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This paper explores the issue of Moral Injury in firefighters and how it can affect their mental and spiritual health, both in and out of the firehouse. Moral Injury (MI) refers to experiences/situations that go against an individual’s internal moral compass such as lack of fairness or the inability todo what is right and just. Its symptoms are similar to those of Post-traumatic Stress Disorder(PTSD), and like PTSD, MI can be addressed and healed. We surveyed 479 firefighters across nine fire/EMS agencies using the Moral Injury Outcomes Scale (MIOS). Of our 479 responses, 276 (57.6%) reported having experienced a morally-injurious event such as mass shootings, car accidents, injured children, evidence of abuse, or their own failure to call out colleagues making mistakes on the job. Write-in comments indicated themes such as management/leadership failures,toxic organizational culture, lack of access to mental health resources, and adverse working conditions caused by personnel shortages, abuse of the 911 system for non-emergency medical calls, and department policies. A third of our sample responded affirmatively to items from The Primary Care PTSD Screen for DSM-5 regarding nightmares, intrusive thoughts, avoidance,hypervigilance, and guilt. Almost half of our sample responded affirmatively to the question about detachment/isolation. Furthermore, our results suggest that firefighters may not understand the definition of Moral Injury, nor its distinction from PTSD. Regardless of the label, even though the fire service culture is changing, more attention needs to be paid to reducing the stigma of behavioral health, implementing mental wellness programs, and improving access to mental health treatment.

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This resource is found in our Actionable Strategies for Public Safety Organizations: Status of Burnout & Moral Injury

AND Drivers (Relational Breakdown) AND Drivers (Operational Breakdown) AND Outcomes

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PURPOSE: This study aimed to evaluate the relationship between sleep, burnout, and psychomotor vigilance in residents working in the medical intensive care unit (ICU). METHODS: A prospective cohort study of residents was implemented during a consecutive 4-week. Residents were recruited to wear a sleep tracker for 2 weeks before and 2 weeks during their medical ICU rotation. Data collected included wearable-tracked sleep minutes, Oldenburg burnout inventory (OBI) score, Epworth sleepiness scale (ESS), psychomotor vigilance testing, and American Academy of Sleep Medicine sleep diary. The primary outcome was sleep duration tracked by the wearable. The secondary outcomes were burnout, psychomotor vigilance (PVT), and perceived sleepiness. RESULTS: A total of 40 residents completed the study. The age range was 26–34 years with 19 males. Total sleep minutes measured by the wearable decreased from 402 min (95% CI: 377–427) before ICU to 389 (95% CI: 360–418) during ICU (p < 0.05). Residents overestimated sleep, logging 464 min (95% CI: 452–476) before and 442 (95% CI: 430–454) during ICU. ESS scores increased from 5.93 (95% CI: 4.89, 7.07) to 8.33 (95% CI: 7.09,9.58) during ICU (p < 0.001). OBI scores increased from 34.5 (95% CI: 32.9–36.2) to 42.8 (95% CI: 40.7–45.0) (p < 0.001). PVT scores worsened with increased reaction time while on ICU rotation (348.5 ms pre-ICU, 370.9 ms post-ICU, p < 0.001). CONCLUSIONS: Resident ICU rotations are associated with decreased objective sleep and self-reported sleep. Residents overestimate sleep duration. Burnout and sleepiness increase and associated PVT scores worsen while working in the ICU. Institutions should ensure resident sleep and wellness checks during ICU rotation.

BACKGROUND: Moral injury (MI) has become a research and organizational priority as frontline personnel have, both during and in the years preceding the COVID-19 pandemic, raised concerns about repeated expectations to make choices that transgress their deeply held morals, values, and beliefs. As awareness of MI grows, so, too, does attention on its presence and impacts in related occupations such as those in public safety, given that codes of conduct, morally and ethically complex decisions, and high-stakes situations are inherent features of such occupations. OBJECTIVE: This paper shares the results of a study of the presence of potentially morally injurious events (PMIEs) in the lived experiences of 38 public safety personnel (PSP) in Ontario, Canada. METHOD: Through qualitative interviews, this study explored the types of events PSP identify as PMIEs, how PSP make sense of these events, and the psychological, professional, and interpersonal impacts of these events. Thematic analysis supported the interpretation of PSP descriptions of events and experiences. RESULTS: PMIEs do arise in the context of PSP work, namely during the performance of role-specific responsibilities, within the organizational climate, and because of inadequacies in the broader healthcare system. PMIEs are as such because they violate core beliefs commonly held by PSP and compromise their ability to act in accordance with the principles that motivate them in their work. PSP associate PMIEs, in combination with traumatic experiences and routine stress, with adverse psychological, professional and personal outcomes. CONCLUSION: The findings provide additional empirical evidence to the growing literature on MI in PSP, offering insight into the contextual dimensions that contribute to the sources and effects of PMIEs in diverse frontline populations as well as support for the continued application and exploration of MI in the PSP context.

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This resource is found in our Actionable Strategies for Public Safety Organizations: Drivers (Relational Breakdown) AND Drivers (Operational Breakdown) AND Outcomes

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Christina Maslach, a Berkeley psychologist defines “burnout” as emotional exhaustion, a sense of personal ineffectiveness, and depersonalization or a cynical instrumental attitude toward others. The Maslach Burnout Inventory is a 22 question survey that has been used to track workers emotional well-being.

Over the last decade, the term trauma-informed care has increased in popularity as human service organizations recognize the increasing need to serve individuals who have experienced trauma and adversity (Becker-Blease, 2017). One evidence-supported approach to trauma-informed organizational culture change is the Trauma Resilient Communities (TRC) Model. The current study focuses on the early experiences of leaders and followers within organizations implementing trauma-informed change during global and national traumatic events – the COVID-19 pandemic and racial trauma from police violence. Using a constant comparative method to thematic analysis, qualitative interviews were conducted with 19 backbone agency members trained in the TRC Model in Louisville, Kentucky. Findings indicate that in the early engagement stage of implementation, two key processes are critical: leadership buy-in and integration of the three organizational realms: clients, staff, and leaders. Implications are discussed and include recommendations for connecting the three realms of the organizational system, identifying capacity barriers, and utilizing the TRC Model to create equitable and trauma-resilient organizational culture.

During the COVID-19 pandemic, healthcare workers (HCW) were categorized as “essential” and “non-essential”, creating a division where some were “locked-in” a system with little ability to prepare for or control the oncoming crisis. others were “locked-out” regardless of whether their skills might be useful. The purpose of this study was to systematically gather data over the course of the COVID-19 pandemic from HCW through an interprofessional lens to examine experiences of locked-out HCW. This convergent parallel mixed-methods study captured perspectives representing nearly two dozen professions through a survey, administered via social media, and video blogs. Analysis included logistic regression models of differences in outcome measures by professional category and Rapid Identification of Themes from Audio recordings (RITA) of video blogs. We collected 1299 baseline responses from 15 April 2020 to 16 March 2021. Of those responses, 12.1% reported no signs of burnout, while 21.9% reported four or more signs. Qualitative analysis identified four themes: (1) professional identity, (2) intrinsic stressors, (3) extrinsic factors, and (4) coping strategies. There are some differences in the experiences of locked-in and locked-out HCW. This did not always lead to differing reports of moral distress and burnout, and both groups struggled to cope with the realities of the pandemic.

BACKGROUND: Increasing diversity in the nurse practitioner (NP) workforce is key to improving outcomes among patients who experience health inequities. However, few studies to date have examined the specific mechanisms by which NPs from diverse backgrounds address inequities in care delivery. PURPOSE: To explore Black NPs’ efforts in addressing inequities, and the facilitators and barriers they face in doing so. METHODOLOGY: We conducted focus groups and interviews of Black NPs (N = 16) in the greater Philadelphia area in early 2022, just following the height of the COVID-19 pandemic and the social unrest of the early 2020s. Data were analyzed using thematic analysis. RESULTS: Emergent themes included: Strategies Utilized to Address Health Inequities; Burnout & the Minority Tax; Risks & Rewards of Taking a Stance; and Uneven Promises of Organizational Engagement. Nurse practitioners prioritized patient-centered, culturally congruent care, taking additional time to explore community resources and learn about patients’ lives to facilitate care planning. Participants advocated to administrators for resources to address inequities while simultaneously navigating organizational dynamics, microaggressions, and racism. Finally, NPs identified organizational-level barriers, leading to emotional exhaustion and several participants’ intent to leave their roles. CONCLUSIONS: Black NPs use a myriad of strategies to improve equity, yet frequently face substantial barriers and emotional exhaustion in doing so with little change to the inequities in care. IMPLICATIONS: The NP workforce has a critical role to play in reducing health inequities. The strategies outlined by Black NPs in this study offer a roadmap for all clinicians and health care organizations to prioritize equity in care delivery.

Social media usage has drastically increased in recent years. In particular, social media usage among medical providers has become commonplace. It may offer a variety of benefits in the medical arena, with respect to information dissemination, health promotion, and education. However, the implications of social media usage and engagement remain to be seen. This narrative review aimed to describe and highlight the effects of social media usage and engagement and to provide guidance for engaging in social media as a medical professional. Our review demonstrates that active social media engagement unequivocally affords the urologist with meaningful opportunities for selfpromotion, branding, education, networking, research, and enhanced recruitment efforts, but this engagement comes with the risk for burdensome exposure to misinformation and harassment. We encourage adherence with American Urological Association/European Association of Urology (AUA/EAU) social media best practices and provide our own recommendations for social media engagement.

eHealth applications are considered a technological fix that can potentially address some of the grand challenges in healthcare, including burnout among healthcare professionals, the growing burden of patients with chronic conditions, and retaining and recruiting healthcare professionals. However, as the deployment of eHealth applications in healthcare is relatively novel, there is a lack of research on how they affect the work environment of healthcare professionals. This study explores how work evolves—particularly for nurses—during the utilisation of three eHealth applications.

BACKGROUND: At the end of life, people experiencing structural vulnerability (e.g. homelessness, poverty, stigmatization) rely on community service workers to fill gaps in access to traditional palliative services. Although high levels of burnout are reported, little is known about these workers' experiences of grief. AIM: To explore community service workers? experiences of grief to identify ways of providing more tailored, meaningful, and equitable supports. DESIGN: A community-based participatory action research methodology, informed by equity perspectives, was employed. SETTING/PARTICIPANTS: In an urban center in western Canada, community service worker (primary) participants (n=18) were engaged as members of an action team. A series of 18 action cycles took place, with secondary participants (n=48) (e.g. palliative, social care, housing support, etc.) being recruited throughout the research process. Focus groups (n=5) and evaluative interviews (n=13) with participants were conducted. Structured observational field notes (n=34) were collected during all team meetings and community interventions. Interpretive thematic analysis ensued through a collaborative and iterative process. RESULTS: During initial meetings, action team participants described experiences of compounding distress, grief, and multiple loss. Analysis showed workers are: (1) grieving as family, not just providers; (2) experiencing complex layers of compounded grief; and (3) are fearful to open the "floodgates" to grief. CONCLUSIONS: Findings contribute to our understanding on the inequitable distribution of grief across society. A collective and material response is needed, including witnessing, acknowledging and valuing the grief process; facilitating community wellness, collective grieving, and advocacy; and providing training and tools in a palliative approach to care.

The effects of burnout on client service provision, organizational health, and individual well-being are increasingly a focus of social work research, particularly against the societal backdrop of the post-COVID-19 era. Children and their families rely on school social workers (SSWs) to meet increasingly pressing and common mental health needs. However, burnout may jeopardize not only SSWs’ well-being, but also their collective ability to serve this vulnerable population. The current study captures SSW perspectives on burnout related to the following themes: SSW–administrator dynamics; role conflict and lack of role definition; presence of trauma in caseload; systemic challenges (including the subthemes of unrealistic workload, the desire for more interprofessional collaboration and social work–specific supervision, and limited resources); and the effects of the COVID-19 pandemic. Using these perspectives as a guide, policy recommendations are made to enhance interprofessional collaboration, clarify roles and responsibilities, and safeguard SSWs as “first responders” for children’s mental health.

Moral injury is the trauma caused by violations of deeply held values and beliefs. This paper draws on relational philosophical anthropologies to develop the connection between moral injury and moral identity and to offer implications for moral repair, focusing particularly on healthcare professionals. We expound on the notion of moral identity as the relational and narrative constitution of the self. Moral identity is formed and forged in the context of communities and narrative and is necessary for providing a moral horizon against which to act. We then explore the relationship between moral injury and damaged moral identities. We describe how moral injury ruptures one’s sense of self leading to moral disorientation. The article concludes with implications for moral repair. Since moral identity is relationally formed, moral repair is not primarily an individual task but requires the involvement of others to heal one’s identity. The repair of moral injury requires the transformation of a moral identity in community.

BACKGROUND: The COVID-19 pandemic worsened the ongoing overdose crisis in the United States (US) and caused significant mental health strain and burnout among health care workers (HCW). Harm reduction, overdose prevention, and substance use disorder (SUD) workers may be especially impacted due to underfunding, resources shortages, and chaotic working environments. Existing research on HCW burnout primarily focuses on licensed HCWs in traditional environments and fails to account for the unique experiences of harm reduction workers, community organizers, and SUD treatment clinicians. METHODS: We conducted a qualitative secondary analysis descriptive study of 30 Philadelphia-based harm reduction workers, community organizers, and SUD treatment clinicians about their experiences working in their roles during the COVID-19 pandemic in July–August 2020. Our analysis was guided by Shanafelt and Noseworthy’s model of key drivers of burnout and engagement. We aimed to assess the applicability of this model to the experiences of SUD and harm reduction workers in non-traditional settings. RESULTS: We deductively coded our data in alignment with Shanafelt and Noseworthy’s key drivers of burnout and engagement: (1) workload and job demands, (2) meaning in work, (3) control and flexibility, (4) work-life integration, (5) organizational culture and values, (6) efficiency and resources and (7) social support and community at work. While Shanafelt and Noseworthy’s model broadly encompassed the experiences of our participants, it did not fully account for their concerns about safety at work, lack of control over the work environment, and experiences of task-shifting. CONCLUSIONS: Burnout among healthcare providers is receiving increasing attention nationally. Much of this coverage and the existing research have focused on workers in traditional healthcare spaces and often do not consider the experiences of community-based SUD treatment, overdose prevention, and harm reduction providers. Our findings indicate a gap in existing frameworks for burnout and a need for models that encompass the full range of the harm reduction, overdose prevention, and SUD treatment workforce. As the US overdose crisis continues, it is vital that we address and mitigate experiences of burnout among harm reduction workers, community organizers, and SUD treatment clinicians to protect their wellbeing and to ensure the sustainability of their invaluable work.

INTRODUCTION: Empathy improves patient outcomes and increases perception of physician competence. However, empathy may contribute to biased decision-making and provider burnout. To help providers harness the benefits of empathy without the pitfalls, comprehensive knowledge about the practice of empathy is needed – particularly in high-stress contexts, such as in critical care. This qualitative study explores how critical care physicians experience empathy in intensive care units and how this might inform the medical education of critical care physicians throughout their training. METHODS: Working from a constructivist orientation, we engaged in thematic analysis of semi-structured interviews with critical care physicians. We asked participants to describe their personal experiences of empathy including how they handled events requiring empathy, managed empathic distress, and reframed their understanding of empathy over time. Data analysis followed the six steps of thematic analysis and used Hoffman’s Theory of Empathy to further inform our understanding of the data. RESULTS: We identified limitations of empathy in the intensivist experience, which were consistent with Hoffman’s theory of empathy. This theory describes arousal, habituation, and bias which were prevalent in the data. Further, intensivists altered their behavior due to these limitations and to manage empathic distress. Additionally, burnout as a consequence of empathy was identified, though interviewees discussed prevention methods and the development of resilience. DISCUSSION: Empathy and empathic distress among intensivists have been understudied in the literature thus far. Our study reveals that critical care physicians acutely experience limitations of empathy to include over-arousal, habituation, and bias—all of which impact interactions with patients, physician stress, and physician burnout. The knowledge that fully trained intensivists struggle with the limitations of empathy has implications to all stages of physician education from medical student through continuing medical education for attendings since all must learn and practice the empathic skills required to optimize patient care and maintain their own wellness.

[This is an excerpt.] Health and preventive interventions have significantly increased life expectancies in most developed countries. Resultantly, individuals are increasingly entering palliative care (PC) circumstances, and may present to the emergency department (ED) [1]. Providing care for individuals needing palliative services or at end-of-life (EOL) in the ED is challenging. Characterized by rapid assessment and initiating treatment with the goal of preserving life and facilitating recovery, the impetus within the ED is to ‘do something’ [[2], [3], [4]]. These goals can conflict with PC, which prioritizes ‘being with’ the patient; exploring goals with empathetic conversation while managing symptoms [3]. As such, the dying person can be ‘out of place’ and the dying process undermined by ED realities (e.g., crowding, time pressure) [5]. Exploring PC and EOL care in the ED is needed [6].Qualitative studies have begun to explore experiences of clinicians providing ED-based EOL care [1]. Across the literature, clinicians have identified ED space issues [[2], [7]], time pressures [[8], [9]], and inadequate PC education in pain management, as points of concern [[2], [7]]. Relational challenges were identified with some clinicians expressing fear of saying the wrong thing [2] and others intentionally distancing themselves [10]. A lack of pre-existing relationship exacerbated these challenges [7]. Additionally, ED staff face high risk of burnout in providing PC and EOL care within this acute care context [2]. [To read more, click View Resource.]

STUDY OBJECTIVES: Increased rates of suicide and suicidal thoughts amongst Emergency Medical Service (EMS) professionals continue to be reported in literature which has directed attention to potential causative factors. Burnout is one of the factors most discussed as being associated with this increase. There are limited studies of factors that correlate with increased burnout. Our objective was to conduct a survey of a statewide population of emergency services providers to evaluate their rate of burnout in addition to identifying both work and personal factors that may contribute to their burnout level. We also looked at self-reported burnout prior to the Covid 19 pandemic and during. METHODS: A voluntary, anonymous electronic survey was distributed to all registered emergency medical providers in the state of Louisiana through the Louisiana Bureau of EMS and the Louisiana Ambulance Alliance from 5/18/2020 to 7/24/2020. These participants represented paid and volunteer providers from a variety of systems to include; fire based, private, third city and air medical services. Data was analyzed utilizing descriptive statistics. RESULTS/FINDINGS: We received a total of 1,505 responses from the 24,000 EMS providers licensed with the Louisiana Bureau of EMS. The overall response rate when factoring all active Louisiana providers was 6.09% However, the response rate increases with increasing level of provider with more 50% of responses from paramedic and advanced emergency medical technicians (AEMT) The paramedic response rate was 22.39%. The advanced EMT response rate was 28.74% The EMT response rate was much lower at 9.03%. Burnout level increased with number of years of EMS experience, increased years at current EMS provider level and more advanced levels of provider. Shift length of 12-24 hours showed the highest level of burnout (2.8, IQR 2-4). Decreased amounts of sleep correlated with increasing burnout levels. Supervisory positions correlated with higher levels of burnout. Services that did transfers only showed the lowest burnout levels (1, IQR 0-2) and those who did scene calls with and without transfer and special events showed the highest levels of burnout (2.75, IQR 2-3.5). Burnout level for pre-COVID (at 2.1) was statistically lower than burnout during COVID (2.7, p=3.15x10- 24). Burnout level pre-COVID was highest when respondents were contemplating leaving the profession and expected their profession to end within less than 1.75 years (135 individuals fall into this category). Burnout during COVID was highest not only with those two categories influencing it, but also with the perception of unfair compensation, typical shift length and years of experience. Unfair compensation had a greater impact for the COVID burnout measurement than years of expected continued service. CONCLUSIONS: Pressures resulting in high burnout changed in this time; although contemplating leaving was still the greatest factor contributing to burnout, the second-most important decision changed from predictions about continued employment to concerns regarding fair compensation. Burnout was significantly higher during COVID and was subject to more variables than pre-COVID burnout.

This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).

Grit is a personality trait that is defined as passion and perseverance for a long-term goal. Resilience is defined as the ability to recover or adjust to misfortune or change. The 2 concepts are inexorably intertwined. Surgery residents demonstrate higher average grit scores than the general population. Increased levels of grit predict success in many areas of life and are positively correlated with satisfaction in surgery residency. Decreased levels of grit correlate with burnout, attrition, and suicidality in resident surgeons. Personal grittiness can be increased by a focused interest in an area, deliberate goal-directed practice, finding a calling in life, and cultivating hope and resilience. Resilience, like grit, can be nurtured over time with deliberate steps. Grit and resilience are important in residency training, and training programs can be tailored to promote a wise environment, with demanding, yet supportive, departments. Organizational grit can be boosted by seeking to maximize successful attributes of dynamic organizations.

Two years into a global pandemic, healthcare team members are in crisis. Leaders are bombarded with competing messages about how to support them and address workforce shortages. A group of experts in collaboration with the National Academy of Medicine identified the top five actions leaders should take to support team members now. These evidence-based actions can be initiated within 3 months and build a foundation for a long-term system well-being strategy.

The National Domestic Worker’s Bill of Rights Act aimed to remedy nearly a century of labor and health inequities facing a majority of the home health workforce—including home health workers, personal care aides, and professional caregivers—who are women of color and immigrants. Although the bill did not pass, the National Domestic Workers Alliance and its affiliates continue to organize a new labor movement inclusive of home care workers that supports federal legislation and adequate labor protections for their members, particularly in right-to-work states like Texas and in municipalities where hazardous working conditions and low wages contribute to the perceived disposability and devaluation of care labor. Home care workers require federal labor protections that will hold states accountable for the health and well-being of this essential workforce.