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Moral injury results from the violation of deeply held moral commitments leading to emotional and existential distress. The phenomenon was initially described by psychologists and psychiatrists associated with the US Departments of Defense and Veterans Affairs but has since been applied more broadly. Although its application to healthcare preceded COVID-19, healthcare professionals have taken greater interest in moral injury since the pandemic’s advent. They have much to learn from combat veterans, who have substantial experience in identifying and addressing moral injury—particularly its social dimensions. Veterans recognise that complex social factors lead to moral injury, and therefore a community approach is necessary for healing. We argue that similar attention must be given in healthcare, where a team-oriented and multidimensional approach is essential both for ameliorating the suffering faced by health professionals and for addressing the underlying causes that give rise to moral injury.

Since the start of the COVID-19 pandemic, nursing home residents have accounted for roughly one of every six COVID-19 deaths in the United States. Nursing homes have also been very dangerous places for workers, with more than one million nursing home workers testing positive for COVID-19 as of April 2022. Labor unions may play an important role in improving workplace safety, with potential benefits for both nursing home workers and residents. We examined whether unions for nursing home staff were associated with lower resident COVID-19 mortality rates and worker COVID-19 infection rates compared with rates in nonunion nursing homes, using proprietary data on nursing home–level union status from the Service Employees International Union for all forty-eight continental US states from June 8, 2020, through March 21, 2021. Using negative binomial regression and adjusting for potential confounders, we found that unions were associated with 10.8 percent lower resident COVID-19 mortality rates, as well as 6.8 percent lower worker COVID-19 infection rates. Substantive results were similar, although sometimes smaller and less precisely estimated, in sensitivity analyses.

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This resource is found in our Actionable Strategies for Government: Empowering Workers & Strengthening Leadership and Governance (Strengthening Protections to Speak Up)

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OBJECTIVES: Religion and spirituality are important aspects of many physicians and patients’ lives and may impact their views of death and the way they interact with terminally ill patients, specifically comfort discussing end-of-life care and death and dying. This study explores the religious and spiritual beliefs of resident physicians, if they affect interactions with their patients and if burnout impedes this interaction. METHODS: A 28-item questionnaire was administered to residents and fellows at an urban academic hospital. RESULTS: 65 residents and fellows answered the survey. Religiosity but not spirituality correlated with reported comfort interacting with patients dealing with death or dying. Resident specialty, biological sex and spirituality were not associated with comfort and conversations about religion and end-of-life care. The majority (60%) reported that the pandemic has not affected how they speak to their patients about death and dying. Caring for a higher volume of terminally ill patients was not associated with high levels of burnout though 71% reported increased burnout due to COVID-19. CONCLUSION: Further research can be done to determine whether additional training or resources should be provided to resident physicians to cope with death and dying in the setting of a pandemic.

The past 3 years mark the largest wave of activism by resident physicians advocating for physician well-being since the mid-1970s. As the COVID-19 pandemic has magnified systemic factors driving persistent burnout in medicine, resident physicians and fellows are increasingly rejecting the status quo of long hours and low pay during medical training. Burnout is commonly defined as a work-related syndrome of emotional exhaustion, depersonalization, and diminished feelings of personal accomplishment. Driven by a desire to counteract physician burnout, improve health care equity, and reprioritize the patient-physician relationship, house staff (ie, resident physicians and fellows) are increasingly taking action through labor unions.

LEARNING OBJECTIVES: 1) Anonymously survey residents to obtain rates of burnout and identify gaps in resident wellness. 2) Create a resident-led, self-sustaining wellness committee 3) Integrate wellness education into a formal grand rounds curriculum 4) Reduce self-reported resident burnout rates. INTRODUCTION/BACKGROUND: Residents suffer from numerous stressors that lead to poor mental health and significant rates of burnout. The Madigan Army Medical Center Emergency Medicine (EM) residency program had aspects of wellness built into its program but lacked a formal wellness curriculum or internal evaluation system. CURRICULAR DESIGN: To address the lack of formal wellness resources, anonymous surveys were sent to residents, a formal wellness curriculum developed, and a resident-led wellness committee was formed. Following an introductory wellness lecture, residents were anonymously surveyed to assess knowledge of local wellness resources, rates of burnout, and gaps in resident wellness. This survey will be administered biannually, at the beginning and middle of each academic year. A resident-led wellness committee was formed with the goals of serving as a monitoring group for resident mental health and wellness, serving as a think tank to address identified mental health and wellness gaps, and creating and planning wellness interventions. A wellness curriculum was added into the current grand rounds curriculum, covering burnout, mindfulness, financial planning, professionalism, peer support, local behavioral health resources, sleep hygiene, and faculty experiences on work-life balancing. IMPACT/EFFECTIVENESS: This innovation will provide an anonymous before and after evaluation of a multi-faceted approach to resident wellness in an EM residency program. Formal reevaluation of resident wellness and burnout rates are pending repeated surveying. The initial survey generated multiple initiatives, which the wellness committee has already addressed such as EM food pantry creation and shift schedule alterations. Anecdotally, residents have responded very positively to these interventions and the renewed focus on resident wellness. Program leadership is supportive of this program and plans are in place to sustain this initiative for the foreseeable future.

OUTCOMES: 1. Explain feasibility and acceptability of the PRISM at Work program for healthcare providers 2. Explain the preliminary efficacy of the PRISM at Work program for healthcare providers on reducing stress, resilience, and burnout IMPORTANCE: Healthcare workers face serious mental health challenges as a result of ongoing work stress. The COVID pandemic exacerbated that stress, highlighting the critical need for evidence-based stress interventions. OBJECTIVE(S): The goal of this study was to examine feasibility, acceptability, and preliminary efficacy of PRISM at Work, a skill-based program designed to reduce stress and build resilience. METHOD(S): In response to COVID-19, we translated the Promoting Resilience in Stress Management (PRISM) program, a manualized, skill-based program originally developed for adolescents and young adults with medical illness, to a program that could support healthcare workers. It included 6 weekly 1-hour sessions on Zoom, covering topics including stress management, goal setting, cognitive reframing, and meaning making. Feasibility and acceptability were assessed by enrollment and completion rates and satisfaction surveys. Preliminary efficacy was assessed with pre-post assessments of resilience, stress, anxiety, and burnout. Descriptive statistics were used to summarize feasibility and acceptability outcomes. Linear mixed effects regression models were used to examine the impact of PRISM on outcomes. RESULTS: Of the 153 participants who enrolled, 92% were female, 46% were ?40 years old, 87% were White, 53% worked in a clinical role, and 59% were married. Feasibility was demonstrated in that all 15 courses were filled to capacity and 91% completed the program. 91% reported being satisfied with PRISM, and 89% were likely to recommend PRISM to colleagues. Regression analyses demonstrated improvements in resilience (1.74, 95% CI [1.00, 2.47]), anxiety (–2.06, 95% CI [–2.75, –1.36]), stress (–2.43, 95% CI [–3.30, –1.55]), and burnout (–0.37, 95% CI [–0.56, –0.18]) (all ps < .001). CONCLUSION(S): PRISM at Work is a feasible and acceptable program that shows promise in managing stress, building resilience, and reducing burnout for healthcare workers. IMPACT: A continuation of this work, beyond the scope of the COVID pandemic, is critical given the historical and ongoing burden and distress prevalent in the healthcare profession.

BACKGROUND: Transitioning to practice during the COVID-19 pandemic multiplied the stressors and challenges typically encountered by new graduate nurses (NGNs), yet research exploring mental health variables of this subset of nurses remains sparse. METHOD: This study used an observational design and convenience sampling. NGN alumni (n = 192) from a pre-licensure nursing program were surveyed during the summer of 2021 regarding their experiences with resilience, anxiety, depression, and stress while transitioning to practice during the COVID-19 pandemic. RESULTS: Participants reported moderate to severe levels of stress (76%), anxiety (27.6%), and depression (31.2%) while transitioning to practice. Most (79%) described themselves as resilient. The highest mean scores for stress, anxiety, and depression occurred during the fourth to eighth month of practice. CONCLUSION: Nursing professional development specialists, managers, and other stakeholders need effective strategies to monitor and promote NGNs' well-being and mental health to prevent burnout and turnover throughout the first year of practice. [J Contin Educ Nurs. 2022;53(12):533–543.]

BACKGROUND: Medical training program and hospital response to the COVID-19 pandemic has varied greatly and has impacted trainee well-being. Which factors have specifically related to trainee wellness, however, has not yet been examined in depth. The aim of the study was to understand trainee perspectives on the individual psychiatry trainee programs' hospitals' objective COVID-19 preparedness management. We also sought and to gauge how program changes, and general pandemic-related concerns, have been associated with trainee satisfaction and burnout. METHODS: A cross-sectional survey study of psychiatric trainees was distributed electronically throughout the country via various psychiatry residency program listservs in April 2020. Statistical analyses were performed utilizing simple linear regression. RESULTS: From 352 respondents (346 complete responses and 6 partial responses), the most frequent program changes were "decreased number of rotations requiring in-person patient care" and "increased call hours or duties." Of pandemic-related concerns surveyed, the two greatest were "spreading COVID-19 to family/friends" and "co-residents' burnout and anxiety." A positive relationship was found between trainee satisfaction with perceived COVID-19 departmental response and comfort level of residents/fellows in expressing concerns with attending clinicians and department leadership. CONCLUSIONS: Since the start of the COVID-19 pandemic, trainees have experienced a variety of changes to trainee program policies and guidelines. Overall, poor communication and trainee dissatisfaction with departmental response correlated with concern of infection and anxiety/burnout. Insights garnered from this study could provide scaffolding for the best practices to reduce trainee physician anxiety/burnout for the current and future pandemics of this variety and magnitude.

BACKGROUND: Effective team communication is an essential aspect of care delivery and the coordination of patients in primary care settings. With the rapid evolution of health information technology (HIT), including the implementation of electronic health records, there remains a gap in the literature about preferred methods of primary care team communication and the subsequent impact of provider and team outcomes (e.g., team cohesiveness; burnout). This study explores the impact of varying modes of communication across provider disciplines and by geographic settings during primary care delivery. METHODS: We used a cross-sectional survey design to collect data from a random convenience sample of PCPs (physicians, nurse practitioners, and physician assistants) (n = 314) in New York State (NYS). We mailed a paper survey with validated measures for communication methods, team cohesiveness, and provider outcomes (burnout, job dissatisfaction, and the intention to leave position). Descriptive statistics, linear regression models, and crude and adjusted odds ratios while controlling for individual and practice characteristics were calculated. RESULTS: In-person communication was found to yield greater job satisfaction and less intention to leave current position in the next year () compared to other forms of communication including electronic health record features. The odds of job satisfaction was 1.51 times higher with in-person communication (OR: 1.51, 95% CI: 1.05, 2.19), and the odds of intending to leave a position was 45% less with in-person communication (OR: 0.55, 95% CI: 0.36, 0.85). The odds of reporting burnout at work was 36% less with in-person communication (OR: 0.64, 95% CI: 0.43, 0.92) compared to other communication modalities. There was no significant association between team communication via the EHR and team cohesiveness, provider burnout, or job satisfaction. CONCLUSION: This study demonstrates evidence that in-person communication is more likely to reduce burnout and job dissatisfaction compared to other forms of communication infrastructure in primary care settings. More research is needed to understand PCP perspectives about the functionality and potential burden that inhibits the use of EHR features for provider-provider communication. In addition, attention to the needs of teams by geographic location and by workforce discipline is warranted to ensure effective HIT communication application adoption.

Hospital epidemiologists, infection preventionists, and antimicrobial stewards are integral to the pandemic workforce. However, regardless of pandemic surge or postsurge conditions, their workload remains high due to constant vigilance for new variants, emerging data, and evolving public health guidance. We describe the factors that have led to burnout and suggest strategies to enhance resilience.

BACKGROUND: It is estimated that over half of medical students experience severe distress, a condition that correlates with low mental quality-of-life, suicidal ideation and serious thoughts of dropping out. While several risk factors for the development of severe distress have been identified, most focus on individual student characteristics. Currently, little is known about the impact medical schools have on student wellbeing. METHODS: Prospective, observational survey study from 2019–2020 from a national cohort of US medical students. Student wellbeing, school characteristics, and wellbeing resource availability was measured with a 30-question electronic survey. Medical student distress was defined as a Medical Student Wellbeing Index (MS-WBI) of ?4. Risk factors for the development of severe distress were evaluated in a multivariate logistic regression model. The impact of the number of wellbeing resources available on student wellbeing was measured along multiple wellbeing domains. Independent reviewers categorized free text analysis of survey responses about desired wellbeing resources into themes. RESULTS: A total of 2,984 responses were included in the study, representing 45 unique medical schools. Medical school characteristics independently associated with severe distress included low faculty support (OR 4.24); the absence of mentorship resources (OR 1.63) and the absence of community building programs (OR 1.45) in a multivariate model. Increased availability of wellbeing resources was associated with lower average MS-WBI (4.58 vs. 3.19, p<0;05) and a smaller percentage of students who had taken or considered taking a leave of absence (40% vs. 16%, p<0.05). The resources most desired by students were mental health services and scheduling adjustments. CONCLUSIONS: The majority of medical school characteristic that contribute to student distress are modifiable. Improving faculty support and offering more and varied wellbeing resources may help to mitigate medical student distress. Student feedback is insightful and should be routinely incorporated by schools to guide wellbeing strategies.

[This is an excerpt.] Purpose: Nurses have a duty to care for patients and are challenged to thoughtfully analyze the balance of professional responsibility and risk, including competing moral obligations and options, in order to preserve the ethical mandates in situations with actual or potential risk to the nurse or profession. Statement of ANA Position: The American Nurses Association (ANA) believes that nurses are obligated to care for patients in a nondiscriminatory manner, with respect for all individuals. The ANA recognizes there may be limits to the personal risk of harm nurses can be expected to accept as an ethical duty. Harm includes emotional, psychological, physical, moral, or spiritual harm. When defining professional nursing responsibilities, nurses consider the required, reciprocal obligations of employers, government, and society to provide the resources necessary to reduce known or unknown risks. Nurses are not obligated to take on extreme risk to prove their value. [To read more, click View Resource.]

Emergency department staff are often affected by incidents of violence. The aim of the study was to generate data on the frequency of violence by patients and accompanying relatives and the correlation between experienced aggression, a possible risk of burnout and a high sense of stress. Additionally, the buffering effect of good preventive preparation of care staff by the facility on aggressive visitors and patients was examined. In this cross-sectional study, members of the German Society for Interdisciplinary Emergency and Acute Medicine were surveyed. The investigation of risk factors, particularly experiences of verbal and physical violence, as well as exhaustion and stress, was carried out using ordinal regression models. A total of 349 staff from German emergency departments took part in the survey, 87% of whom had experienced physical violence by patients and 64% by relatives. 97% had been confronted with verbal violence by patients and 94% by relatives. Violence by relatives had a negative effect on perceived stress. High resilience or effective preparation of employees for potential attacks was shown to have a protective effect with regard to the burnout risk and perceived stress. Therefore, management staff play a major role in preventing violence and its impact on employees.

PURPOSE: Research evaluating the well-being of rural family physicians is limited, resulting in minimal understanding of how to prepare family medicine residents to succeed in rural practice postresidency. Our study aimed to investigate factors associated with maintaining wellness within rural family medicine practices and highlight interventions that rural family physicians identify as important to promote wellness among those seeking future employment in rural settings postresidency. METHODS: Forty-eight rural family physicians completed an online survey with qualitative and multiple-choice items including the Mini-Z about physician demographics, burnout, and wellness. We conducted data analysis using NVivo 12 software for qualitative analyses and R 3.6.1 software for descriptive statistics. RESULTS: The majority of participants reportedly maintained wellness in rural family practice (maintenance of wellness=79.17%; denied burnout=62.26%). Burnout rates were similar to the national burnout rates for family physicians (37.74% vs 46%). Participants identified multiple residency interventions that could be implemented to prepare rural family physicians to succeed. CONCLUSIONS: This study highlights factors that are associated with the maintenance of wellness among rural family physicians. This is the first study to investigate rural family physician perspectives on residency interventions that may have positive outcomes on wellness postresidency.

OBJECTIVE: To measure wellness and burnout among gynecologic oncology clinicians and identify trends and at-risk populations to inform future interventions. METHODS: Gynecologic oncologist (GO) and advanced practice provider (APP) responses to the 2020 Society of Gynecologic Oncology State of the Society survey were analyzed. The Maslach Burnout Inventory criteria for burnout was used. Work-life balance was scored on a 5-point Likert scale. Chi-square tests were used to compare mental health factors and the prevalence of burnout. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for associations between burnout and gender. RESULTS: 543 survey responses were included for analysis. Most GO (54%) and all APP respondents were female. Female GOs were disproportionately affected by burnout particularly in the Northeast (female(F): 40.9% vs male(M): 19.1%, p = 0.007) and South (F: 42.5% vs M:22.9%, p = 0.01). Burnout in female GOs over 40 was 1.79 (CI: 1.13–2.83; p-value 0.01) times higher than similarly aged males. Females in non-private practice experienced burnout 1.66 times that of males in similar positions (CI: 1.18–2.94; p < 0.0001). Female GOs reported the worst work-life balance across all 5 domains. APPs and female GOs experienced more stress and feeling overwhelmed compared to men. GOs were more reluctant to see a mental health professional (p = 0.0003) or take medication (p = 0.009) than APPs. CONCLUSIONS: Burnout in gynecologic oncology persists in both genders and is felt most acutely by female GOs. APPs are not immune and would benefit from inclusion in future research to mitigate burnout in healthcare clinicians.

The optimal staffing model for physicians in the ICU is unknown. Patient-to-intensivist ratios may offer a simple measure of workload and be associated with patient mortality and physician burnout. To evaluate the association of physician workload, as measured by the patient-to-intensivist ratio, with physician burnout and patient mortality. DESIGN: Cross-sectional observational study. SETTING: Fourteen academic centers in the United States from August 2020 to July 2021. SUBJECTS: We enrolled ICU physicians and collected data on adult ICU patients under the physician's care on the single physician-selected study day for each physician. MEASUREMENTS AND MAIN RESULTS: The primary exposure was workload (self-reported number of patients' physician was responsible for) modeled as high (>14 patients) and low (?14 patients). The primary outcome was burnout, measured by the Well-Being Index. The secondary outcome measure was 28-day patient mortality. We calculated odds ratio for burnout and patient outcomes using a multivariable logistic regression model and a binomial mixed effects model, respectively. We enrolled 122 physicians from 62 ICUs. The median patient-to-intensivist ratio was 12 (interquartile range, 10-14), and the overall prevalence of burnout was 26.4% (n = 32). Intensivist workload was not independently associated with burnout (adjusted odds ratio, 0.74; 95% CI, 0.24-2.23). Of 1,322 patients, 679 (52%) were discharged alive from the hospital, 257 (19%) remained hospitalized, and 347 (26%) were deceased by day 28; 28-day outcomes were unknown for 39 of patients (3%). Intensivist workload was not independently associated with 28-day patient mortality (adjusted odds ratio, 1.33; 95% CI, 0.92-1.91). CONCLUSIONS: In our cohort, approximately one in four physicians experienced burnout on the study day. There was no relationship be- tween workload as measured by patient-to-intensivist ratio and burnout. Factors other than the number of patients may be important drivers of burnout among ICU physicians.

BACKGROUND: Sabbaticals are an important feature of academia for faculty and their institutions. Whereas sabbaticals are common in institutions of higher learning, little is known about their role and utilization in US medical schools. This perspective piece examining sabbaticals in medical school faculty was undertaken at a time that well-being of health professionals was increasingly being recognized as a workforce health priority. METHODS: We surveyed associate deans at US medical schools in 2021 about faculty who had taken sabbaticals within the past 3 years, the parameters of the sabbaticals, and institutional policies and respondents' predictions of future sabbatical use. RESULTS: A total of 53% of respondents reported any faculty had taken sabbaticals in the past 3 years (M = 6.27; Median = 3; range = 1-60). Institutions rated enhancing research as the most important objective, while recognizing other benefits. Sabbaticals were more commonly taken by male, white, senior faculty PhDs. Details about sabbaticals, including eligibility, expectations, length, financial support, and benefits were reviewed. Most (54.8%) respondents expected no change in the number of faculty seeking sabbaticals. Nearly all anticipated the COVID-19 pandemic would not affect sabbatical policies. CONCLUSION: In contrast to other institutions of higher learning, sabbatical-taking by medical school faculty is rare. We explore factors that may contribute to this phenomenon (eg, the tripartite mission, faculty clinical responsibilities, culture of medicine, and student debt). Despite financial and other barriers, a closer look at the benefits of sabbaticals is warranted as a mechanism that may support faculty well-being, retention, and mental health.

BACKGROUND: The increasing number of physicians leaving practice, especially hospitalists, has been well-documented. The most commonly examined factor associated with this exodus has been burnout. The COVID-19 pandemic has put a unique and unprecedented stress on hospitalists who have been at the front lines of patient care. Therefore, the investigation of burnout and its related factors in hospitalists is essential to preventing future physician shortages. OBJECTIVE: This study examined the relationship between burnout, second victim, and moral injury experiences before and during the COVID-19 pandemic among hospitalists. METHODS: Two anonymous cross-sectional surveys of hospitalists from a community hospital in the metropolitan Washington, DC area were conducted. One was conducted pre-COVID-19 (September-November 2019) and one was conducted during COVID-19 (July-August 2020). The surveys were sent to all full-time hospitalists via an online survey platform. A variety of areas were assessed including demographic (e.g., age, gender), work information (e.g., hours per week, years of experience), burnout, second victim experiences, well-being, and moral injury. RESULTS: Burnout rates among providers during these two time periods were similar. Second victim experiences remained prevalent in those who experienced burnout both pre and during COVID-19, but interestingly the prevalence increased in those without burnout during COVID-19. Moral injury was predictive of burnout during COVID-19. CONCLUSION: While there were some factors that predicted burnout that were similar both pre- and during-pandemic, moral injury was unique to predicting burnout during COVID-19. With burnout as a contributing factor to future physician shortages, it is imperative that predictive factors in a variety of different environments are well understood to prevent future shortages. Hospitalists may be an excellent barometer of these factors given their presence on the front line during the pandemic, and their experiences need to be further explored so that targeted interventions aimed at addressing those factors may be created.

OBJECTIVE: Within the last 20 years, there has been a 500% increase in public safety suicides, the exact cause of which is unknown. METHODS: This was a cross-sectional survey of emergency medical services (EMS) personnel. Nine EMS agencies were selected to participate based on geography and population. The survey assessed sociodemographic, occupational, and military factors. Childhood adversity and traumatic experiences were evaluated using the Adverse Childhood Experiences Questionnaire and the Life Events Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, respectively. Using factors signi?cant in univariate analyses, a logistic regression was conducted to determine predictors of suicidality while controlling for potential confounders. RESULTS: A total of 681 EMS providers participated; 56.1% were male, 12.6% were minorities, and 72.8% were paramedics. Nearly a quarter (24.4%) had considered suicide. Approximately twice as many had received counseling for a stress-related event, and 1.5 times as many identi?ed as currently in counseling. Indigenous populations were 4.76 times more likely to have suicidality (odds ratio [OR] = 4.76; 95% confidence interval [CI], 1.22-18.62). Suicidality was 97% more likely in EMS professionals with prior military service (OR = 1.97; 95% CI, 1.08-3.57) and 2.22 times more likely in sexual minorities (OR = 2.22; 95% CI, 1.16-4.25). Emotional abuse (OR = 1.86; 95% CI, 1.08-3.21) and burnout (OR = 2.88; 95% CI, 1.78-4.66) were also predictive. CONCLUSIONS: Suicidality is an indisputable concern for the EMS profession and represents a multifaceted issue that must be addressed.

BACKGROUND: Advanced practice RNs (APRNs) working in rural primary care provide a spectrum of health care needs that can lead to professional burnout. As a preventative for burnout, the Institute of Medicine developed a strategy focused on self-care. Understanding the importance of self-care as a preventive for building professional resilience to manage workplace stressors during students' academic years may improve retention. METHOD: Twenty-two APRN students participated in a rural primary care immersion course with a specific component on self-care. Preand postsurveys, student journaling, class discussions, and a posttraining focus group were used to assess students' progress. RESULTS: Students reported strengthening patient and team relationships, enhanced interpersonal communication, and increased self-awareness of stressors for managing their emotions. These self-imposed processes improved student confidence, job satisfaction, and workplace resilience. CONCLUSION: Heath-promoting behaviors via self-care during APRN students' formal education may assist them in their clinical practice as rural primary care providers. [J Nurs Educ. 2022;61(4):187-191.].