1
|
Elbasheir A, Fulton TM, Choucair KC, Lathan EC, Spivey BN, Guelfo A, Carter SE, Powers A, Fani N. Moral injury, race-related stress and post-traumatic stress disorder in a trauma-exposed Black population. J Psychiatr Res 2024; 173:326-332. [PMID: 38574596 DOI: 10.1016/j.jpsychires.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/17/2024] [Accepted: 03/15/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Race-related stress (RRS) is an unrecognized source of moral injury (MI)-or the emotional and/or spiritual suffering that may emerge after exposure to events that violate deeply held beliefs. Additionally, MI has not been explored as a mechanism of risk for post-traumatic stress disorder (PTSD) in trauma-exposed civilians. We examined relations among exposure to potentially morally injurious events (moral injury exposure, MIE), related distress (moral injury distress, MID), and RRS in Black Americans. Potential indirect associations between RRS and PTSD symptoms via MID were also examined. METHODS Black Americans (n = 228; 90.4% female; Mage = 31.6 years. SDage = 12.8 years) recruited from an ongoing study of trauma completed measures assessing civilian MIE and MID, RRS, and PTSD. Bivariate correlations were conducted with MIE and MID, and mediation analysis with MID, to examine the role of MI in the relationship between RRS and PTSD symptom severity. RESULTS MIE was significantly correlated with cultural (r = 0.27), individual (r = 0.29), and institutional (r = 0.25) RRS; MID also correlated with cultural (r = 0.31), individual (r = 0.31), and institutional (r = 0.26) RRS (ps < 0.001). We found an indirect effect of RRS on PTSD symptoms via MID (β = 0.10, p < 0.005). CONCLUSIONS All types of RRS were associated with facets of MI, which mediated the relationship between RRS and current PTSD symptoms. MI may be a potential mechanism through which RRS increases the risk for PTSD in Black individuals.
Collapse
Affiliation(s)
- Aziz Elbasheir
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, USA; Neuroscience PhD Program, Emory University, USA
| | - Travis M Fulton
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, USA; Molecular and Systems Pharmacology PhD Program, Emory University, USA
| | - Khaled C Choucair
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, USA
| | - Emma C Lathan
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, USA
| | | | - Alfonsina Guelfo
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, USA
| | | | - Abigail Powers
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, USA
| | - Negar Fani
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, USA.
| |
Collapse
|
2
|
Foster W, McKellar L, Fleet JA, Creedy D, Sweet L. The barometer of moral distress in midwifery: A pilot study. Women Birth 2024; 37:101592. [PMID: 38418320 DOI: 10.1016/j.wombi.2024.101592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Moral distress is a phenomena that occurs following a compromise to moral beliefs. Moral distress has been reported across health professions, including midwifery. Although there are validated tools to assess for moral distress, none have been identified that suit the Australian healthcare system or midwifery. AIM The aim of this study was to pilot the Barometer of Moral Distress in Midwifery. METHODS This study was the fourth stage of a mixed method project. Using a cross-sectional approach, a survey tool including demographic questions, the Barometer of Moral Distress in Midwifery, and the Copenhagen Burnout Inventory assessed tool stability, reliability, and validity. FINDINGS A total of 103 surveys were completed. A test-retest demonstrated tool reliability and stability (a =.97). Factor analysis confirmed internal consistency; Factor 1 - Professional Identity (a=.91), Factor 2 - Inadequate Resources (a=.85), and Factor 3 - Unethical Cultures (a=.88). Concurrent validity was demonstrated through positive correlations between self-reported types of moral distress with mean scores for each Factor. Strong correlations were identified between work-related burnout and mean scores, while only weak correlations were noted between client-related burnout and mean scores. Only Factor 1 demonstrated a correlation between leaving the profession and mean scores. DISCUSSION/CONCLUSION This was the first moral distress tool that assessed both frequency of exposure and psychological outcomes to score moral distress. Findings indicate that moral distress in midwifery is not associated with caring work but with occupational environments. Further research is required to assess self-sacrifice in moral distress.
Collapse
Affiliation(s)
- Wendy Foster
- Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia.
| | - Lois McKellar
- Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia; School of Health and Social Care, Edinburgh Napier University, Scotland, UK
| | - Julie-Anne Fleet
- Clinical and Health Sciences, Rosemary Bryant AO Research Centre, University of South Australia, Australia
| | - Debra Creedy
- School of Nursing and Midwifery, Griffith University, Queensland, Australia; Transforming Maternity Care Collaborative, Australia
| | - Linda Sweet
- School of Nursing and Midwifery, Deakin University, Victoria, Australia; Centre for Quality and Patient Safety Research, Western Health Partnership, Institute for Health Transformation, Victoria, Australia
| |
Collapse
|
3
|
Nichter B, Hill ML, Maguen S, Norman SB, Fischer IC, Pietrzak RH. Health and psychiatric impairment associated with moral injury, military sexual trauma, and their co-occurrence in U.S. combat veterans. J Psychosom Res 2024; 179:111617. [PMID: 38394711 DOI: 10.1016/j.jpsychores.2024.111617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/16/2024] [Accepted: 02/17/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Military sexual trauma (MST) and moral injury (MI) are associated with adverse psychiatric and health outcomes among military veterans. However, no known population-based studies have examined the incremental burden associated with the co-occurrence of these experiences relative to either alone. METHOD Cross-sectional data were analyzed from the National Health and Resilience in Veterans Study, a nationally representative sample of 1330 U.S. combat veterans. Veterans reported on history of exposure to MST and potentially morally injurious events (PMIEs). Analyses estimated the lifetime prevalence of MST only, PMIEs only, and co-occurring MST and PMIEs; and examined associations between MST/PMIEs status and psychiatric and physical health comorbidities, functioning, and suicidality. RESULTS The lifetime weighted prevalence of exposure to MST only, PMIEs only, and co-occurring MST and PMIEs were 2.7%, 32.3%, and 4.5%, respectively. Compared with all other groups, the co-occurring MST + PMIEs group reported greater severity of posttraumatic stress, depression, generalized anxiety, and insomnia symptoms. They also scored lower on measures of physical, mental, and psychosocial functioning, and reported a greater number of chronic medical conditions and somatic complaints. Veterans with co-occurring MST + PMIEs were more than twice as likely as those with MST only to report past-year suicidal ideation. CONCLUSIONS The co-occurrence of MST and MI is associated with a greater psychiatric and health burden among combat veterans than either experience alone. Results underscore the importance of assessing and treating MST and MI in this population. Findings underscore the importance for future work to parse overlap between morally salient aspects of MST and the concept of moral injury.
Collapse
Affiliation(s)
- Brandon Nichter
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America.
| | - Melanie L Hill
- Department of Psychiatry, University of California San Diego, La Jolla, CA, United States of America
| | - Shira Maguen
- San Francisco VA Health Care System, San Francisco, CA, United States of America; University of California - San Francisco, San Francisco, United States of America
| | - Sonya B Norman
- Department of Psychiatry, University of California San Diego, La Jolla, CA, United States of America; VA San Diego Healthcare System, San Diego, CA, USA; National Center for PTSD, White River Junction, VT, United States of America
| | - Ian C Fischer
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America; National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Robert H Pietrzak
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America; National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA; Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, United States of America
| |
Collapse
|
4
|
Levi-Belz Y, Levinstein Y, Zerach G. The impact of moral injury on trajectories of depression: a five-year longitudinal study among recently discharged Israeli veterans. Anxiety Stress Coping 2024:1-12. [PMID: 38529565 DOI: 10.1080/10615806.2024.2333374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/08/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Perpetrating or witnessing acts that violate one's moral code are frequent among military personnel and active combatants. These events, termed potentially morally injurious events (PMIEs), were found to be associated with an increased risk of depression, in cross-sectional studies. However, the longitudinal contribution of PMIEs to depression among combatants remains unclear. METHOD Participants were 374 active-duty combatants who participated in a longitudinal study with four measurement points: T1-one year before enlistment, T2-at discharge from army service, and then again 6- and 12-months following discharge (T3 and T4, respectively). At T1, personal characteristics assessed through semi-structured interviews. At T2-T4, PMIEs and depressive symptoms were assessed. RESULTS At discharge (T2), a total of 48.7% of combatants reported experiencing PMIEs incident, compared with 42.4% at T3 and 30.7% at T4. We found a significant interaction effect in which combatants endorsing PMIEs at discharge reported higher severity of depression symptoms at discharge (T2) than combatants who reported no PMIEs. This effect decreased over time as depression levels were lower at T3 and T4. CONCLUSIONS PMIE experiences, and especially PMIE-Betrayal experiences, were found to be valid predictors of higher severity of depression symptoms after the first year following discharge.
Collapse
Affiliation(s)
- Yossi Levi-Belz
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
| | - Yoav Levinstein
- Department of Social Work, Bar -Ilan University, Ramat Gan, Israel
- Department of Health and Well-being, Medical Corps, IDF, Ramat Gan, Israel
| | - Gadi Zerach
- Department of Psychology, Ariel University, Ariel, Israel
| |
Collapse
|
5
|
Woerner AJ, Greenberg CH, Chick JFB, Monroe EJ, Abad-Santos M, Kim H, Lee E, Makary MS, Hage AN, Covello B, Shin DS. Moral Injury Among Interventional Radiologists. Acad Radiol 2024; 31:1122-1129. [PMID: 37926643 DOI: 10.1016/j.acra.2023.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 09/01/2023] [Accepted: 09/05/2023] [Indexed: 11/07/2023]
Abstract
RATIONALE AND OBJECTIVES To evaluate moral injury (MI) among interventional radiologists using validated assessment tools. MATERIALS AND METHODS An anonymous 29-question online survey was distributed to interventional radiologists using the Society of Interventional Radiology Connect Open Forum website, Twitter, Facebook, LinkedIn, and electronic mail. The survey consisted of demographic and practice environment questions, a global quality of life (QoL) scale (scored 1-100), the MI Symptom Scale‑Healthcare Professional (MISS-HP) (scored 1-100), and two open-ended questions. A MISS-HP score ≥ 36 was indicative of experiencing MI. P < .05 was considered statistically significant for all two-sided tests. RESULTS Beginning on March 30, 2023, 365 surveys were completed over 5 days. Of the respondents, 299 (81.9%) were male, 65 (17.8%) were female, and one preferred not to disclose gender. The respondents included practicing interventional radiologists (299; 81.9%) and interventional radiologists-in-training (66; 18.1%). Practice settings included academic (146; 40.0%), community (121; 33.2%), hybrid (84; 23.0%), or other (14; 3.8%) centers. Mean QoL was 71.1 ± 17.0 (range: 0-100) suggestive of "good" QoL. Mean QoL in the MI subgroup was significantly different from that for the rest of the group (67.6 ± 17.0 vs. 76.6 ± 16.0; P < 0.05). 223 (61.1%) respondents scored ≥ 36 on the MISS-HP, and thus were categorized as having profession-related MI. Mean MISS-HP was 39.9 ± 12.6 (range: 10-83). Mean MISS-HP in the MI subgroup was significantly different from that for the rest of the group (47.4 ± 9.6 vs. 28.0 ± 5.7; P < 0.05). There was a negative correlation between MI and QoL (r = -0.4; P < 0.001). Most common themes for greatest contribution to MI were ineffective leadership, barriers to patient care, corporatization of medicine, non-physician administration, performing futile procedures, turf battles, and reduced resources. Most common themes for ways to reduce MI were more autonomy, less bureaucracy, more administrative support, physician-directed leadership, adequate staffing, changes to the medical system, physician unionization, transparency with insurance companies, more time off, and leaving medicine/retirement. CONCLUSION MI is prevalent among interventional radiologists, and it negatively correlates with QoL. Future work should investigate causative factors and mitigating solutions.
Collapse
Affiliation(s)
- Andrew J Woerner
- Section of Vascular and Interventional Radiology, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, Washington, 98195, USA (A.J.W., C.H.G., J.F.B.C., M.A.S., D.S.S.)
| | - Colvin H Greenberg
- Section of Vascular and Interventional Radiology, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, Washington, 98195, USA (A.J.W., C.H.G., J.F.B.C., M.A.S., D.S.S.)
| | - Jeffrey Forris Beecham Chick
- Section of Vascular and Interventional Radiology, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, Washington, 98195, USA (A.J.W., C.H.G., J.F.B.C., M.A.S., D.S.S.)
| | - Eric J Monroe
- Section of Vascular and Interventional Radiology, Department of Radiology, University of Wisconsin, Madison, Wisconsin, USA (E.J.M.)
| | - Matthew Abad-Santos
- Section of Vascular and Interventional Radiology, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, Washington, 98195, USA (A.J.W., C.H.G., J.F.B.C., M.A.S., D.S.S.)
| | - HeeJin Kim
- Department of Information and Statistics, Chungnam National University, Yuseong-gu, Daejeon, South Korea (H.K., E.L.)
| | - Eunjee Lee
- Department of Information and Statistics, Chungnam National University, Yuseong-gu, Daejeon, South Korea (H.K., E.L.)
| | - Mina S Makary
- Department of Radiology, Division of Vascular and Interventional Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA (M.S.M.)
| | - Anthony N Hage
- Department of Radiology, Division of Vascular and Interventional Radiology, Thomas Jefferson Hospital, Philadelphia, Pennsylvania, USA (A.N.H.)
| | - Brian Covello
- Division of Interventional Radiology, Department of Radiology, Aventura Hospital & Medical Center, Aventura, Florida, USA (B. C.)
| | - David S Shin
- Section of Vascular and Interventional Radiology, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, Washington, 98195, USA (A.J.W., C.H.G., J.F.B.C., M.A.S., D.S.S.).
| |
Collapse
|
6
|
Houle SA, Ein N, Gervasio J, Plouffe RA, Litz BT, Carleton RN, Hansen KT, Liu JJW, Ashbaugh AR, Callaghan W, Thompson MM, Easterbrook B, Smith-MacDonald L, Rodrigues S, Bélanger SAH, Bright K, Lanius RA, Baker C, Younger W, Bremault-Phillips S, Hosseiny F, Richardson JD, Nazarov A. Measuring moral distress and moral injury: A systematic review and content analysis of existing scales. Clin Psychol Rev 2024; 108:102377. [PMID: 38218124 DOI: 10.1016/j.cpr.2023.102377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/03/2023] [Accepted: 12/21/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Moral distress (MD) and moral injury (MI) are related constructs describing the negative consequences of morally challenging stressors. Despite growing support for the clinical relevance of these constructs, ongoing challenges regarding measurement quality risk limiting research and clinical advances. This study summarizes the nature, quality, and utility of existing MD and MI scales, and provides recommendations for future use. METHOD We identified psychometric studies describing the development or validation of MD or MI scales and extracted information on methodological and psychometric qualities. Content analyses identified specific outcomes measured by each scale. RESULTS We reviewed 77 studies representing 42 unique scales. The quality of psychometric approaches varied greatly across studies, and most failed to examine convergent and divergent validity. Content analyses indicated most scales measure exposures to potential moral stressors and outcomes together, with relatively few measuring only exposures (n = 3) or outcomes (n = 7). Scales using the term MD typically assess general distress. Scales using the term MI typically assess several specific outcomes. CONCLUSIONS Results show how the terms MD and MI are applied in research. Several scales were identified as appropriate for research and clinical use. Recommendations for the application, development, and validation of MD and MI scales are provided.
Collapse
Affiliation(s)
- Stephanie A Houle
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Research Directorate, Veterans Affairs Canada, Charlottetown, Canada
| | - Natalie Ein
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada
| | - Julia Gervasio
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada
| | - Rachel A Plouffe
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychology, University of Dundee, Dundee, UK
| | - Brett T Litz
- Department of Psychiatry, Boston University, Boston, USA; Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, USA; Department of Psychological and Brain Sciences, Boston University, Boston, USA
| | | | - Kevin T Hansen
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada
| | - Jenny J W Liu
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada
| | | | - Walter Callaghan
- Department of Anthropology, University of Toronto, Toronto, Canada
| | | | - Bethany Easterbrook
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, Canada
| | | | - Sara Rodrigues
- The Atlas Institute for Veterans and Families, Ottawa, Canada
| | | | | | - Ruth A Lanius
- Department of Psychiatry, Western University, London, Canada
| | - Clara Baker
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada
| | - William Younger
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada
| | | | | | - J Don Richardson
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada; St. Joseph's Operational Stress Injury Clinic, St. Joseph's Health Care London, London, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
| | - Anthony Nazarov
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada.
| |
Collapse
|
7
|
Boska RL, Bishop TM, Capron DW, Paxton Willing MM, Ashrafioun L. Difficulties with emotion regulation within PTSD clusters and moral injury subtypes. Mil Psychol 2024:1-9. [PMID: 38421375 DOI: 10.1080/08995605.2024.2322904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 02/12/2024] [Indexed: 03/02/2024]
Abstract
Treatment and research centered on trauma-related mental health issues have largely focused on posttraumatic stress disorder (PTSD); however, moral injury is another important mental health concern requiring attention. There is a paucity of research examining how PTSD and moral injury affect emotion regulation. The current investigation examined how PTSD clusters and moral injury subtypes were uniquely associated with difficulties with emotion regulation. Participants consisted of 253 previously deployed military personnel who were recruited online. To be included in the study, participants had to verify that they had served in the U.S. Military, had been deployed as part of their military service, and endorsed elevated levels of symptoms associated with PTSD and/or moral injury. A hierarchical linear regression was conducted to examine the association between PTSD symptom clusters, moral injury subtypes, and difficulties with emotion regulation. Results indicated that alterations in arousal and reactivity was the only PTSD symptom cluster associated with difficulties with emotion regulation. Self-transgressions was the only facet of moral injury significantly associated with difficulties with emotion regulation. This is the first study to examine the association between emotion dysregulation, PTSD symptom clusters, and moral injury in previously deployed U.S. Military.
Collapse
Affiliation(s)
- Rachel L Boska
- The War Related Illness and Injury Study Center, The VA New Jersey Healthcare System, East Orange, New Jersey
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, Canandaigua, New York
| | - Todd M Bishop
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, Canandaigua, New York
- Department of Psychiatry, University of Rochester School of Medicine & Dentistry, Rochester, New York
| | - Daniel W Capron
- Department of Psychology, Louisiana State University, Baton Rouge, Louisiana
| | - Maegan M Paxton Willing
- Center for Deployment Psychology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland
| | - Lisham Ashrafioun
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, Canandaigua, New York
- Department of Psychiatry, University of Rochester School of Medicine & Dentistry, Rochester, New York
| |
Collapse
|
8
|
Levi-Belz Y, Ben-Yehuda A, Levinstein Y, Zerach G. Moral injury and pre-deployment personality factors as contributors to psychiatric symptomatology among combatants: a two-year prospective study. Eur J Psychotraumatol 2024; 15:2312773. [PMID: 38334135 PMCID: PMC10860427 DOI: 10.1080/20008066.2024.2312773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/13/2024] [Indexed: 02/10/2024] Open
Abstract
Background: Combatants who are exposed to events that transgress deeply held moral beliefs might face lasting psychopathological outcomes, referred to as Moral Injury (MI). However, knowledge about pre-deployment factors that might moderate the negative consequences of MI is sparse. In this prospective study, we examined pre-enlistment characteristics and pre-deployment personality factors as possible moderators in the link between exposure to potentially morally injurious events (PMIEs) and psychiatric symptomatology among Israeli active-duty combatants.Methods: A sample of 335 active-duty Israeli combatants participated in a 2.5-year prospective study with three waves of measurements (T1: 12 months before enlistment, T2: Six months following enlistment - pre-deployment, and T3: 18 months following enlistment - post-deployment). Participants' characteristics were assessed via semi-structured interviews (T1) and validated self-report measures of personality factors: emotional regulation, impulsivity, and aggression (T2) and combat exposure, PMIEs, psychiatric symptomology and posttraumatic symptoms (T3) between 2019 and 2021.Results: Pre-enlistment psychiatric difficulties and negative life events contributed to higher exposure to PMIEs post-deployment. Higher levels of pre-deployment aggression and lower levels of emotional regulation and impulsivity moderated the association between betrayal, PMIEs and psychiatric symptomology post-deployment, above and beyond pre-enlistment psychiatric difficulties and life events.Conclusions: Our results highlight that pre-deployment emotional regulation, impulsivity and aggressiveness levels should be assessed, screened, and identified among combatants, as they all facilitate psychiatric symptomology (and PTSS) after combatants are exposed to PMIEs of betrayal. Such pre-assessment will enable the identification of at-risk combatants and might provide them with tailor-made preparation regarding moral and ethical situations that should be investigated in future research.
Collapse
Affiliation(s)
- Yossi Levi-Belz
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
| | - Ariel Ben-Yehuda
- Department of Health and Well-being, Medical Corps, IDF, Israel
- Shalvata Mental Health Center, Clalit Health Services, Hod Hasharon, Israel
| | - Yoav Levinstein
- Shalvata Mental Health Center, Clalit Health Services, Hod Hasharon, Israel
- School of Social Work, Bar-Ilan University, Ramat-Gan, Israel
| | - Gadi Zerach
- Department of Psychology, Ariel University, Ariel, Israel
| |
Collapse
|
9
|
Coimbra BM, Zylberstajn C, van Zuiden M, Hoeboer CM, Mello AF, Mello MF, Olff M. Moral injury and mental health among health-care workers during the COVID-19 pandemic: meta-analysis. Eur J Psychotraumatol 2024; 15:2299659. [PMID: 38189775 PMCID: PMC10776063 DOI: 10.1080/20008066.2023.2299659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/11/2023] [Indexed: 01/09/2024] Open
Abstract
Background: During the COVID-19 pandemic, health-care workers (HCWs) may have been confronted with situations that may culminate in moral injury (MI). MI is the psychological distress that may result from perpetrating or witnessing actions that violate one's moral codes. Literature suggests that MI can be associated with mental health problems.Objective: We aimed to meta-analytically review the literature to investigate whether MI is associated with symptoms of posttraumatic stress disorder (PTSD), anxiety, depression, burnout, and suicidal ideation among active HCWs during the COVID-19 pandemic.Method: We searched eight databases for studies conducted after the onset of the COVID-19 pandemic up to 18 July 2023, and performed random-effects meta-analyses to examine the relationship between MI and various mental health outcomes.Results: We retrieved 33 studies from 13 countries, representing 31,849 individuals, and pooled 79 effect sizes. We found a positive association between MI and all investigated mental health problems (rs = .30-.41, all ps < .0001). Between-studies heterogeneity was significant. A higher percentage of nurses in the samples was associated with a stronger relationship between MI and depressive and anxiety symptoms. Samples with a higher percentage of HCWs providing direct care to patients with COVID-19 exhibited a smaller effect between MI and depressive and anxiety symptoms. We observed a stronger effect between MI and PTSD symptoms in US samples compared to non-US samples.Conclusion: We found that higher MI is moderately associated with symptoms of PTSD, anxiety, depression, burnout, and suicidal ideation among HCWs during the COVID-19 pandemic. Our findings carry limitations due to the array of MI scales employed, several of which were not specifically designed for HCWs, but underscore the need to mitigate the effect of potentially morally injurious events on the mental health of HCWs.
Collapse
Affiliation(s)
- Bruno Messina Coimbra
- Programme for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
- Department of Methodology and Statistics, Faculty of Social and Behavioral Sciences, Utrecht University, Utrecht, The Netherlands
- Amsterdam UMC, Department of Psychiatry, Amsterdam Public Health Research Institute and Amsterdam Neuroscience Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Cecilia Zylberstajn
- Programme for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Mirjam van Zuiden
- Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands
| | - Chris Maria Hoeboer
- Amsterdam UMC, Department of Psychiatry, Amsterdam Public Health Research Institute and Amsterdam Neuroscience Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Andrea Feijo Mello
- Programme for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Marcelo Feijo Mello
- Programme for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Albert Einstein, São Paulo, Brazil
| | - Miranda Olff
- Amsterdam UMC, Department of Psychiatry, Amsterdam Public Health Research Institute and Amsterdam Neuroscience Research Institute, University of Amsterdam, Amsterdam, The Netherlands
- ARQ National Psychotrauma Centre, Diemen, The Netherlands
| |
Collapse
|
10
|
Onnink B, Correll MC, Correll A, Correll T. Psychotherapy's Role in Evaluating the Invisible Wounds of Moral Injury. Innov Clin Neurosci 2024; 21:36-42. [PMID: 38495605 PMCID: PMC10941865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Moral injury is a relatively new concept with varying definitions that attempts to define a profound and lasting insult to one's conscience caused by perpetration of or directly witnessing harm to another person in a high-pressure situation. This entity is separate from posttraumatic stress disorder (PTSD), but it can coexist with PTSD. This article provides psychotherapeutic examples of the diagnosis of moral injury from a psychodynamic perspective, focusing on morally challenging situations related to warfare and the healthcare system.
Collapse
Affiliation(s)
- Ben Onnink
- Dr. Onnink is a resident, Department of Psychiatry, Wright State University Boonshoft School of Medicine in Dayton, Ohio
| | - Matthew C Correll
- Mr. M. Correll is a student at Wright State University Raj Soin School of Business in Dayton, Ohio
| | - Andrew Correll
- Mr. A. Correll is with Wright State University Boonshoft School of Medicine in Dayton, Ohio
| | - Terry Correll
- Dr. T. Correll is Clinical Professor, Department of Psychiatry, Wright State University Boonshoft School of Medicine in Dayton, Ohio
| |
Collapse
|
11
|
Fulton T, Lathan EC, Karkare MC, Guelfo A, Eghbalzad L, Ahluwalia V, Ely TD, Turner JA, Turner MD, Currier JM, Mekawi Y, Fani N. Civilian Moral Injury and Amygdala Functional Connectivity During Attention to Threat. Biol Psychiatry Cogn Neurosci Neuroimaging 2024; 9:112-120. [PMID: 37487958 PMCID: PMC10803642 DOI: 10.1016/j.bpsc.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/27/2023] [Accepted: 07/06/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Moral injury references emotional and spiritual/existential suffering that may emerge following psychological trauma. Despite being linked to adverse mental health outcomes, little is known about the neurophysiological mechanisms of this phenomenon. In this study, we examined neural correlates of moral injury exposure and distress using the Moral Injury Exposure and Symptom Scale for Civilians. We also examined potential moderation of these effects by race (Black vs. White individuals) given the likely intersection of race-related stress with moral injury. METHODS Forty-eight adults ages 18 to 65 years (mean age = 30.56, SD = 11.93) completed the Moral Injury Exposure and Symptom Scale for Civilians and an affective attentional control measure, the affective Stroop task (AS), during functional magnetic resonance imaging; the AS includes presentation of threat-relevant and neutral distractor stimuli. Voxelwise functional connectivity of the bilateral amygdala was examined in response to threat-relevant versus neutral AS distractor trials. RESULTS Functional connectivity between the right amygdala and left postcentral gyrus/primary somatosensory cortex was positively correlated with the Moral Injury Exposure and Symptom Scale for Civilians exposure score (voxelwise p < .001, cluster false discovery rate-corrected p < .05) in response to threat versus neutral AS distractor trials. Follow-up analyses revealed significant effects of race; Black but not White participants demonstrated this significant pattern of amygdala-left somatosensory cortex connectivity. CONCLUSIONS Increased exposure to potentially morally injurious events may lead to emotion-somatosensory pathway disruptions during attention to threat-relevant stimuli. These effects may be most potent for individuals who have experienced multilayered exposure to morally injurious events, including racial trauma. Moral injury appears to have a distinct neurobiological signature that involves abnormalities in connectivity of emotion-somatosensory paths, which may be amplified by race-related stress.
Collapse
Affiliation(s)
- Travis Fulton
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia; Molecular and Systems Pharmacology PhD Program, Emory University, Atlanta, Georgia
| | - Emma C Lathan
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Maya C Karkare
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Alfonsina Guelfo
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Leyla Eghbalzad
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Vishwadeep Ahluwalia
- Center for Advanced Brain Imaging, Georgia Institute of Technology, Atlanta, Georgia
| | - Timothy D Ely
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | | | | | - Joseph M Currier
- Department of Psychology, University of South Alabama, Mobile, Alabama
| | - Yara Mekawi
- Department of Psychological and Brain Sciences, University of Louisville, Louisville, Kentucky
| | - Negar Fani
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia.
| |
Collapse
|
12
|
Lei Q, He Z, Koenig HG, Hu X, Xiong M, Shi X, Liu J, Wang Z. Light Personality Style and Moral Injury Among Chinese Health Professionals. J Relig Health 2023; 62:3942-3956. [PMID: 37777659 DOI: 10.1007/s10943-023-01921-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 10/02/2023]
Abstract
Moral injury has attracted attention widely in various occupations, particularly health professionals. Personality traits involve the professional values in clinical decision-making associated with mental outcomes. The current study examines the relationship between "light personality" style and moral injury. Scores on three subscales of the Light Triad Scale were negatively correlated with the Moral Injury Symptoms Scale-Health Professional. Health professionals more likely to have light personality styles may be less likely to suffer from moral injury under high-stake situations. The findings provide evidence to better understand the inner core of the moral injury, suggesting a potential pathway to improve the moral well-being of health professionals by strengthening key elements of light personality.
Collapse
Affiliation(s)
- Qiuhui Lei
- Department of Epidemiology and Health Statistics, School of Public Health at Guangdong Medical University, Dongguan, 560001, People's Republic of China
| | - Zhehao He
- Department of Epidemiology and Health Statistics, School of Public Health at Guangdong Medical University, Dongguan, 560001, People's Republic of China
| | - Harold G Koenig
- Departments of Psychiatry and Medicine, Duke University Medical Center, Durham, NC, 27710, USA
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Xue Hu
- Department of Epidemiology and Health Statistics, School of Public Health at Guangdong Medical University, Dongguan, 560001, People's Republic of China
| | - Mengyun Xiong
- Department of Epidemiology and Health Statistics, School of Public Health at Guangdong Medical University, Dongguan, 560001, People's Republic of China
| | - Xiuquan Shi
- Department of Preventive Medicine, School of Public Health at Zunyi Medical University, Zunyi, 56006, People's Republic of China
| | - Jun Liu
- Department of Epidemiology and Health Statistics, School of Public Health, Zunyi Medical University, Zunyi, 56006, People's Republic of China
| | - Zhizhong Wang
- Department of Epidemiology and Health Statistics, School of Public Health at Guangdong Medical University, Dongguan, 560001, People's Republic of China.
- The First Dongguan Affiliated Hospital, Guangdong Medical University, #1 Xincheng Road, Songshanhu, Dongguan, 523808, People's Republic of China.
| |
Collapse
|
13
|
Alvarez NA, Gaither CA, Schommer JC, Lee S, Shaughnessy AM. Moral Distress and Moral Injury in Pharmacy and Why the Academy Needs to Care. Am J Pharm Educ 2023; 87:100610. [PMID: 37865387 DOI: 10.1016/j.ajpe.2023.100610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 10/10/2023] [Accepted: 10/17/2023] [Indexed: 10/23/2023]
Abstract
Pharmacists and other pharmacy personnel are experiencing job stress and burnout, and in some instances, suicidal ideation and death by suicide. However, the described lived experiences of pharmacists and other pharmacy personnel are not defined by burnout. Thus, consideration of and research about whether pharmacy personnel are possibly experiencing moral distress or moral injury is necessary and urgent. The pharmacy academy is served by considering workplace conditions and lived experiences of pharmacists because of the potential, negative impact on prospective student recruitment, quality of experiential sites and preceptors, sites for clinical faculty placement, and the well-being of alumni. Understanding phenomena occurring for pharmacy personnel and determining how they impact the pharmacy academy can lend itself to the future development of solutions.
Collapse
Affiliation(s)
- Nancy A Alvarez
- University of Arizona, R. Ken Coit College of Pharmacy, Phoenix, AZ, USA.
| | | | - Jon C Schommer
- University of Minnesota, College of Pharmacy, Minneapolis, MN, USA
| | - SuHak Lee
- University of Minnesota, College of Pharmacy, Minneapolis, MN, USA
| | | |
Collapse
|
14
|
Mosca CG, Kruger JP. Financial medicine as a source of moral distress: An unrecognised pathway to moral injury in the South African EMS systems. Afr J Emerg Med 2023; 13:235-240. [PMID: 37753241 PMCID: PMC10518332 DOI: 10.1016/j.afjem.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 09/28/2023] Open
Abstract
Introduction The phenomenon of Financial Medicine is a wide spread practice within the South African prehospital domain, which remains poorly researched. Similarly the impact of this phenomenon is not well understood, with many healthcare providers grappling with the moral dilemmas introduced into the work systems through the effects of the practice of Financial Medicine. Persisting, repetitive moral dilemmas can lead to instances of Moral Distress and Moral Injury. The practice of Financial Medicine in the South African prehospital domain proves to introduce many moral dilemmas and subsequently can serve as a source of Moral Distress and Moral Injury. Methods This study used a qualitative research methodology in the form of a constructivist grounded theory design. Participants voluntarily consented to be enrolled into one-on-one in-depth interviews, and were selected using purposive and theoretical sampling techniques. Data was subjected to validated coding procedures and analysed using the constant comparative analysis approach, analytical diagramming, and supported by researcher theoretical sensitivity. Results The sub-category presented in this study stems from the development of 6 final analytical labels that were abstracted in the process of a theory construction, not presented in this article. This sub-category is nested under 1 of the final analytical labels, and comprised of 3 preliminary analytical labels and an associated code and proposition list. Conclusion Understanding the sources of Moral Distress and Moral Injury within the South African prehospital domain are key steps in promoting and supporting the adoption and sustainability of ethical practices. This article presents a key finding that demonstrates a link between the experience of the phenomenon of Financial Medicine and the suffering of a Moral Injury by South African prehospital personnel.
Collapse
Affiliation(s)
- Colin Giovanni Mosca
- Department of Emergency Medical Care, University of Johannesburg, Doornfontein, Johannesburg, South Africa
| | - Jaco P Kruger
- St Augustine College of South Africa, Woodmead, Johannesburg, South Africa
| |
Collapse
|
15
|
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. J Relig 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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
16
|
Jamieson N, Carey LB, Jamieson A, Maple M. Examining the Association Between Moral Injury and Suicidal Behavior in Military Populations: A Systematic Review. J Relig 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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
17
|
Phelps AJ, Madden K, Carleton RN, Johnson L, Carey LB, Mercier JM, Mellor A, Baills J, Forbes D, Devenish-Meares P, Hosseiny F, Dell L. Towards a Holistic Model of Care for Moral Injury: An Australian and New Zealand Investigation into the Role of Police Chaplains in Supporting Police Members following exposure to Moral Transgression. J Relig Health 2023; 62:3995-4015. [PMID: 37697218 PMCID: PMC10682271 DOI: 10.1007/s10943-023-01908-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 09/13/2023]
Abstract
Police members can be exposed to morally transgressive events with potential for lasting psychosocial and spiritual harm. Through interviews with police members and police chaplains across Australia and New Zealand, this qualitative study explores the current role that police chaplains play in supporting members exposed to morally transgressive events. The availability of chaplains across police services and the close alignment between the support they offer, and the support sought by police, indicates they have an important role. However, a holistic approach should also consider organizational factors, the role of leaders, and access to evidence-based treatment in collaboration with mental health practitioners.
Collapse
Affiliation(s)
- Andrea J Phelps
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Level 3, 161 Barry Street, Carlton, VIC, 3053, Australia.
| | - Kelsey Madden
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Level 3, 161 Barry Street, Carlton, VIC, 3053, Australia
| | | | - Lucinda Johnson
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Level 3, 161 Barry Street, Carlton, VIC, 3053, Australia
| | - Lindsay B Carey
- School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | | | - Andrew Mellor
- National Police Chaplaincy Group, Brisbane, Queensland, Australia
| | - Jeffrey Baills
- National Police Chaplaincy Group, Brisbane, Queensland, Australia
| | - David Forbes
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Level 3, 161 Barry Street, Carlton, VIC, 3053, Australia
| | | | | | - Lisa Dell
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Level 3, 161 Barry Street, Carlton, VIC, 3053, Australia
| |
Collapse
|
18
|
Carey LB, Bambling M, Hodgson TJ, Jamieson N, Bakhurst MG, Koenig HG. Pastoral Narrative Disclosure: The Development and Evaluation of an Australian Chaplaincy Intervention Strategy for Addressing Moral Injury. J Relig Health 2023; 62:4032-4071. [PMID: 37891396 DOI: 10.1007/s10943-023-01930-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/01/2023] [Indexed: 10/29/2023]
Abstract
This paper describes the development and initial chaplaincy user evaluation of 'Pastoral Narrative Disclosure' (PND) as a rehabilitation strategy developed for chaplains to address moral injury among veterans. PND is an empirically informed and integrated intervention comprising eight stages of pastoral counselling, guidance and education that was developed by combining two previously existing therapeutic techniques, namely Litz et al's (2017) 'Adaptive Disclosure' and 'Confessional Practice' (Joob & Kettunen, 2013). The development and results of PND can be categorized into five phases. Phase 1: PND Strategy Formation-based upon extensive international research demonstrating that MI is a complex bio-psycho-social-spiritual syndrome with symptoms sufficiently distinct from post-traumatic stress disorder. The review also provided evidence of the importance of chaplains being involved in moral injury rehabilitation. Phase II: Development and Implementation of 'Moral Injury Skills Training' (MIST)-which involved the majority of available Australian Defence Force (ADF) Chaplains (n = 242/255: 94.9%) completing a basic 'Introduction to Moral Injury' (MIST-1) as well as an 'Introduction to PND' (MIST-2). Phase III: MIST-3-PND-Pilot evaluation-involved a representative chaplaincy cohort (n = 13) undergoing the PND eight-stage strategy to ensure the integrity and quality of PND from a chaplaincy perspective prior to wider implementation. The pilot PND evaluation indicated a favourable satisfaction rating (n = 11/13: 84.6%; M = 4.73/5.0 satisfaction). Phase IV: MIST-3-PND Implementation-involved a larger cohort of ADF Chaplaincy participants (n = 210) completing a revised and finalized PND strategy which was regarded favourably by the majority of ADF Chaplains (n = 201/210: 95.7%; M = 4.73/5.0 satisfaction). Phase V: Summation. In conclusion the positive satisfaction ratings by a significant number of ADF chaplaincy personnel completing MIST-3-PND, provided evidence that chaplains evaluated PND as a suitable counselling, guidance and education strategy, which affirmed its utilisation and justifies further research for using PND to address MI among veterans, that may also prove valuable for other chaplains working in community health and first responder contexts.
Collapse
Affiliation(s)
- Lindsay B Carey
- Palliative Care Unit, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, 3083, Australia.
- Australian Institute of Ethics and Society, University of Notre Dame, Sydney, Australia.
| | - Matthew Bambling
- Brisbane Central Clinical School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Timothy J Hodgson
- School of Historical and Philosophical Enquiry, University of Queensland, Brisbane, QLD, Australia
| | | | - Melissa G Bakhurst
- School of Psychology, The University of Queensland, St Lucia, Brisbane, Australia
| | - Harold G Koenig
- Duke University Medical Center, Durham, North Carolina, USA
- King Abdulaziz University, Jeddah, Saudi Arabia
| |
Collapse
|
19
|
Berdida DJE, Grande RAN. Moral Distress, Moral Resilience, Moral Courage, and Moral Injury Among Nurses in the Philippines During the COVID-19 Pandemic: A Mediation Analysis. J Relig Health 2023; 62:3957-3978. [PMID: 37442900 DOI: 10.1007/s10943-023-01873-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 07/15/2023]
Abstract
Investigations about moral resilience and moral courage as mediators between moral distress and moral injury remain underreported among nurses during the COVID-19 pandemic. Nurses (n = 412) from the Philippines were conveniently recruited via social media platforms and completed four self-report scales. The mediation model depicts that moral distress negatively impacts moral resilience and moral courage while positively affecting moral injury. Moral resilience and moral courage negatively impact moral injury, whereas moral resilience directly impacts moral courage. Finally, moral resilience and moral courage demonstrated a mediating effect between moral distress and moral injury. Findings indicate that healthcare organizations and nurse managers should nurture morally resilient and courageous therapeutic practices among frontline healthcare professionals to mitigate the negative effects of moral distress and moral injury.
Collapse
Affiliation(s)
- Daniel Joseph E Berdida
- College of Nursing, University of Santo Tomas, St. Martin de Porres Bldg., España Boulevard, 1015, Manila, Philippines.
| | - Rizal Angelo N Grande
- Mental Health Nursing Department, College of Nursing, University of Ha'il, Ha'il, 55473, Kingdom of Saudi Arabia
| |
Collapse
|
20
|
Carey LB, Hill T, Koenig HG, Drummond D, Gabbay E, Cohen J, Aiken C, Paal P. Suicide, Moral Injury, Parkinson's Disease, Diabetes and Dialysis. J Relig Health 2023; 62:3703-3708. [PMID: 37947998 DOI: 10.1007/s10943-023-01940-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
This issue of JORH presents the first of a two-part series specifically exploring suicide. Research relating to moral injury is also included-a topic which has previously been discussed within earlier editions of JORH and an issue that is increasingly recognised as being associated with suicide. Other topic areas explored within this issue are Parkinson's Disease, Diabetes, and Haemodialysis. Finally, readers are once again reminded of the 9th European Congress on Religion, Spirituality and Health (ECRSH) to be held in May 2024, 16-18th at the Paracelsus Medical University in Salzburg, Austria. We would also like to announce a proposed inaugural International Moral Injury and Wellbeing Conference (IMIWC), 19-20 September 2024, Brisbane Exhibition and Convention Centre, Australia.
Collapse
Affiliation(s)
- Lindsay B Carey
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia.
- Institute for Ethics and Society, The University of Notre Dame, Sydney, Australia.
| | - Terrence Hill
- The University of Texas at San Antonio, San Antonio, TX, USA
| | - Harold G Koenig
- Department of Psychiatry and Behavioral Sciences, Duke University Health Systems, Durham, NC, USA
- Department of Medicine, Duke University Health Systems, Durham, NC, USA
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Ezra Gabbay
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, Hospital Medicine Section, New York, NY, USA
| | - Jeffery Cohen
- School of Medicine (Sydney), University of Notre Dame Australia and St Vincent's Private Hospital Sydney, Sydney, NSW, Australia
| | - Carl Aiken
- Emeritus Chaplain, Women's and Children's Hospital, Adelaide, Australia
- Drew University, Madison, USA
| | - Piret Paal
- Institute for Palliative Care, Paracelsus Medizinische Privatuniversität, Salzburg, Austria
| |
Collapse
|
21
|
Whitehead PB, Haisch CE, Hankey MS, Mutcheson RB, Dewitt SA, Stewart CA, Stewart JD, Bath JL, Boone SM, Jileaeva I, Faulks ER, Musick DW. Studying moral distress (MD) and moral injury (MI) among inpatient and outpatient healthcare professionals during the COVID-19 pandemic. Int J Psychiatry Med 2023:912174231205660. [PMID: 37807925 DOI: 10.1177/00912174231205660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
BACKGROUND COVID-19 increased moral distress (MD) and moral injury (MI) among healthcare professionals (HCPs). MD and MI were studied among inpatient and outpatient HCPs during March 2022. OBJECTIVES We sought to examine (1) the relationship between MD and MI; (2) the relationship between MD/MI and pandemic-related burnout and resilience; and (3) the degree to which HCPs experienced pandemic-related MD and MI based on their background. METHODS A survey was conducted to measure MD, MI, burnout, resilience, and intent to leave healthcare at 2 academic medical centers during a 4-week period. A convenience sample of 184 participants (physicians, nurses, residents, respiratory therapists, advanced practice providers) completed the survey. In this mixed-methods approach, researchers analyzed both quantitative and qualitative survey data and triangulated the findings. RESULTS There was a moderate association between MD and MI (r = .47, P < .001). Regression results indicated that burnout was significantly associated with both MD and MI (P = .02 and P < .001, respectively), while intent to leave was associated only with MD (P < .001). Qualitative results yielded 8 sources of MD and MI: workload, distrust, lack of teamwork/collaboration, loss of connection, lack of leadership, futile care, outside stressors, and vulnerability. CONCLUSIONS While interrelated conceptually, MD and MI should be viewed as distinct constructs. HCPs were significantly impacted by the COVID-19 pandemic, with MD and MI being experienced by all HCP categories. Understanding the sources of MD and MI among HCPs could help to improve well-being and work satisfaction.
Collapse
Affiliation(s)
| | | | | | - Ryan B Mutcheson
- Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | | | | | | | | | | | - Ilona Jileaeva
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | | | - David W Musick
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| |
Collapse
|
22
|
Abbara A, Rayes D, Tappis H, Hamze M, Wais R, Alahmad H, Almhawish N, Rubenstein L, Haar R. "Actually, the psychological wounds are more difficult than physical injuries:" a qualitative analysis of the impacts of attacks on health on the personal and professional lives of health workers in the Syrian conflict. Confl Health 2023; 17:48. [PMID: 37807074 PMCID: PMC10561459 DOI: 10.1186/s13031-023-00546-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/26/2023] [Indexed: 10/10/2023] Open
Abstract
INTRODUCTION Attacks on healthcare in armed conflict have far-reaching impacts on the personal and professional lives of health workers, as well as the communities they serve. Despite this, even in protracted conflicts such as in Syria, health workers may choose to stay despite repeated attacks on health facilities, resulting in compounded traumas. This research explores the intermediate and long-term impacts of such attacks on healthcare on the local health professionals who have lived through them with the aim of strengthening the evidence base around such impacts and better supporting them. METHODS We undertook purposive sampling of health workers in northwest and northeast Syria; we actively sought to interview non-physician and female health workers as these groups are often neglected in similar research. In-depth interviews (IDIs) were conducted in Arabic and transcribed into English for framework analysis. We used an a priori codebook to explore the short- and long-term impacts of attacks on the health workers and incorporated emergent themes as analysis progressed. RESULTS A total of 40 health workers who had experienced attacks between 2013 and 2020 participated in IDIs. 13 were female (32.5%). Various health cadres including doctors, nurses, midwives, pharmacists, students in healthcare and technicians were represented. They were mainly based in Idlib (39.5%), and Aleppo (37.5%) governorates. Themes emerged related to personal and professional impacts as well as coping mechanisms. The key themes include firstly the psychological harms, second the impacts of the nature of the attacks e.g. anticipatory stress related to the 'double tap' nature of attacks as well as opportunities related to coping mechanisms among health workers. CONCLUSION Violence against healthcare in Syria has had profound and lasting impacts on the health workforce due to the relentless and intentional targeting of healthcare facilities. They not only face the challenges of providing care for a conflict-affected population but are also part of the community themselves. They also face ethical dilemmas in their work leading to moral distress and moral injury. Donors must support funding for psychosocial support for health workers in Syria and similar contexts; the focus must be on supporting and enhancing existing context-specific coping strategies.
Collapse
Affiliation(s)
- Aula Abbara
- Syrian American Medical Society, Washington, DC, USA.
- Department of Infectious Diseases, Imperial College, London, St Marys Hospital, Praed Street, London, W2 1NY, UK.
- Syria Public Health Network, London, UK.
| | - Diana Rayes
- Syria Public Health Network, London, UK
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Hannah Tappis
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Mohamed Hamze
- Syrian American Medical Society, Washington, DC, USA
| | - Reham Wais
- Syrian American Medical Society, Gaziantep, Turkey
| | | | - Naser Almhawish
- Syria Public Health Network, London, UK
- Assistance Coordination Unit, Gaziantep, Turkey
| | | | - Rohini Haar
- School of Public Health, University of California, Berkeley, Berkeley, USA
| |
Collapse
|
23
|
Williamson V, Lamb D, Hotopf M, Raine R, Stevelink S, Wessely S, Docherty M, Madan I, Murphy D, Greenberg N. Moral injury and psychological wellbeing in UK healthcare staff. J Ment Health 2023; 32:890-898. [PMID: 36883341 DOI: 10.1080/09638237.2023.2182414] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 12/13/2022] [Accepted: 01/28/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Potentially morally injurious events (PMIEs) can negatively impact mental health. The COVID-19 pandemic may have placed healthcare staff at risk of moral injury. AIM To examine the impact of PMIE on healthcare staff wellbeing. METHODS Twelve thousand nine hundred and sixty-five healthcare staff (clinical and non-clinical) were recruited from 18 NHS-England trusts into a survey of PMIE exposure and wellbeing. RESULTS PMIEs were significantly associated with adverse mental health symptoms across healthcare staff. Specific work factors were significantly associated with experiences of moral injury, including being redeployed, lack of PPE, and having a colleague die of COVID-19. Nurses who reported symptoms of mental disorders were more likely to report all forms of PMIEs than those without symptoms (AOR 2.7; 95% CI 2.2, 3.3). Doctors who reported symptoms were only more likely to report betrayal events, such as breach of trust by colleagues (AOR 2.7, 95% CI 1.5, 4.9). CONCLUSION A considerable proportion of NHS healthcare staff in both clinical and non-clinical roles report exposure to PMIEs during the COVID-19 pandemic. Prospective research is needed to identify the direction of causation between moral injury and mental disorder as well as continuing to monitor the longer term outcomes of exposure to PMIEs.
Collapse
Affiliation(s)
- Victoria Williamson
- Institute of Psychology, Psychiatry and Neuroscience, King's Centre for Military Health Research, King's College London, London, UK
- Department of Experimental Psychology, Anna Watts Building, University of Oxford, Oxford, UK
| | - Danielle Lamb
- Department of Applied Health Research, NIHR ARC North Thames, UCL, London, UK
| | - Matthew Hotopf
- Department of Psychological Medicine, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Rosalind Raine
- Department of Applied Health Research, NIHR ARC North Thames, UCL, London, UK
| | - Sharon Stevelink
- Institute of Psychology, Psychiatry and Neuroscience, King's Centre for Military Health Research, King's College London, London, UK
- Department of Psychological Medicine, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK
| | - Simon Wessely
- Department of Psychological Medicine, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK
| | - Mary Docherty
- Department of Psychological Medicine, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK
| | - Ira Madan
- Department of Occupational Health, Guy's and St Thomas' NHS Trust and King's College London, London, UK
| | - Dominic Murphy
- Institute of Psychology, Psychiatry and Neuroscience, King's Centre for Military Health Research, King's College London, London, UK
- Combat Stress, Tyrwhitt House, Leatherhead, UK
| | - Neil Greenberg
- Institute of Psychology, Psychiatry and Neuroscience, King's Centre for Military Health Research, King's College London, London, UK
| |
Collapse
|
24
|
İlhan B, Berikol GB, Eroğlu O, Deniz T. Prevalence and associated risk factors of post-traumatic stress disorder among survivors of the 2023 Turkey earthquake. Am J Emerg Med 2023; 72:39-43. [PMID: 37480590 DOI: 10.1016/j.ajem.2023.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/24/2023] [Accepted: 07/14/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND Earthquakes can cause psychological trauma among survivors as well as physical trauma. This study aims to determine the prevalence of post-traumatic stress disorder (PTSD) and identify associated risk factors among earthquake survivors after the 2023 Turkey earthquake. METHODS This prospective cross-sectional study was conducted in the emergency department of a tertiary university hospital between May 6, 2023, and May 16, 2023. An online questionnaire was sent to the participants. The questionnaire form consisted of three parts. In the first part, the sociodemographic characteristics of the participants were included. In the second part, the participants were asked about their experiences with the earthquake. In the third part, the post-traumatic stress disorder checklist for the Diagnostic and Statistical Manual of Mental Disorders, which screens PTSD among the participants, was included. Participants who did not complete all the questions and had severe communication disorders were excluded. RESULTS The prevalence of probable PTSD among the participants was 51.4% (n = 197). Age (OR: 0.96 95% CI: 0.93-99), female gender (OR: 4.54 95% CI: 2.39-8.61), being the head of the family (OR: 2.00 95% CI: 1.04-3.82), bereavement (OR: 1.71 95% CI: 1.03-2.82), lost loved ones (OR: 3.15 95% CI: 1.67-5.92), low social support (OR: 1.80 95% CI: 1.12-2.90) and receiving emergency care at the field (OR: 6.67 95% CI: 1.03-43.2) were the associated risk factors of PTSD among earthquake survivors. CONCLUSIONS The prevalence of PTSD among survivors three months after the 2023 Turkey earthquake is over half of the survivors. Younger age, female gender, being the head of the family, bereavement, lost loved ones, low social support, and receiving emergency care in the field were the associated risk factors of PTSD among earthquake survivors. Considering survivors may visit EDs until other outpatient clinics are re-established and the high rate of PTSD, rapid psychological evaluations can be performed in emergency departments. Emergency physicians should be aware of possible risk factors and high rate of PTSD.
Collapse
Affiliation(s)
- Buğra İlhan
- Department of Emergency Medicine, Kırıkkale University Faculty of Medicine, Kırıkkale, Turkey.
| | - Göksu Bozdereli Berikol
- Department of Emergency Medicine, University of Health Sciences, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Oğuz Eroğlu
- Department of Emergency Medicine, Kırıkkale University Faculty of Medicine, Kırıkkale, Turkey
| | - Turgut Deniz
- Department of Emergency Medicine, Kırıkkale University Faculty of Medicine, Kırıkkale, Turkey
| |
Collapse
|
25
|
Lathan EC, Sheikh IS, Guelfo A, Choucair KC, Fulton T, Julian J, Mekawi Y, Currier JM, Powers A, Fani N. Moral injury appraisals and dissociation: Associations in a sample of trauma-exposed community members. J Trauma Dissociation 2023; 24:692-711. [PMID: 37387238 PMCID: PMC10771817 DOI: 10.1080/15299732.2023.2231010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 03/22/2023] [Indexed: 07/01/2023]
Abstract
Appraisal of trauma is a critical factor in the development of impairing post-traumatic stress symptoms, such as dissociation. Individuals may appraise trauma as morally injurious (i.e., moral injury exposure [MIE]) and experience subsequent moral distress related to this exposure (i.e., moral injury distress [MID]). To date, however, investigation into the relations between moral injury appraisals and dissociation has been limited, particularly within community populations. This study investigated MIE and MID in relation to six facets of dissociation (disengagement, depersonalization, derealization, memory disturbances, emotional constriction, identity dissociation) in a sample of trauma-exposed community members (n = 177, 58.2% Black, 89.3% female) recruited from a public hospital and/or community advertisements. Participants completed measures assessing trauma exposure, MIE, MID, dissociation, and posttraumatic stress disorder (PTSD) symptoms. Partial correlation analyses revealed that after controlling for PTSD symptoms, MIE was correlated with disengagement, r = .23, p ≤ .025, and depersonalization, r = .25, p ≤ .001, and MID was correlated with depersonalization, r = .19, p ≤ .025. Sex moderated each association, with stronger associations observed for female participants. Findings suggest that moral injury appraisals are linked to more severe dissociative symptoms among female civilians, and as such, may need to be specifically targeted in empirically supported treatments.
Collapse
Affiliation(s)
- Emma C. Lathan
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | | | - Alfonsina Guelfo
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - Khaled C. Choucair
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - Travis Fulton
- Molecular and Systems Pharmacology PhD Program, Emory University
| | - Jacob Julian
- Department of Psychology, Georgia State University
| | - Yara Mekawi
- Department of Psychological and Brain Sciences, University of Louisville
| | | | - Abigail Powers
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - Negar Fani
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| |
Collapse
|
26
|
Zasiekina L, Zasiekin S, Kuperman V. Post-traumatic Stress Disorder and Moral Injury Among Ukrainian Civilians During the Ongoing War. J Community Health 2023; 48:784-792. [PMID: 37119352 PMCID: PMC10148618 DOI: 10.1007/s10900-023-01225-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/01/2023]
Abstract
While severity of post-traumatic stress disorder (PTSD) symptoms and moral injury among civilians affected by armed conflicts is generally understudied, even less research exists on civilian populations during an active war. This paper reports a large-scale study that administered standard assessments of PTSD and moral injury severity, as well as rich demographic questionnaires, to nearly 1300 Ukrainian civilians during the ongoing Russian invasion. Analyses revealed an extremely high prevalence of severe PTSD symptoms and moral injury, relative to both proposed clinical cut-offs and to earlier measurements from a similar population. Further regression analyses identified risk factors and protective factors. Greater severity of PTSD symptoms was observed among women, older and forcibly displaced individuals, and individuals from geographic regions under Russian occupation. Higher education correlated with milder PTSD symptoms. Moral injury was particularly strong in younger individuals. The present study is one of the first to report a large scale set of psychological data collected from the civilian population of Ukraine during the ongoing Russian invasion. It is obvious from the scope and long-term nature of the atrocities that psychological treatment of the civilian population will be required both presently, while the hostilities are ongoing, and in the future. This data contributes to a detailed understanding of the psychological response to traumatic stress, including its overall prevalence and presence in specific demographically and geographically defined civilian groups.
Collapse
Affiliation(s)
- Larysa Zasiekina
- Lesya Ukrainka Volyn National University, Lutsk, Ukraine.
- University of Cambridge, Cambridge, UK.
| | - Serhii Zasiekin
- Lesya Ukrainka Volyn National University, Lutsk, Ukraine
- University College London, London, UK
| | | |
Collapse
|
27
|
Chew QH, Lee TS, Sim K. Moral injury and associated context, contributors and consequences within mental healthcare professionals: a scoping review. Postgrad Med 2023; 135:646-668. [PMID: 37776227 DOI: 10.1080/00325481.2023.2266007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/28/2023] [Indexed: 10/02/2023]
Abstract
OBJECTIVES We sought to examine the contributory factors as well as consequences of moral injury amongst healthcare workers within mental healthcare settings. METHODS Several databases were searched for relevant studies from database inception until May 2023. Keywords and concepts included moral injury and distress in mental healthcare and psychiatry. We identified 961 studies, of which 48 were assessed for eligibility. Eventually, 35 studies were included in the review. Papers were selected for inclusion if 1) they included mental healthcare professionals (MHP) regardless of practice setting, 2) moral injury as experienced by MHP was one of their main variables of interest, 3) were written in English. Year of publication, location of study, participant characteristics, study design, settings in which injury occur (context), factors contributing to moral injury (contributors), and its effects on MHP (consequences) were extracted from the studies. RESULTS The majority of studies were conducted in the West (n = 26, 74.3%). Contributors to moral injury were found at the individual (e.g. poor competence), practice setting (e.g. lack of resources), and organizational levels (e.g. inconsistent policies). Moral injury had negative repercussions for the individual (e.g. psychological and physical symptoms), healthcare teams (e.g. lack of trust and empathy), and healthcare system (e.g. staff attrition). CONCLUSIONS Seen through the moral habitability framework, interventions must include an acknowledgment of the influence of various factors on the ability of MHP to enact their moral agency, and seek to establish safe moral communities within a supportive moral climate.
Collapse
Affiliation(s)
- Qian Hui Chew
- Research Division, Institute of Mental Health, Singapore, Singapore
| | - Tih-Shih Lee
- Neuroscience and Behavioral Disorders Program, Duke-NUS Medical School, Singapore, Singapore
| | - Kang Sim
- West Region, Institute of Mental Health, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| |
Collapse
|
28
|
Foster MW, McKellar L, Fleet JA, Sweet L. Moral distress in midwifery practice: A Delphi study. Women Birth 2023; 36:e544-e555. [PMID: 37164777 DOI: 10.1016/j.wombi.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Moral distress is a psychological concept that describes the harm associated with actions or inactions that oppose an individuals' moral beliefs. Moral distress is linked to moral compromise in the workplace that may negatively impact mental wellbeing. Current tools available to assess moral distress are not specific for the Australian health care system or midwifery practice. AIM The aim of this study was to develop a list of situational and outcome statements associated with moral compromise and levels of moral distress in midwifery to inform the development of a tool to measure levels of moral distress in midwives. METHODS This e-Delphi study was the third stage of a sequential exploratory mixed-methods study. Using an online strategy, three iterative rounds of e-Delphi were collected and analysed for consensus on situations leading to moral distress and the associated psychological outcomes. FINDINGS Twenty participants contributed across the three rounds. Consensus was met in 40 morally compromising situation statements. The highest level of consensus related to excessive workloads and the associated negative impact of this on women and families. Consensus on outcomes following exposure to morally distressing situations led to the development of a continuum scale from moral frustration to moral injury. DISCUSSION/CONCLUSION This is the first study to use a consensus method to establish different levels of moral compromise, frustration, distress, and injury in midwifery practice. The findings of this study contribute to a growing body of literature that supports the concept of moral distress occurring across a continuum.
Collapse
Affiliation(s)
- Mrs Wendy Foster
- Clinical and Health Sciences, University of South Australia, Australia; Rosemary Bryant AO Research Centre, University of South Australia, Adelaide, SA 5000, Australia.
| | - Lois McKellar
- Clinical and Health Sciences, University of South Australia, Australia; School of Health and Social Care, Edinburgh Napier University, Scotland, UK
| | - Julie-Anne Fleet
- Clinical and Health Sciences, University of South Australia, Australia; Rosemary Bryant AO Research Centre, University of South Australia, Adelaide, SA 5000, Australia
| | - Linda Sweet
- School of Health and Social Care, Edinburgh Napier University, Scotland, UK; School of Nursing and Midwifery, Deakin University and Western Health Partnership, Australia
| |
Collapse
|
29
|
Wirpsa MJ, Galchutt P, Price CS, Schaefer B, Szilagyi C, Palmer PK. Mandatory COVID-19 vaccination for healthcare workers: The experience of chaplains evaluating religious accommodation requests from coworkers. Soc Sci Med 2023; 332:116103. [PMID: 37506485 DOI: 10.1016/j.socscimed.2023.116103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 07/06/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023]
Abstract
Mandatory COVID-19 vaccination requirements for healthcare workers in the United States, instituted at the height of the pandemic to protect vulnerable patients and preserve the infrastructure of healthcare, nonetheless met with resistance by some members of the work force. As unprecedented numbers of employees sought religious accommodations, chaplain leaders were recruited by institutional leadership to adjudicate these requests, either alone or as part of a committee. This study reports results of a survey conducted from 6/1/2022 to 7/15/2022 with U.S. healthcare chaplains (n = 76) who were involved in the evaluation of coworker requests for religious exemption to the COVID-19 vaccine anytime during the pandemic until they accessed the survey. Chaplains were recruited online through national chaplaincy and ethics organizations. A mixed methods design facilitates integration of statistically significant associations with chaplains' in-depth reflections on their experience. Surveying the religious experts on the review committee affords a rare look into how the tension between the free exercise of religion in the workplace and the obligation to protect the public played out during the pandemic. The study further addresses a gap in research literature on the experience of chaplains during the pandemic and identifies unique features of moral injury experienced by a subset of healthcare providers. Chaplains largely perceived their involvement as promoting an ethical, informed process of review. Although all chaplains found this role stressful, high levels of meaning were protective against distress. Sources of distress identified included: ethical concern that granting exemptions would lead to the spread of the virus; inconsistencies in the review process; and, repeated exposure to coworkers' misunderstanding and political use of religious teachings. Featuring prominently in comments from chaplains was the difficulty navigating requests in the context of anti-science, anti-vaccine, and politically charged public discourse.
Collapse
Affiliation(s)
| | - P Galchutt
- M Health Fairview, University of Minnesota Medical Center, USA
| | - C S Price
- University of Texas Medical Branch, USA
| | | | | | - P K Palmer
- Woodruff Health Sciences Center, Emory University, USA
| |
Collapse
|
30
|
Johanson LS, Hughes V, Fingerhood ML, Mewborn E. Addressing moral injury in nursing education. J Prof Nurs 2023; 48:194-199. [PMID: 37775235 DOI: 10.1016/j.profnurs.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 07/14/2023] [Accepted: 07/25/2023] [Indexed: 10/01/2023]
Affiliation(s)
- Linda S Johanson
- 2078 East Winds Ave., Morganton, NC 28655, United States of America; Walden University (virtual university), 100 Washington Ave. S. Suite 900, Minneapolis, MN 55401, United States of America.
| | - Victoria Hughes
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD 21205, United States of America.
| | | | - Emily Mewborn
- The University of Tennessee Health Science Center, United States of America
| |
Collapse
|
31
|
Berdida DJE. The mediating roles of moral courage and moral resilience between nurses' moral distress and moral injury: An online cross-sectional study. Nurse Educ Pract 2023; 71:103730. [PMID: 37499534 DOI: 10.1016/j.nepr.2023.103730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/03/2023] [Accepted: 07/18/2023] [Indexed: 07/29/2023]
Abstract
AIMS To investigate the mediating role of moral resilience and moral courage in the association between moral distress and moral injury. BACKGROUND There is a preponderance of nursing literature about moral distress, moral resilience, moral courage and moral injury. However, examining moral resilience and moral courage as mediators remain underreported during the COVID-19 pandemic and in the context of a developing nation. DESIGN Correlational, cross-sectional design compliant with the STROBE guidelines. METHODS A convenience sample of nurses (n = 412) from the Philippines were recruited using social media platforms (e.g., Facebook, Messenger, Twitter). Four self-report and validated scales (8-item Moral-Distress Appraisal Scale, 21-item Nurses' Moral Courage Scale, 17-item Rushton Moral Resilience Scale and 10-item Moral Injury Symptom Scale: Healthcare Professionals Version) were used to collect data from January to July 2022. Pearson's r, bivariate analysis and multistage regression analyses were used for data analysis. RESULTS This study afforded a model that depicted the interrelationships of moral distress, moral resilience, moral courage and moral injury. Moral distress has a negative impact on moral resilience and moral courage while positively affecting moral injury. Moral resilience positively influences moral courage while having a negative impact on moral injury. Moral courage has an indirect impact on moral injury. Finally, moral resilience and moral courage demonstrated a mediating effect between moral distress and moral injury. CONCLUSIONS Healthcare organizations, policymakers and nurse managers should include policies and programs that include improving approaches to modifying workplace conditions and evaluating nurses' moral resilience and courage. Nurse managers need to advocate ethics education and professionalism. Nurses must practice self-care strategies to strengthen morally resilient and courageous therapeutic practices.
Collapse
Affiliation(s)
- Daniel Joseph E Berdida
- College of Nursing, University of Santo Tomas, Manila 1015, Philippines; College of Graduate Studies and Teacher Education Research (CGSTER), Philippine Normal University, Taft Ave., Manila 1000, Philippines.
| |
Collapse
|
32
|
Zasiekina L, Duchyminska T, Bifulco A, Bignardi G. War trauma impacts in Ukrainian combat and civilian populations: Moral injury and associated mental health symptoms. Mil Psychol 2023:1-12. [PMID: 37486615 DOI: 10.1080/08995605.2023.2235256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 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.
Collapse
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
| |
Collapse
|
33
|
Nemiroff S, Blanco I, Burton W, Fishman A, Joo P, Meholli M, Karasz A. Moral injury and the hidden curriculum in medical school: comparing the experiences of students underrepresented in medicine (URMs) and non-URMs. Adv Health Sci Educ Theory Pract 2023:10.1007/s10459-023-10259-2. [PMID: 37382857 DOI: 10.1007/s10459-023-10259-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 06/18/2023] [Indexed: 06/30/2023]
Abstract
Underrepresented students in medicine (URM) have more negative perceptions of the medical school learning environment (LE), a phenomenon that can contribute to higher rates of burnout and attrition in these populations. The hidden curriculum (HC)-defined as a set of values informally conveyed to learners through clinical role-modeling-is a LE socialization construct that has been critically examined for its role in shaping students' professional identities. Yet differences in how URMs and non-URMs experience the HC remain underexplored. The study used a pragmatic approach that drew on elements of grounded theory and employed both deductive and inductive reasoning. Investigators conducted qualitative, semi-structured interviews with a purposive sample of 13 URM and 21 non-URM participants at a Bronx, NY medical school. Interviews examined student experiences and reactions to the HC. Both cohorts witnessed patient disparagement and mistreatment. However, from these encounters, URM participants expressed more moral injury-the adverse emotional consequence of feeling pressured to accept ideologically incongruent values. URMs were also more likely to describe resisting the HC. Differences in group reactions appeared to arise from URMs' identity resonance with patients' lived experiences. Participants across cohorts emphasized increasing URM recruitment as one step toward mitigating these circumstances. URM participants experienced more distress and offered more resistance to the HC relative to non-URMs. The etiology of these differential reactions may stem from relative barriers in negotiating personal and professional identities. As such, URMs' perceptions of the LE may be adversely impacted given their more negative interactions with the HC.
Collapse
Affiliation(s)
- Samuel Nemiroff
- Albert Einstein College of Medicine, New York City, NY, USA.
- Mount Sinai Morningside-West, New York City, USA.
| | - Irene Blanco
- Medicine-Rheumatology, Clinical Research Ethics & Equity Consultative Service (CREEC), Northwestern University, Chicago, IL, USA
| | - William Burton
- Assessment, Evaluation and Quality Improvement in the Office of Medical Education, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ariel Fishman
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Pablo Joo
- Department of Family Medicine, University of California, Riverside, CA, USA
| | - Mimoza Meholli
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Alison Karasz
- Department of Family Medicine and Community Health, Chan Medical School, University of Massachusetts, Worcester, MA, USA
| |
Collapse
|
34
|
Linden M, Lieberei B. Injustice and Embitterment: Crucial Stressors in Psychosomatic Patients. Psychopathology 2023; 57:39-44. [PMID: 37379807 DOI: 10.1159/000531254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 04/24/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE "Disorders specifically associated with stress" are receiving increasing attention in clinical practice, research, and modern classification systems of mental disorders. This includes not only reactions to "extremely threatening or horrific events" as it is characteristic for "post-traumatic stress disorders" but also a variety of day-to-day experiences. Examples are experiences of injustice, humiliation, or breach of trust which can have dire psychological consequences such as feelings of embitterment, a strong and crippling emotion. This study investigated the frequency of feelings of injustice and concomitant embitterment across different areas of daily life of psychosomatic patients. METHODS In an observational archival study, 200 inpatients of a department of behavioral medicine filled in the "Differential Life Burden Scale, DLB-Scale" and the "Post-Traumatic Embitterment Scale, PTED-Scale" which asks for experiences of injustice and embitterment. RESULTS More than half of all patients (58.5%) reported about very or extremely unjust and unfair life events and 51.5% additionally about feelings of embitterment. This was primarily associated with complaints about problems in the family and the workplace and was accompanied by an impairment of well-being. CONCLUSIONS The findings indicate that experiences of injustice and embitterment are frequently seen in psychosomatic inpatients and should get special attention.
Collapse
Affiliation(s)
- Michael Linden
- Research Group Psychosomatic Rehabilitation, Charité University Medicine Berlin, Berlin, Germany
| | - Barbara Lieberei
- Heinrich-Heine-Center for Psychosomatic Medicine Potsdam, Potsdam, Germany
| |
Collapse
|
35
|
Kidwell MC, Kerig PK. To Trust is to Survive: Toward a Developmental Model of Moral Injury. J Child Adolesc 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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
36
|
Layson MD, Carey LB, Best MC. The Impact of Faith-Based Pastoral Care in Decreasingly Religious Contexts: The Australian Chaplaincy Advantage in Critical Environments. J Relig Health 2023; 62:1491-1512. [PMID: 36976458 PMCID: PMC10044095 DOI: 10.1007/s10943-023-01791-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 05/15/2023]
Abstract
This article considers the contribution of faith-based chaplains who provide holistic pastoral and spiritual care within critical environments such as the military, first responders, and hospitals. The contribution of faith-based chaplains can sometimes be taken for granted or not properly understood, particularly in some Western countries which are currently experiencing a decline in religiosity. Following on from a previous paper regarding chaplaincy utilization (Layson et al. 2022), this article presents an alternative argument to the secularist-humanist perspective by noting five ways by which the faith based chaplaincy model provides best practice service and builds a capability advantage for organizations that engage faith-based chaplaincy services. The first section discusses faith-based chaplaincy and organizational holistic care; the second section considers the role of faith-based chaplains-much of which is largely unknown and poorly appreciated; the third section considers the unique capability of faith-based chaplains to provide spiritual and religious care to those of faith and for those of none; the fourth section explores how faith-based chaplains can leverage the positive impact of religious organizations to provide additional low-cost resources for other organizations and their staff; and lastly, the operational advantage of faith-based chaplains on the world stage is considered, particularly in light of culturally and linguistically diverse populations to whom religiosity is increasingly important.
Collapse
Affiliation(s)
- Mark D. Layson
- Faculty of Arts and Education, St Mark’s National Theological Centre, Charles Sturt University, Canberra, ACT, NSW Australia
| | - Lindsay. B. Carey
- Palliative Care Unit, La Trobe University, Melbourne, VIC Australia
- Institute for Ethics and Society, University of Notre Dame, Sydney, Australia
- Centre for Spirituality, Theology and Health, Duke University, North Carolina, USA
| | - Megan C. Best
- Institute for Ethics and Society, University of Notre Dame, Sydney, Australia
- School of Medicine, University of Sydney, New South Wales, Australia
| |
Collapse
|
37
|
Cahill JM, Moyse AJ, Dugdale LS. "Ruptured selves: moral injury and wounded identity". Med Health Care Philos 2023; 26:225-231. [PMID: 36780060 DOI: 10.1007/s11019-023-10138-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 05/13/2023]
Abstract
Moral injury is the trauma caused by violations of deeply held values and beliefs. This paper draws on relational philosophical anthropologies to develop the connection between moral injury and moral identity and to offer implications for moral repair, focusing particularly on healthcare professionals. We expound on the notion of moral identity as the relational and narrative constitution of the self. Moral identity is formed and forged in the context of communities and narrative and is necessary for providing a moral horizon against which to act. We then explore the relationship between moral injury and damaged moral identities. We describe how moral injury ruptures one's sense of self leading to moral disorientation. The article concludes with implications for moral repair. Since moral identity is relationally formed, moral repair is not primarily an individual task but requires the involvement of others to heal one's identity. The repair of moral injury requires the transformation of a moral identity in community.
Collapse
Affiliation(s)
- Jonathan M Cahill
- Center for Clinical Medical Ethics, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA
| | - Ashley J Moyse
- Center for Clinical Medical Ethics, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA
| | - Lydia S Dugdale
- Department of Medicine, Center for Clinical Medical Ethics, Columbia University, Vagelos College of Physicians & Surgeons, 622 W 168th St, PH 8E-105, 10032-3784, New York, NY, USA.
| |
Collapse
|
38
|
Kerig PK. Introduction to the Special Section: Developmental Perspectives on Trauma Exposure and Posttraumatic Stress. J Child Adolesc Trauma 2023; 16:381-390. [PMID: 37234830 PMCID: PMC10205950 DOI: 10.1007/s40653-023-00557-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/12/2023] [Indexed: 05/28/2023]
Abstract
This article provides an introduction and overview of the current special section devoted to developmental perspectives on trauma exposure and posttraumatic stress reactions. Although there have been many revisions to the posttraumatic stress disorder (PTSD) diagnosis in the four decades that have ensued since its inclusion in our diagnostic systems, and many decades of empirical and clinical work investigating the differential effects of traumatic stress on children and adolescents, a truly developmental perspective is still lacking in the diagnosis. In a call to address this gap, this article outlines principles of developmental psychopathology as applied to the phenomenology of trauma and points to potential developmental transformations in the expression of posttraumatic stress across developmental epochs. The introduction then goes on to describe the valuable contributions to the literature represented by the six teams of contributing authors to this present special section, in which they discuss stability and change in posttraumatic symptom expression across development, the current state of validation research on the proposed diagnosis of Developmental Trauma Disorder, complex symptom arrays in children who have been complexly traumatized, distinctions between Complex PTSD and emerging personality pathology, developmental perspectives on prolonged grief, and developmental considerations for understanding the intersection between trauma and moral injury. It is hoped that this collection of articles will serve to stimulate new research and inform effective interventions for young persons affected by traumatic stress.
Collapse
Affiliation(s)
- Patricia K. Kerig
- Department of Psychology, University of Utah, Salt Lake City, UT 84112 USA
| |
Collapse
|
39
|
Kearney BE, Terpou BA, Densmore M, Shaw SB, Théberge J, Jetly R, McKinnon MC, Lanius RA. How the body remembers: Examining the default mode and sensorimotor networks during moral injury autobiographical memory retrieval in PTSD. Neuroimage Clin 2023; 38:103426. [PMID: 37207593 PMCID: PMC10206209 DOI: 10.1016/j.nicl.2023.103426] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 05/21/2023]
Abstract
Neural representations of sensory percepts and motor responses constitute key elements of autobiographical memory. However, these representations may remain as unintegrated sensory and motor fragments in traumatic memory, thus contributing toward re-experiencing and reliving symptoms in trauma-related conditions such as post-traumatic stress disorder (PTSD). Here, we investigated the sensorimotor network (SMN) and posterior default mode network (pDMN) using a group independent component analysis (ICA) by examining their functional connectivity during a script-driven memory retrieval paradigm of (potentially) morally injurious events in individuals with PTSD and healthy controls. Moral injury (MI), where an individual acts or fails to act in a morally aligned manner, is examined given its inherent ties to disrupted motor planning and thus sensorimotor mechanisms. Our findings revealed significant differences in functional network connectivity across the SMN and pDMN during MI retrieval in participants with PTSD (n = 65) as compared to healthy controls (n = 25). No such significant group-wise differences emerged during retrieval of a neutral memory. PTSD-related alterations included hyperconnectivity between the SMN and pDMN, enhanced within-network connectivity of the SMN with premotor areas, and increased recruitment of the supramarginal gyrus into both the SMN and the pDMN during MI retrieval. In parallel with these neuroimaging findings, a positive correlation was found between PTSD severity and subjective re-experiencing intensity ratings after MI retrieval. These results suggest a neural basis for traumatic re-experiencing, where reliving and/or re-enacting a past morally injurious event in the form of sensory and motor fragments occurs in place of retrieving a complete, past-contextualized narrative as put forth by Brewin and colleagues (1996) and Conway and Pleydell-Pearce (2000). These findings have implications for bottom-up treatments targeting directly the sensory and motoric elements of traumatic experiences.
Collapse
Affiliation(s)
- Breanne E Kearney
- Department of Neuroscience, Western University, London, Ontario, Canada
| | - Braeden A Terpou
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Maria Densmore
- Department of Psychiatry, Western University, London, Ontario, Canada; Imaging Division, Lawson Health Research Institute, London, Ontario, Canada
| | - Saurabh B Shaw
- Department of Psychiatry, Western University, London, Ontario, Canada
| | - Jean Théberge
- Department of Psychiatry, Western University, London, Ontario, Canada; Imaging Division, Lawson Health Research Institute, London, Ontario, Canada; Department of Medical Biophysics, Western University, London, Ontario, Canada
| | - Rakesh Jetly
- Institute of Mental Health Research, University of Ottawa, Ottawa, Ontario, Canada
| | - Margaret C McKinnon
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada; Mood Disorders Program, St. Joseph's Healthcare, Hamilton, Ontario, Canada; Homewood Research Institute, Guelph, Ontario, Canada
| | - Ruth A Lanius
- Department of Neuroscience, Western University, London, Ontario, Canada; Department of Psychiatry, Western University, London, Ontario, Canada; Imaging Division, Lawson Health Research Institute, London, Ontario, Canada; Homewood Research Institute, Guelph, Ontario, Canada.
| |
Collapse
|
40
|
Williams AY, Butts CC. Stress Disorders: the Trauma Surgeon as the Second Victim. Curr Trauma Rep 2023; 9:1-8. [PMID: 37362905 PMCID: PMC10134724 DOI: 10.1007/s40719-023-00259-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 06/28/2023]
Abstract
Purpose of Review We review the vocabulary and studies regarding stress disorders, as it relates to trauma care providers, specifically trauma surgeons. In addition, we make recommendations regarding strategies to address the needs identified and future areas of research to assess the adequacy of these strategies. Recent Findings Stress disorders in trauma are common and constant, identified at levels similar to those seen among first-responders to mass-casualty events. These disorders are identified at every level-from trainee to the most experienced. Trauma surgeons experience the trauma firsthand, as well as through forced re-traumatization as a part of routine care. High levels of cumulative stress result due to the volume of patients that can be difficult to process due to the frequency of shifts and disrupted sleep patterns. This level of chronic stress can lead to a cycle of burnout and increased stress, which is harmful to surgeons and patients. Summary Stress disorders are common and poorly understood. Treatment options are infrequently encountered. In order to more adequately respond to this, systematic change is necessary.
Collapse
Affiliation(s)
- Ashley Y. Williams
- Department of Surgery, Division of Trauma, Acute Care Surgery, and Burns, Whiddon College of Medicine, University of South Alabama, Mobile, AL USA
| | - C. Caleb Butts
- Department of Surgery, Division of Trauma, Acute Care Surgery, and Burns, Whiddon College of Medicine, University of South Alabama, Mobile, AL USA
| |
Collapse
|
41
|
He Z, Lei Q, Hu X, Xiong M, Liu J, Wen J, Shi X, Wang Z. Moral injury and suicidal ideation among health professionals: The role of mental health. J Affect Disord 2023; 333:58-64. [PMID: 37080491 PMCID: PMC10111858 DOI: 10.1016/j.jad.2023.04.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/23/2023] [Accepted: 04/14/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND The prolonged COVID-19 pandemic has burdened health professionals mentally and physically. This study aims to explore the relationship between moral injury (MI) and suicidal ideation (SI), and the role of mental health conditions in this relationship. METHODS Three-wave repeated online cross-sectional study with a total of 10,388 health professionals were conducted in different stages (2020-2022) of the COVID-19 pandemic in mainland China. Participants completed the Chinese version of the Moral Injury Symptoms Scale-Health Professional, Post-Traumatic Stress Disorder (PTSD) Checklist for DSM-5 coupled with a blanket of scales. RESULTS The prevalence of SI and MI among health professionals was 9.8 % and 40.2 %, respectively. The prevalence risk of SI was lower in wave 2 (OR = 0.64, 95 % CI: 0.54-0.77) and wave 3 (OR = 0.71, 95 % CI: 0.60-0.84) when compared with wave 1. MI (OR = 4.66, 95 % CI: 3.99-5.43), medical error (OR = 1.15, 95 % CI: 1.00-1.32), workplace violence (OR = 1.13, 95 % CI: 0.97-1.32), depression (OR = 94.08, 95 % CI: 63.37-139.69), anxiety (OR = 25.54, 95 % CI: 21.22-30.74), PTSD (OR = 24.51, 95 % CI: 19.01-31.60) were associated with a higher risk of SI. The mediation model revealed that depressive, anxiety, and PTSD symptoms explained 90.6 % of the total variance in the relationship between MI and SI. CONCLUSIONS The risk of SI has reduced among health professionals since the first peak of the COVID-19 pandemic in China. MI may contribute to prevalent SI, and mental health conditions, especially depressive symptoms, play a significant role as mediators. LIMITATIONS Cross-sectional design precludes the investigation of casual relationships. The nonrandom sampling method limits the generalization.
Collapse
Affiliation(s)
- Zhehao He
- Department of Epidemiology and Health Statistics, School of Public Health at Guangdong Medical University, Dongguan 560001, China
| | - Qiuhui Lei
- Department of Epidemiology and Health Statistics, School of Public Health at Guangdong Medical University, Dongguan 560001, China
| | - Xue Hu
- Department of Epidemiology and Health Statistics, School of Public Health at Guangdong Medical University, Dongguan 560001, China
| | - Mengyun Xiong
- Department of Epidemiology and Health Statistics, School of Public Health at Guangdong Medical University, Dongguan 560001, China
| | - Jun Liu
- Department of Preventive Medicine, School of Public Health at Zunyi Medical University, Zunyi 56006, China
| | - Jing Wen
- Department of Epidemiology and Health Statistics, School of Public Health and Management at Ningxia Medical University, China
| | - Xiuquan Shi
- Department of Epidemiology and Health Statistics, School of Public Health, Zunyi Medical University, Zunyi, Guizhou, China.
| | - Zhizhong Wang
- Department of Epidemiology and Health Statistics, School of Public Health at Guangdong Medical University, Dongguan 560001, China; The First Dongguan Affiliated Hospital, Guangdong Medical University, Dongguan 523808, China.
| |
Collapse
|
42
|
Jack FJG, Kotronoulas G. The Perceptions of Healthcare Staff Regarding Moral Injury and the Impact on Staff Life and Work During COVID-19: A Scoping Review of International Evidence. J Relig Health 2023:1-25. [PMID: 37027110 PMCID: PMC10080521 DOI: 10.1007/s10943-023-01803-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/17/2023] [Indexed: 06/19/2023]
Abstract
The COVID-19 response introduced legal restrictions on social distancing globally, affecting healthcare staff personally and professionally. These restrictions suspended routine hospital visiting, which may have left staff feeling they had to compromise on the care they provided. Such conflict may be experienced as moral injury. This scoping review aimed to synthesise international evidence, to answer this question: "Have COVID-19 restrictions affected healthcare staff's experiences of moral injury? If so, how?" Nine studies met the search criteria. Although healthcare staff seemed to be aware of the risks and effects of moral injury, they were still reluctant to "name" it. Healthcare staff's own emotional and spiritual needs were mostly ignored. Although psychological support is often the recommended approach by organisations, a greater focus on spiritual and emotional support is recommended.
Collapse
Affiliation(s)
- Fiona J. G. Jack
- NHS Fife–Department of Spiritual Care, Queen Margaret Hospital, Whitefield Road, Dunfermline, Fife, KY12 OSU Scotland, UK
| | - Grigorios Kotronoulas
- School of Medicine Dentistry and Nursing, Nursing and Health Care School, College of Medical, Veterinary and Life Sciences, University of Glasgow, 57-61 Oakfield Avenue, Glasgow, G12 8LL Scotland, UK
| |
Collapse
|
43
|
Cenkner DP, Usman H, Zalta AK. Differential associations of rumination and cognitive flexibility with guilt and shame following potentially morally injurious events. J Affect Disord 2023; 325:135-40. [PMID: 36621679 DOI: 10.1016/j.jad.2022.12.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 12/29/2022] [Accepted: 12/31/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Guilt and shame are common moral emotions following potentially morally injurious events (PMIEs), which involve events that violate one's deeply held moral values. However, not all individuals will experience guilt and shame following PMIEs and the mechanisms by which PMIEs lead to guilt and shame are not well understood. This study set out to examine the role of event-related intrusive rumination, event-related deliberate rumination, cognitive flexibility, and their interactions, in predicting PMIE-related guilt and shame. METHODS A subsample of undergraduate participants exposed to an objective PMIE and endorsing a subjective PMIE (N = 323) completed self-report assessments. RESULTS Higher levels of event-related intrusive rumination and event-related deliberate rumination and lower levels of cognitive flexibility were associated with higher levels of PMIE-related shame. Only higher levels of event-related deliberate rumination were associated with greater PMIE-related guilt. Moreover, the predictors explained much greater variance in PMIE-related shame (R2Adj = 0.44) than PMIE-related guilt (R2Adj = 0.05). There was no significant interaction between event-related rumination and cognitive flexibility in predicting PMIE-related guilt or shame. LIMITATIONS This study was cross-sectional, the sample was mostly female, and all data was collected via self-report. Longitudinal studies are needed to explore these potential mechanistic processes. CONCLUSIONS Our findings suggest that differential pathways may affect whether individuals experience guilt or shame following PMIEs. Rumination and cognitive flexibility may be valuable clinical targets for interventions aimed at addressing PMIE-related shame.
Collapse
|
44
|
Zerach G, Ben-Yehuda A, Levi-Belz Y. Pre-deployment aggressiveness, combat exposure and moral injury as contributors to posttraumatic stress symptoms among combatants: A two-year prospective study. J Psychiatr Res 2023; 161:158-64. [PMID: 36931133 DOI: 10.1016/j.jpsychires.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/19/2023]
Abstract
Combatants who are exposed to events which transgress deeply held moral beliefs might face lasting psychopathological outcomes such as Moral Injury (MI) and posttraumatic stress symptoms (PTSS). However, insight about pre-deployment personality factors which might facilitate the MI process and its negative consequences is sparse. In this prospective study, we examined pre-deployment aggressiveness as a possible predictor of exposure to combat and potentially morally injurious events (PMIEs), trauma-related guilt and shame and PTSS among Israeli active-duty combatants. A sample of 335 active-duty Israeli combatants participated in a 2.5-year prospective study with three waves of measurements (T1: 12 months before enlistment, T2: 6 months following enlistment-pre deployment, and T3: 18 months following enlistment-post deployment). Participants' characteristics were assessed via semi-structured interviews (T1) and validated self-report measures of aggressiveness (T2), combat exposure, PMIEs and PTSS (T3) between 2019 and 2021. Results show that higher levels of pre-deployment aggressiveness predicted both combat exposure and PMIEs-'betrayal'. Combat exposure mediated the association between aggressiveness and PTSS post deployment. Importantly, pre-deployment aggressiveness was significantly associated with the PMIEs-'betrayal' that are associated with trauma-related guilt and shame, which in turn were associated with high levels of PTSS post deployment. Our results highlight the implications of pre-deployment aggressiveness for different forms of exposure to potentially traumatic events during military service. Identification of at-risk combatants for PTSS following exposure to PMIEs of betrayal might provide these combatants with a tailor-made type of preparation regarding moral and ethical situations, which should be investigated in future studies.
Collapse
|
45
|
Sert-Ozen A, Kalaycioglu O. The Effect of Occupational Moral Injury on Career Abandonment Intention Among Physicians in the Context of the COVID-19 Pandemic. Saf Health Work 2023; 14:78-84. [PMID: 36536655 PMCID: PMC9750509 DOI: 10.1016/j.shaw.2022.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 12/03/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022] Open
Abstract
Background Since the advent of the COVID-19 pandemic, physicians have been the unsung heroes of the pandemic. However, many are about to give up the battlefield. This study investigated the effect of occupational moral injury on physicians' career abandonment intention, taking into account the possible mediating role of emotional exhaustion. Methods Cross-sectional data collected from 201 physicians were analyzed using the partial least squares structural equation modeling (PLS-SEM) with SmartPLS to determine the relationship among physicians' moral injuries, emotional exhaustion, and career abandonment intention. Results The results indicated that occupational moral injury was positively related to emotional exhaustion and career abandonment intention. In addition, emotional exhaustion was found to play a mediating role in the relationship. Conclusion To reduce physicians' intention to leave their career, physicians should be prepared for moral injury and psychological issues by offering psychological support and meeting their needs early at both the individual and organizational levels during and after the pandemic.
Collapse
Affiliation(s)
- Arzu Sert-Ozen
- Department of Business Administration, Istanbul Kent University, Istanbul, Turkey
| | | |
Collapse
|
46
|
Maguen S, Nichter B, Norman SB, Pietrzak RH. Moral injury and substance use disorders among US combat veterans: results from the 2019-2020 National Health and Resilience in Veterans Study. Psychol Med 2023; 53:1364-1370. [PMID: 34409932 PMCID: PMC10009375 DOI: 10.1017/s0033291721002919] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/24/2021] [Accepted: 07/01/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Exposure to potentially morally injurious events (PMIEs) is associated with increased risk for substance use disorders (SUDs), although population-based studies remain limited. The goal of this study was to better understand the relationships between PMIE exposure and lifetime and past-year alcohol use disorder (AUD), drug use disorder (DUD), and SUD. METHODS Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 1321 combat veterans. Multivariable analyses examined associations between three types of PMIE exposure (perpetration, witnessing, and betrayal), and lifetime and past-year AUD, DUD, and SUD, adjusting for sociodemographic variables, combat exposure severity, prior trauma, and lifetime posttraumatic stress disorder and major depressive disorder. RESULTS Perpetration was associated with increased odds of lifetime AUD (OR 1.15; 95% CI 1.01-1.31) and lifetime SUD (OR 1.18; 95% CI 1.03-1.35). Witnessing was associated with greater odds of past-year DUD (OR 1.20; 95% CI 1.04-1.38) and past-year SUD (OR 1.14; 95% CI 1.02-1.28). Betrayal was associated with past-year AUD (OR 1.20; 95% CI 1.03-1.39). A large proportion of the variance in past-year AUD was accounted for by betrayal (38.7%), while witnessing accounted for 25.8% of the variance in past-year DUD. CONCLUSIONS Exposure to PMIEs may be a stronger contributor to SUDs among veterans than previously known. These findings highlight the importance of targeted assessment and treatment of moral injury among veterans with SUDs, as well as attending to specific types of morally injurious experiences when conceptualizing and planning care.
Collapse
Affiliation(s)
- Shira Maguen
- San Francisco VA Health Care System, San Francisco, CA, USA
- University of California – San Francisco, San Francisco, CA, USA
| | - Brandon Nichter
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Sonya B. Norman
- National Center for PTSD, White River Junction, VT, USA
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- VA Center of Excellence for Stress and Mental Health, San Diego, CA, USA
| | - Robert H. Pietrzak
- National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
| |
Collapse
|
47
|
Levi-Belz Y, Ben-Yehuda A, Zerach G. Suicide risk among combatants: The longitudinal contributions of pre-enlistment characteristics, pre-deployment personality factors and moral injury. J Affect Disord 2023; 324:624-31. [PMID: 36621681 DOI: 10.1016/j.jad.2022.12.160] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 12/14/2022] [Accepted: 12/31/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Recent studies have shown that exposure to potentially morally injurious events (PMIEs) in deployment situations facilitates higher suicide risk among combatants. However, knowledge about pre-deployment factors that may moderate the negative contribution of PMIEs to suicide risk is rare. In this prospective study, we examined pre-enlistment characteristics and pre-deployment personality factors as possible moderators in the link between exposure to self, other, and betrayal dimensions of PMIEs and post-deployment suicide risk among Israeli active-duty combatants. METHODS A sample of 335 active-duty Israeli combatants participated in a 2.5-year prospective study with three waves of measurements: T1-12 months before enlistment, T2-6 months following enlistment (pre-deployment), and T3-18 months following enlistment (post-deployment). Participants were assessed via semi-structured interviews of personal characteristics (e.g., cognitive index) at T1, validated self-report measures of personality factors for emotional regulation, impulsivity, and aggression at T2, and combat exposure, PMIEs, and suicide risk at T3 between 2019 and 2021. RESULTS All three dimensions of PMIEs were significantly associated with higher suicidal risk among combatants. Importantly, higher levels of pre-deployment aggression and lower levels of emotional regulation moderated the association between PMIEs and suicide risk post-deployment, above and beyond pre-enlistment psychiatric difficulties and life events. CONCLUSIONS Our results highlight the roles of pre-deployment factors of emotional regulation and aggressiveness as possible moderators in the PMIEs-suicide risk link. These results emphasize the need for higher awareness of suicide risk among deployed combatants with low emotional regulation and high aggressiveness. Moreover, tailored interventions aiming to decrease emotional dysregulation and aggressiveness levels should be considered, as such interventions may help reduce suicide risk following combat-related transgressive acts.
Collapse
|
48
|
Erlandson E, Ramirez C, Dean W. Medicine shouldn't be this hard: The intersection of physician moral injury and patient healthcare experience in pediatric complex care. J Pediatr Rehabil Med 2023; 16:443-447. [PMID: 37694318 PMCID: PMC10578270 DOI: 10.3233/prm-230027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/07/2023] [Indexed: 09/12/2023] Open
Abstract
Dr. Jay Neufeld's story in If I Betray These Words is a detailed account of one physician's catastrophic journey through moral injury when caring for pediatric patients with complex medical conditions [1]. Many clinicians may recognize Jay's journey in their own experiences, but what deserves parallel consideration are the journeys of patients and families when they are accompanied by physicians at risk of moral injury. This case study illustrates the tight link between drivers of physician moral injury and patients' negative healthcare experiences. These include (1) decisions directed by health insurance regulations and prior authorizations; (2) the electronic medical record (EMR); and (3) healthcare systems focused on revenue generation.
Collapse
Affiliation(s)
- Erika Erlandson
- Departments of Pediatrics and Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine, Lansing, MI, USA
| | | | - Wendy Dean
- Moral Injury of Healthcare, Carlisle, PA, USA
| |
Collapse
|
49
|
Rodrigues S, Mercier JM, McCall A, Nannarone M, Hosseiny F. 'Against everything that got you into the job': experiences of potentially morally injurious events among Canadian public safety personnel. Eur J Psychotraumatol 2023; 14:2205332. [PMID: 37170904 PMCID: PMC10184585 DOI: 10.1080/20008066.2023.2205332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/07/2023] [Accepted: 04/12/2023] [Indexed: 05/13/2023] Open
Abstract
Background: Moral injury (MI) has become a research and organizational priority as frontline personnel have, both during and in the years preceding the COVID-19 pandemic, raised concerns about repeated expectations to make choices that transgress their deeply held morals, values, and beliefs. As awareness of MI grows, so, too, does attention on its presence and impacts in related occupations such as those in public safety, given that codes of conduct, morally and ethically complex decisions, and high-stakes situations are inherent features of such occupations.Objective: This paper shares the results of a study of the presence of potentially morally injurious events (PMIEs) in the lived experiences of 38 public safety personnel (PSP) in Ontario, Canada.Method: Through qualitative interviews, this study explored the types of events PSP identify as PMIEs, how PSP make sense of these events, and the psychological, professional, and interpersonal impacts of these events. Thematic analysis supported the interpretation of PSP descriptions of events and experiences.Results: PMIEs do arise in the context of PSP work, namely during the performance of role-specific responsibilities, within the organizational climate, and because of inadequacies in the broader healthcare system. PMIEs are as such because they violate core beliefs commonly held by PSP and compromise their ability to act in accordance with the principles that motivate them in their work. PSP associate PMIEs, in combination with traumatic experiences and routine stress, with adverse psychological, professional and personal outcomes.Conclusion: The findings provide additional empirical evidence to the growing literature on MI in PSP, offering insight into the contextual dimensions that contribute to the sources and effects of PMIEs in diverse frontline populations as well as support for the continued application and exploration of MI in the PSP context.
Collapse
Affiliation(s)
- Sara Rodrigues
- Research and Policy, Atlas Institute for Veterans and Families, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
- Institute of Mental Health Research, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
| | - Jean-Michel Mercier
- Research and Policy, Atlas Institute for Veterans and Families, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
- Institute of Mental Health Research, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
| | - Adelina McCall
- Research and Policy, Atlas Institute for Veterans and Families, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
- Institute of Mental Health Research, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
| | - Molly Nannarone
- Research and Policy, Atlas Institute for Veterans and Families, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
- Institute of Mental Health Research, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
| | - Fardous Hosseiny
- Research and Policy, Atlas Institute for Veterans and Families, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
- Institute of Mental Health Research, Royal Ottawa Mental Health Centre, Ottawa, ON, Canada
| |
Collapse
|
50
|
Abstract
Moral injury is an emerging concept that captures the psychosocial consequences of involvement in and exposure to morally transgressive events. In the past decade, research on moral injury has grown exponentially. In this special collection we review papers on moral injury published in the European Journal of Psychotraumatology from its inception until December 2022, that have a primary focus on moral injury as evidenced by the words 'moral injury' in the title or abstract. We included 19 papers on quantitative (n = 9) and qualitative (n = 5) studies of different populations including (former) military personnel (n = 9), healthcare workers (n = 4) and refugees (n = 2). Most papers (n = 15) focused on the occurrence of potentially morally injurious experiences (PMIEs), moral injury and associated factors, while four papers primarily concerned treatment. Together, the papers offer a fascinating overview of aspects of moral injury in different populations. Research is clearly widening from military personnel to other populations such as healthcare workers and refugees. Focal points included the impact of PMIEs involving children, the association of PMIEs and personal childhood victimisation, the prevalence of betrayal trauma, and the relationship between moral injury and empathy. As for treatment, points of interest included new treatment initiatives as well as findings that PMIE exposure does not impede help-seeking behaviour and response to PTSD treatment. We further discuss the wide range of phenomena that fall under moral injury definitions, the limited diversity of the moral injury literature, and the clinical utility of the moral injury construct. From conceptualisation to clinical utility and treatment, the concept of moral injury matures. Whether or not moral injury becomes a formal diagnosis, the need to examine tailored interventions to alleviate moral injury is clear.
Collapse
Affiliation(s)
| | - Miranda Olff
- Department of Psychiatry, Amsterdam University Medical Center, Amsterdam, the Netherlands
- ARQ National Psychotrauma Center, Diemen/Oegstgeest, the Netherlands
| |
Collapse
|