Resource Library

BACKGROUND: While understaffing and work-related stress are not unusual within first responder professions, the past few years have added additional strain. COVID-19, political and civil unrest, and economic downturn have stretched the first responder workforce thinner than ever, contributing to a reduction in the workforce through death, early retirement, attrition, or decreased vocational effectiveness. Unfortunately, public stereotypes coupled with the tenets of first responder culture have done little to support those who serve. Public perception often involves polarized stereotypes about first responders (e.g., good guys or bad guys, heroes or villains), and first responder culture encourages a machine-like demeanor. The imagery of heroes, villains, and machines is indicative of dehumanization, or denial of some aspect(s) of humanity. The purpose of this study was to examine how first responders’ perceptions of dehumanization (meta-dehumanization) relate to workforce threats including suicidality, burnout, and decreased self-efficacy. METHODOLOGY: A total of 211 first responders from the US and Canada participated in this study by completing two measures of meta-dehumanization, the Suicide Behaviors Questionnaire- Revised, the Burnout subscale of the Professional Quality of Life Scale, and the General Self- Efficacy Scale. Analyses included Pearson product-moment correlation, ANOVAs, and hierarchical regression analyses. RESULTS: Statistically significant relationships were found between meta-dehumanization for each of the three workforce threats when controlling for time in the profession. Results from ancillary analyses indicate that these relationships continued to be statistically significant even after controlling for country of residence (US or Canada).

Caring for people with chronic kidney disease, let alone during a pandemic, can place nurses at risk for burnout. This study explored the effects of the Mindful Self- Compassion (MSC) 8-week training on nephrology nurses' levels of self-compassion, burnout, and resilience. Twelve nurses participated. Surveys were completed before, immediately after, and three months after training. A focus group was also conducted. Results demonstrated in - creased levels of self-compassion, mindfulness, and resilience while levels of burnout decreased. The central qualitative theme was enhanced resilience. Subthemes were creating a community of support, awareness and discovery, and the mastery of the techniques. The MSC training was an effective intervention to build essential skills for maintaining a healthy workforce. Implementation of such training programs within the health care environment are highly encouraged.

OBJECTIVE: Stress and burnout are serious problems that impair the well-being and academic performance of medical students. Published systematic reviews and meta-analyses on interventions to reduce the stress experienced by medical students did not conclude which interventions are the most effective due to the heterogeneity of the studies. To enhance the hierarchy of evidence, our study selected only randomized controlled studies. The aims were to obtain more reliable outcomes and to precisely summarize the specific interventions which effectively reduce the stress levels and burnout of medical students. METHODS: We performed a systematic review and meta-analysis according to PRISMA guidelines. Medical databases (Embase, Ovid, and CINAHL) were searched for relevant randomized controlled studies published up to December 2019. Two treatment timepoints (postintervention, and the 6-month follow-up) were chosen. Stress measure outcomes were the main outcomes. A random effects model was used. An intention-to-treat analysis was conducted. RESULTS: Six high-quality studies were found. They compared the efficacies of mindfulness-based interventions and clerkship as usual (N = 689). The stress measurement scores of each mindfulness-based intervention at postintervention were significantly better than those of the control groups, with medium effect size and low heterogeneity (95% CI 0.07–0.51; p = 0.01; I-squared index = 45%). At the 6-month follow-up, the mindfulness groups had significantly better results than the control groups, with medium effect size and negligible heterogeneity (95% CI 0.06–0.55; p = 0.02; I-squared index = 0%). DISCUSSION: The results indicate that mindfulness-based interventions are effective in reducing subjective stress in medical students at both the short- and long-term intervention timepoints.

INTRODUCTION: There is a lack of curricula addressing the alarming rates of resident physician mistreatment. As the ACGME works to address diversity, equity, and inclusion in GME, there has been increasing attention paid to the issue of mistreatment. Previous studies have noted a high prevalence of mistreatment within GME. Despite this, there are few published interventions to address the mistreatment of residents. We developed a workshop for residents to provide an overview of mistreatment in residency and teach them REWIND (relax, express, why, inquire, negotiate, determine), a communication tool to address mistreatment directly. METHODS: We designed a 60-minute workshop for residents with didactics on mistreatment in GME, followed by three case discussions. Four case scenarios were developed to represent different types of mistreatment and situations. We implemented the workshop twice and asked participants to self-rate proficiency around the workshop objectives with pre- and postsurveys. RESULTS: A total of 11 GME learners completed both the pre- and postsurveys between the two workshop implementations. GME learners who responded demonstrated significantly higher self-rated proficiency on each objective postworkshop compared to preworkshop (p < .05). Free responses on the survey demonstrated that participants particularly enjoyed the case discussions and wanted more practice with REWIND. DISCUSSION: Our workshop improved participant self-rated proficiency around the mistreatment of resident physicians. The workshop can be used in the future as part of a multifaceted institutional response to mistreatment.

[This is an excerpt.] Acknowledge that “Burnout is not a ME problem, but a WE problem.”Identify aspects of workplace culture at your organization that impact the well-being of staff (both positive and negative). Look for ways to implement aspects of integration that will benefit staff at your organization such as increasing collaborative opportunities. Take steps to prevent isolation by celebrating the value you bring to your colleagues and taking the time to acknowledge the realities of your work with fellow team members. You are not alone! [To read more, click View Resource.]

This quality improvement project used data from individual conversations and group development theory to implement a team-building intervention to mitigate burnout and improve team climate in a group of advanced practice providers. Two validated questionnaires were used to measure the impact of a teambuilding workshop and the drafting of a team agreement. Results demonstrated signi?cant improvement in team burnout scores immediately post-intervention; however, improvement was not sustained. Anecdotally, the team agreement has successfully improved con?ict resolution among group members.

RATIONALES AND OBJECTIVES: The purpose is to describe a hybrid teleradiology solution utilized in an academic medical center and its outcomes on radiology report turnaround time (RTAT) and physician wellness. MATERIALS AND METHODS: During coronavirus disease 2019, we utilized an alternating teleradiology solution with procedural and education attendings working in the hospital and other faculty remote to keep the worklist clean. RTAT data was collected for remote vs. in house emergency department (ED) and inpatient cases over a 6-month period. Pre and post implementation burnout surveys were administered. RESULTS: RTAT significantly improved for ED and inpatient MR and CT, and inpatient US and radiographs when interpreted remotely compared to in-hospital. Physician wellness scores improved and open-ended comments reflected positive feedback about the hybrid work solution. 74% enjoyed the autonomy and flexibility, and 51% said the solution positively influences my desire to remain in my current institution and improves their clinical and/or academic productivity. CONCLUSION: Hybrid work from home solutions allow faculty autonomy and flexibility with work-life balance, improving wellness. It is important to alternate the at-home faculty to maintain interdepartmental relations, particularly for junior faculty, and prevent isolation. The hybrid solution also demonstrated improved patient care metrics, possibly due to decreased distractions at home compared to the reading room.

OBJECTIVE: There is currently little consensus as to how burnout is best defined and measured, and whether the syndrome should be afforded clinical status. The latter issue would be advanced by determining whether burnout is a singular dimensional construct varying only by severity (and with some level of severity perhaps indicating clinical status), or whether a categorical model is superior, presumably reflecting differing ‘sub-clinical’ versus ‘clinical’ or ‘burning out’ vs ‘burnt out’ sub-groups. This study sought to determine whether self-diagnosed burnout was best modelled dimensionally or categorically. METHODS: We recently developed a new measure of burnout which includes symptoms of exhaustion, cognitive impairment, social withdrawal, insularity, and other psychological symptoms. Mixture modelling was utilised to determine if scores from 622 participants on the measure were best modelled dimensionally or categorically. RESULTS: A categorical model was supported, with the suggestion of a sub-syndromal class and, after excluding such putative members of that class, two other classes. Analyses indicated that the latter bimodal pattern was not likely related to current working status or differences in depression symptomatology between participants, but reflected subsets of participants with and without a previous diagnosis of a mental health condition. CONCLUSION: Findings indicated that sub-categories of self-identified burnout experienced by the lay population may exist. A previous diagnosis of a mental illness from a mental health professional, and therefore potentially a psychological vulnerability factor, was the most likely determinant of the bimodal data, a finding which has theoretical implications relating to how best to model burnout.

OBJECTIVE: To explore the causes and levels of moral distress experienced by clinicians caring for the low-i­ncome patients of safety net practices in the USA during the COVID-1­ 9 pandemic. DESIGN: Cross-­sectional survey in late 2020, employing quantitative and qualitative analyses. SETTING: Safety net practices in 20 US states. Participants: 2073 survey respondents (45.8% response rate) in primary care, dental and behavioural health disciplines working in safety net practices and participating in state and national education loan repayment programmes. MEASURES: Ordinally scaled degree of moral distress experienced during the pandemic, and open-e­ nded response descriptions of issues that caused most moral distress. RESULTS: Weighted to reflect all surveyed clinicians, 28.4% reported no moral distress related to work during the pandemic, 44.8% reported ‘mild’ or ‘uncomfortable’ levels and 26.8% characterised their moral distress as ‘distressing’, ‘intense’ or ‘worst possible’. The most frequently described types of morally distressing issues encountered were patients not being able to receive the best or needed care, and patients and staff risking infection in the office. Abuse of clinic staff, suffering of patients, suffering of staff and inequities for patients were also morally distressing, as were politics, inequities and injustices within the community. Clinicians who reported instances of inequities for patients and communities and the abuse of staff were more likely to report higher levels of moral distress. CONCLUSIONS: During the pandemic’s first 9 months, moral distress was common among these clinicians working in US safety net practices. But for only one-­quarter was this significantly distressing. As reported for hospital-­based clinicians during the pandemic, this study’s clinicians in safety net practices were often morally distressed by being unable to provide optimal care to patients. New to the literature is clinicians’ moral distress from witnessing inequities and other injustices for their patients and communities.

Moral distress has been well reviewed in the literature with established deleterious side effects for all healthcare professionals, including nurses, physicians, and others. Yet, little is known about the quality and effectiveness of interventions directed to address moral distress. The aim of this integrative review is to analyze published intervention studies to determine their efficacy and applicability across hospital settings. Of the initial 1373 articles discovered in October 2020, 18 were appraised as relevant, with 1 study added by hand search and 2 after a repeated search was completed in January and then in May of 2021, for a total of 22 reviewed articles. This review revealed data mostly from nurses, with some studies making efforts to include other healthcare professions who have experienced moral distress. Education-based interventions showed the most success, though many reported limited power and few revealed statistically lowered moral distress post intervention. This may point to the difficulty in adequately addressing moral distress in real time without adequate support systems. Ultimately, these studies suggest potential frameworks which, when bolstered by organization-wide support, may aid in moral distress interventions making a measurable impact.

Moral challenges have clear impacts on physician well-being. The concept of moral injury emerged from work with combat veterans. Existing diagnostic categories did not adequately capture the psychological challenges and distress seen in soldiers returning from war. The concept of moral injury was later applied to augment the understanding of physician distress, with the aim of considering varying etiologies of the symptoms of distress seen in healthcare workers. Healthcare worker moral injury occurs when physicians are repeatedly asked to participate in or witness acts which are not in accordance with their personal moral compass. System changes which acknowledge these distinct drivers of physician distress will be needed to improve physician well-being and enhance individual self-resilience.

BACKGROUND: "Moral distress" describes the psychological strain a provider faces when unable to uphold professional values because of external constraints. Recurrent or intense moral distress risks moral injury, burnout, and physician attrition but has not been systematically studied among neurosurgeons. OBJECTIVE: To develop a unique instrument to test moral distress among neurosurgeons, evaluate the frequency and intensity of scenarios that may elicit moral distress and injury, and determine their impact on neurosurgical burnout and turnover. METHODS: An online survey investigating moral distress, burnout, and practice patterns was emailed to attending neurosurgeon members of the Congress of Neurological Surgeons. Moral distress was evaluated through a novel survey designed for neurosurgical practice. RESULTS: A total of 173 neurosurgeons completed the survey. Half of neurosurgeons (47.7%) reported significant moral distress within the past year. The most common cause was managing critical patients lacking a clear treatment plan; the most intense distress was pressure from patient families to perform futile surgery. Multivariable analysis identified burnout and performing ≥2 futile surgeries per year as predictors of distress (P < .001). Moral distress led 9.8% of neurosurgeons to leave a position and 26.6% to contemplate leaving. The novel moral distress survey demonstrated excellent internal consistency (Cronbach alpha = 0.89). CONCLUSION: We developed a reliable survey assessing neurosurgical moral distress. Nearly, half of neurosurgeons suffered moral distress within the past year, most intensely from external pressure to perform futile surgery. Moral distress correlated with burnout risk caused 10% of neurosurgeons to leave a position and a quarter to consider leaving.

A specific kind of trauma results when a person’s core principles are violated during wartime or a pandemic

BACKGROUND: The 2019 coronavirus (COVID-19) pandemic placed unprecedented strains on the U.S. health care system, putting health care workers (HCWs) at increased risk for experiencing moral injury (MI). Moral resilience (MR), the ability to preserve or restore integrity, has been proposed as a resource to mitigate the detrimental effects of MI among HCWs. OBJECTIVES: The objectives of this study were to investigate the prevalence of MI among HCWs, to identify the relationship among factors that predict MI, and to determine whether MR can act as buffer against it. DESIGN: Web-based exploratory survey. SETTING/SUBJECTS: HCWs from a research network in the U.S. mid-Atlantic region. MEASUREMENTS: Survey items included: our outcome, Moral Injury Symptoms Scale–Health Professional (MISS-HP), and predictors including demographics, items derived from the Rushton Moral Resilience Scale (RMRS), and ethical concerns index (ECI). RESULTS: Sixty-five percent of 595 respondents provided COVID-19 care. The overall prevalence of clinically significant MI in HCWs was 32.4%; nurses reporting the highest occurrence. Higher scores on each of the ECI items were significantly positively associated with higher MI symptoms ( p < 0.05). MI among HCWs was significantly related to the following: MR score, ECI score, religious af?liation, and having ‡20 years in their profession. MR was a moderator of the effect of years of experience on MI. CONCLUSIONS: HCWs are experiencing MI during the pandemic. MR offers a promising individual resource to buffer the detrimental impact of MI. Further research is needed to understand how to cultivate MR, reduce ECI, and understand other systems level factors to prevent MI symptoms in U.S. HCWs.

Police and law enforcement agents in their professional work can, at times, face and experience situations which put them at risk of suffering from moral distress and moral injury. Moral distress and moral injury result from the discrepancy of one’s moral norms and values, on the one hand, and the organisational policy that a police and law enforcement agent has to implement, or the actual professional conduct she is performing, on the other hand. For example, a police officer using force to protect herself (or others), or being unable to help arriving at an accident, crime scene, or in a conflict situation. In this chapter, we first explore moral distress and moral injury from an ethical perspective. Then, since the concepts of moral conflict and moral dilemma are key to understanding moral injury, they are explained from a normative point of view. A brief exploration of the (philosophical) concept of the conscience follows. The second focus of this chapter is on the role of ethics, and particularly ethics education, in police conflict management and use of force training. One approach of how ethical theories, traditions and insights can help to frame moral conflicts and dilemmas is presented. The potential role of ethics in the prevention and healing of moral suffering is sketched. It is argued that – even basic – knowledge of ethical theories and recognising the underlying dimensions of moral conflicts and dilemmas can help one to better understand professional conduct and to deal with different layers of responsibility for the outcome of (in)actions. This understanding is important for reflecting on individual professional conduct – but also for police organisations to better deal with the challenges of moral stress and injury and support for their officers and agents.

[This is an excerpt.] Moral injury can occur when someone engages in, fails to prevent, or witnesses acts that conflict with their values or beliefs. Examples of events that may lead to moral injury include: Having to make decisions that affect the survival of others or where all options will lead to a negative outcome; Doing something that goes against your beliefs (referred to as an act of commission); Failing to do something in line with your beliefs (referred to as an act of omission); Witnessing or learning about such an act; Experiencing betrayal by trusted others. Such potentially morally injurious experiences may lead to feelings of moral distress such as guilt, shame, and anger. Moral injury is the lasting psychological, spiritual, behavioral or social impact that may result from these experiences. [To read more, click View Resource.]

Frontline health-care workers experienced moral injury long before COVID-19, but the pandemic highlighted how pervasive and damaging this psychological harm can be. Moral injury occurs when individuals violate or witness violations of deeply held values and beliefs. We argue that a continuum exists between moral distress, moral injury, and burnout. Distinguishing these experiences highlights opportunities for intervention and moral repair, and may thwart progression to burnout.

This paper presents the presence and impact of different models of occupational distress and their relationship with functioning. Evidence suggests that whilst multiple pathology frameworks contribute to overall distress, moral injury plays a unique role, with significant impacts on functioning

In recognition that existing theoretical paradigms may not offer a comprehensive account of the range of occupational stressors and responses experienced by healthcare professionals, interest in moral injury has grown. The Moral Injury Events Scale (MIES) remains the dominant assessment tool used to measure poten­ tially morally injurious experiences (PMIEs) across different occupational groups, including healthcare professionals. Given the proliferation of research using the MIES in healthcare, in the context of ongoing debates about its structure and utility, an exploration of the psychometric properties of the MIES with this population is timely. Using the data (N = 235) from a study exploring the prevalence of exposure to PMIEs, the current study reports on the factor structure of the MIES in healthcare professionals working within a secure mental health setting. The results yielded a two-factor model representing transgressions and betrayals by ‘others’, and transgressions committed by the ‘self’. Exploration of the internal consistency of the scale yielded a McDonald’s ω of .93. Multi-group confirmatory factor analysis highlighted the model was an adequate fit for White females, tentatively suggesting that experiences of moral injury may vary by gender, intersected by ethnicity. Accordingly, future frameworks, measures and interventions to remediate the impact of moral injury may require an intersectional approach.

Healthcare workers in secure psychiatric settings operate within highly restrictive legal frameworks and are often exposed to ethically complex scenarios. They also have an increased risk of experiencing a constellation of occupational traumas, resulting from exposure to violence and self-harm, which cumulatively can affect wellbeing and violate deeply held moral codes. Moral injury, which results from perpetrating, failing to prevent, witnessing, or learning about acts that transgress deeply held moral beliefs and expectations, has been posited as a construct that can account for a range of deleterious psychological outcomes. The current study sought to explore whether moral injury was endorsed, and related to wellbeing, within a secure psychiatric setting. The cross-sectional survey data (N = 237) showed that exposure to potentially morally injurious events and distress resulting from such events, were prevalent in healthcare professionals. Furthermore, moral injury was predictive of higher secondary trauma and burnout, and lower compassion satisfaction. The perceived impact of COVID-19 was also predictive of secondary trauma and burnout, though held no relationship with moral injury nor compassion satisfaction. The findings indicate that models of occupational distress would benefit from including consideration of the morally challenging nature of working in secure settings.