturbance and treatment-seeking behaviours (n = 11). The majority of studies found significant positive associations between moral injury-related constructs, mental health and behavioural health outcomes; however, the majority were also cross-sectional and focused on military samples. Proposed mediators included lack of social support, negative cognitions and meaning-making. Moderators included self-compassion, pre-deployment mental health education and mindfulness. Moral injury is associated with a variety of negative health outcomes. Research is needed to determine the mechanisms by which moral injury may influence these outcomes over time.
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Affiliation(s)
- Nicole A Hall
- Department of Psychiatry, University of Missouri, Columbia, Missouri, USA
| | - Adam T Everson
- Department of Psychiatry, University of Missouri, Columbia, Missouri, USA
| | | | - Mary Beth Miller
- Department of Psychiatry, University of Missouri, Columbia, Missouri, USA
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Lentz LM, Smith-MacDonald L, Malloy D, Carleton RN, Brémault-Phillips S. Compromised Conscience: A Scoping Review of Moral Injury Among Firefighters, Paramedics, and Police Officers. Front Psychol 2021; 12:639781. [PMID: 33868111 PMCID: PMC8044342 DOI: 10.3389/fpsyg.2021.639781] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Public Safety Personnel (e.g., firefighters, paramedics, and police officers) are routinely exposed to human suffering and need to make quick, morally challenging decisions. Such decisions can affect their psychological wellbeing. Participating in or observing an event or situation that conflicts with personal values can potentially lead to the development of moral injury. Common stressors associated with moral injury include betrayal, inability to prevent death or harm, and ethical dilemmas. Potentially psychologically traumatic event exposures and post-traumatic stress disorder can be comorbid with moral injury; however, moral injury extends beyond fear to include spiritual, cognitive, emotional or existential struggles, which can produce feelings of severe shame, guilt, and anger. OBJECTIVE This scoping review was designed to identify the extant empirical research regarding the construct of moral injury, its associated constructs, and how it relates to moral distress in firefighters, paramedics, and police officers. METHODS A systematic literature search of peer-reviewed research was conducted using databases MEDLINE, EMBASE, APA PsychInfo, CINHAL PLUS, Web of Science, SCOPUS, and Google Scholar. Included studies were selected based on the inclusion criteria before being manually extracted and independently screened by two reviewers. RESULTS The initial database search returned 777 articles, 506 of which remained after removal of duplicates. Following review of titles, abstracts, and full texts, 32 studies were included in the current review. Participants in the articles were primarily police officers, with fewer articles focusing on paramedics and firefighters. There were two studies that included mixed populations (i.e., one study with police officers, firefighters, and other emergency service workers; one study with paramedic and firefighter incident commanders). Most studies were qualitative and focused on four topics: values, ethical decision-making, organizational betrayal, and spirituality. CONCLUSION Public safety organizations appear to recognize the experience of moral distress or moral injury among public safety personnel that results from disconnects between personal core values, formal and informal organizational values, vocational duties, and expectations. Further research is needed to better understand moral distress or moral injury specific to public safety personnel and inform training and treatment in support of public safety personnel mental health.
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Affiliation(s)
- Liana M. Lentz
- Faculty of Health Science, Western University, London, ON, Canada
- Canadian Institute for Public Safety Research and Treatment, University of Regina, Regina, SK, Canada
| | - Lorraine Smith-MacDonald
- Faculty of Health Science, Western University, London, ON, Canada
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - David Malloy
- King’s University College, University of Western Ontario, London, ON, Canada
| | - R. Nicholas Carleton
- Canadian Institute for Public Safety Research and Treatment, University of Regina, Regina, SK, Canada
| | - Suzette Brémault-Phillips
- Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
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29
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Health, Resilience, and Successful Aging in the Older US Veterans. Am J Geriatr Psychiatry 2021; 29:257-259. [PMID: 32933819 DOI: 10.1016/j.jagp.2020.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 08/28/2020] [Indexed: 11/21/2022]
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30
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Fani N, Currier JM, Turner MD, Guelfo A, Kloess M, Jain J, Mekawi Y, Kuzyk E, Hinrichs R, Bradley B, Powers A, Stevens JS, Michopoulos V, Turner JA. Moral injury in civilians: associations with trauma exposure, PTSD, and suicide behavior. Eur J Psychotraumatol 2021; 12:1965464. [PMID: 34603635 PMCID: PMC8480773 DOI: 10.1080/20008198.2021.1965464] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Moral injury (MI) describes emotional, spiritual, and social suffering that can arise following psychological trauma. Prior research in military pop ulations indicates the relevance of MI to adverse psychological outcomes, such as post-traumatic stress disorder (PTSD) and suicidal behaviours, and shows evidence for MI as a unique construct. Minimal studies of MI have been implemented in civilians, usually restricted to small samples with a specific set of traumatic experiences, despite the conceptual relevance of MI to non-military trauma reactions more broadly (e.g. feelings of betrayal towards a perpetrator of sexual abuse). OBJECTIVE To address this problem, we assessed MI in trauma-exposed civilians to examine ways in which this construct was related to and distinct from trauma and traumatic stress-related problems, including PTSD and depression. METHOD We adapted an existing MI scale, Moral Injury Events Scale (MIES) and administered this measure to 81 men and women along with measures of trauma exposure, PTSD and depression, and also asked participants about past suicide attempts. RESULTS We observed that both greater exposure and distress related to potentially morally injurious events were associated with higher trauma exposure, particularly childhood maltreatment, as well as post-traumatic and depressive psychopathology. However, even after accounting for current PTSD and depression symptoms, MI exposure (F = 6.05, p = .017) was significantly higher among participants who had previously attempted suicide. CONCLUSIONS These pilot data reveal the ways in which MI is associated with trauma exposure, PTSD and depression and highlight the salience of MI in civilians. Similarly, these data demonstrate the unique relevance of MI to suicide behaviours, independent of post-traumatic psychopathology, indicating that this construct may be an understudied contributor to suicide risk in civilians.
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Affiliation(s)
- Negar Fani
- Department of Psychiatry, Emory University, Atlanta, GA, USA
| | - Joseph M Currier
- Department of Psychology, University of South Alabama, Mobile, AL, USA
| | - Matthew D Turner
- Department of Psychology, Georgia State University, Atlanta, USA
| | | | | | - Jahnvi Jain
- Department of Psychiatry, Emory University, Atlanta, GA, USA
| | - Yara Mekawi
- Department of Psychiatry, Emory University, Atlanta, GA, USA
| | - Eva Kuzyk
- Department of Psychiatry, Emory University, Atlanta, GA, USA
| | | | - Bekh Bradley
- Department of Psychiatry, Emory University, Atlanta, GA, USA
| | - Abigail Powers
- Department of Psychiatry, Emory University, Atlanta, GA, USA
| | | | | | - Jessica A Turner
- Department of Psychology, Georgia State University, Atlanta, USA
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31
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Jamieson N, Maple M, Ratnarajah D, Usher K. Military moral injury: A concept analysis. Int J Ment Health Nurs 2020; 29:1049-1066. [PMID: 33078522 DOI: 10.1111/inm.12792] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 08/30/2020] [Accepted: 09/04/2020] [Indexed: 12/14/2022]
Abstract
Moral injury is the current term describing the breaching or violation of one's moral code and has gained international research attention due to suicide linkages in military populations (Jamieson et al., Invisible wounds and suicide: Moral injury and veteran mental health. International Journal of Mental Health Nursing, 29, 105-109, 2020). Moral injury's core features are spiritual/existential conflict, shame, guilt and self-condemnation. To date, research focuses on the core features of moral injury and or the nature of events that exposed individuals to moral injury. Walker and Avant (Strategies for Theory Construction in Nursing, Prentice Hall New York, 2011) concept analysis model was used to examine the literature. The aim of this study is to enhance understanding of the defining attributes, antecedents, consequences and empirical referents of moral injury and systematically analyse the concept of moral injury in the context of military members. A literature search was undertaken using specific websites and journals, electronic databases, library catalogues and hand-searches. Concept analysis was used to explicate moral injury, focusing exclusively on use of the concept in the included literature, comparing the terms used over time and across disciplines, and measurement tools for the concept. This concept analysis provides a renewed definition of moral injury in relation to the experience of veterans - 'moral trauma' and defined as: 'the existential, psychological, emotional and or spiritual trauma arising from a conflict, violation or betrayal, either by omission or commission, of or within one's moral beliefs or code(s)'. The analysis will facilitate understanding and operationalization of the concept applied to teaching, learning, practice and research.
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Affiliation(s)
- Nikki Jamieson
- School of Health, University of New England, Armidale, New South Wales, Australia
| | - Myfanwy Maple
- School of Health, University of New England, Armidale, New South Wales, Australia
| | - Dorothy Ratnarajah
- School of Health, University of New England, Armidale, New South Wales, Australia
| | - Kim Usher
- School of Health, University of New England, Armidale, New South Wales, Australia.,Ngangk Yira Research Centre for Aboriginal Health & Social Equity, Murdoch University, Perth, Western Australia, Australia.,Murdoch University, Hervey Bay, Queensland, Australia
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32
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Mantri S, Lawson JM, Wang Z, Koenig HG. Identifying Moral Injury in Healthcare Professionals: The Moral Injury Symptom Scale-HP. JOURNAL OF RELIGION AND HEALTH 2020; 59:2323-2340. [PMID: 32681398 PMCID: PMC7366883 DOI: 10.1007/s10943-020-01065-w] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
This study aims to develop and assess the psychometric properties of a measure of moral injury (MI) symptoms for identifying clinically significant MI in health professionals (HPs), one that might be useful in the current COVID-19 pandemic and beyond. A total of 181 HPs (71% physicians) were recruited from Duke University Health Systems in Durham, North Carolina. Internal reliability of the Moral Injury Symptom Scale-Healthcare Professionals version (MISS-HP) was examined, along with factor analytic, discriminant, and convergent validity. A cutoff score was identified from a receiver operator curve (ROC) that best identified individuals with significant impairment in social or occupational functioning. The 10-item MISS-HP measures 10 theoretically grounded dimensions of MI assessing betrayal, guilt, shame, moral concerns, religious struggle, loss of religious/spiritual faith, loss of meaning/purpose, difficulty forgiving, loss of trust, and self-condemnation (score range 10-100). Internal reliability of the MISS-HP was 0.75. PCA identified three factors, which was confirmed by CFA, explaining 56.8% of the variance. Discriminant validity was demonstrated by modest correlations (r's = 0.25-0.37) with low religiosity, depression, and anxiety symptoms, whereas convergent validity was evident by strong correlations with clinician burnout (r = 0.57) and with another multi-item measure of MI symptoms (r = 0.65). ROC characteristics indicated that a score of 36 or higher was 84% sensitive and 93% specific for identifying MI symptoms causing moderate to extreme problems with family, social, and occupational functioning. The MISS-HP is a reliable and valid measure of moral injury symptoms in health professionals that can be used in clinical practice to screen for MI and monitor response to treatment, as well as when conducting research that evaluates interventions to treat MI in HPs.
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Affiliation(s)
- Sneha Mantri
- Duke University Movement Disorders Center, and Trent Center for Bioethics, Humanities, and History of Medicine, Duke University Medical Center, Durham, NC USA
| | - Jennifer Mah Lawson
- Faculty Associate, Trent Center for Bioethics, Humanities, and History of Medicine, and Associate of the Duke Initiative for Science and Society, Duke University Medical Center, Durham, NC USA
| | - ZhiZhong Wang
- Department of Epidemiology, School of Public Health, Zunyi Medical University, Zunyi, Guizhou People’s Republic of China
| | - Harold G. Koenig
- Department of Psychiatry & Behavioral Sciences, and Department of Medicine, Duke University Medical Center, Box 3400, Durham, NC USA
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- School of Public Health, Ningxia Medical University, Yinchuan, People’s Republic of China
- Department of Psychiatry, Shiraz University of Medical Sciences, Shiraz, Iran
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33
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Jamieson N, Usher K, Maple M, Ratnarajah D. Invisible wounds and suicide: Moral injury and veteran mental health. Int J Ment Health Nurs 2020; 29:105-109. [PMID: 32162834 DOI: 10.1111/inm.12704] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Nikki Jamieson
- School of Health, University of New England, Armidale, New South Wales, Australia
| | - Kim Usher
- School of Health, University of New England, Armidale, New South Wales, Australia
| | - Myfanwy Maple
- School of Health, University of New England, Armidale, New South Wales, Australia
| | - Dorothy Ratnarajah
- School of Health, University of New England, Armidale, New South Wales, Australia
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34
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Nazarov A, Fikretoglu D, Liu A, Richardson JD, Thompson M. Help-seeking for mental health issues in deployed Canadian Armed Forces personnel at risk for moral injury. Eur J Psychotraumatol 2020; 11:1729032. [PMID: 32194921 PMCID: PMC7067158 DOI: 10.1080/20008198.2020.1729032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 02/01/2020] [Accepted: 02/04/2020] [Indexed: 10/31/2022] Open
Abstract
Objective: Potentially morally injurious experiences (PMIE) (events that transgress an individual's subjective moral standards) have been associated with psychologically distressing moral emotions such as shame and guilt. Military leaders and clinicians have feared that those with PMIEs may be less likely to seek help due to the withdrawing nature of shame/guilt; however, to date, help-seeking patterns of military personnel with PMIEs has not been explored. Our objective is to address this research gap. Method: Data from a nationally-representative mental health survey of active Canadian military personnel were analysed. To assess the association between exposure to three PMIEs and past-year help-seeking across different provider categories (i.e. professionals, para-professionals (those delegated with mental health advisory tasks but are not licenced to practice as medical professionals), non-professionals), a series of logistic regressions were conducted, controlling for exposure to other deployment and non-deployment-related psychological trauma, psychiatric variables, military factors, and sociodemographic variables. Analytical data frame included only personnel with a history of Afghanistan deployment (N = 4854). Results: Deployed members exposed to PMIEs were more likely to seek help from their family doctor/general practitioner (OR = 1.72; 95%CI = 1.25-2.36), paraprofessionals (OR = 1.72; 95%CI = 1.25-2.36), and non-professionals (OR = 1.44; 95%CI = 1.06-1.95) in comparison to members not exposed to PMIEs. Those exposed to PMIEs were also more likely to seek professional care from the civilian health care system (OR = 1.94; 95%CI = 1.27-2.96). Conclusion: Contrary to long-held, but untested, assumptions regarding the impact of PMIEs on help-seeking, we found those with PMIEs are more likely to seek help from gatekeeper professionals (i.e. general practitioners), para-professionals, and non-professionals rather than specialized mental health professionals (e.g. psychologists). Increased utilization of civilian professionals raises concerns that active military members may be avoiding military health services. Clinically, this highlights the need to increase awareness of moral injury to ensure that actively serving military members are provided with appropriate advice and treatment.
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Affiliation(s)
- Anthony Nazarov
- The MacDonald Franklin OSI Research Centre, Lawson Health ResearchInstitute, London, Ontario, Canada.,Department of Psychiatry, Western University, London, Ontario, Canada.,Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Deniz Fikretoglu
- Department of National Defence, Defence Research and Development Canada, Toronto, Ontario, Canada.,Douglas Mental Health University Institute, McGill University, Montreal, Quebec, Canada
| | - Aihua Liu
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - J Don Richardson
- The MacDonald Franklin OSI Research Centre, Lawson Health ResearchInstitute, London, Ontario, Canada.,Department of Psychiatry, Western University, London, Ontario, Canada.,Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada.,Operational Stress Injury Clinic, St. Joseph's Health Care, London, Ontario, Canada
| | - Megan Thompson
- Department of National Defence, Defence Research and Development Canada, Toronto, Ontario, Canada
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35
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Koenig HG, Ames D, Büssing A. Editorial: Screening for and Treatment of Moral Injury in Veterans/Active Duty Military With PTSD. Front Psychiatry 2019; 10:596. [PMID: 31496962 PMCID: PMC6712088 DOI: 10.3389/fpsyt.2019.00596] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 07/29/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Harold G. Koenig
- Department of Psychiatry and Behavioral Sciences and Department of Medicine, Duke University Medical Center, Durham, NC, United States
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- School of Public Health, Ningxia Medical University, Yinchuan, China
| | - Donna Ames
- Department of Psychiatry, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States
- Department of Psychiatry, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Arndt Büssing
- Quality of Life, Spirituality and Coping, Faculty of Health, Witten/Herdecke University, Witten, Germany
- IUNCTUS—Competence Center for Christian Spirituality, Philosophical-Theological Academy, Münster, Germany
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36
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Smith-MacDonald LA, Morin JS, Brémault-Phillips S. Spiritual Dimensions of Moral Injury: Contributions of Mental Health Chaplains in the Canadian Armed Forces. Front Psychiatry 2018; 9:592. [PMID: 30487762 PMCID: PMC6246733 DOI: 10.3389/fpsyt.2018.00592] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/25/2018] [Indexed: 11/13/2022] Open
Abstract
Moral Injury (MI) describes the profound distress experienced by military personnel as a result of a violation of personal beliefs. Impacting not only psychological, but spiritual, health, and well-being, MI is associated with spiritual/religious (S/R) suffering and a need to find hope, trust, connection, reconciliation, and wholeness. Addressing spiritual wounds can help military personnel overcome fundamental barriers that may impede them from effectively engaging in or benefitting from traditional trauma therapies and having a more complete recovery. Military Chaplains in the Canadian Armed Forces (CAF) are both embedded with the troops in garrison and theater and work closely with service providers such as the Royal Canadian Medical Services. In their role, they offer front-line support and services to members and their families and facilitate access to care. Specific to the assessment and treatment of MI, Mental Health Chaplains (MHCs) offer S/R expertise and a complimentary clinical skill set to service members and interdisciplinary teams. This perspectives article explores the S/R dimension of MI, discusses the role of MHCs in CAF Mental Health (MH) Clinics, and provides clinical perspectives of a MHC regarding the treatment of MI. Key focuses of MHC interventions include bridging to other mental health services and supports, facilitating S/R coping and grounding, reconciling worldviews, resolving anger at a God-figure (not specific to any S/R perspective) and fostering reconciliation. Based on the literature, Mental Health practitioner's feedback, and clinical experience, MHCs are integral to service provision regarding MI and warrant more widespread inclusion on interdisciplinary teams in CAF MH Clinics.
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Affiliation(s)
| | | | - Suzette Brémault-Phillips
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
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