Reliability and validity of the revised Rushton Moral Resilience Scale for healthcare workers.

AIM: To refine the Rushton Moral Resilience Scale (RMRS) by creating a more concise scale, improving the reliability, particularly of the personal integrity subscale and providing further evidence of validity. BACKGROUND: Healthcare workers are exposed to moral adversity in practice. When unable to preserve/restore their integrity, moral suffering ensues. Moral resilience is a resource that may mitigate negative consequences. To better understand mechanisms for doing so, a valid and reliable measurement tool is necessary. DESIGN: Cross-sectional survey. METHODS: Participants (N = 1297) had completed ≥1 items on the RMRS as part of the baseline survey of a larger longitudinal study. Item analysis, confirmatory factor analyses, reliability analyses (Cronbach's alpha), and correlations were used to establish reliability and validity of the revised RMRS. RESULTS: Item and confirmatory factor analysis were used to refine the RMRS from 21 to 16 items. The four-factor structure (responses to moral adversity, personal integrity, relational integrity and moral efficacy) demonstrated adequate fit in follow-up confirmatory analyses in the initial and hold-out sub-samples. All subscales and the total scale had adequate reliabilities (α ≥ 0.70). A higher-order factor analysis supports the computation of either subscale scores or a total scale score. Correlations of scores with stress, anxiety, depression and moral distress provide evidence of the scale's validity. Reliability of the personal integrity subscale improved. CONCLUSION AND IMPLICATIONS: The RMRS-16 demonstrates adequate reliability and validity, particularly the personal integrity subscale. Moral resilience is an important lever for reducing consequences when confronted with ethical challenges in practice. Improved reliability of the four subscales and having a shorter overall scale allow for targeted application and will facilitate further research and intervention development. PATIENT/PUBLIC CONTRIBUTION: Data came from a larger study of Canadian healthcare workers from multiple healthcare organizations who completed a survey about their experiences during COVID-19.

Over a third of palliative medicine physicians meet burnout criteria: Results from a survey study during the COVID-19 pandemic.

BACKGROUND: Palliative medicine physicians may be at higher risk of burnout due to increased stressors and compromised resilience during the COVID-19 pandemic. Burnout prevalence and factors influencing this among UK and Irish palliative medicine physicians is unknown. AIM: To determine the prevalence of burnout and the degree of resilience among UK and Irish palliative medicine physicians during the COVID-19 pandemic, and associated factors. DESIGN: Online survey using validated assessment scales assessed burnout and resilience: The Maslach Burnout Inventory Human Services Survey for Medical Personnel [MBI-HSS (MP)] and the Connor-Davidson Resilience Scale (CD-RISC). Additional tools assessed depressive symptoms, alcohol use, and quality of life. SETTING/PARTICIPANTS: Association of Palliative Medicine of UK and Ireland members actively practising in hospital, hospice or community settings. RESULTS: There were 544 respondents from the 815 eligible participants (66.8%), 462 provided complete MBI-HSS (MP) data and were analysed. Of those 181/462 (39.2%) met burnout criteria, based on high emotional exhaustion or depersonalisation subscales of the MBI-HSS (MP). A reduced odds of burnout was observed among physicians who worked ⩽20 h/week (vs 31-40 h/week, adjusted odds ratio (aOR) 0.03, 95% confidence interval (CI) 0.002-0.56) and who had a greater perceived level of clinical support (aOR 0.70, 95% CI 0.62-0.80). Physicians with higher levels of depressive symptoms had higher odds of burnout (aOR 18.32, 95% CI 6.75-49.73). Resilience, mean (SD) CD-RISC score, was lower in physicians who met burnout criteria compared to those who did not (62.6 (11.1) vs 70.0 (11.3); p < 0.001). CONCLUSIONS: Over one-third of palliative medicine physicians meet burnout criteria. The provision of enhanced organisational and colleague support is paramount in both the current and future pandemics.

The new frontline: exploring the links between moral distress, moral resilience and mental health in healthcare workers during the COVID-19 pandemic.

BACKGROUND: Global health crises, such as the COVID-19 pandemic, confront healthcare workers (HCW) with increased exposure to potentially morally distressing events. The pandemic has provided an opportunity to explore the links between moral distress, moral resilience, and emergence of mental health symptoms in HCWs. METHODS: A total of 962 Canadian healthcare workers (88.4% female, 44.6 + 12.8 years old) completed an online survey during the first COVID-19 wave in Canada (between April 3rd and September 3rd, 2020). Respondents completed a series of validated scales assessing moral distress, perceived stress, anxiety, and depression symptoms, and moral resilience. Respondents were grouped based on exposure to patients who tested positive for COVID-19. In addition to descriptive statistics and analyses of covariance, multiple linear regression was used to evaluate if moral resilience moderates the association between exposure to morally distressing events and moral distress. Factors associated with moral resilience were also assessed. FINDINGS: Respondents working with patients with COVID-19 showed significantly more severe moral distress, anxiety, and depression symptoms (F > 5.5, p < .020), and a higher proportion screened positive for mental disorders (Chi-squared > 9.1, p = .002), compared to healthcare workers who were not. Moral resilience moderated the relationship between exposure to potentially morally distressing events and moral distress (p < .001); compared to those with higher moral resilience, the subgroup with the lowest moral resilience had a steeper cross-sectional worsening in moral distress as the frequency of potentially morally distressing events increased. Moral resilience also correlated with lower stress, anxiety, and depression symptoms (r > .27, p < .001). Factors independently associated with stronger moral resilience included: being male, older age, no mental disorder diagnosis, sleeping more, and higher support from employers and colleagues (B [0.02, |-0.26|]. INTERPRETATION: Elevated moral distress and mental health symptoms in healthcare workers facing a global crisis such as the COVID-19 pandemic call for the development of interventions promoting moral resilience as a protective measure against moral adversities.

A cross-sectional study of the interrelationship between burnout, empathy and resilience in academic physicians.

Burnout is a growing concern, with significant negative consequences for physicians and patient care. Burnout is negatively associated with physician empathy, while resilience may be a protective factor against the development of burnout but few studies have examined all three constructs in the same cohort. Understanding the associations between these constructs could aid in the development of interventions for physicians experiencing burnout and improve the delivery of compassionate care. We conducted a cross-sectional survey to determine levels of burnout, empathy and resilience in a sample of academic physicians and investigate the relationships between these variables. Validated scales were administered online to measure burnout (Maslach Burnout Inventory - Human Services Survey, MBI-HSS), empathy (Jefferson Scale of Empathy - Physicians/Health Professions Version, JSE) and resilience (Connor-Davidson Resilience Scale, CD-RISC). Descriptive statistics, correlation coefficients, and group comparisons were examined. Eighty-three physicians completed the JSE and CD-RISC, while a subset of 49 physicians also completed the MBI-HSS. Response rates were 31.9% and 18.8%, respectively. High burnout was reported by 49% of the sample. Physicians with high burnout reported lower levels of resilience than those who were not burnt-out. No differences in levels of empathy were observed between these two groups. Older physicians (>45 years) reported higher resilience scores than younger physicians. Resilience and empathy were significantly positively correlated. The reported rate of physician burnout in this sample of academic physicians is concerning, with burnout associated with lower levels of resilience. Further research is required to explore the relationship between physician age and resilience, the impact of resilience-building interventions on burnout and empathy in physicians, and how modifying these variables influences the delivery of compassionate care for patients.

Burnout and resilience among Canadian palliative care physicians.

BACKGROUND: Physicians experience high rates of burnout, which may negatively impact patient care. Palliative care is an emotionally demanding specialty with high burnout rates reported in previous studies from other countries. We aimed to estimate the prevalence of burnout and degree of resilience among Canadian palliative care physicians and examine their associations with demographic and workplace factors in a national survey. METHODS: Physician members of the Canadian Society of Palliative Care Physicians and Société Québécoise des Médecins de Soins Palliatifs were invited to participate in an electronic survey about their demographic and practice arrangements and complete the Maslach Burnout Inventory for Medical Professionals (MBI-HSS (MP)), and Connor-Davidson Resilience Scale (CD-RISC). The association of categorical demographic and practice variables was examined in relation to burnout status, as defined by MBI-HSS (MP) score. In addition to bivariable analyses, a multivariable logistic regression analysis, reporting odds ratios (OR), was conducted. Mean CD-RISC score differences were examined in multivariable linear regression analysis. RESULTS: One hundred sixty five members (29%) completed the survey. On the MBI-HSS (MP), 36.4% of respondents reported high emotional exhaustion (EE), 15.1% reported high depersonalization (DP), and 7.9% reported low personal accomplishment (PA). Overall, 38.2% of respondents reported a high degree of burnout, based on having high EE or high DP. Median CD-RISC resilience score was 74, which falls in the 25th percentile of normative population. Age over 60 (OR = 0.05; CI, 0.01-0.38), compared to age ≤ 40, was independently associated with lower burnout. Mean CD-RISC resilience scores were lower in association with the presence of high burnout than when burnout was low (67.5 ± 11.8 vs 77.4 ± 11.2, respectively, p < 0.0001). Increased mean CD-RISC score differences (higher resilience) of 7.77 (95% CI, 1.97-13.57), 5.54 (CI, 0.81-10.28), and 8.26 (CI, 1.96-14.57) occurred in association with age > 60 as compared to ≤40, a predominantly palliative care focussed practice, and > 60 h worked per week as compared to ≤40 h worked, respectively. CONCLUSIONS: One in three Canadian palliative care physicians demonstrate a high degree of burnout. Burnout prevention may benefit from increasing resilience skills on an individual level while also implementing systematic workplace interventions across organizational levels.

Wrestling With the Invincibility Myth: Exploring Physicians' Resistance to Wellness and Resilience-Building Interventions.

PURPOSE: Physicians are expected to provide compassionate, error-free care while navigating systemic challenges and organizational demands. Many are burning out. While organizations are scrambling to address the burnout crisis, physicians often resist interventions aimed at enhancing their wellness and building their resilience. The purpose of this research was to empirically study this phenomenon. METHOD: Constructivist grounded theory was used to inform the iterative data collection and analysis process. In spring 2018, 22 faculty physicians working in Canada participated in semistructured interviews to discuss their experiences of wellness and burnout, their perceptions of wellness initiatives, and how their experiences and perceptions influence their uptake of the rapidly proliferating strategies aimed at nurturing their resilience. Themes were identified using constant comparative analysis. RESULTS: Participants suggested that the values of compassion espoused by health care organizations do not extend to physicians, and they described feeling dehumanized by professional values steeped in an invincibility myth in which physicians are expected to be "superhuman" and "sacrifice everything" for medicine. Participants described that professional values and organizational norms impeded work-life balance, hindered personal and professional fulfillment, and discouraged disclosure of struggles. In turn, participants seemed to resist wellness and resilience-building interventions focused on fixing individuals rather than broader systemic, organizational, and professional issues. Participants perceived that efforts aimed at building individual resilience are futile without changes in professional values and sustained organizational support. CONCLUSIONS: Findings suggest that professional and organizational norms and expectations trigger feelings of dehumanization for some physicians. These feelings likely exacerbate burnout and may partly explain physicians' resistance to resilience-building strategies. Mitigating burnout and developing and sustaining a resilient physician workforce will require both individual resistance to problematic professional values and an institutional commitment to creating a culture of compassion for patients and physicians alike.

The impact of Stress Management and Resailience Training (SMART) on academic physicians during the implementation of a new Health Information System: An exploratory randomized controlled trial.

OBJECTIVE: The Stress Management and Resilience Training (SMART) program is an evidence-based intervention designed to build resilience in physicians in clinical practice. The objective of the current study was to assess the impact of the SMART program on academic physicians' levels of resilience, subjective happiness, stress, and anxiety, and specifically during the implementation of a new hospital-wide Health Information System (HIS). METHODS: A total of 40 physicians in a tertiary care academic hospital were randomized (allocation ratio 1:1) to either the SMART intervention or the control condition. The SMART intervention consisted of one mandatory two-hour in-person workshop and an optional 24-week online program, designed to support the materials delivered in the workshop. Outcome measures were assessed using validated scales administered online at baseline and at 3-months and 6-months follow-up. RESULTS: After adjusting for baseline levels of each outcome, no statistically significant intervention effect was observed for resilience, subjective happiness, stress or anxiety at 3-months or 6-months follow-up. However, physicians in the intervention group demonstrated improvements in resilience, stress and anxiety at follow-up that were within the range of clinically relevant differences. CONCLUSIONS: The findings of this exploratory study provide modest support that the SMART intervention may be beneficial for proactively addressing physician wellness during the implementation of a new HIS and that larger randomized trials are warranted. TRIAL REGISTRATION: NCT04384861.

Interventions to improve resilience in physicians who have completed training: A systematic review.

BACKGROUND: Resilience is a contextual phenomenon where a complex and dynamic interplay exists between individual, environmental, and socio-cultural factors. With growing interest in enhancing resilience in physicians, given their high risk for experiencing prolonged or intense stress, effective strategies are necessary to improve resilience and reduce negative outcomes including burnout. The objective of this review was to identify effective interventions to improve resilience in physicians who have completed training, working in any setting. METHODS AND FINDINGS: We included randomized controlled trials (RCT), and observational studies (including pilot studies) published in English, French, and Spanish that included an intervention to improve resilience in physicians who have completed training. We included studies that implemented interventions to reduce burnout, anxiety, and depression or to improve empathy to ultimately enhance resilience, rather than studies designed solely to reduce stress or trauma-induced stress. We performed a systematic search of Medline, EMBASE, PsychInfo, CINAHL and Cochrane Library with no publication year limit. The last search was conducted on March 29, 2017. We used random effect models to calculate pooled standardized mean differences. Resilience was the primary outcome measure using validated resilience scores. Secondary outcome measures included proxy measures of resilience such as burnout, empathy, anxiety and depression. Our search strategy identified 7,579 records;74 met the criteria for full-text review. Seventeen studies were included in the final review published between 1998 and 2016 of which 9 (4 RCT, 5 observational) had physician data extractable. Interventions varied greatly regarding their approach, duration, and follow-up. Two RCTs measured resilience using validated scales; both found a significant improvement. No meta-analysis for resilience was conducted due to the presence of high clinical and methodological heterogeneity. CONCLUSIONS: Our systematic review demonstrates that there is weak evidence to support one intervention over another to improve resilience in physicians who have completed training. The quality of evidence for the outcomes ranged from very low to low. There is a need for a consensus on the definition of resilience and how it is measured. Longer follow-up is required to ensure any intervention effects are sustained over time.

Correction: Interventions to improve resilience in physicians who have completed training: A systematic review.

[This corrects the article DOI: 10.1371/journal.pone.0210512.].

Randomized controlled trial of homocysteine-lowering vitamin treatment in elderly patients with vascular disease.

BACKGROUND: Homocysteine is an independent risk factor for vascular disease and is associated with dementia in older people. Potential mechanisms include altered endothelial and hemostatic function. OBJECTIVE: We aimed to determine the effects of folic acid plus vitamin B-12, riboflavin, and vitamin B-6 on homocysteine and cognitive function. DESIGN: This was a factorial 2 x 2 x 2, randomized, placebo-controlled, double-blind study with 3 active treatments: folic acid (2.5 mg) plus vitamin B-12 (500 microg), vitamin B-6 (25 mg), and riboflavin (25 mg). We studied 185 patients aged >or=65 y with ischemic vascular disease. Outcome measures included plasma homocysteine, fibrinogen, and von Willebrand factor at 3 mo and cognitive change (determined with the use of the Letter Digit Coding Test and on the basis of the Telephone Interview of Cognitive Status) after 1 y. RESULTS: The mean (+/-SD) baseline plasma homocysteine concentration was 16.5 +/- 6.4 micromol/L. This value was 5.0 (95% CI: 3.8, 6.2) micromol/L lower in patients given folic acid plus vitamin B-12 than in patients not given folic acid plus vitamin B-12 but did not change significantly with vitamin B-6 or riboflavin treatment. Homocysteine lowering with folic acid plus vitamin B-12 had no significant effect, relative to the 2 other treatments, on fibrinogen, von Willebrand factor, or cognitive performance as measured by the Letter Digit Coding Test (mean change: -1; 95% CI: -2.3, 1.4) and the Telephone Interview of Cognitive Status (-0.7; 95% CI: -1.7, 0.4). CONCLUSION: Oral folic acid plus vitamin B-12 decreased homocysteine concentrations in elderly patients with vascular disease but was not associated with statistically significant beneficial effects on cognitive function over the short or medium term.

Falls risk following discharge from a geriatric day hospital.

OBJECTIVE: To assess the predictive validity of the Elderly Mobility Scale (EMS), Functional Reach (FR) and the Barthel Index (BI) in identifying recurrent fallers following discharge from a geriatric day hospital (GDH). SUBJECTS: Seventy-six GDH patients with identified mobility problems. METHODS: Each patient was assessed by an independent physiotherapist before and after a programme of physiotherapy using the EMS, FR and BI and a 'falls follow-up' assessment was performed after four months. RESULTS: Fifty-four per cent (29 out of 54) of patients had reduced mobility at follow-up. Twenty-five per cent (18 out of 71) of patients had two or more falls post discharge. Using logistic regression analysis for EMS, FR and BI at discharge, each of these variables individually was significantly associated with the risk of having two or more falls (p = 0.008, 0.017 and 0.031 respectively). A prognostic tree was developed for GDH patients identifying high-risk and low-risk groups. CONCLUSION: EMS, FR and BI were all significantly associated with GDH patients with mobility problems having two or more falls. A prognostic tree identified high- and low-risk groups of GDH patients and should now be tested prospectively.