Moral injury: An unspoken burden of transplant surgery.

Moral injury in health care is characterized as the lasting psychological, biological, and social impact on providers that occurs following an adverse patient outcome. Moral injury can contribute to second victim syndrome and lasting psychological harm. Although many surgeons face moral injury due to patient acuity and the potential for intraoperative or postoperative complications, the transplant ecosystem compounds the impact of moral injury. Institutional blame placed on the transplant surgeon following a posttransplant death or graft loss is magnified by public reporting. Centers whose outcomes fall below threshold levels are subject to regulatory citation and financial loss. Moral injury can also result in risk aversion, limiting access to transplants for higher-risk candidates and reducing acceptance of marginal organs hurting donor families. Strategies to increase resilience, reduce accusation and blame, and focus on system quality improvement are vital to mitigate the impact of moral injury on transplant professionals. The transplant community must proactively work to reduce moral injury to protect surgeons, ensure access to life-saving transplant procedures, and avoid unnecessary organ offer declines.

A Palliative Care Curriculum May Promote Resident Self-Reflection and Address Moral Injury.

INTRODUCTION: There is a lack of formal palliative care education for surgical trainees, and the demanding nature of surgical training and exposure to challenging clinical scenarios can contribute to moral injury. We developed a palliative care curriculum to promote self-reflection, aiming to address moral injury in residents. METHODS: Five 1-h palliative care sessions were delivered over the academic year to all post-graduate year (PGY) levels covering the following topics: personal awareness, delivering bad news, surgical palliation for cancer pathology, surgical palliation for noncancer pathology, and urgent palliative care. The curriculum focused on reflection and small group discussions. The Moral Injury Symptom Scale-Health Professional was administered to assess feelings of moral injury. Descriptive statistics, chi-squared analysis, and Mann-Whitney U-test were used to compare the demographics and survey responses. RESULTS: 23 participants completed the preintervention survey, and 9 participants completed it postintervention. Over 50% of participants were PGY1 or PGY2 residents. Preintervention, 52% of participants reported feeling guilt over failing to save someone from being seriously injured or dying. 30% of participants reported that the feelings of guilt, shame, or distrust impaired their ability to function in relationships, at work, or other areas of life to at least a moderate degree. CONCLUSIONS: The described palliative care curriculum accomplishes several goals as follows: it educates residents on palliative care topics, teaches communication tools, encourages self-reflection, and provides space for building peer relationships. The ease of implementation makes this curriculum applicable across various types of institutions, offering the potential to positively impact surgical training on a national scale.

Enhancing Conceptual Clarity regarding the Construct of Moral Injury.

BACKGROUND: The construct of "moral injury" is used widely in the research literature and media to broadly describe the impact of events involving perceived violations of one's sense of right and wrong (herein referred to as "potentially morally injurious events" [PMIEs]). SUMMARY: In this theoretical review, we provided a brief overview of the "moral injury" construct and its limitations including the lack of consensus-drawn boundaries and operational definitions to guide hypothesis-driven research. We discussed whether this construct can be reliably distinguished from established psychiatric diagnoses and psychological constructs and the inherent challenges in separating or classifying the impact of high-magnitude stressful life events that likely form the majority of PMIEs. Assessments that purportedly measure "moral injury" are reviewed and limitations are discussed such as shared measurement variance with established psychological instruments. KEY MESSAGES: We identified conceptual strategies for investigating behavioral and neurobiological features of PMIEs that could be used to inform the field of traumatic stress. We concluded that the construct of "moral injury" may provide an interpretive framework for positing why someone may be beset by guilt, shame, and/or rage whereas existing psychiatric diagnoses such as post-traumatic stress disorder and depression provide comprehensive descriptions regarding what someone might experience following extremely stressful events. We proposed directions to better clarify the boundaries of "moral injury" versus established psychiatric categories that could be used to enhance the conceptualization and assessment of this construct.

Moral injury among women military veterans and demand for cigarettes: A behavioral economic investigation using a hypothetical purchase task.

OBJECTIVES: Unlike the United States general population, veteran women - as opposed to veteran men - have greater smoking prevalence; yet, little is known regarding factors that influence smoking in veteran women. The purpose of this study was to begin examining the relationship between a psychological concept known as moral injury and demand for cigarettes among veteran women. METHODS: Veteran women who smoke (n = 44) were recruited for this cross-sectional study from Amazon MTurk, Reddit, and a veteran-serving non-profit organization in June-July 2023. Consenting participants received $2 for completing the cigarette purchase task (CPT), Fagerstrom Test for Nicotine Dependence (FTND), and the military version of the Moral Injury Symptom Scale (MISS-M-SF). We examined five CPT demand indices and calculated a modified exponential demand model stratified by moral injury severity status (i.e., probable vs. unlikely). RESULTS: Probable morally injured women exhibited significantly higher relative reinforcing value (RRV) for smoking than unlikely morally injured women (F1, 920 = 9.16, p = 0.003). Average cigarette consumption at $0 (i.e., Q0) was 48.56% higher (M = 22.24 vs. M = 13.55) in probable compared to unlikely morally injured women (p = 0.04, Hedge's g = 0.74). FTND scores were significantly correlated with Pmax (i.e., demand elasticity point) and Omax (i.e., maximum expenditure) values in both populations (rs = 0.42-0.68, ps < 0.05). CONCLUSIONS: We provide preliminary evidence of the relatively high RRV of smoking in morally injured veteran women. Continued research is needed to refine the characterization of this relationship.

The contribution of exposure to potentially morally injurious events to trajectories of posttraumatic stress symptoms among discharged veterans - a five-year study.

PURPOSE: Combatants and veterans are at risk of developing post traumatic stress symptoms (PTSS). The long-term responses to traumatic events are variable and can be classified into distinct PTSS trajectories. In this prospective study, we evaluated PTSS trajectories among combat veterans during the initial year after discharge from military service. Subsequently, we analyzed how combat exposure and PMIEs contributed to these trajectories. METHODS: Our study encompassed 374 combat veterans who participated in a five-year prospective study, with four waves of measurements, T1 - one year before enlistment, T2 - one month prior to discharge from military service (July 2021), and then again at six months (T3 - February 2022) and twelve months after discharge (T4, July-August 2022) . RESULTS: The utilization of Latent Profile Analysis (LPA) revealed a diverse array of PTSS trajectories. Predominantly, a resilient trajectory emerged as the most frequently observed (69.3%), with 'delayed onset'(13.6%), 'improving'(9.9%) and 'chronic'(6.1%) trajectories following in order. Importantly, multinominal regression analysis indicated that combat exposure and PMIE-betrayal contributed to alignment with symptomatic trajectories. CONCLUSIONS: This study represents the first of its kind to establish longitudinal, time-dependent associations between PMIEs and PTSS trajectories. These results emphasize the critical importance of ongoing screening and the development of tailored interventions for combat veterans.

Combat stress in a small-scale society suggests divergent evolutionary roots for posttraumatic stress disorder symptoms.

Military personnel in industrialized societies often develop posttraumatic stress disorder (PTSD) during combat. It is unclear whether combat-related PTSD is a universal evolutionary response to danger or a culture-specific syndrome of industrialized societies. We interviewed 218 Turkana pastoralist warriors in Kenya, who engage in lethal cattle raids, about their combat experiences and PTSD symptoms. Turkana in our sample had a high prevalence of PTSD symptoms, but Turkana with high symptom severity had lower prevalence of depression-like symptoms than American service members with high symptom severity. Symptoms that facilitate responding to danger were better predicted by combat exposure, whereas depressive symptoms were better predicted by exposure to combat-related moral violations. The findings suggest that some PTSD symptoms stem from an evolved response to danger, while depressive PTSD symptoms may be caused by culturally specific moral norm violations.

Injustice and Embitterment: Crucial Stressors in Psychosomatic Patients.

OBJECTIVE: "Disorders specifically associated with stress" are receiving increasing attention in clinical practice, research, and modern classification systems of mental disorders. This includes not only reactions to "extremely threatening or horrific events" as it is characteristic for "post-traumatic stress disorders" but also a variety of day-to-day experiences. Examples are experiences of injustice, humiliation, or breach of trust which can have dire psychological consequences such as feelings of embitterment, a strong and crippling emotion. This study investigated the frequency of feelings of injustice and concomitant embitterment across different areas of daily life of psychosomatic patients. METHODS: In an observational archival study, 200 inpatients of a department of behavioral medicine filled in the "Differential Life Burden Scale, DLB-Scale" and the "Post-Traumatic Embitterment Scale, PTED-Scale" which asks for experiences of injustice and embitterment. RESULTS: More than half of all patients (58.5%) reported about very or extremely unjust and unfair life events and 51.5% additionally about feelings of embitterment. This was primarily associated with complaints about problems in the family and the workplace and was accompanied by an impairment of well-being. CONCLUSIONS: The findings indicate that experiences of injustice and embitterment are frequently seen in psychosomatic inpatients and should get special attention.

A latent profile analysis of moral emotions following moral transgressions.

OBJECTIVE: Moral transgressions (MTs), events that violate one's moral code, are associated with the moral emotions of guilt and shame. However, there may be different patterns by which people experience guilt and shame that affect distress following MTs. METHOD: Undergraduates (N = 1371) exposed to an MT completed self-report assessments. This study used latent profile analysis (LPA) to examine profiles based on guilt cognitions, internalized shame, and distress in relation to a reported MT. Cognitive flexibility, years since the MT, and deliberate and intrusive rumination were examined as variables to determine how these factors predicted profile membership. RESULTS: Results from the LPA revealed a three-profile solution: a low moral distress profile (n = 1002), a moderate moral distress profile (n = 262), and a shame prominent profile (n = 107). Results indicated that higher levels of deliberate and intrusive rumination and lower levels of cognitive flexibility significantly increased the likelihood of belonging to the moderate moral distress or shame prominent profiles compared to the low moral distress profile. Higher levels of intrusive rumination and lower levels of cognitive flexibility also significantly increased the likelihood of belonging to the shame prominent profile over the moderate distress profile. CONCLUSION: Three different profiles emerged, with the shame prominent profile being driven primarily by internalized shame. Results suggest that intrusive rumination and cognitive inflexibility are risk factors to experiencing adverse responses to MTs.

Understanding psychological outcomes following exposure to potentially morally injurious events in animal care: development of the Moral Distress-Posttraumatic Growth Scale for Veterinary Professionals.

AIMS: To generate a taxonomy of potentially morally injurious events (PMIE) encountered in veterinary care and develop an instrument to measure moral distress and posttraumatic growth following exposure to PMIE in the veterinary population. METHODS: Development and preliminary evaluation of the Moral Distress-Posttraumatic Growth Scale for Veterinary Professionals (MD-PTG-VP) employed data from veterinary professionals (veterinarians, veterinary nurses, veterinary technicians) from Australia and New Zealand across three phases: (1) item generation, (2) content validation, and (3) construct validation. In Phase 1 respondents (n = 46) were asked whether they had experienced any of six PMIE and to identify any PMIE not listed that they had experienced. In Phase 2 a different group of respondents (n = 11) assessed a list of 10 PMIE for relevance, clarity and appropriateness. In Phase 3 the final instrument was tested with a third group of respondents (n = 104) who also completed the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT), a measure of posttraumatic stress, and the Stress-Related Growth Scale-Short Form (SRGS-SF) a measure of perceived posttraumatic growth. Spearman's correlation coefficients were calculated between respondent scores on each of the MD-PTG-VP subscales, the SPRINT, and the SRGS-SF to assess construct validity. RESULTS: A 10-item taxonomy of PMIE encountered in veterinary care was generated in Phase 1. Items were deemed relevant, clear and appropriate by veterinary professionals in Phase 2. These were included in the developed instrument which measures frequency and impact of exposure to 10 PMIE, yielding three subscale scores (exposure frequency, moral distress, and posttraumatic growth). Assessment of construct validity by measuring correlation with SPRINT and SRGS-SF indicated satisfactory validity. CONCLUSIONS: The MD-PTG-VP provides an informative tool that can be employed to examine professionals' mental health and wellbeing following exposure to PMIE frequently encountered in animal care. Further evaluation is required to ascertain population norms and confirm score cut-offs that reflect clinical presentation. CLINICAL RELEVANCE: Once fully validated this instrument may be useful to quantify the frequency and intensity of positive and negative aspects of PMIE exposure on veterinary professionals so that accurate population comparisons can be made and changes measured over time.

Psychological Group Interventions for Reducing Distress Symptoms in Healthcare Workers: A Systematic Review.

Healthcare workers exposed to emergencies and chronic stressors are at high risk of developing mental health problems. This review synthesized existing studies of group psychological therapy to reduce distress symptoms in healthcare workers (i.e., as complex and heterogeneous emotional states, characterized by the presence of symptoms associated with post-traumatic stress disorder, burnout, anxiety, depression and moral injury). Searches were conducted using PRISMA guidelines and databases such as PubMed, PsycINFO, Medline and Web of Science, along with manual searches of reference lists of relevant articles. The search returned a total of 1071 randomized trials, of which 23 met the inclusion criteria. Of the total studies, nine were mindfulness interventions, seven were cognitive behavioural programmes, one was a programme based on acceptance and commitment therapy, one was an EMDR protocol and two focused on systemic and art therapy. Most studies aimed to reduce burnout, anxiety and depression; only three focused on post-traumatic stress disorder, and no studies were found that addressed moral injury. The results suggested that group interventions could be an effective tool to improve the mental health of healthcare workers and reduce their symptoms of distress, although many of the studies have methodological deficiencies. Limitations and future directions are discussed.

Do nurse spiritual responses to trauma explain nurse outcomes? A correlational observational study.

BACKGROUND: Various facets of spirituality are associated with well-being. Given the current urgency to promote nurse well-being, nurse spirituality merits exploration. PURPOSE: To investigate how spiritual distress and growth (i.e., spiritual/religious struggle, moral injury, and post-traumatic growth) contributed to nurse outcomes (i.e., burnout, job satisfaction, and intent to leave). METHODS: Registered nurse (RNs) providing direct patient care in three Southern California hospitals completed an online survey that included psychometrically robust measures. Hierarchical multiple regression analyses were used to test spiritual variables as predictors of nurse outcomes after accounting for demographic and work-related factors. FINDINGS: In this sample of 531 demographically diverse RNs, spiritual struggle contributed to burnout and turnover intention; post-traumatic growth and employer respect for nurse well-being contributed to all three nurse outcomes. DISCUSSION: Spiritual distress and growth are understudied but potentially important influences on job outcomes for nurses. The results here suggest that continued development of interventions to address spiritual health is worth investment.

Betrayal-Based Moral Injury and Mental Health Problems Among Healthcare and Hospital Workers Serving COVID-19 Patients.

One factor potentially driving healthcare and hospital worker (HHW)'s declining mental health during the COVID-19 pandemic is feeling betrayed by institutional leaders, coworkers, and/or others' pandemic-related responses and behaviors. We investigated whether HHWs' betrayal-based moral injury was associated with greater mental distress and post-traumatic stress disorder (PTSD) symptoms related to COVID-19. We also examined if these associations varied between clinical and non-clinical staff. From July 2020 to January 2021, cross-sectional online survey data were collected from 1,066 HHWs serving COVID-19 patients in a large urban US healthcare system. We measured betrayal-based moral injury in three groups: institutional leaders, coworkers/colleagues, and people outside of healthcare. Multivariate logistic regression analyses were performed to investigate whether betrayal-based moral injury was associated with mental distress and PTSD symptoms. Approximately one-third of HHWs reported feeling betrayed by institutional leaders, and/or people outside healthcare. Clinical staff were more likely to report feelings of betrayal than non-clinical staff. For all respondents, 49.5% reported mental distress and 38.2% reported PTSD symptoms. Having any feelings of betrayal increased the odds of mental distress and PTSD symptoms by 2.9 and 3.3 times, respectively. These associations were not significantly different between clinical and non-clinical staff. As health systems seek to enhance support of HHWs, they need to carefully examine institutional structures, accountability, communication, and decision-making patterns that can result in staff feelings of betrayal. Building trust and repairing ruptures with HHWs could prevent potential mental health problems, increase retention, and reduce burnout, while likely improving patient care.

Investigating the relationship between compassion fatigue and moral injury in nurses.

Background: Compassion fatigue and professional quality of life are important in health and professional ethics. Aim: This study aimed to determine the relationship between compassion satisfaction, compassion fatigue, secondary traumatic stress, and moral injury in nurses. Research design: This research is a cross-sectional descriptive-analytical study. The research community of this research was all the nurses of the teaching hospitals of Ardabil city. Three questionnaires on demographic characteristics, the Professional Quality of Life Scale (ProQOL), and the Moral Injury Events Scale were used to collect data. SPSS (version 22) software was used for data analysis. Participants and research context: The study recruited 297 nurses randomly selected from five teaching hospitals in Ardabil city. Ethical considerations: Ethical approval was obtained from the Ardabil University of Medical Sciences ethics committee (with the code of ethics IR.ARUMS.REC.1401.198). Informed consent was obtained from the participants. Results: The results showed that the mean compassion satisfaction score of this study's participants was 37.61 ± 8.86, the mean compassion fatigue score of this study's participants was 28.73 ± 7.04, and the mean secondary traumatic stress score of this study's participants was 29.95 ± 7.84. The mean score of moral injury among nurses was 31.19 ± 8.54. The results showed a negative significant relationship between compassion satisfaction and moral injury (p < 0.001). Also, there is a positive significant relationship between compassion fatigue and secondary traumatic stress with moral injury (p < 0.001). Conclusion: The results of this study show a negative relationship between compassion satisfaction and moral injury. According to the results of the present study, nurse managers should implement educational interventions, create ethical processes, and clear ethical guidelines to reduce moral injury and increase compassion satisfaction.

Resilience, compassion fatigue, moral distress and moral injury of nurses.

Background: Compassion fatigue, moral distress, and moral injury are interconnected phenomena that have a detrimental impact on the delivery of nursing care. Nurses possess the inherent resilience necessary to effectively handle these three adverse occurrences. Aim: To determine the mediating impact of resilience on compassion fatigue, moral distress, and moral injury among nurses in Saudi Arabia. Design: The final product was a structural equation model (SEM) generated using a quantitative correlation cross-sectional design, and we followed the STROBE guidelines for this study. Methods: The study involved a sample of 511 staff nurses, who were selected using consecutive sampling. The study was conducted in three government hospitals in Saudi Arabia. Ethical considerations: This study received approval from Ethics Committee under approval number H-2021-151 on March 5, 2021. The survey's description and consent statements were clearly presented on Google survey forms in both English and Arabic. Results: Results showed that resilience negatively influenced moral distress, while compassion fatigue and moral injury had a positive influence. Likewise, compassion fatigue had a direct, positive effect on moral distress and moral injury, and moral distress had a direct, positive effect on moral injury. Analyses also showed that resilience had positive, indirect effects on moral injury through the mediation of both compassion fatigue and moral distress. Similarly, compassion fatigue had a positive, indirect effect on moral injury through the mediation of moral distress. Conclusion: Because resilience enables nurses to adapt, it helps them overcome obstacles in their career and professional lives. Resilience is frequently cited by nurses as a protective quality. Moral injury, compassion fatigue, and moral distress can negatively impact the health of nurses. Implications for the profession and/or patient care: Nurse leaders should develop programs and initiate efforts to improve nurses' resilience as an important protective trait against compassion fatigue, moral distress, and moral injury. Patient or Public Contribution: There was no public or patient participation in this study.

Moral injury and mental health outcomes in nurses: A systematic review.

Introduction: Moral injury involves the adverse psychological, biological, spiritual, behavioural, and social consequences of actions that violate moral values. It can lead to anxiety, depression, burnout, and post-traumatic stress disorder. Nurses, who often face ethical dilemmas, are particularly vulnerable. Despite its significance, the relationship between moral injury and mental health outcomes in nurses remains underexplored. Aim: This systematic review aimed to describe the associations among moral injury, anxiety, depression, and quality of life in nurses. Methods: The review was registered in PROSPERO (CRD42023438731) and was conducted following the PRISMA guidelines. A literature search was performed in December 2023 across PubMed, CINAHL, Scopus, and Web of Science. Peer-reviewed primary research involving nurses, published in English or Italian, without time restrictions, was considered eligible. The risk of bias and the quality of evidence were assessed using the Joanna Briggs Institute checklist and the GRADE approach. Results: Out of 4730 articles identified, eight met the inclusion criteria. The analysis revealed significant positive associations between moral injury, anxiety, and depression, along with a significant negative association with quality of life. Conclusion: These findings highlight the need for healthcare systems to implement strategies that mitigate moral injury among nurses. Future research should prioritize longitudinal studies to explore causal relationships and develop targeted interventions. Additionally, standardizing the concept and measurements of moral injury is crucial for enhancing the comparability and understanding of this phenomenon.

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.

The RANZCP Workforce Report: Action is needed, now.

OBJECTIVE: The RANZCP conducted an anonymous survey of 7200 members (trainees and psychiatrists) in December 2023, receiving 1269 responses, representing the views of roughly 1 in 6 members, and of the respondents, three quarters reported experiencing burnout in the last 3 years. We provide a commentary, citing evidence from relevant previous research, discussing the implications and proposing potential interventions. CONCLUSIONS: Members of the RANZCP reported worsening workforce shortages, with 9 in 10 respondents stating that these negatively impacted patient care, and 7 in 10 experiencing symptoms of burnout. Eighty per cent identified workforce shortages as the top contributing factor to such burnout. The aetiology of workforce shortages and burnout is likely due to operational and structural shortfalls in psychiatric services. However, public and private sector employment information was not included in the report. There are a range of strategic, evidence-based interventions to address the psychiatrist and trainee workforce challenges, comprising general healthcare service as well as specific initiatives. Based on the findings of the report, such interventions are needed, now.

Difficulties with emotion regulation within PTSD clusters and moral injury subtypes.

Treatment and research centered on trauma-related mental health issues have largely focused on posttraumatic stress disorder (PTSD); however, moral injury is another important mental health concern requiring attention. There is a paucity of research examining how PTSD and moral injury affect emotion regulation. The current investigation examined how PTSD clusters and moral injury subtypes were uniquely associated with difficulties with emotion regulation. Participants consisted of 253 previously deployed military personnel who were recruited online. To be included in the study, participants had to verify that they had served in the U.S. Military, had been deployed as part of their military service, and endorsed elevated levels of symptoms associated with PTSD and/or moral injury. A hierarchical linear regression was conducted to examine the association between PTSD symptom clusters, moral injury subtypes, and difficulties with emotion regulation. Results indicated that alterations in arousal and reactivity was the only PTSD symptom cluster associated with difficulties with emotion regulation. Self-transgressions was the only facet of moral injury significantly associated with difficulties with emotion regulation. This is the first study to examine the association between emotion dysregulation, PTSD symptom clusters, and moral injury in previously deployed U.S. Military.

Enhancing the Utility of the Moral Injury Experience Wheel: Manualized Applications for Diverse Contexts.

Moral injury has emerged as an important construct for understanding the distress experienced in the aftermath of a moral violation, initially among combat veterans and increasingly among other populations, such as healthcare workers and first responders. While numerous measures have been validated to assess for exposure to potentially morally injurious events and/or sequelae, additional tools are needed to facilitate nuanced discussion of the experience of moral injury in therapeutic encounters. The Moral Injury Experience Wheel (MIEW; Fleming, 2023) is an infographic instrument that is designed to elicit precise language and help differentiate feelings in an effort to process morally perplexing circumstances. This paper describes the contents and potential clinical applications of a newly developed manual to guide the use of the MIEW. The MIEW and manual are designed to be used independently or alongside existing moral injury interventions. A case study featuring the use of the MIEW and manual demonstrates how the tools can be used in a professional healthcare setting. Recommendations for moral injury care practitioners are provided.

"Anxiety, COVID, Burnout and Now Depression": a Qualitative Study of Primary Care Clinicians' Perceptions of Burnout.

BACKGROUND: Clinician burnout has become a major issue in the USA, contributing to increased mental health challenges and problems with quality of care, productivity, and retention. OBJECTIVE: The objective of this study was to understand primary care clinicians' perspectives on burnout during the COVID-19 pandemic as well as their perspectives on the causes of burnout and strategies to improve clinician well-being. APPROACH: This qualitative research involved in-depth interviews with 27 primary care clinicians practicing in a range of settings across the USA. Semi-structured interviews lasted between 60 and 90 min and were conducted using Zoom video conferencing software between July 2021 and February 2023. Transcripts were analyzed in NVivo software using multiple cycles of coding. KEY RESULTS: Clinicians shared their experiences with burnout and mental health challenges during the COVID-19 pandemic. Contributors to burnout included high levels of documentation, inefficiencies of electronic health record (EHR) systems, high patient volume, staffing shortages, and expectations for responding to patient emails and telephone calls. The majority of participants described the need to work after clinic hours to complete documentation. Many clinicians also discussed the need for health system leaders to make sincere efforts to enhance work-life balance and create a culture of health and well-being for health professionals. Suggested strategies to address these issues included supportive leadership, accessible mental health services, and additional administrative time to complete documentation. CONCLUSIONS: The results of this study provide an in-depth view of participating primary care clinicians' experiences and perceptions of burnout and other mental health challenges. These viewpoints can improve awareness of the issues and strategies to improve the health and well-being of our clinician workforce. Strategies include aligning payment models with the best approaches for delivering quality patient care, reducing administrative burden related to documentation, and redesigning EHR systems with a human factors approach.