Developing a Decision Pathway for Family Presence During Resuscitation.

BACKGROUND: The standard of care for family presence during resuscitation (FPDR) is evolving, and leading organizations collectively recommend establishing institutional policy for its practice. Although FPDR is supported at this single institution, the process was not standardized. METHODS: An interprofessional group authored a decision pathway to standardize the care of families during inpatient code blue events at one institution. The pathway was reviewed and applied in code blue simulation events to highlight the role of the family facilitator and the importance of interprofessional teamwork skills. RESULTS: The decision pathway is a patient-centered algorithm that promotes safety and family autonomy. Pathway recommendations are shaped by current literature, expert consensus, and existing institutional regulations. An on-call chaplain responds to all code blue events as the family facilitator and conducts assessments and decision making per the pathway. Clinical considerations include patient prioritization, family safety, sterility, and team consensus. One year after implementation, staff felt that it positively affected patient and family care. The frequency of inpatient FPDR did not increase after implementation. CONCLUSION: As a result of the decision pathway implementation, FPDR is consistently a safe and coordinated option for patients' family members.

Patient Religiosity and Desire for Chaplain Services in an Outpatient Primary Care Clinic.

Outpatient chaplaincy is a new specialty in healthcare, with a relative paucity of research studies exploring the need for spiritual care interventions in ambulatory settings. Over the past 3 years, our interdisciplinary team at the Duke Outpatient Clinic has piloted the extension of professional spiritual care into this hospital-based resident teaching clinic offering primary care to underserved populations in Durham, NC. In this article, we report the results of a series of surveys that we conducted at the clinic to assess patients' perceptions of chaplain services, understanding of Chaplains' roles, and desire for chaplain services in specific hypothetical scenarios. As part of this survey, we also asked patients about their personal levels of extrinsic and intrinsic religiosity using the well-validated Duke University Religion Index. Our results indicate which chaplain interventions are most desired among this patient population in relation to patients' self-reported religiosity. We hypothesized that only our more religious patients would strongly desire chaplain support for the majority of scenarios presented. We were surprised to find that a majority of our patients-regardless of their own level of religiosity-express desire for support from an outpatient healthcare chaplain when they need a listening ear, are grieving a loss, or are seeking prayer.

A Descriptive Study of Chaplains' Code Blue Responses.

BACKGROUND: Family presence during resuscitation is the compassionate practice of allowing a patient's family to witness treatment for cardiac or respiratory arrest (code blue event) when appropriate. Offering family presence during resuscitation as an interprofessional practice is consistent with patient- and family-centered care. In many institutions, the role of family facilitator is not formalized and may be performed by various staff members. At the large academic institution of this study, the family facilitator is a member of the chaplain staff. OBJECTIVES: To examine the frequency of family presence during code blue events and describe the role of chaplains as family facilitators. METHODS: Chaplain staff documented information about their code responses daily from January 2012 through April 2020. They documented their response time, occurrence of patient death, presence of family at the event, and services they provided. A retrospective data review was performed. RESULTS: Chaplains responded to 1971 code blue pages during this time frame. Family members were present at 53% of code blue events. Chaplains provided multiple services, including crisis support, compassionate presence, spiritual care, bereavement support, staff debriefing, and prayer with and for patients, families, and staff. CONCLUSIONS: Family members are frequently present during code blue events. Chaplains are available to respond to all such events and provide a variety of immediate and longitudinal services to patients, families, and members of the health care team. Their experience in crisis management, spiritual care, and bereavement support makes them ideally suited to serve as family facilitators during resuscitation events.

Hope, Religiosity, and Mental Health in U.S. Veterans and Active Duty Military with PTSD Symptoms.

INTRODUCTION: Many studies have linked hope with better mental health and lower risk of suicide. This is especially true in those who have experienced severe physical or emotional trauma. Religious involvement is associated with greater hope. We examine here the relationship between hope, religiosity, and mental health in a sample of Veterans and Active Duty Military (ADM) with PTSD symptoms. MATERIALS AND METHODS: A cross-sectional multi-site study was conducted involving 591 Veterans and ADM from across the United States. Inclusion criteria were having served in a combat theater and the presence of PTSD symptoms. Measures of religiosity, PTSD symptoms, depression, and anxiety were administered, along with a single question assessing the level of hope on a visual analog scale from 1 to 10. Bivariate and multivariate relationships were examined, along with the moderating effects of religiosity on the relationship between hope and symptoms of PTSD, depression, and anxiety. RESULTS: Hope was inversely related to PTSD, depression, and anxiety symptoms (r = -0.33, -0.56, and -0.40, respectively, all p < 0.0001), but was positively related to religiosity (r = 0.32, p < 0.0001). Religiosity remained significantly related to hope (p < 0.0001) after controlling for demographics, military characteristics, as well as PTSD, depression, and anxiety symptoms, and this relationship was partly but not entirely mediated by social factors (marital status, relationship quality, community involvement). Religiosity did not, however, moderate the strong inverse relationships between hope and PTSD, depression or anxiety symptoms. CONCLUSION: Hope is inversely related to PTSD, depression, and anxiety in Veterans and ADM with PTSD symptoms. Although religiosity is positively related to hope, independent of demographic, military, social, and psychological factors, it does not buffer the negative relationships between hope and PTSD, depression, or anxiety. While further research is warranted, particularly longitudinal studies capable of addressing questions about causality, providing support for the existing religious beliefs of current and former military personnel may help to enhance hope and mental health in the setting of severe combat-related trauma.

Moral Injury, Religiosity, and Suicide Risk in U.S. Veterans and Active Duty Military with PTSD Symptoms.

INTRODUCTION: There is growing evidence that moral injury (MI) is related to greater suicide risk among Veterans and Active Duty Military (V/ADM). This study examines the relationship between MI and suicide risk and the moderating effect of religiosity on this relationship in V/ADM with post-traumatic stress disorder (PTSD) symptoms. MATERIALS AND METHODS: This was a cross-sectional multi-site study involving 570 V/ADM from across the USA. Inclusion criteria were having served in a combat theater and the presence of PTSD symptoms. Multidimensional measures assessed MI, religiosity, PTSD symptoms, anxiety, and depression. In this secondary data analysis, a suicide risk index was created based on 10 known risk factors. Associations between MI and the suicide risk index were examined, controlling for demographic, religious, and military characteristics, and the moderating effects of religiosity were explored. RESULTS: MI overall was correlated strongly with suicide risk (r = 0.54), as were MI subscales (ranging from r = 0.19 for loss of trust to 0.48 for self-condemnation). Controlling for other characteristics had little effect on this relationship (B = 0.016, SE = 0.001, p < 0.0001). Religiosity was unrelated to suicide risk and did not moderate the relationship between suicide risk and MI or any of its subscales. CONCLUSION: MI is strongly and independently associated with risk factors for suicide among V/ADM with PTSD symptoms, and religiosity does not mediate or moderate this relationship. Whether interventions that target MI reduce risk of suicide or suicidal ideation remains unknown and needs further study.

Moral Injury and Religiosity in US Veterans With Posttraumatic Stress Disorder Symptoms.

Moral injury (MI) involves feelings of shame, grief, meaninglessness, and remorse from having violated core moral beliefs related to traumatic experiences. This multisite cross-sectional study examined the association between religious involvement (RI) and MI symptoms, mediators of the relationship, and the modifying effects of posttraumatic stress disorder (PTSD) severity in 373 US veterans with PTSD symptoms who served in a combat theater. Assessed were demographic, military, religious, physical, social, behavioral, and psychological characteristics using standard measures of RI, MI symptoms, PTSD, depression, and anxiety. MI was widespread, with over 90% reporting high levels of at least one MI symptom and the majority reporting at least five symptoms or more. In the overall sample, religiosity was inversely related to MI in bivariate analyses (r = -0.25, p < 0.0001) and multivariate analyses (B = -0.40, p = 0.001); however, this relationship was present only among veterans with severe PTSD (B = -0.65, p = 0.0003). These findings have relevance for the care of veterans with PTSD.

Screening for Moral Injury: The Moral Injury Symptom Scale - Military Version Short Form.

Introduction: To develop a short form (SF) of the 45-item multidimensional Moral Injury Symptom Scale - Military Version (MISS-M) to use when screening for moral injury and monitoring treatment response in veterans and active duty military with PTSD. Methods: A total of 427 veterans and active duty military with PTSD symptoms were recruited from VA Medical Centers in Augusta, GA; Los Angeles, CA; Durham, NC; Houston, TX; and San Antonio, TX; and from Liberty University, Lynchburg, Virginia. The sample was randomly split in two. In the first half (n = 214), exploratory factor analysis identified the highest loading item on each of the 10 MISS scales (guilt, shame, moral concerns, loss of meaning, difficulty forgiving, loss of trust, self-condemnation, religious struggle, and loss of religious faith) to form the 10-item MISS-M-SF; confirmatory factor analysis was then performed to replicate results in the second half of the sample (n = 213). Internal reliability, test-retest reliability, and convergent, discriminant, and concurrent validity were examined in the overall sample. The study was approved by the institutional review boards and the Research & Development (R&D) Committees at Veterans Administration medical centers in Durham, Los Angeles, Augusta, Houston, and San Antonio, and the Liberty University and Duke University Medical Center institutional review boards. Findings: The 10-item MISS-M-SF had a median of 50 and a range of 12-91 (possible range 10-100). Over 70% scored a 9 or 10 (highest possible) on at least one item. Cronbach's alpha was 0.73 (95% CI 0.69-0.76), and test-retest reliability was 0.87 (95% CI 0.79-0.92). Convergent validity with the 45-item MISS-M was r = 0.92. Discriminant validity was demonstrated by relatively weak correlations with social, religious, and physical health constructs (r = 0.21-0.35), and concurrent validity was indicated by strong correlations with PTSD, depression, and anxiety symptoms (r = 0.54-0.58). Discussion: The MISS-M-SF is a reliable and valid measure of MI symptoms that can be used to screen for MI and monitor response to treatment in veterans and active duty military with PTSD.

The Moral Injury Symptom Scale-Military Version.

The purpose of this study was to develop a multi-dimensional measure of moral injury symptoms that can be used as a primary outcome measure in intervention studies that target moral injury (MI) in Veterans and Active Duty Military with PTSD. This was a multi-center study of 427 Veterans and Active Duty Military with PTSD symptoms recruited from VA Medical Centers in Augusta, Los Angeles, Durham, Houston, and San Antonio, and from Liberty University in Lynchburg. Internal reliability of the Moral Injury Symptom Scale-Military Version (MISS-M) was examined along with factor analytic, discriminant, and convergent validity. Participants were randomly split into two equal samples, with exploratory factor analysis conducted in the first sample and confirmatory factor analysis in the second. Test-retest reliability was assessed in a subsample of 64 Veterans. The 45-item MISS-M consists of 10 theoretically grounded subscales assessing guilt, shame, moral concerns, religious struggles, loss of religious faith/hope, loss of meaning/purpose, difficulty forgiving, loss of trust, and self-condemnation. The Cronbach's alpha of the overall scale was .92 and of individual subscales ranged from .56 to .91. The test-retest reliability was .91 for the total scale and ranged from .78 to .90 for subscales. Discriminant validity was demonstrated by relatively weak correlations with other psychosocial, religious, and physical health constructs, and convergent validity was indicated by strong correlations with PTSD, depression, and anxiety symptoms. The MISS-M is a reliable and valid multi-dimensional symptom measure of moral injury that can be used in studies targeting MI in Veterans and Active Duty Military with PTSD symptoms and may also be used by clinicians to identify those at risk.