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OBJECTIVES: The potential usefulness of mindfulness-based interventions (MBIs) is being investigated for healthcare staff burnout and associated problems, but empirical research on MBI's for end-of-life (EOL) professionals is still in its infancy. The aim of this review is to describe and evaluate the body of evidence-based research on the use of MBIs to support the psychological wellbeing of professional staff in EOL care settings. METHODS: A systematic review of the literature was conducted. Database records were extracted from ERIC, PsycInfo, EBSCO, PubMed Central (PMC) and Web of Science, using search terms to locate peer-reviewed studies on professional (not volunteer) staff in dedicated end-of-life settings, administering MBIs not embedded in more general therapeutic modalities (such as ACT or DBT). After removing duplicates, 8701 potential studies were identified: eliminating those that did not fit the eligibility criteria reduced the number of eligible studies to six. RESULTS: A total of six empirical studies were identified and further evaluated. Interventions primarily focussed on reducing burnout symptoms, increasing self-care and self-compassion, and fostering mindfulness. Studies demonstrated very little overlap in treatment, methodology and measures. Only one study was a randomised control trial, which on application of the 3-item Jadad quality scoring, (evidence of randomisation, blinding of researcher to participants’ identity and accounts provided of all participants), achieved 1 out of 5 possible points. Furthermore, other concerns were identified as to the study's methodology. CONCLUSIONS: Results of this review point to significant gaps in the research on the potential of MBIs to improve the wellbeing of EOL professionals.

BACKGROUND: Female and racial/ethnic minority representation in surgical programs continues to trail behind other medical specialties. Various structural and perceived obstacles which contribute to a difficult path for underrepresented minority (URM) trainees have been identified, and efforts to reduce these hurdles are underway. Gaining perspective and insight from current surgical minority trainees may add valuable insight to aid with improving and innovating strategies to recruit and retain URM surgeons. OBJECTIVE: To characterize how race/ethnicity, cultural background, and gender affect the surgical training experience of URM surgical residents in all areas of surgery a focus on the field of Orthopedic Surgery, given its particularly poor rates of diversity. METHODS: Authors conducted semi-structured video interviews on current surgical residents or fellows who were members of underrepresented populations including Female, African-American/Black, Latino, Asian, Native American, and First or Second-generation immigrant status. Recruitment was achieved through a combination of voluntary, convenience, and snowball sampling procedures. Interview transcripts were then coded using conventional thematic analysis. Themes were iteratively expanded into subthemes and subsequently categorized utilizing a pile-sorting methodology. RESULTS: Among 23 surgical trainees 12 self-identified as Black (60.9%), 5 as Asian (17.4%), 1 as Hispanic (4.4%), and 5 as Caucasian (17.4%). Twelve residents identified as male (52%) and 11 as female (48%). Six surgical specialties were represented with the majority of participants (83%) being trainees in surgical subspecialties, among those orthopedic surgery was most strongly represented (57%). Analysis of their responses revealed 4 major themes: positive experiences, problems related to minority status, coping strategies, and participant suggested interventions. Themes were distilled further to sub-themes. Positive experiences' sub-themes included finding a supportive community, pride in minority status, and being able to better relate to patients. Negative experiences related to minority status' subthemes included perceived microaggressions and additional pressures, such as greater scrutiny and harsher punishments relative to their nonminority counterparts, which negatively impacted their surgical training. Most respondents did not feel there were dedicated resources to help alleviate these additional burdens, so some sought help outside of their training programs while others tried to assimilate, and others felt isolated. Recommended proposed interventions included validating the URM resident experience, providing education/training, and creating opportunities for mentorship. IMPLICATIONS/CONCLUSIONS: URM surgical trainees face numerous challenges related to their minority status. Recruitment and retention of URM in medicine would benefit from individual early and longitudinal mentorship, mitigating imposter syndrome, acknowledging the challenges faced by residents, and seeking feedback from both past and current residents.

This resource is found in our Actionable Strategies for Health Organizations: Promoting Diversity, Equity, & Inclusion.

International medical graduates (IMGs) represent 16% of general surgery residents.1 Mistreatment is common in general surgical training, particularly for non-White or Hispanic residents, and is associated with burnout.2 We assessed whether mistreatment and wellness differ between IMGs and US medical graduates in a national sample of general surgery residents.

In recent years, social workers have paid increased attention to ethical issues. The profession’s literature has burgeoned on topics such as ethical dilemmas in social work practice, ethical decision making, boundary issues and dual relationships, ethics-related risk management, and moral injury. This noteworthy trend builds on social work’s rich and long-standing commitment to the development of core values and ethical standards evident throughout its history. Unlike allied human service and behavioral health professions, social work’s ethics-related literature has not focused on the critically important issue of moral disengagement. Moral disengagement is typically defined as the process whereby individuals convince themselves that ethical standards do not apply to them. In social work, moral disengagement can lead to ethics violations and practitioner liability, particularly when social workers believe that they are not beholden to widely embraced ethical standards in the profession. The purpose of this article is to explore the nature of moral disengagement in social work, identify possible causes and consequences, and present meaningful strategies designed to prevent and respond to moral disengagement in the profession.

BACKGROUND: There is growing concern about moral distress and injury associated with the COVID-19 pandemic in healthcare professions. This study aimed to quantify the nature, frequency, severity and duration of the problem in the public health professional workforce. METHODS: Between 14 December 2021 and 23 February 2022, Faculty of Public Health (FPH) members were surveyed about their experiences of moral distress before and during the pandemic. RESULTS: In total, 629 FPH members responded, of which, 405 (64%; 95% confidence interval [95%CI] = 61–68%) reported one or more experience of moral distress associated with their own action (or inaction), and 163 (26%; 95%CI = 23–29%) reported experiencing moral distress associated with a colleague’s or organization’s action (or inaction) since the start of the pandemic. The majority reported moral distress being more frequent during the pandemic and that the effects endured for over a week. In total, 56 respondents (9% of total sample, 14% of those with moral distress), reported moral injury severe enough to require time off work and/or therapeutic help. CONCLUSIONS: Moral distress and injury are significant problems in the UK public health professional workforce, exacerbated by the COVID-19 pandemic. There is urgent need to understand the causes and potential options for its prevention, amelioration and care.

Pharmacists and other pharmacy personnel are experiencing job stress and burnout, and in some instances, suicidal ideation and death by suicide. However, the described lived experiences of pharmacists and other pharmacy personnel are not defined by burnout. Thus, consideration of and research about whether pharmacy personnel are possibly experiencing moral distress or moral injury is necessary and urgent. The pharmacy academy is served by considering workplace conditions and lived experiences of pharmacists because of the potential, negative impact on prospective student recruitment, quality of experiential sites and preceptors, sites for clinical faculty placement, and the well-being of alumni. Understanding phenomena occurring for pharmacy personnel and determining how they impact the pharmacy academy can lend itself to the future development of solutions.

[This is an excerpt.] Kolbe and de Melo-Martin (2023) describe fatal problems in current definitions and measurement of moral distress and injury (MD/I) in medical professionals, which impede development of genuine attempts at its prevention and treatment. We agree, and note that these problems are of particular consideration and concern for military medicine given the complementarity of professional duties borne by military healthcare professionals. [To read more, click View Resource.]

BACKGROUND: Emergency medical technicians (EMTs) or paramedics may not be able to do according to their moral standards during the COVID-19 pandemic, which can cause burnout and job dissatisfaction. 0BJECTIVES: This study aimed to evaluate moral distress (MD), job satisfaction, and burnout among EMTs during the COVID-19 pandemic. METHODS: This cross-sectional study was conducted in Bam, Iran in 2020. In total, 134 EMTs completed the online survey that included demographic information, a MD scale, the Maslach Burnout Inventory, and an item for assessing job satisfaction. Descriptive statistics along with independent samples t-test, one-way analysis of variance, Mann–Whitney U, and Kruskal–Wallis tests, as well as multiple linear regression analysis were used to analyze data. RESULTS: The mean scores of MD and job satisfaction were 25.44 ± 12.78 and 3.63 ± 1.07, respectively. Concerning severity, the mean scores of emotional exhaustion, depersonalization, and personal accomplishment (PA) were 35.45 ± 5.04, 20.61 ± 3.40, and 33.04 ± 4.07, respectively. All three burnout subscales were significantly correlated with job satisfaction (P < 0.05) and MD (P < 0.05). Access to personal protective equipment and education level significantly predicted MD (P < 0.05). CONCLUSION: Despite high burnout and moderate MD, EMTs reported high job satisfaction, possibly because of increased social respect and salary. EMTs can avoid MD and burnout by learning how to handle ethical challenges during the COVID-19 pandemic.

PURPOSE: Moral distress (MD) is the result of barriers or constraints that prevent providers from carrying out what they believe to be ethically appropriate care. This study was initiated to explore associations between MD, burnout, and the organizational climate (OC) for oncology physician assistants (PAs). METHODS: A national survey of oncology PAs was conducted to explore the associations between MD, OC, and burnout. The Nurse Practitioner-Primary Care OC Questionnaire was revised for oncology PAs to assess OC for PA practice. MD and burnout were assessed using the Measure of MD-Healthcare Professionals (MMD-HP) and the Maslach Burnout Inventory. RESULTS: One hundred forty-six oncology PAs are included in the analysis. PAs were mostly female (90%), White/Caucasian (84%), married/partnered (78%), and in medical oncology (73%), with mean age 41.0 years. The mean MMD-HP score for oncology PAs was 71.5 and there was no difference in MD scores on the basis of oncology subspecialty, practice setting, practice type, or hours worked per week. PAs currently considering leaving their position because of MD had significantly higher mean scores on the MMD-HP compared with those not considering leaving their position (108.2 v 64.8; P = .001). PAs with burnout also had significantly higher mean scores for MD compared with PAs without burnout (97.6 v 54.3; P < .001). A negative relationship between OC for PA practice and MD was only found for the PA-administration relations subscale, whereas all subscales were negatively associated with burnout. CONCLUSION: This study demonstrates that the risk of professional burnout increases significantly with increasing levels of MD. Additional research exploring the relationship between MD and burnout is needed.

Moral Injury is a concept developing in psychology literature to review the impact of war on veterans and has especially focused on individual symptoms and finding clear diagnosis tools. This paper explores the connection between moral injury and the context in which they occur, a relationship that provides valuable understanding about the experience, but also the systemic factors that increase the vulnerability. The article begins by setting the groundwork for the discussion and introducing moral injury and its associate concepts. Part two explores the institutional dimension of moral injury and how an individual's professions can contribute to the injury. Part three proposes how moral injury insights can be implemented as guiding principles within peace and security, and particularly in peacekeeping missions. The final conclusion points to the context and the institutional system as the frame where personal reaction, values and systemic influences combine to produce moral injury. Therefore, looking for solutions to prevent and treat moral injury must acknowledge the true roots causes of distress that is not part of individualistic pathologizing mental health diagnosis.

[This is an excerpt.] Moral injury has been defined as the combined psychological, social, and spiritual impact of events involving violation of personal moral beliefs and values, especially in high-stress situations. 1 For centuries, this phenomenon has been experienced by military service members who perpetrated, witnessed, or failed to prevent acts that transgressed their own moral values or code of conduct. Examples include causing the deaths of civilians, following illegal or immoral orders, or failing to provide needed medical assistance. General mechanisms of moral injury include acts of commission, acts of omission, and betrayal. [To read more, click View Resource.]

INTRODUCTION: Ethical issues are pervasive in healthcare, but few specialties rival the moral complexity of transplant medicine. Transplant providers must regularly inform patients that they are no longer eligible to receive a potentially life-saving operation and the stress of these conversations poses a high risk of moral injury. Training in end of life counseling (EOLC) has been shown to significantly reduce provider stress and burnout. We hypothesized that training in EOLC reduces levels of moral injury among transplant providers. METHODS: This was a mixed methods study. A survey was administered to staff in the solid organ transplant department at the University of Kansas health-system. Providers indicated whether they had received training in EOLC and completed the standardized Moral Injury Symptom Scale-Healthcare Professionals version (MISS-HP). A two-sample, one-sided t-test compared levels of moral injury between trained and untrained staff. Subsequently, semi-structured interviews were conducted with transplant providers, and inductive coding followed by thematic network analysis was performed. RESULTS: Thirty-seven percent of respondents reported a moral injury score at or above the threshold for psychosocial dysfunctioning associated with moral injury. Analysis revealed no difference in moral injury scores between the trained and untrained groups (p=0.362, power=0.842). Ten participants were interviewed. Thematic network analysis demonstrated high-level themes of “challenges”, “training” and “stress relief”. CONCLUSIONS: Our study demonstrated a concerning prevalence of moral injury among transplant providers and suggested that EOLC training does not significantly mitigate the threat of moral injury.

[This is an excerpt.] Physicians make a promise, when joining this profession, to care for ill and injured patients, to the best of their ability, absent self-interest. Throughout training that obligation is ingrained in our every decision. Mentors and colleagues demand that we live up to the same exceptionally high standards they have maintained, or risk rebuke, shunning, and serious sanctions. Our patients believe our oath—that we will put their best interests ahead of personal or professional gain—and, as one author said, they “offer their trust as a gift.”2 In accepting the honor of such freely given vulnerability, most physicians strive, in every encounter, to be worthy of it. However, over the last three decades reimbursement and regulatory pressures have corporatized medicine. Physicians, small business/private practice owners in decades past, are now mostly employed and increasingly torn between their covenant with patients and the allegiance they owe to employers. When that rift is irreconcilable, the result can be moral injury. [To read more, click View Resource.]

BACKGROUND: Potentially morally injurious events (PMIEs) can negatively impact mental-health. The COVID-19 pandemic may have placed healthcare staff at risk of moral injury. AIM: To examine the impact of PMIE on healthcare staff wellbeing. METHODS: Twelve thousand nine hundred and sixty-five healthcare staff (clinical and non-clinical) were recruited from 18 NHS-England trusts into a survey of PMIE exposure and wellbeing. RESULTS: PMIEs were significantly associated with adverse mental health symptoms across healthcare staff. Specific work factors were significantly associated with experiences of moral injury, including being redeployed, lack of PPE, and having a colleague die of COVID-19. Nurses who reported symptoms of mental disorders were more likely to report all forms of PMIEs than those without symptoms (AOR 2.7; 95% CI 2.2, 3.3). Doctors who reported symptoms were only more likely to report betrayal events, such as breach of trust by colleagues (AOR 2.7, 95% CI 1.5, 4.9). CONCLUSION: A considerable proportion of NHS healthcare staff in both clinical and non-clinical roles report exposure to PMIEs during the COVID-19 pandemic. Prospective research is needed to identify the direction of causation between moral injury and mental disorder as well as continuing to monitor the longer term outcomes of exposure to PMIEs.

Moral injury (i.e., perpetrating, witnessing, failing to prevent, or being a victim of acts that transgress one's moral beliefs, values, or ethics) has largely been studied in military-connected populations and is associated with a range of adverse psychological sequelae. Emerging literature suggests that healthcare workers also experience moral injury, particularly in the context of the ongoing COVID-19 pandemic. However, it is not known if moral injury contributes to substance use among healthcare workers or whether these effects might differ by gender, race/ethnicity, or occupational level. In March 2022, we collected self-reported pilot data from a diverse sample of US healthcare workers (N = 200) We examined the cross-sectional relationships between moral injury and several measures of substance use (i.e., current non-medical use of prescription drugs [NMUPD], current cannabis use, current use of other illicit drugs, and hazardous drinking) using separate logistic regression models. Next, we used separate interaction models to examine if any of these relations differed by gender, race/ethnicity, or occupational level. In main effects models, healthcare workers reporting greater moral injury had greater odds of current NMUPD (adjusted odds ratio (aOR) = 1.07; p < 0.001), current use of other illicit drugs (aOR = 1.09; p < 0.01), and hazardous drinking (aOR = 1.07; p < 0.01). These relations did not differ by race/ethnicity or occupational level (ps > 0.05); however, men were more likely to report current NMUPD and hazardous drinking (ps < 0.05) in the presence of high moral injury than women healthcare workers. Our findings suggest that healthcare workers experience substantial distress related to morally injurious events, which may affect their likelihood of NMUPD, cannabis use, use of other illicit drugs, and hazardous drinking, and that men in healthcare may be particularly at risk. Healthcare organizations should address systemic issues driving moral injury (e.g., resource shortages, lack of psychosocial support) to prevent substance-related harms among healthcare workers.

The framework of moral injury adds a relational and moral dimension to the discussion of physician distress and burnout, and it aids in the quest for effective interventions.

Nurse leaders face immense organizational pressures exacerbating their distress, which has not been prioritized as much as frontline nurses. This review synthesized the literature to examine theoretical models, measures, contributing factors, outcomes, and coping strategies related to moral distress in nurse leaders. PubMed, Embase, CINAHL, and PsycINFO were searched, and 15 articles—2 quantitative and 13 qualitative studies were extracted. The scoping review identified one study using a theoretical model and two measures—the ethical dilemmas questionnaire and the Brazilian moral distress scale. Contributing factors of moral distress include internal and organizational constraints, increased workload, and lack of support impacting physical and emotional well-being and intention to quit. This review did not yield any intervention studies emphasizing the need for research to identify specific predictors of moral distress and examine their relationship to nurse leader retention, so organizations can explore targeted interventions to promote coping and mitigate distress.

In modern primary care practice, clinicians face increasing volumes of asynchronous, electronic, non-visit care (NVC). Systems for completing this work, however, remain under-developed and often lack definition around patient and practice expectations for work completion and team member contributions. The resulting reactive, unstructured, and unscheduled NVC workflows cause and exacerbate physicians’ cognitive overload, distraction, and dissatisfaction. Herein, we propose that primary care practices take an intentional, holistic approach to managing systems of NVC and offer a conceptual model for managing NVC work, analogizing the flow of these tasks to the flow of water through a river system: (1) by carefully controlling the inputs into the NVC system (the tributaries entering the river system); (2) by carefully defining the workflows, roles and responsibilities for completion of common tasks (the direction of river flow); (3) by improving the interface of the electronic health record (obstacles encountered in the river); and (4) by optimizing effectiveness of primary care teams (the contours of the river determining rate of flow). This framework for managing NVC, viewed from a broader system perspective, has the potential to improve productivity, quality of care, and clinician work experience.

NYC Health + Hospitals implemented a large-scale nurse residency program to reduce turnover, improvetransition to practice and support first-year nurses.

Healthcare providers (HCPs) experience unprecedented burnout. During the COVID-19 pandemic, the healthcare workforce was pushed beyond its capacity, driving some out of the field, leaving hospitals and healthcare agencies to face unrelenting demand for care. Limited staff and resources challenged organizations to redesign infrastructure and processes to meet COVID-19 safety guidelines while balancing the priorities of finance and people. Two years into the pandemic, the signs of burnout among nurses in an RN-BSN program surfaced, which paralleled the bitter resentment happening across the nursing profession. Nurses working on the front lines reported feelings of abandonment, lack of resources, staffing shortages, exhaustion, fatigue, hopelessness, and a sense that healthcare systems were falling short in caring for the caregivers. Similar to military service members who returned from combat, nurses project the workforce will experience considerable post-traumatic stress disorder after the pandemic.