Moral Distress and Moral Injury in Military Healthcare Clinicians: A Scoping Review.

Introduction: Healthcare clinicians are often at risk of psychological distress due to the nature of their occupation. Military healthcare providers are at risk for additional psychological suffering related to unique moral and ethical situations encountered in military service. This scoping review identifies key characteristics of moral distress and moral injury and how these concepts relate to the military healthcare clinician who is both a care provider and service member. Methods: A scoping review of moral distress and moral injury literature as relates to the military healthcare clinician was conducted on the basis of the Joanna Briggs Institute scoping review framework. Databases searched included CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE (Ovid), Embase (Ovid), PsycInfo, 2 U.S. Defense Department sources, conference papers index, and dissertation abstracts. Reference lists of all identified reports and articles were searched for additional studies. Results: A total of 573 articles, published between the years 2009 and 2021, were retrieved to include a portion of the COVID-19 pandemic period. One hundred articles met the inclusion criteria for the final full-text review and analysis. Discussion: This scoping review identified moral distress and moral injury literature to examine similarities, differences, and overlaps in the defining characteristics of the concepts and the associated implications for patients, healthcare clinicians, and organizations. This review included the unfolding influence of the COVID-19 pandemic on moral experiences in health care and the blurring of those lines between civilian and military healthcare clinicians. Future directions of moral injury and moral distress research, practice, and care are discussed.

Adaptation and Testing of a Military Version of the Measure of Moral Distress for Healthcare Professionals.

BACKGROUND: Moral distress is well-documented among civilian critical care nurses and adversely affects patient outcomes, care delivery, and retention of health care providers. Despite its recognized significance, few studies have addressed moral distress in military critical care nurses. OBJECTIVES: To refine and validate an instrument to assess moral distress in military critical care nurses. METHODS: This study examined moral distress in military critical care nurses (N = 245) using a new instrument, the Measure of Moral Distress for Healthcare Professionals-Military (MMD-HP-M). The psychometric properties of the refined scale were assessed by use of descriptive statistics, tests of reliability and validity, exploratory factor analysis, correlations, and qualitative analysis of open-ended responses. RESULTS: Initial testing showed promising evidence of instrument performance. The Cronbach α (0.94) suggested good internal consistency of the instrument for the overall sample. Scores for the MMD-HP items and the MMD-HP-M items showed a strong, significant correlation (α= 0.78, P < .001). Unique attributes of military nursing that contribute to moral distress included resource access, futile care, and austere conditions. Exploratory factor analysis established a new military-centric factor for question items associated with inadequate training for patient care, providing care in resource-limited settings, and personal exhaustion. CONCLUSIONS: These results will help guide specific, targeted interventions to reduce the negative effects of moral distress on our military health care providers, especially in terms of readiness for the next global pandemic and retention of these invaluable personnel.

The Role of Spirituality Among Military En Route Care Nurses: Source of Strength or Moral Injury?

BACKGROUND: Military nurses provide care to seriously injured service members in flight, on the ground, or at sea during transport from the point of injury to a facility capable of providing higher levels of care. From this experience nurses are at increased risk of developing negative behavioral health symptoms. Spirituality, a belief in someone or something greater than oneself, could provide behavioral health support for military nurses who serve in this role. OBJECTIVE: To determine the impact of spirituality on the behavioral health of nurses who provided en route care while deployed to Iraq or Afghanistan. METHODS: This exploratory mixed-methods study used 5 instruments to determine levels of anxiety, depression, posttraumatic stress, posttraumatic growth, and resilience among 119 military nurses. Interviews provided rich data about the experiences of these nurses and extended quantitative outcomes. RESULTS: Posttraumatic Growth Inventory findings showed no significant change in spirituality based on deployment experiences (mean, 3.07; SD, 3.26). However, interviews revealed that spirituality served as a buffer against developing behavioral health issues. Many relied on spirituality to get them through difficult experiences. There was also a sense of moral injury as a few expressed regrets for things they witnessed or experienced. CONCLUSIONS: Spirituality can insulate military nurses from negative behavioral health symptoms. Nurses included in the study relied on their spirituality to stay mentally fit. For nurses who experienced moral injury, supervisory recognition of this and appropriate referral may decrease the long-term effects of deployment on their behavioral health.

Understanding Post-Deployment Reintegration Concerns Among En Route Care Nurses: A Mixed-Methods Approach.

The objective of this study was to better understand the post-deployment behavior health symptoms and readjustment/reintegration experienced by military nurses who provided en route care while serving in Operation Enduring Freedom/Operation Iraqi Freedom. Employing an exploratory, concurrent, mixed-methods design with an electronic survey consisting of several valid instruments and single, face-to-face interviews; data were gathered from 119 surveys and 22 interviews. Four qualitative themes aligned with the Post-Deployment Readjustment Inventory items. Findings from interviews support and illuminate the outcomes of the Post-Deployment Readjustment Inventory. Behavioral health usage was high in the quantitative sample. Nearly 74% (n = 88) of respondents indicating they had used Military Behavioral Health services following deployment. Statistically significant differences were noted among all subscales except Intimate Relationship Problems. Combined results indicated en route care nurses encountered difficulties when attempting to return to predeployment roles; behavioral health problems mirrored those of combat warriors. Interventions to assist post-deployment reintegration of en route care nurses should be conducted at the peer, leader, and health care provider levels. Embedding military mental health providers into en route care units is needed. It is imperative to gather lessons learned and identify ways to improve preparation for future conflicts and behavioral health of en route care nurses.

A Daily Goals Tool to Facilitate Indirect Nurse-Physician Communication During Morning Rounds on a Medical-Surgical Unit.

Interprofessional bedside rounds are essential for patient-centered care. However, it may be difficult for nurses to round with physicians on medical-surgical units. Using a daily goals tool for indirect rounds improved nurse-physician communication and interprofessional care for patients.

Measuring intravenous cannulation skills of practical nursing students using rubber mannequin intravenous training arms.

This study examined the effectiveness of two training methods for peripheral intravenous (IV) cannulation; one using rubber mannequin IV training arms, and the other consisting of students performing the procedure on each other. Two hundred-sixty Phase II Army Practical Nursing students were randomized into two groups and trained to perform an IV cannulation procedure. All students watched a 12-minute training video covering standard IV placement procedures. Afterward, both groups practiced the procedure for an hour according to their assigned group. Students were then tested on IV placement in a live human arm using a 14-item testing instrument in three trials that were scored pass/fail. There was no difference in the groups' performance of the IV procedure on the first attempt: 51.7% (n = 92) of the human arm group passed the test, and 48.3% (n = 86) of the rubber mannequin group passed the test (p = 0.074). These data suggest that using rubber mannequin IV arms for IV skills training may be just as effective as training students using traditional methods. In addition, using simulation provides an extra benefit of reducing risks associated with learning the procedure on a fellow student.

Telemedicine and telesurgery in cancer care: inaugural conference at MD Anderson Cancer Center.

BACKGROUND: Despite the growing incidence of cancer worldwide, there are an insufficient number of primary care physicians, community oncologists, and surgeons to meet the demand for cancer care, especially in rural and other medically underserved areas. Teleoncology, including diagnostics, treatment, and supportive care, has the potential to enhance access to cancer care and to improve clinician education and training. OBJECTIVES: Major cancer centers such as The University of Texas MD Anderson Cancer Center must determine how teleoncology will be used as part of strategic planning for the future. The Telemedicine and Telesurgery in Cancer Care (TTCC) conference was convened to determine technologically based strategies for addressing global access to essential cancer care services. RESULTS: The TTCC conference brought policy makers together with physicians, legal and regulatory experts to define strategies to optimize available resources, including teleoncology, to advance global cancer care. CONCLUSIONS: The TTCC conference discourse provided insight into the present state of access to care, expertise, training, technology and other interventions, including teleoncology, currently available through MD Anderson, as well as a vision of what might be achievable in the future, and proposals for moving forward with a comprehensive strategy.

Winter Wheat Cultivars with Temperature-Sensitive Resistance to Wheat streak mosaic virus Do Not Recover from Early-Season Infections.

Wheat streak mosaic virus (WSMV), Triticum mosaic virus, and Wheat mosaic virus, all vectored by the wheat curl mite Aceria tosichella Keifer, frequently cause devastating losses to winter wheat production throughout the central and western Great Plains. Resistant 'Mace' and 'RonL are commercially available and contain the wsm1 and wsm2 genes, respectively, for resistance to WSMV. However, the resistance in these cultivars is temperature sensitive, ineffective above 27°C, and does not protect against the other common wheat viruses. The majority of winter wheat in the Southern Great Plains is planted in early fall as a dual-purpose crop for both grazing and grain production. Early planting exposes wheat plants to warmer temperatures above the threshold for effective resistance. Studies were conducted to determine whether the resistance found in these cultivars would give infected plants the ability to recover as temperatures cooled to a range conducive to effective genetic resistance. RonL, Mace, 'TAM 111', 'TAM 112', and 'Karl 92' wheat were infested with WSMV viruliferous mites at temperatures above the resistance threshold. After the initial 4-week infection period, plants were subjected to progressively cooler temperatures during the winter months, well below the resistance threshold. Throughout the study, plant samples were taken to quantify virus titer and mite populations. Resistant RonL and Mace, which became severely infected during the initial infection period, were not able to recover even when temperatures dropped below the resistance threshold. However, TAM 112 showed resistance to WSMV but, more importantly, it also showed resistance to the wheat curl mite, because the mite population in this cultivar was significantly lower than on all other cultivars. The results of this study are significant in that they represent the first evidence of quantitative resistance to both WSMV and the wheat curl mite in a single wheat cultivar. Resistance to the wheat curl mite has potential to reduce losses to all mite-vectored virus diseases of wheat and not just WSMV.

Military resilience: a concept analysis.

BACKGROUND: Since the events surrounding September 11, 2011, and natural disasters, research on resilience has shifted from children to adult resilience. The military began to embrace the concept in 2008 in an effort to decrease the number of military service member (SM) suicides. PURPOSE: The purpose of this article is to explain resilience as it relates to military SMs using the process for concept analysis outlined by Walker and Avant (2005). FINDINGS: Adaptive coping, personal control, hardiness, and social support are the attributes that characterize psychological resilience in SMs. Antecedents for resilience are life events such as serious accidents, prior deployments where death is witnessed, and combat involvement. Consequences of high resilience include decreased mental health symptoms and career and personal success, while consequences of low resilience include increased mental health symptoms and participating in high-risk behaviors. PRACTICE IMPLICATIONS: Understanding resilience as it relates to SMs is critical. Nurses must be able to assess SMs and be equipped to refer them or their family members to the most appropriate care. As more is learned about resilience in the military community, there may be broader implications to the civilian community. Improved understanding of psychological resilience may lead to improved interventions appropriate for both civilians and military SMs.

Factors influencing the utilization of empirically supported treatments for eating disorders.

This study expands upon previous research investigating the use of empirically supported treatments (ESTs) for eating disorders by surveying a large sample of clinicians who specialize in treating eating disorders. Surveys developed for this study were sent to 698 members of a large, professional, eating disorder organization who were listed as treatment providers on the organization's website. Despite clinicians reporting frequently using CBT techniques, most identified something other than CBT or IPT as their primary approach to treatment. In contrast with previous research, the majority had received prior training in the use of manual-based treatments. However, consistent with previous investigations, most denied regular use of such treatments. Although manual-based CBT and IPT are referred to as "treatments of choice," professional clinicians in the field are not consistently using them. Responses suggest several barriers to the utilization of ESTs in practice.

Effect of response format on endorsement of eating disordered attitudes and behaviors.

OBJECTIVE: The present study was designed to compare response rates on a standard self-report questionnaire that was nominally anonymous to an unmatched count questionnaire that allowed for true anonymity in responding. METHOD: Four hundred and fifty-four college students were asked about several topics, including attitudes towards weight and shape, dieting, and eating disordered behavior using one of two response formats; either a standard questionnaire in true-false format or an unmatched count questionnaire that did not require participants to directly answer sensitive questions. RESULTS: Both males and females had significantly different rates of endorsement between the two methods of assessment on the majority of the eating-related questions. CONCLUSION: Response format and degree of anonymity affect endorsement of eating-related thoughts and behaviors. Understanding response bias is critical to determining accurate rates of eating disordered thoughts and behaviors.

The relationship between disordered eating behavior and drinking motives in college-age women.

Previous research has documented that alcohol use disorders and eating disorders often co-occur. One possible reason for these high rates of co-occurrence is that problematic eating and alcohol use serve similar functions for the persons engaging in them. In particular, both have been hypothesized to serve an avoidant coping function. This study was designed to examine the relationships between drinking motives and disordered eating in a sample of college-age women. A total of 257 women completed the Eating Attitudes Test-26 (EAT-26), Rutgers Alcohol Problems Index (RAPI), and Drinking Motives Measure (DMM). As hypothesized, problematic eating and problematic drinking were positively correlated. Also, regression analyses indicated a strong relationship between problematic eating and the coping scale of the DMM, which measures avoidant coping. This study extends previous research and provides support for the idea that problematic eating and problematic drinking serve similar avoidant coping functions. This line of research may hold important implications for treatment interventions targeting comorbid alcohol use disorders and eating disorders.

Development of the Protective Behavioral Strategies Survey.

OBJECTIVE: Heavy alcohol use among college students represents a public health problem on American college campuses. A promising area for combating this problem is identifying protective behavioral strategies that may reduce consumption and its resulting negative consequences among students who do choose to use alcohol. The purpose of this study was to develop and conduct initial psychometric analyses on a new scale, which we named the Protective Behavioral Strategies Survey. METHOD: Data were collected on 437 undergraduate students, who volunteered to participate in the study, at a large, public university in the northeast region of the United States. RESULTS: Results from an exploratory factor analysis yielded three theoretically meaningful factors that we labeled Limiting/Stopping Drinking, Manner of Drinking and Serious Harm Reduction. The three factors were, as a group, significantly associated with both alcohol consumption and alcohol-related problems, but the strongest unique relationship existed between Manner of Drinking and the outcome variables. CONCLUSIONS: Protective behavioral strategies seem to be a measurable construct that are related to alcohol consumption and alcohol-related problems, and thus may be a useful component of intervention and prevention programs with college students.

Eating disorders in Asian populations: a critique of current approaches to the study of culture, ethnicity, and eating disorders.

There is increasing evidence that eating disorders are present among ethnically diverse populations, and researchers have suggested that investigations in this area may inform the field's understanding of how sociocultural factors are related to the development of eating disorders. Although it is generally accepted that sociocultural factors are key in eating disorder etiology, knowledge on how best to study these influences in diverse groups is still limited. In this article, the authors review how the research literature has explored relationships among culture, ethnicity, and eating disorders in Asian populations and critically examine strategies that have been used to investigate these issues across 1 ethnic/racial group. The methodological challenges encountered in these approaches are identified and considered in the provision of recommendations for future endeavors to improve the field's understanding of how culture is related to eating disorders.

The new apheresis and blood and marrow transplantation-related current procedural terminology codes for payment of apheresis and blood and marrow transplantation services.

To address deficiencies in Current Procedural Terminology (CPT) codes that describe many of the clinical services offered to patients, several physicians in the blood and marrow transplantation and apheresis field joined with a coalition including the American Society of Hematology, American Society for Blood and Marrow Transplantation, American Association of Blood Banks, American Society of Clinical Oncology, American Society for Apheresis, National Marrow Donor Program, and American Red Cross to collaborate in addressing these deficiencies by designing new CPT codes. The CPT editorial panel approved 18 new or revised codes. All these codes were given permanent or temporary value by the relative value unit update committee, but not all values were approved by the Centers for Medicare & Medicaid Services (CMS), in particular, the cell-processing codes and the unrelated donor search code. Further discussions addressing these concerns are under way with the CMS. Use of these new codes allows apheresis and transplant centers to charge appropriately for these services. This will help transplant center contracts with CPT codes, with payers more specifically describing services offered to these patients. In turn, this will give better justification for payment. This may allow certain payments for services to increase and help transplant centers better allocate revenue from fixed global case rate payments. Details about the individual codes and their approval process are reviewed in this article.

Blood and marrow transplantation compensation: perspective in payer and provider relations.

The high cost per patient of hematopoietic cell transplantation (HCT) causes this therapy to be the focus of much controversy, given the competing societal demands to provide all possible therapy to preserve life while simultaneously limiting global health care expenditures. Treatment and eligibility decisions for HCT often are heavily scrutinized by both governmental and private payers and not simply determined by physicians, facility providers, and the patient. In an effort to control costs, payers have administrative infrastructure to review resource utilization by these patients. Additionally payers have developed payment methodologies, usually in the form of a case rate payment structure, that place facilities and physician providers of HCT at financial risk for adverse patient financial outcomes in an effort to promote optimal utilization and selection of patients for HCT. As providers enter into such financial risk arrangements with payers, the providers need to understand the true cost of care and be able to identify predictable and unpredictable outlier risks for the financial consequences of medical complications. HCT providers try to protect themselves from excessive financial risk by having different payment rates for different types of transplant, eg, autologous versus HLA or genotypically matched related versus HLA mismatched transplants. Because at certain times in the HCT process risk is more unpredictable, HCT providers require different payment system strategies for the different time periods of care such as evaluation, pre-transplant disease management, harvesting, and cell processing, as well as short- and long-term follow-up. Involvement by clinicians is essential for this process to be done well, especially given the rapid changes technological innovation brings to HCT. Constant dialogue and interaction between providers and payers on these difficult financial issues with HCT is essential to preserve patient access to this potentially lifesaving therapy.