Moral Distress: What Are We Measuring?

While various definitions of moral distress have been proposed, some agreement exists that it results from illegitimate constraints in clinical practice affecting healthcare professionals' moral agency. If we are to reduce moral distress, instruments measuring it should provide relevant information about such illegitimate constraints. Unfortunately, existing instruments fail to do so. We discuss here several shortcomings of major instruments in use: their inability to determine whether reports of moral distress involve an accurate assessment of the requisite clinical and logistical facts in play, whether the distress in question is aptly characterized as moral, and whether the moral distress reported is an appropriate target of elimination. Such failures seriously limit the ability of empirical work on moral distress to foster appropriate change.

Hospital Discharge as a Locus for Curiosity, Affirmation, and Advocacy.

Acknowledging the "dignity of risk" in hospital discharge planning requires a determination to work towards serious change in the livability and healthfulness of our communities, balanced with a positive affirmation of patients' resourcefulness and enmeshment in networks of coping and care. Unfortunately, when clinicians err single-mindedly towards either extreme, we can perpetuate harm, either by unwitting reenactment of structural power dynamics already present in patients' lives or by failures of curiosity that miss opportunities to uncover resources and supports. This article explores two clinical vignettes involving patient-doctor discordance over hospital discharge preferences in the context of patient risk. By shifting these scenarios away from principlist conflicts between the physician's duty to act beneficently and yet uphold patient autonomy-narratives which center the clinician as primary ethical agent-this article recenters the patient as chief protagonist undertaking the dignity of risk. Through conceptual explorations of structural competency, strengths-based approaches to individuals and communities, and the notion of abundance as a catalyst for imaginative redesign of health (in)equities as we currently find them, this article envisions patient "risk" as an activating state, one capable of inspiring the clinician to undertake a historically and socially informed, structure- and solution-oriented practice.

Health Equity, History, and a New Presidential Bioethics Commission: Lessons from the "Lost" Reports.

Convening a national bioethics commission has historically been one of the most powerful bioethical legacies a US presidential administration can undertake. The Biden Administration has not yet created such a commission; here we argue that centering health equity and healthcare access would provide a vital framework for a new commission's legacy. Moreover, we demonstrate two crucial historical episodes when American presidents appointed commissions to examine the practical and ethical implications of these very issues. We turn first to the 1952 President's Commission report on "Building America's Health," a lofty vision of universal healthcare access stymied by both political conflict and unaddressed problems of racism in the era's legislation. Its rich yet incomplete account of American health inequities serves as a valuable forerunner to questions of justice in bioethics. We then explore the President's Commission's 1983 report "Securing Access to Healthcare: A Report on the Ethical Implications of Differences in the Availability of Health Services." This report took up the mantle of equity in healthcare access, again with mixed results. Only by understanding the checkered history of these overlooked, practically "lost" reports can a new era in American bioethics successfully re-center the goal of equitable health for all.

Assessing measurement invariance with moderated nonlinear factor analysis using the R package OpenMx.

Assessing measurement invariance is an important step in establishing a meaningful comparison of measurements of a latent construct across individuals or groups. Most recently, moderated nonlinear factor analysis (MNLFA) has been proposed as a method to assess measurement invariance. In MNLFA models, measurement invariance is examined in a single-group confirmatory factor analysis model by means of parameter moderation. The advantages of MNLFA over other methods is that it (a) accommodates the assessment of measurement invariance across multiple continuous and categorical background variables and (b) accounts for heteroskedasticity by allowing the factor and residual variances to differ as a function of the background variables. In this article, we aim to make MNLFA more accessible to researchers without access to commercial structural equation modeling software by demonstrating how this method can be applied with the open-source R package OpenMx. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Is a Video Worth a Thousand Words?

Bodily imagery elicits strong affective responses and is highly salient, potentially altering viewers' decision making. When clinicians engage surrogates in video calls showing the patient's body, several competing ethical issues must be considered. On the one hand, surrogates may require visual information to make informed decisions, and video technology closes crucial information gaps. On the other, video technology puts an increased amount of control in the hands of clinicians over how the patient's condition is perceived. This article explores some situations that can result in manipulation due to the affective impact of bodily images and the potential for selectivity and framing. Focusing on goals of care, the paper outlines the foremost ethical considerations for clinicians and provides recommendations for clinicians on how to reduce possible manipulation when making these video calls.

The Birth of Naloxone: An Intellectual History of an Ambivalent Opioid.

Naloxone, which reverses the effects of opioids, was synthesized in 1960, though the hunt for opioid antagonists began a half-century earlier. The history of this quest reveals how cultural and medical attitudes toward opioids have been marked by a polarization of discourse that belies a keen ambivalence. From 1915 to 1960, researchers were stymied in seeking a "pure" antidote to opioids, discovering instead numerous opioid molecules of mixed or paradoxical properties. At the same time, the quest for a dominant explanatory and therapeutic model for addiction was likewise unsettled. After naloxone's discovery, new dichotomizing language arose in the "War on Drugs," in increasingly divergent views between addiction medicine and palliative care, and in public debates about layperson naloxone access. Naloxone, one of the emblematic drugs of our time, highlights the ambivalence latent in public and biomedical discussions of opioids as agents of risk and relief.

Meta-analytic structural equation modeling made easy: A tutorial and web application for one-stage MASEM.

Meta-analytic structural equation modeling (MASEM) refers to fitting structural equation models (SEMs) (such as path models or factor models) to meta-analytic data. Currently, fitting MASEMs may be challenging for researchers that are not accustomed to working with R software and packages. Therefore, we developed webMASEM; a web application for MASEM. This app implements the one-stage MASEM approach, and allows users to apply MASEM in a user-friendly way. The aim of this article is to provide a tutorial on one-stage MASEM and a practical guide to webMASEM. We will pay specific attention to how the data should be structured and prepared for webMASEM, because mistakes in this step may lead to faulty results without receiving an error message. The use of webMASEM is illustrated with an analysis of a meta-analytic path model in which the path coefficients are moderated by a study-level variable, a meta-analytic factor model in which the factor loadings are moderated by a study-level variable, and a meta-analytic panel model in which the effects are moderated by a study-level variable. All used datafiles and R scripts are available online.

Use of virtual reality in the inpatient rehabilitation of COVID-19 patients.

INTRODUCTION: Use of virtual reality (VR) in healthcare has expanded in recent years. The challenges faced by patients with prolonged COVID-19-related hospitalizations - social isolation, disability, neurologic sequelae, adjustment-related anxiety, depression, and stress - may be mitigated by the novel use of VR as one modality of a comprehensive rehabilitation plan. This descriptive study aimed to understand patient satisfaction and perceived benefit of virtual reality on a COVID-19 recovery unit, as well as the logistical and operational feasibility of providing VR content for patients and staff. MATERIALS AND METHODS: During the COVID-19 surge in New York City in 2020, the COVID-19 Recovery Unit (CRU) of a large academic hospital invited patients and staff to participate in VR sessions with three categories of experience: (1) Guided meditation, (2) Exploration of natural environments, (3) Cognitive stimulation games. Patients and staff were surveyed about satisfaction and perceived benefit. RESULTS: 13 patients and 11 staff were surveyed, with median patient satisfaction scores of 9 out of 10, with ten representing "extremely satisfied," and median staff satisfaction scores of 10. 13/13 patients answered "yes" to recommending the therapy to others, and 12/13 answered "yes" to perceived enhancement of their treatment. 11/11 staff answered "yes" to recommending the therapy to others, and 11/11 answered "yes" to perceived enhancement of their wellbeing. DISCUSSION: A VR program implemented on a COVID-19 rehabilitation unit for patients and healthcare providers was rated as highly satisfactory with perceived benefit by survey respondents. Participants commented that the use of VR was useful in coping with isolation and loneliness, and could be implemented within the context of clinical care for COVID-19 patients as part of a comprehensive rehabilitation model. The use of VR was also logistically and operationally feasible on the CRU. Future work to compare benefits of VR to standard neuropsychological rehabilitation is needed.

On Gifts and Heroes.

The language of gratitude and of heroism, pervasive in public discourse about essential workers, is well-intended but belies a problematic blurring of the difference between gifts, contracts, and professionalism. "Heroism," a term frequently invoked by society, usually describes the giving of oneself beyond reasonable boundaries. This noble concept affirms our essential connections to each other. However, labeling someone's labor as a gift can make givers feel obligated exceed both contracts and professionalism. Contracts define the boundaries of expected work for expected compensation. Like heroism, professionalism in healthcare implies undertaking duties to others beyond the contractual. Careless use of these words, however, can lead to negative consequences. Gifts and heroism are best applied to special needs in special circumstances. Professionalism goes beyond special circumstances to address ongoing commitments to others. When the language of gifts, heroism, or professionalism are used to promote the ongoing performance of dangerous, excessive work, however, they become instruments of injustice and burnout. The experiences of the COVID pandemic can help identify the proper scope of gift-giving, heroism and professionalism - which cement our social bonds - while avoiding misuses of these terms, in order to improve the safety and fairness of the work environment.

Psychosocial Predictors of Weight Loss and Quality of Life at 1 Year Post-Bariatric Surgery: A Cohort Study.

Background: Psychosocial factors, identified in pre-bariatric surgery evaluation, may affect surgical outcomes, as well as defer surgery, making it important to identify psychosocial predictors of surgery outcomes. Methods: Baseline depressive and social anxiety symptom scores were analyzed as predictors of post-surgical weight loss (WL) and quality of life (QOL) following Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (AGB). Eighty-nine (82F, 7M) participants underwent surgery and completed depression, anxiety and QOL questionnaires 3-weeks pre-surgery and 1-year post-surgery. Results: Depressive scores and QOL scores improved post-surgery (P < 0.001), whereas social anxiety scores did not (P = 0.20). Baseline depressive (P = 0.90) and social anxiety (P = 0.20) scores did not predict % weight loss (WL) at 1 year, but higher baseline depressive (P = 0.04) and social anxiety (P = 0.005) scores predicted lower post-surgical QOL at 1 year. RYGB showed greater improvement in %WL (P < 0.001) than AGB, but no difference between the groups in QOL (P = 0.10). Improvement in QOL correlated with %WL (P < 0.001), whereas improvement in depressive scores did not correlate with %WL (P = 0.70) but did correlate with improvement in QOL (P = 0.01). Conclusions: Baseline depressive and social anxiety scores predicted QOL but not %WL. Depressive and QOL scores improved post-surgery, but social anxiety scores did not. The findings suggest that patients who present with depressive or social anxiety symptoms pre-surgery perhaps should not be deferred; however, more studies are needed to confirm this. Patients with pre-operative social anxiety symptoms may benefit from counseling.

Using restricted factor analysis to select anchor items and detect differential item functioning.

Restricted factor analysis (RFA) is a powerful method to test for uniform differential item functioning (DIF), but it may require empirically selecting anchor items to prevent inflated Type I error rates. We conducted a simulation study to compare two empirical anchor-selection strategies: a one-step rank-based strategy and an iterative selection procedure. Unlike the iterative procedure, the rank-based strategy had a low risk and degree of contamination within the empirically selected anchor set, even with small samples. To detect nonuniform DIF, RFA requires an interaction effect with the latent factor. The latent moderated structural equations (LMS) method has been applied to RFA and has revealed inflated Type I error rates. We propose using product indicators (PI) as a more widely available alternative to measure the latent interaction. A simulation study, involving several sample-size conditions and magnitudes of uniform and nonuniform DIF, revealed that PI obtained similar power but lower Type I error rates, as compared to LMS.

Parent feeding behavior and child appetite: associations depend on feeding style.

OBJECTIVE: Eating behavior traits measured in early life predict eating behavior and weight trajectories later in development, and may be associated with certain parental feeding behaviors. Our goal was to investigate the relationship between a range of feeding behaviors, and preschoolers' appetitive traits. METHOD: Four hundred thirty-nine parents of UK 3-5 year olds completed scales measuring authoritarian vs. authoritative forms of limiting (Restriction vs. Monitoring) and promoting (Pressuring vs. Prompting) intake, as well as Emotional and Instrumental Feeding. Parents also completed scales measuring child Food responsiveness and Satiety responsiveness. Child BMI z-scores were calculated based on measured heights and weights. RESULTS: Parental Restriction was significantly associated with greater child Food responsiveness (p < .001), but parental Monitoring was not. Parental Pressuring was significantly associated with greater child Satiety responsiveness (p < .001), while parental Prompting was not. Parental Instrumental and Emotional feeding were both associated with greater child Food responsiveness (p < .001). All relationships were independent of child BMI z-score. DISCUSSION: Prospective data are needed to determine whether the parent-child feeding relationships identified here promote, or protect against, the development of eating pathology in children. However, our results suggest that cross-sectional associations depend on the style (e.g., authoritarian vs. authoritative), as well as the type of feeding behavior measured.

Supermarket discounts of low-energy density foods: effects on purchasing, food intake, and body weight.

OBJECTIVE: To assess the effects of a 50% discount on low-energy density (ED) fruits and vegetables (F&V), bottled water, and diet sodas on shoppers' purchasing, food intake, and body weight. DESIGN AND METHODS: A randomized, controlled trial was conducted at two Manhattan supermarkets, in which a 4-week baseline period (no discounts) preceded an 8-week intervention period (50% discount), and a 4-week follow-up period (no discounts). Twenty-four hour dietary recall, as well as body weight and body composition measures were obtained every 4 weeks. Participants (n = 47, 33f; 14m) were overweight and obese (BMI ≥ 25) shoppers. RESULTS: Purchasing of F&V during intervention was greater in the discount group than in the control group (P < 0.0001). Purchasing of these items by the discount group relative to the control group during follow-up was reduced from intervention (P = 0.002), but still remained higher than during baseline (P = 0.01), indicating a partially sustained effect. Intake of F&V increased from baseline to intervention in the discount group relative to the control group (P = 0.037) and was sustained during follow-up. Body weight change did not differ significantly between groups, although post hoc analysis indicated a change within the discount group (-1.1 kg, P = 0.006) but not within the control group. CONCLUSIONS: Discounts of low-ED F&V led to increased purchasing and intake of those foods.