Measuring morality: Analyzing the factor structure of the moral foundations questionnaire in veterans.

OBJECTIVES: Moral reasoning is an underexamined and potentially useful area of research relative to the care of moral injury in veterans. However, the most widely used measure of moral reasoning, the moral foundations questionnaire (MFQ), has not been validated in this population. METHODS: Post-9/11 veterans (N = 311) completed questionnaires which included the MFQ. Veterans' scores were compared to the general US population. Confirmatory factor analysis was used to test existing models of the MFQ in the sample. Exploratory factor analysis (EFA) was also used to examine potentially improved model fits. RESULTS: The two leading, preexisting MFQ models were both poor fits for the data. EFA results produced a four-factor model for the veteran sample using 25 of the original 30 items of the MFQ. CONCLUSIONS: Measuring moral reasoning among veterans may be important in understanding the experience of moral injury. However, the most widely used scale (MFQ) performs poorly among a sample of post-9/11 veterans, indicating that veterans may respond differently to the measure than the general US population. Military culture may uniquely influence veterans' moral reasoning, suggesting the need for military specific measures for this construct.

Patterns of Potential Moral Injury in Post-9/11 Combat Veterans and COVID-19 Healthcare Workers.

BACKGROUND: Moral injury has primarily been studied in combat veterans but might also affect healthcare workers (HCWs) due to the COVID-19 pandemic. OBJECTIVE: To compare patterns of potential moral injury (PMI) between post-9/11 military combat veterans and healthcare workers (HCWs) surveyed during the COVID-19 pandemic. DESIGN: Cross-sectional surveys of veterans (2015-2019) and HCWs (2020-2021) in the USA. PARTICIPANTS: 618 military veterans who were deployed to a combat zone after September 11, 2001, and 2099 HCWs working in healthcare during the COVID-19 pandemic. MAIN MEASURES: Other-induced PMI (disturbed by others' immoral acts) and self-induced PMI (disturbed by having violated own morals) were the primary outcomes. Sociodemographic variables, combat/COVID-19 experience, depression, quality of life, and burnout were measured as correlates. KEY RESULTS: 46.1% of post-9/11 veterans and 50.7% of HCWs endorsed other-induced PMI, whereas 24.1% of post-9/11 veterans and 18.2% of HCWs endorsed self-induced PMI. Different types of PMI were significantly associated with gender, race, enlisted vs. officer status, and post-battle traumatic experiences among veterans and with age, race, working in a high COVID-19-risk setting, and reported COVID-19 exposure among HCWs. Endorsing either type of PMI was associated with significantly higher depressive symptoms and worse quality of life in both samples and higher burnout among HCWs. CONCLUSIONS: The potential for moral injury is relatively high among combat veterans and COVID-19 HCWs, with deleterious consequences for mental health and burnout. Demographic characteristics suggestive of less social empowerment may increase risk for moral injury. Longitudinal research among COVID-19 HCWs is needed. Moral injury prevention and intervention efforts for HCWs may benefit from consulting models used with veterans.

Religion in Medicine and Health.

Jeff Levin's Religion and Medicine (2020) offers a substantial review of the multicultural intersections of these significant threads of the human story. While Levin's framing of the conceptual significance and intellectual implications of these intersections in the last few decades falls short, the arc of his historical overview and his inclusive commitments give readers a broad sense of this story through the lens of religion and public health. This essay considers the conceptual, sociopolitical, and intellectual dynamics and implications within his historical recounting, with particular attention to the distortions of both religion and medicine that arise from commodified presumptions of the merit-based cultural notion that "we get what we deserve." In order to best interpret how the significant human dimension of religion and spirituality should be understood in considering the health and care of pluralistic diverse communities, it is crucial to examine the implications of the intersections of religion and medicine in clinical practice and in the health of communities.

Screening for moral injury and comparatively evaluating moral injury measures in relation to mental illness symptomatology and diagnosis.

Moral injury merits further study to clarify its identification, prevalence, assessment and intersection with psychosocial and psychiatric problems. The present study investigated the screening potential of the Brief Moral Injury Screen (BMIS) in a sample of post-9/11 veterans (N = 315) and comparatively evaluated how this tool, the Moral Injury Events Scale (MIES), and the Moral Injury Questionnaire-Military Version (MIQ-M) relate to psychiatric diagnoses and mental illness symptom severity. Those who endorsed failing to prevent or doing something morally wrong had the highest symptomatology scores on measures of posttraumatic stress disorder, depression, suicidality, alcohol abuse and drug abuse, followed by those who reported solely witnessing a moral injury event. Posttraumatic stress disorder and depressive symptoms correlated most strongly with scores on the MIQ-M; suicidality, alcohol abuse and drug abuse scores correlated most strongly with scores on the BMIS and MIQ-M. Moral injury, as measured by three scales, was robustly correlated with worse outcomes on various symptom measures. The three scales appear to differentially predict mental illness symptomatology and diagnoses, with the BMIS predicting suicidality and alcohol and drug abuse as well as better than other measures.

Religion, spirituality, and suicide risk in Iraq and Afghanistan era veterans.

BACKGROUND: United States military veterans experience disproportionate rates of suicide relative to the general population. Evidence suggests religion and spirituality may impact suicide risk, but less is known about which religious/spiritual factors are most salient. The present study sought to identify the religious/spiritual factors most associated with the likelihood of having experienced suicidal ideation and attempting suicide in a sample of recent veterans. METHODS: Data were collected from 1002 Iraq/Afghanistan-era veterans (Mage = 37.68; 79.6% male; 54.1% non-Hispanic White) enrolled in the ongoing Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center multi-site Study of Post-Deployment Mental Health. RESULTS: In multiple regression models with stepwise deletion (p < .05), after controlling for depression and posttraumatic stress disorder (PTSD) diagnoses, independent variables that demonstrated a significant effect on suicidal ideation were perceived lack of control and problems with self-forgiveness. After controlling for age, PTSD diagnosis, and substance use problems, independent variables that demonstrated a significant effect on suicide attempt history were perceived as punishment by God and lack of meaning/purpose. CONCLUSIONS: Clinical screening for spiritual difficulties may improve detection of suicidality risk factors and refine treatment planning. Collaboration with spiritual care providers, such as chaplains, may enhance suicide prevention efforts.

Embedding Ethics Education in Clinical Clerkships by Identifying Clinical Ethics Competencies: The Vanderbilt Experience.

The clinical clerkships in medical school are the first formal opportunity for trainees to apply bioethics concepts to clinical encounters. These clerkships are also typically trainees' first sustained exposure to the "reality" of working in clinical teams and the full force of the challenges and ethical tensions of clinical care. We have developed a specialized, embedded ethics curriculum for Vanderbilt University medical students during their second (clerkship) year to address the unique experience of trainees' first exposure to clinical care. Our embedded curriculum is centered around core "ethics competencies" specific to the clerkship: for Medicine, advanced planning and end-of-life discussions; for Surgery, informed consent; for Pediatrics, the patient-family-provider triad; for Obstetrics and Gynecology, women's autonomy, unborn child's interests, and partner's rights; and for Neurology/Psychiatry, decision-making capacity. In this paper, we present the rationale for these competencies, how we integrated them into the clerkships, and how we assessed these competencies. We also review the additional ethical issues that have been identified by rotating students in each clerkship and discuss our strategies for continued evolution of our ethics curriculum.

Collaborating across the Departments of Veterans Affairs and Defense to integrate mental health and chaplaincy services.

BACKGROUND: Recognizing that clergy and spiritual care providers are a key part of mental health care systems, the Department of Veterans Affairs (VA) and Department of Defense (DoD) jointly examined chaplains' current and potential roles in caring for veterans and service members with mental health needs. OBJECTIVE: Our aim was to evaluate the intersection of chaplain and mental health care practices in VA and DoD in order to determine if improvement is needed, and if so, to develop actionable recommendations as indicated by evaluation findings. DESIGN: A 38-member multidisciplinary task group partnered with researchers in designing, implementing, and interpreting a mixed methods study that included: 1) a quantitative survey of VA and DoD chaplains; and 2) qualitative interviews with mental health providers and chaplains. PARTICIPANTS: Quantitative: the survey included all full-time VA chaplains and all active duty military chaplains (n = 2,163 completed of 3,464 invited; 62 % response rate). Qualitative: a total of 291 interviews were conducted with mental health providers and chaplains during site visits to 33 VA and DoD facilities. MAIN MEASURES: Quantitative: the online survey assessed intersections between chaplaincy and mental health care and took an average of 37 min to complete. Qualitative: the interviews assessed current integration of mental health and chaplain services and took an average of 1 h to complete. KEY RESULTS: When included on interdisciplinary mental health care teams, chaplains feel understood and valued (82.8-100 % of chaplains indicated this, depending on the team). However, findings from the survey and site visits suggest that integration of services is often lacking and can be improved. CONCLUSIONS: Closely coordinating with a multidisciplinary task group in conducting a mixed method evaluation of chaplain-mental health integration in VA and DoD helped to ensure that researchers assessed relevant domains and that findings could be rapidly translated into actionable recommendations.

A spiritual problem? Primary care physicians' and psychiatrists' interpretations of medically unexplained symptoms.

BACKGROUND: Patients commonly present to their physicians with medically unexplained symptoms (MUS), and there is no consensus about how physicians should interpret or treat such symptoms. OBJECTIVE: To examine how variations in physicians' interpretations of MUS are associated with physicians' religious characteristics and with physician specialty (primary care vs. psychiatry). DESIGN AND PARTICIPANTS: A national survey of a stratified random sample of 1,504 primary care physicians and 512 psychiatrists in 2009-2010. MAIN MEASURES: The extent to which physicians believe MUS reflect a root problem that is spiritual in nature or result from conditions that scientific research will eventually explain, and whether such patients would benefit from attention to their relationships, attention to their spiritual life, taking medications, and/or treatment by physicians. KEY RESULTS: Response rate was 63 % (1,208/1,909). More religious/spiritual physicians were more likely to believe that MUS reflect a spiritual problem (55 % for high vs. 24 % for low spirituality; OR = 2.8, 1.7-4.5) and that these patients would benefit from paying attention to their spiritual life (79 % for high vs. 55 % for low spirituality; OR = 3.1, 1.8-5.3). Psychiatrists were more likely to believe that scientific research will one day explain MUS (66 % vs. 52 %; OR = 1.9, 1.4-2.5) and that these symptoms will improve with treatment by a physician (54 % vs. 35 %; OR = 2.4, 1.8-3.3). They were less likely to believe that MUS reflect a spiritual problem (23 % vs. 38 %; OR = 0.5, 0.4-0.8). CONCLUSIONS: Physicians' interpretations of MUS vary widely, depending in part on physicians' religious characteristics and specialty. One in three physicians believes that patients with MUS have root problems that are spiritual in nature. Physicians who are more religious or spiritual are more likely to think of MUS as stemming from spiritual concerns. Psychiatrists are more optimistic that these patients will get better with treatment by physicians.

Psychotropic medication claims among religious clergy.

This study examined psychotropic medication claims in a sample of Protestant clergy. It estimated the proportion of clergy in the sample who had a claim for psychotropic medication (i.e., anti-depressants and anxiolytics) in 2005 and examined associations between sociodemographic characteristics, occupational distress and having a claim. Protestant clergy (n = 749) from nine denominations completed a mail survey and provided access to their pharmaceutical records. Logistic regression models assessed the effect of sociodemographic characteristics and occupational distress on having a claim. The descriptive analysis revealed that 16 % (95 % Confidence interval [CI] 13.3 %-18.5 %) of the clergy in the sample had a claim for psychotropic medication in 2005 and that, among clergy who experienced frequent occupational distress, 28 % (95 % CI 17.5 %-37.5 %) had a claim. The regression analysis found that older clergy, female clergy, and those who experienced frequent occupational distress were more likely to have a claim. Due to recent demographic changes in the clergy population, including the increasing mean age of new clergy and the growing number of female clergy, the proportion of clergy having claims for psychotropic medication may increase in the coming years. To the best of our knowledge, this is the first study to examine the use of psychotropic medication among clergy.

The Clergy Occupational Distress Index (CODI): background and findings from two samples of clergy.

This study demonstrates the reliability and validity of the Clergy Occupational Distress Index (CODI). The five-item index allows researchers to measure the frequency that clergy, who traditionally have not been the subject of occupational health studies, experience occupational distress. We assess the reliability and validity of the index using two samples of clergy: a nationally representative sample of clergy and a sample of clergy from nine Protestant denominations. Exploratory factor analysis and Cronbach's scores are generated. Construct validity is measured by examining the association between CODI scores and depressive symptoms while controlling for demographic, ministerial, and health variables. In both samples, the five items of the CODI load onto a single factor and the Cronbach's alpha scores are robust. The regression model indicates that a high score on the CODI (i.e., more frequent occupational distress) is positively associated with having depressive symptoms within the last 4 weeks. The CODI can be used to identify clergy who frequently experience occupational distress and to understand how occupational distress affects clergy's health, ministerial career, and the functioning of their congregation.

Validation of the Moral Injury Outcome Scale in acute care nurses.

Introduction: Moral injury, predominantly studied in military populations, has garnered increased attention in the healthcare setting, in large part due to the psychological and emotional consequences of the COVID-19 pandemic. The measurement of moral injury with instrumentation adapted from military settings and validated by frontline healthcare personnel is essential to assess prevalence and guide intervention. This study aimed to validate the Moral Injury Outcome Scale (MIOS) in the population of acute care. Methods: A sample of 309 acute care nurses completed surveys regarding moral injury, depression, anxiety, burnout, professional fulfillment, spiritual wellbeing, and post-traumatic stress disorder symptoms. Confirmatory factor analysis was conducted as well as an assessment of reliability and validity. Results: The internal consistency of the 14-item MIOS was 0.89. The scale demonstrated significant convergent and discriminant validity, and the test of construct validity confirmed the two-factor structure of shame and trust violations in this clinical population. Regression analysis indicated age, race, and marital status-related differences in the experience of moral injury. Discussion: The MIOS is valid and reliable in acute care nursing populations and demonstrates sound psychometric properties. Scores among nurses diverge from those of military personnel in areas that may inform distinctions in interventions to address moral injury in these populations.

Collaborative spiritual care for moral injury in the veterans Affairs Healthcare System (VA): Results from a national survey of VA chaplains.

The psychospiritual nature of moral injury invites consideration regarding how chaplains understand the construct and provide care. To identify how chaplains in the VA Healthcare System conceptualize moral injury, we conducted an anonymous online survey (N = 361; 45% response rate). Chaplains responded to a battery of items and provided free-text definitions of moral injury that generally aligned with key elements in the existing literature, though with different emphases. Over 90% of chaplain respondents indicated that they encounter moral injury in their chaplaincy care, and a similar proportion agreed that chaplains and mental health professionals should collaborate in providing care for moral injury. Over one-third of chaplain respondents reported offering or planning to offer a moral injury group. Separately, nearly one-quarter indicated present or planned collaboration with mental health to provide groups that in some manner address moral injury. Previous training in evidence-based and collaborative care approaches appears to contribute to the likelihood of providing integrated psychosocial-spiritual care. Results and future directions are discussed, including a description of moral injury that may be helpful to understand present areas of emphasis in VA chaplains' care for moral injury.

Increasing chaplain support for veterans at high risk for suicide through targeted outreach: A quality improvement initiative.

The Department of Veterans Affairs (VA) has prioritized improving the identification of veterans at risk for suicide and ensuring adequate staffing of personnel to assist veterans in need. It is imperative that suicide prevention efforts make use of the full range of available resources, including diverse professionals with distinctive skillsets. Chaplains are engaged in suicide prevention efforts in VA, but the literature lacks examples of chaplain-involved suicide prevention efforts that clearly describe how chaplains are engaged, the training and/or qualifications chaplains possess in the area of suicide prevention, and the reach and impact of such efforts. The purpose of this report is to describe the development and implementation of a novel, innovative, and ongoing chaplain-led suicide prevention outreach initiative for veterans at high risk for suicide. Results indicated the program was feasible and supported at the systems level, and chaplains were able to collaboratively sustain outreach efforts over the course of a year. Chaplain suicide prevention outreach was found to be acceptable to veterans, who overwhelmingly indicated openness to and appreciation for outreach. Chaplains can address the spiritual crisis underlying suicidality, bolster spiritual protective factors, and are a part of holistic care. Considerations for implementation and future investigation are discussed.

The choices we make: Ethical challenges in trauma surgery.

BACKGROUND: Ethical issues in trauma surgery are commonplace but scarcely studied. We aim to characterize the ethical dilemmas trauma surgeons encounter in clinical practice and describe perceptions about the ability to manage these dilemmas and strategies they use to address them. METHODS: Members of a U.S. trauma society were electronically surveyed on handling ethically challenging scenarios. The survey instrument was developed using published ethics literature and iterative cognitive interviews. Domains included perceived frequency of encountering and self-efficacy of managing ethical situations in trauma surgery. Common situations were defined as those encountered monthly or weekly. Ethical problems were categorized within 7 larger categories: general ethics, autonomy, communication, justice, end-of-life, conflict, and other. Descriptive analyses were performed; group comparisons were analyzed using analysis of variance. RESULTS: Of 1,748 surveyed, 548 responded (30.6%) and 154 (28%) were female. Most were White, under 55 years age, had completed fellowship training, and were practicing at a level I or II trauma center. The most encountered ethical categories were generic ethics and communication (79%). Issues involving conflict were least frequent (21%). Respondents felt most uncomfortable with autonomy topics. Respondents with high self-efficacy in handling ethical situations were older, in practice ≥15 years, served on an ethics committee, and/or frequently experienced ethical challenges. CONCLUSION: Most trauma surgeons regularly encounter ethical challenges, especially those related to communication. Trauma surgeons encounter ethical issues involving conflict least often, and lowest self-efficacy scores with issues involving autonomy. Experienced trauma surgeons reported higher self-efficacy scores in managing ethical issues. Future work should examine how self-efficacy translates to observed behavior, and how trauma surgeons build and enhance their ethical skillsets in the care of the injured patient.

Spiritual needs of couples facing pregnancy termination because of fetal anomalies.

The spiritual needs of couples (9 mothers and 5 fathers) who were planning to terminate wanted second trimester pregnancies because of serious fetal anomalies were surveyed. Their greatest needs were for a "guidance from a higher power" and for "someone to pray for them." Unlike other reported groups of patients, they did not want or expect their healthcare team to discuss their faith, or to pray with them. Most would prefer support from their own pastors, but their religious community was involved to only a small extent. They would welcome support from hospital chaplains, who could play a substantive and unique pastoral role in this clinical context.

"It's medically proven!": Assessing the dissemination of religion and health research.

The recent proliferation of research on the connection between religion and health has raised concerns among some scholars about how these studies affect people's understanding of that connection. However, such concerns assume that religion and health research reaches religious audiences and informs their understanding of the connection between religion and health. We explore the veracity of these assumptions, asking two questions: (1) Is religion and health research disseminating into the American public? (2) Do religious persons incorporate religion and health research into their understanding of the connection between religion and health? We conduct two studies to answer these questions. First, we search three newspapers (The New York Times, The Los Angeles Times, and The Atlanta Journal-Constitution) and three news magazines (Newsweek, Time, and U. S. News and World Report) for articles that mention religion and health research. In the second study, we analyze interview transcripts for respondents' mentions of religion and health research when discussing the relationship between religion and health. Our results indicate substantial growth over time in media reporting on religion and health research but reveal that only a limited portion of religious persons cite such research in explaining their conceptualizations of the connection between religion and health.

Episcopal measure of faith tradition: a context-specific approach to measuring religiousness.

Precise measurement of religiousness remains a vexing problem. In addition to relying almost exclusively on self-report, existing measures of religiousness pay little attention to the specific context of religious belief, and this may override distinctive norms of particular faith traditions and potentially confound the conclusions drawn from such research. To address these limitations, the authors describe a modified form of narrative content analysis that could eventually sort respondents into distinct theological traditions. A pilot test among Episcopalians demonstrates encouraging reliability (kappa 0.74, 95% LCI 0.47, P < 0.0002), and tests for convergent and discriminate validity suggest that the context of religious belief is both relevant and insufficiently assessed by the existing paradigm of religious measurements. If validated in a religiously diverse sample, this approach could be combined with existing, context-free measures of religiousness to generate more meaningful findings.

Examining faith-based collaboration in U.S. States' suicide prevention guidelines.

Faith-based communities (FBCs) are recognized by most states as key players within systematic suicide prevention efforts. The aim of the present study was to conduct a thematic analysis of documents that detail the suicide prevention efforts of individual states with respect to the role(s) delegated to FBCs. Thematic analysis is recognized as a useful methodology for identifying implications for policy and practice. Documents were procured from all states, with the exception of New Mexico (n = 49). The findings suggest six areas relevant to collaboration with FBCs: suicide prevention training for the FBC, suicide prevention training for individual faith leaders, community engagement, faith leaders as gatekeepers, culturally sensitive suicide prevention, and postvention support. These state guideline documents consistently affirm the importance of engaging FBCs in suicide prevention efforts and cover a range of recommendations, though generally lack specifics with respect to how FBCs can optimally engage.

Measuring religiousness in health research: review and critique.

Although existing measures of religiousness are sophisticated, no single approach has yet emerged as a standard. We review the measures of religiousness most commonly used in the religion and health literature with particular attention to their limitations, suggesting that vigilance is required to avoid over-generalization. After placing the development of these scales in historical context, we discuss measures of religious attendance, private religious practice, and intrinsic/extrinsic religious motivation. We also discuss measures of religious coping, wellbeing, belief, affiliation, maturity, history, and experience. We also address the current trend in favor of multi-dimensional and functional measures of religiousness. We conclude with a critique of the standard, "context-free" approach aimed at measuring "religiousness-in-general", suggesting that future work might more fruitfully focus on developing ways to measure religiousness in specific, theologically relevant contexts.

Hitting the target: why existing measures of "religiousness" are really reverse-scored measures of "secularism".

Over 100 measures of religiousness and spirituality are used in research investigating the associations between religion and health. These measures are often used to assess "religiousness in general," but this approach lumps together widely divergent worldviews in ways that can distort religion beyond recognition. The authors suggest that the existing measures of religiousness are perhaps better understood as reverse-coded measures of "secularism." This argument suggests that the existing data regarding religiousness and health might be best interpreted as demonstrating a small, robust health liability associated with a deliberately secular worldview. If true, this conclusion might change the direction of future research, and it would imply that meaningful inferences about the health associations of religious practice will depend on developing tools that measure specific religions in their particularity.