Implementing a Multi-Disciplinary, Evidence-Based Resilience Intervention for Moral Injury Syndrome: Systemic Barriers and Facilitators.

Moral injury syndrome (MIS) is a mental health (MH) problem that substantially affects resilience; the presence of MIS reduces responsiveness to psychotherapy and increases suicide risk. Evidence-based treatment for MIS is available; however, it often goes untreated. This project uses principles of the Consolidated Framework for Implementation Research (CFIR) to assess barriers and facilitators to the implementation of Building Spiritual Strength (BSS), a multi-disciplinary treatment for MIS. Interviews were conducted with chaplains and mental health providers who had completed BSS facilitator training at six sites in the VA. Data were analyzed using the Hamilton Rapid Turnaround method. Findings included multiple facilitators to the implementation of BSS, including its accessibility and appeal to VA chaplains; leadership by VA chaplains trained in the intervention; and effective collaboration between the chaplains and mental health providers. Barriers to the implementation of BSS included challenges in engaging mental health providers and incorporating them as group leaders, veterans' lack of familiarity with the group format of BSS, and the impact of the COVID-19 pandemic. Results highlight the need for increased trust and collaboration between VA chaplains and mental health providers in the implementation of BSS and treatment of MIS.

Multi-professional perspectives to reduce moral distress: A qualitative investigation.

BACKGROUND: Encounters of moral distress have long-term consequences on healthcare workers' physical and mental health, leading to job dissatisfaction, reduced patient care, and high levels of burnout, exhaustion, and intentions to quit. Yet, research on approaches to ameliorate moral distress across the health workforce is limited. RESEARCH OBJECTIVE: The aim of our study was to qualitatively explore multi-professional perspectives of healthcare social workers, chaplains, and patient liaisons on ways to reduce moral distress and heighten well-being at a southern U.S. academic medical center. PARTICIPANTS & RESEARCH CONTEXT: Purposive sampling and chain-referral methods assisted with recruitment through hospital listservs, staff meetings, and newsletters. Interested participants contacted the principal investigator and all interviews were conducted in-person. Consent was attained prior to interviews. All interviews were recorded and transcribed verbatim. RESEARCH DESIGN: Directed content analysis was used to deductively organize codes and to develop themes in conjunction with the National Academy of Medicine's National Plan for Health Workforce Well-Being. Rigor was attained through peer-debriefing, data triangulation methods, and frequent research team meetings. ETHICAL CONSIDERATIONS: Ethics approval was obtained from the university and medical center institutional review boards. FINDINGS: Themes demonstrate that rather than offering interventions in the aftermath of moral distress, multilevel daily practices ought to be considered that pre-emptively identify and reduce morally distressing encounters through (1) the care team, (2) management and leadership, and (3) the health care industry. Strategies include interdisciplinary decision-making, trusting managerial relationships, and organizational policies and practices that explicitly invest in mental health promotion and diverse leadership opportunities. CONCLUSION: Moral distress interventions ought to target short-term stress reactions while also addressing the long-term impacts of moral residue. Health systems must financially commit to an ethical workplace culture that explicitly values mental health and well-being.

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.

Factors Associated With Healthcare Clinician Stress and Resilience: A Scoping Review.

GOAL: Clinician stress and resilience have been the subjects of significant research and interest in the past several decades. We aimed to understand the factors that contribute to clinician stress and resilience in order to appropriately guide potential interventions. METHODS: We conducted a scoping review (n = 42) of published reviews of research on clinician distress and resilience using the methodology of Peters and colleagues (2020). Our team examined these reviews using the National Academy of Medicine's framework for clinician well-being and resilience. PRINCIPAL FINDINGS: We found that organizational factors, learning/practice environment, and healthcare responsibilities were three of the top four factors identified in the reviews as contributing to clinician distress. Learning/practice environment and organizational factors were two of the top four factors identified in the reviews as contributing to their resilience. PRACTICAL APPLICATIONS: Clinicians continue to face numerous external challenges that complicate their work. Further research, practice, and policy changes are indicated to improve practice environments for healthcare clinicians. Healthcare leaders need to promote resources for organizational and system-level changes to improve clinician well-being.

An Evidence Map for Social and Structural Determinants for Maternal Morbidity and Mortality: A Systematic Review.

OBJECTIVE: To identify the social-structural determinants of health risk factors associated with maternal morbidity and mortality in the United States during the prenatal and postpartum periods. DATA SOURCES: We searched MEDLINE, CINAHL, and Social Sciences Citation Index through November 2022 for eligible studies that examined exposures related to social and structural determinants of health and at least one health or health care-related outcome for pregnant and birthing people. METHODS OF STUDY SELECTION: After screening 8,378 unique references, 118 studies met inclusion criteria. TABULATION, INTEGRATION, AND RESULTS: We grouped studies by social and structural determinants of health domains and maternal outcomes. We used alluvial graphs to summarize results and provide additional descriptions of direction of association between potential risk exposures and outcomes. Studies broadly covered risk factors including identity and discrimination, socioeconomic, violence, trauma, psychological stress, structural or institutional, rural or urban, environment, comorbidities, hospital, and health care use. However, these risk factors represent only a subset of potential social and structural determinants of interest. We found an unexpectedly large volume of research on violence and trauma relative to other potential exposures of interest. Outcome domains included maternal mortality, severe maternal morbidity, hypertensive disorders, gestational diabetes, cardiac and metabolic disorders, weathering depression, other mental health or substance use disorders, and cost per health care use outcomes. Patterns between risk factors and outcomes were highly mixed. Depression and other mental health outcomes represented a large proportion of medical outcomes. Risk of bias was high, and rarely did studies report the excess risk attributable to a specific exposure. CONCLUSION: Limited depth and quality of available research within each risk factor hindered our ability to understand underlying pathways, including risk factor interdependence. Although recently published literature showed a definite trend toward improved rigor, future research should emphasize techniques that improve the ability to estimate causal effects. In the longer term, the field could advance through data sets designed to fully ascertain data required to robustly examine racism and other social and structural determinants of health, their intersections, and feedback loops with other biological and medical risk factors. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022300617.

Moral injury and psychosocial functioning in health care workers during the COVID-19 pandemic.

Studies of moral injury among nonmilitary samples are scarce despite repeated calls to examine the prevalence and outcomes of moral injury among civilian frontline workers. The purpose of this study was to describe the prevalence of moral injury and to examine its association with psychosocial functioning among health care workers during the COVID-19 pandemic. We surveyed health care workers (N = 480), assessing exposure to potentially morally injurious events (PMIEs) and psychosocial functioning. Data were analyzed using latent class analysis (LCA) to explore patterns of PMIE exposure (i.e., classes) and corresponding psychosocial functioning. The minimal exposure class, who denied PMIE exposure, accounted for 22% of health care workers. The moral injury-other class included those who had witnessed PMIEs for which others were responsible and felt betrayed (26%). The moral injury-self class comprised those who felt they transgressed their own values in addition to witnessing others' transgressions and feeling betrayed (11%). The betrayal-only class included those who felt betrayed by government and community members but otherwise denied PMIE exposure (41%). Those assigned to the moral injury-self class were the most impaired on a psychosocial functioning composite, followed by those assigned to the moral injury-other and betrayal-only classes, and finally the minimal exposure class. Moral injury is prevalent and impairing for health care workers, which establishes a need for interventions with health care workers in organized care settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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.

Patient-Family Experience at the Onset of COVID-19: Interviews with Ten Palliative Chaplains.

Background: As thousands of patients, often with complex care needs, were hospitalized due to the coronavirus disease 2019 (COVID-19) pandemic, demand for palliative care was magnified. Part of hospitals' palliative care teams, palliative chaplains delivered emotional support while specializing in the religious, spiritual, and the existential aspects of care. With COVID-19 containment measures increasing isolation and disrupting supportive family connections, the emotional and spiritual well-being of the patients and families were unclear. Objectives: Through the unique perspectives and insights of inpatient palliative care chaplains, we sought to qualitatively capture their perceptions and the patient-family experience as the pandemic emerged. Setting/Subjects: This investigation was based in the United States. Design: Individual semistructured telephone interviews (n = 10) were conducted between April 22 and May 6, 2020. Through thematic analysis, analyses progressed through initial coding sessions, refining a codebook, identifying representative quotes, and recognizing themes. Results: Five themes were identified and described through the coding process and recognizing representative quotes: (1) visitor restrictions-patients, (2) visitor restrictions-families, (3) religious struggle, (4) spiritual distress, and (5) decision making. Conclusions: Inpatient palliative care chaplains were active interprofessional partners caring for patients and families as the uncertainty of the pandemic unfolded. The crises of this pandemic magnified chaplain specialization as they attended to emotional, spiritual, and religious suffering and as well as complex decision making with patients and their family members.

Antidepressant Effect of the VA Weight Management Program (MOVE) Among Veterans With Severe Obesity.

INTRODUCTION: Obesity is prevalent among users of Veteran's Health Administration services, where it is comorbid with depression, post-traumatic stress disorder, type 2 diabetes, cardiovascular disease, colon, and breast cancer. Among obese subjects, severe obesity represents a subpopulation with the highest risk of depression. We investigate the antidepressant effect of a local VA weight management program (Managing Overweight Veterans Everywhere - MOVE) among depressed veterans with severe obesity. MATERIAL AND METHODS: In a 10-week prospective pilot study, 14 clinically depressed veterans with severe obesity were recruited from: (1) the 2-week residential based intense MOVE program (IMP) (N = 7) and (2) the 10-week educational module of self-management MOVE program (SMP) (N = 7). Subjects had a Beck Depression Inventory, 2nd edition (BDI-II) score > 12 and BMI > 40 or BMI > 35 with associated to comorbid conditions. Concurrent treatment for depression such as medications or psychotherapy was excluded. The primary efficacy endpoint was the change in BDI-II score form baseline to week 10. Analysis consisted of linear mixed model with baseline BDI-II score as a covariate, and level of MOVE intervention (IMP vs. SMP), time, and time by treatment interaction as fixed effects, and random patient effect. Pearson's correlation examined the relationships between clinical and demographic variables and change in severity of depression by BDI-II scores. Secondary outcomes include weight loss and energy expenditure. RESULTS: The sample was composed by 14 subjects (IMP = 7; SMP = 7) mostly unemployed (N = 9), married (N = 10), mid-aged (mean = 58.2, SD = 8.4), Caucasian (N = 13), male (N = 12), with recurrent depression (N = 11), and a mean overall duration of current depressive episode of 13.5 months (SD = 10.2). Out of 14 participants; seven had a family history of mood disorder, two had previous psychiatric hospitalization, three had a previous suicidal attempt, and eight had a history of substance use disorder. There was a significant decrease in severity of depression among all 14 (F3,36.77 = 5.28; P < 0.01); antidepressant effect favored the IMP compared to SMP at day 12 (F1,15.10 = 9.37, P = 0.01) and week 6 (F2,27.34 = 4.26, P = 0.03), but effect fell short of significance at week 10. The change in severity of depression measured by BDI-II score significantly correlated with total weight loss (r = -0.60; P = 0.04) and daily energy expenditure at 12 days (r = -0.67; P = 0.01), week 6 (r = -0.59; P = 0.03), and week 10 (r = -0.71; P = 0.01). CONCLUSIONS: Depressed veterans with severe obesity improved their depressive symptoms by participating in the MOVE program. Veterans in the IMP had greater but short-term antidepressant effect as compared to educational intervention for obesity. Future studies with larger sample size may elucidate the underlying mechanisms of weight reduction to improve depression and, more importantly, sustain response among veterans with severe obesity.

Developing Organizational Interventions to Address Stigma Among Mental Health Providers: A Pilot Study.

This article outlines a pilot study of "It's Just Us," an organizational intervention designed to reduce stigma among mental health providers by increasing awareness of the stigma they hold toward both clients and other providers with lived experience of mental health challenges. The targeted organization was the Mental Health Service Line in a large, Midwestern VA health care system. About 30% of the clinicians in the service provided information about their levels of stigma toward clients and providers who manage mental health challenges at baseline, 1 year later, and 2 years later. Educational and contact interventions targeting stigma are detailed; the first year included education and short-term contact interventions, while the second year included continuous contact interventions. At the end of the first year, scores on a measure of stigma toward mental health providers with lived experience were significantly lower, while scores on (a) a self-report measure of stigma toward clients and (b) self-disclosure of lived experience to professional peers were unchanged. At the end of the second year, scores for stigma toward clients had improved, and providers in the sample were more likely to share their lived experience with professional peers. Further research is necessary to validate these findings. Data provides preliminary support for the use of the "It's Just Us" curriculum as a means of reducing stigma among mental health providers. This model may also be useful in addressing stigma among other types of health care providers as well.

Spiritually integrated care for PTSD: A randomized controlled trial of "Building Spiritual Strength".

Previous literature documents important cross-sectional and longitudinal relationships between spiritual distress and posttraumatic stress disorder (PTSD) outcomes. This study tests the efficacy of a spiritually integrated intervention "Building Spiritual Strength" (BSS) that can be delivered by trained chaplains. The intervention addresses spiritual concerns expressed by trauma survivors, including concerns in relationship with a Higher Power, difficulty with forgiveness, and theodicy. In a randomized controlled trial with blinded assessment, veterans were randomized to engage in a BSS condition (n = 71) or Present Centered Group Therapy (PCGT; control) condition (n = 67) with assessments at baseline, posttreatment, and a two-month follow up. Both groups showed similar, statistically significant reductions in symptoms of PTSD as measured by the Clinician Administered PTSD Scale (CAPS). BSS was shown to be more effective than PCGT in treating distress in relationship with a Higher Power. This was the second clinical trial of BSS with promising results and highlights the need for further study in psychospiritual interventions. More research is warranted on BSS being offered by non-specialized chaplains and on the application of BSS in suicide prevention.

Spiritual/Religious Distress Is Associated with Pain Catastrophizing and Interference in Veterans with Chronic Pain.

Objective: Few studies have examined relations between one important aspect of spiritual/religious functioning-spiritual distress-and pain-related outcomes, and none has examined how spiritual distress and depression conjointly relate to chronic pain. The goal of the present study, then, was to examine veterans' spiritual distress as a predictor of two aspects of chronic pain, catastrophizing and interference, testing a mediational model of depression. Design: Four hundred thirty-six patients seeking treatment in a chronic pain management clinic responded to a mailed survey assessing demographics, spiritual distress, depression, pain catastrophizing, and pain interference. Setting: Participants were drawn from a list of patients enrolled in a chronic pain rehabilitation program at a large Midwestern Veterans Affairs health care system. Subjects: Participants were 436 veterans seeking chronic pain rehabilitation. The sample was predominantly Caucasian and male. Methods: Survey data were subjected to mediational analysis, assessing both direct effects of spiritual distress on pain outcomes and indirect effects of spiritual distress through depression. Results: Results showed that spiritual distress was moderately strongly related to both pain outcomes. Further, depression mediated links between spiritual distress and pain catastrophizing (partially) and interference (fully). Conclusions: These results have implications for further research in spiritually integrated care as a component of holistic, integrative approaches to the management of chronic pain.