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3. Moral Injuries in Healthcare Workers: What Causes Them and What to Do About Them?

Author

Rabin S, Kika N, Lamb D, Murphy D, AM Stevelink S, Williamson V, Wessely S, and Greenberg N

Subjects
moral injury, healthcare workers, causes, effects, mitigation, pandemic, prevention, treatment, Public aspects of medicine, RA1-1270
Abstract

Sarah Rabin,1 Natalia Kika,1 Danielle Lamb,2 Dominic Murphy,1,3 Sharon AM Stevelink,1 Victoria Williamson,1,4 Simon Wessely,1 Neil Greenberg1 1Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK; 2Department of Applied Health Research, University College London, London, UK; 3Research Department, Combat Stress, Leatherhead, UK; 4Department of Experimental Psychology, University of Oxford, Oxford, UKCorrespondence: Sarah Rabin, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, Weston Education Centre, London, SE5 9RJ, UK, Tel +44 02078485351, Email sarah.p.rabin@kcl.ac.ukAbstract: Moral injury (MI) refers to the persisting distress which may occur following exposure to potentially morally injurious events (PMIEs). The COVID-19 pandemic has drawn attention to MI in healthcare workers, who have been found to experience more frequent PMIEs in their day-to-day work than those in other occupational groups such as the military. These events may occur on an individual, team, organizational or system level and have been associated with increased clinician burnout and distress, and poor psychological wellbeing. This paper focuses on healthcare workers’ experiences of MI, including potential causes and ways to reduce them. There are myriad challenges that influence the development of MI, such as chronic understaffing and the pressure to treat high numbers of patients with limited resources. There are also multiple impacts of MI: at the individual-level, MI can lead to increased staff absences and understaffing, and prolonged patient contact with limited decision-making power. COVID-19 exacerbated such impacts, with a lack of organizational support during a time of increased patient mortality, and uncertainty and heightened pressure on the clinical frontline associated with scarce resources and understaffing. Potential methods for reduction of MI in healthcare workers include pre-exposure mitigation, such as fostering work environments which treat PMIEs in the same way as other occupational hazards and post-exposure mitigation, such as facilitating healthcare workers to process their experiences of PMIEs in peer support groups or with spiritual advisors and, if MI is associated with mental ill-health, talking therapies using trauma-focused and compassion-oriented frameworks.Keywords: moral injury, healthcare workers, causes, effects, mitigation, pandemic, prevention, treatment

Published
2023

9. ICMA: an integrated cardiac modeling and analysis platform.

Author

Wu, Alan, Hussan, JR, Hunter, PJ, Gladding, PA, Greenberg, N, Christie, R, Sorby, H, and Thomas, JD

Abstract

ICMA, a software framework to create 3D finite element models of the left ventricle from cardiac ultrasound or magnetic resonance imaging (MRI) data, has been made available as an open-source code. The framework is hardware vendor independent and uses spec

Published
2015

13. ‘Thrown in at the deep end’: a qualitative analysis into the transition from trainee to consultant during the COVID-19 pandemic and lessons for the future

Author

Zhang, X, Johannsson, H, Tucker, JD, Riyat, A, Chiu, Y-LT, Greenberg, N, and Sharpe, R

Abstract

Background Sustained crises such as the COVID-19 pandemic would be expected to impact the transition from trainee to consultant for anaesthetists or intensivists, but limited research exists on this important topic. This study aimed to examine the social context of this crucial career transition during the pandemic and post-pandemic periods. Methods We conducted semi-structured interviews with anaesthetists and intensivists who became consultants after the first UK lockdown. Thematic analysis was used and data saturation was reached at 33 interviews. Results The pandemic substantially impacted the transition to consultant role in various ways, including professional identity, clinical and non-clinical responsibilities, and wellbeing. Participants experienced identity confusion, self-doubt, and moral injury, resulting in intense emotional distress, feelings of guilt and helplessness, which persisted beyond the pandemic. They also felt unprepared for their consultant roles because of disruptions in training. The pandemic exaggerated the vulnerability of those transitioning to consultants, because of increased clinical uncertainties, and pressures of the growing backlog. Additionally, the pandemic impacted on the wellbeing of those transitioning to consultants, intensifying feelings of anxiety and stress. We also identified unique opportunities presented by the pandemic, which accelerated learning and encouraged post-traumatic growth. Our study identified practical solutions that may improve transition experience at individual, organisational, and national levels. Conclusions Persistent crises significantly impact the transition from trainee to consultant. Our findings generated insights into the challenges of this critical career transition and staff wellbeing, and serve to inform approaches of ongoing support for those transitioning to consultants.

Published
2023

16. Mental health issues and illness and substance use disorder (non-)disclosure to a supervisor: A cross-sectional study on beliefs, attitudes and needs of military personnel

Author

Bogaers, Rebecca, Geuze, Elbert, van Weeghel, Jaap, Leijten, Fenna, van de Mheen, Dike, Greenberg, N, Rozema, Andrea D., Brouwers, Evelien, Bogaers, Rebecca, Geuze, Elbert, van Weeghel, Jaap, Leijten, Fenna, van de Mheen, Dike, Greenberg, N, Rozema, Andrea D., and Brouwers, Evelien

Abstract

Objectives Research suggests that military personnel frequently delay disclosing mental health issues and illness (MHI), including substance use disorder, to supervisors. This delay causes missed opportunities for support and workplace accommodations which may help to avoid adverse occupational outcomes. The current study aims to examine disclosure-related beliefs, attitudes and needs, to create a better understanding of personnel’s disclosure decision making. Design A cross-sectional questionnaire study among military personnel with and without MHI. Beliefs, attitudes and needs regarding the (non-)disclosure decision to a supervisor were examined, including factors associated with (non-)disclosure intentions and decisions. Descriptive and regression (logistic and ordinal) analyses were performed. Setting The study took place within the Dutch military. Participants Military personnel with MHI (n=324) and without MHI (n=554) were participated in this study. Outcome measure (Non-)disclosure intentions and decisions. Results Common beliefs and attitudes pro non-disclosure were the preference to solve one’s own problems (68.3%), the preference for privacy (58.9%) and a variety of stigma-related concerns. Common beliefs and attitudes pro disclosure were that personnel wanted to be their true authentic selves (93.3%) and the desire to act responsibly towards work colleagues (84.5%). The most reported need for future disclosure (96.8%) was having a supervisor who shows an understanding for MHI. The following factors were associated both with non-disclosure intentions and decisions: higher preference for privacy (OR (95% CI))=(1.99 (1.50 to 2.65)intention, 2.05 (1.12 to 3.76)decision) and self-management (OR (95% CI))=(1.64 (1.20 to 2.23)intention, 1.79 (1.00 to 3.20)decision), higher stigma-related concerns (OR (95% CI))=(1.76 (1.12 to 2.77)intention, 2.21 (1.02 to 4.79)decision) and lower quality o

Published
2023

18. Addressing moral injury in the military

Author

Phelps, Andrea J, Adler, A B, Belanger, S A H, Bennett, C, Cramm, H, Dell, L, Fikretoglu, D, Forbes, D, Heber, A, Hosseiny, F, Morganstein, J C, Murphy, D, Nazarov, A, Pedlar, D, Richardson, J D, Sadler, N, Williamson, V, Greenberg, N, and Jetly, R

Abstract

Moral injury is a relatively new, but increasingly studied, construct in the field of mental health, particularly in relation to current and ex-serving military personnel. Moral injury refers to the enduring psychosocial, spiritual or ethical harms that can result from exposure to high-stakes events that strongly clash with one’s moral beliefs. There is a pressing need for further research to advance understanding of the nature of moral injury; its relationship to mental disorders such as posttraumatic stress disorder and depression; triggering events and underpinning mechanisms; and prevalence, prevention and treatment. In the meantime, military leaders have an immediate need for guidance on how moral injury should be addressed and, where possible, prevented. Such guidance should be theoretically sound, evidence-informed and ethically responsible. Further, the implementation of any practice change based on the guidance should contribute to the advancement of science through robust evaluation. This paper draws together current research on moral injury, best-practice approaches in the adjacent field of psychological resilience, and principles of effective implementation and evaluation. This research is combined with the military and veteran mental health expertise of the authors to provide guidance on the design, implementation and evaluation of moral injury interventions in the military. The paper discusses relevant training in military ethical practice, as well as the key roles leaders have in creating cohesive teams and having frank discussions about the moral and ethical challenges that military personnel face.

Published
2024
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20. A Qualitative Review of Comments by Faculty Who Cite Work-Life Balance as a Reason to Leave

Author

Magdaleno, Y., Rishel Brakey, H., Greenberg, N., Myers, O., and Sood, A.

Subjects
Article
Abstract

Despite growing evidence for the need for work-life balance (WLB) for faculty at academic health centers, mentors frequently do not know how to advise their mentees on this topic. WLB impacts job satisfaction and intent to stay, and physicians are particularly at risk. In this study, we explored exit survey comments of faculty of the University of New Mexico School of Medicine citing work-life balance as a reason to leave (WLB-ARTL). Between July 2017 and December 2020, 59 faculty provided open-ended survey responses related to reasons for leaving, what they liked and disliked about being faculty, mentorship, and more. Using a qualitative descriptive design, we analyzed open-ended responses using a systematic, iterative, thematic approach via NVIVO software. We classified themes using Shanafelt’s drivers of engagement and burnout: workload/job demands; efficiency/ resources; meaning in work; culture/values; control/flexibility; social support/community at work; and work-life integration. While there were numerous quotes across all themes, we chose to summarize emergent codes with the most faculty representation and those that can most easily be addressed through mentorship: career development, culture and people, and hours and schedule (related to themes of meaning in work, culture and values, community at work, work-life integration, and control and flexibility). To improve faculty retention, institutional leaders should focus on developing mentors’ career coaching and mentoring skills. Additional focus should be placed on training mentors to discuss and address WLB among their faculty mentees.

Published
2022

21. The Pandemic Effect on Faculty Attrition at a School of Medicine

Author

Greenberg, N., Myers, O., Magdaleno, Y., and Sood, A.

Subjects
Article
Abstract

Mentors at Academic Health Centers (AHC) are challenged by mentee attrition, with one in five physicians reporting an intent to leave in 2020. AHCs struggle with physician replacement costs, which are exorbitant. Data-driven efforts to mitigate attrition during the pandemic require an understanding of reasons to leave. This study compares characteristics of exiting faculty at the University of New Mexico School of Medicine (UNM SOM) two years before to two years after April 1, 2020. Demographic and reason to leave variables from exit interviews of 168 faculty that left UNM SOM between April 2018-to-March 2020 and 151 faculty that left between April 2020-to-March 2022 were compared. Exiting faculty were stratified into those resigning vs. retiring. Distributions of each variable were analyzed for statistically significant differences using a chi-square or Fisher’s 2-sided exact test. The pandemic was associated with an approximately three-fold higher proportion of retirement contributing to total attrition than before (25.8% vs. 8.9%; p

Published
2022

25. Addressing moral injury in the military

Author

Phelps, Andrea J, primary, Adler, A B, additional, Belanger, S A H, additional, Bennett, C, additional, Cramm, H, additional, Dell, L, additional, Fikretoglu, D, additional, Forbes, D, additional, Heber, A, additional, Hosseiny, F, additional, Morganstein, J C, additional, Murphy, D, additional, Nazarov, A, additional, Pedlar, D, additional, Richardson, J D, additional, Sadler, N, additional, Williamson, V, additional, Greenberg, N, additional, and Jetly, R, additional

Published
2022
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26. Combat exposure and co-occurring mental health problems in UK Armed Forces personnel

Author

Chui, Z, Fear, NT, Greenberg, N, Jones, N, Jones, E, Goodwin, L, Chui, Z, Fear, NT, Greenberg, N, Jones, N, Jones, E, and Goodwin, L

Abstract

Background: Mental disorders and alcohol misuse are often comorbid, and this comorbidity is more common in those who develop mental disorders following exposure to traumatic events. Aims: To investigate the relationship between combat exposure and operational role (support versus combat) with mental disorders and associated comorbidity in a UK military cohort. Methods: 4896 participants from a UK military cohort reported their operational role and frequency of exposure to combat events during deployment. Outcome measures included self-reported post-traumatic stress disorder, common mental disorder and alcohol misuse. Results: Personnel reporting higher levels of combat exposure were more likely to meet criteria for two or more co-occurring mental disorders (odds ratio [OR] 3.90, 95% confidence interval [CI] 2.73–5.58). While having a combat role increased the risk of developing co-occurring disorders compared to having a support role (OR 1.67, 95% CI 1.26–2.23), this effect diminished following adjustment for variables including combat exposure (OR 0.89, 95% CI 0.62–1.27). Conclusions: Combat exposure may play a greater role in the development of comorbid mental disorders than operational role, i.e. job title. Clinicians treating military personnel should be alert to the increased risk of comorbid mental disorders and alcohol misuse among those with a history of combat exposure.

Published
2022

27. Mental health disorders and alcohol misuse among UK military veterans and the general population:a comparison study

Author

Rhead, R, MacManus, D, Jones, M, Greenberg, N, Fear, NT, Goodwin, L, Rhead, R, MacManus, D, Jones, M, Greenberg, N, Fear, NT, and Goodwin, L

Abstract

Background For a small minority of personnel, military service can have a negative impact on their mental health. Yet no studies have assessed how the mental health of UK veterans (who served during the recent operations in Afghanistan or Iraq) compares to non-veterans, to determine if they are at a disadvantage. We examine the prevalence of mental disorders and alcohol misuse in UK veterans compared to non-veterans. Methods Veteran data were taken from the third phase of the King's Centre for Military Health Research cohort study (n = 2917). These data were compared with data on non-veterans taken from two large general population surveys: 2014 Adult Psychiatric Morbidity Survey (n = 5871) and wave 6 of the UK Household Longitudinal Study (UKHLS, n = 22 760). Results We found that, overall, UK veterans who served at the time of recent military operations were more likely to report a significantly higher prevalence of common mental disorders (CMD) (23% v. 16%), post-traumatic stress disorder (PTSD) (8% v. 5%) and alcohol misuse (11% v. 6%) than non-veterans. Stratifying by gender showed that the negative impact of being a veteran on mental health and alcohol misuse was restricted to male veterans. Being ill or disabled was associated with a higher prevalence of CMD and PTSD for both veterans and non-veterans. Conclusion Whilst the same sociodemographic groups within the veteran and non-veteran populations seemed to have an increased risk of mental health problems (e.g. those who were unemployed), male veterans, in particular, appear to be at a distinct disadvantage compared to those who have never served.

Published
2022

28. Pathways to mental health care in active military populations across the Five-Eyes nations: An integrated perspective.

Author

Fikretoglu, D, Sharp, M-L, Adler, AB, Bélanger, S, Benassi, H, Bennett, C, Bryant, R, Busuttil, W, Cramm, H, Fear, N, Greenberg, N, Heber, A, Hosseiny, F, Hoge, CW, Jetly, R, McFarlane, A, Morganstein, J, Murphy, D, O'Donnell, M, Phelps, A, Richardson, DJ, Sadler, N, Schnurr, PP, Smith, P, Ursano, R, Hooff, MV, Wessely, S, Forbes, D, Pedlar, D, Fikretoglu, D, Sharp, M-L, Adler, AB, Bélanger, S, Benassi, H, Bennett, C, Bryant, R, Busuttil, W, Cramm, H, Fear, N, Greenberg, N, Heber, A, Hosseiny, F, Hoge, CW, Jetly, R, McFarlane, A, Morganstein, J, Murphy, D, O'Donnell, M, Phelps, A, Richardson, DJ, Sadler, N, Schnurr, PP, Smith, P, Ursano, R, Hooff, MV, Wessely, S, Forbes, D, and Pedlar, D

Abstract

Military service is associated with increased risk of mental health problems. Previous reviews have pointed to under-utilization of mental health services in military populations. Building on the most recent systematic review, our narrative, critical review takes a complementary approach and considers research across the Five-Eyes nations from the past six years to update and broaden the discussion on pathways to mental healthcare in military populations. We find that at a broad population level, there is improvement in several indicators of mental health care access, with greater gains in initial engagement, time to first treatment contact, and subjective satisfaction with care, and smaller gains in objective indicators of adequacy of care. Among individual-level barriers to care-seeking, there is progress in improving recognition of need for care and reducing stigma concerns. Among organizational-level barriers, there are advances in availability of services and cultural acceptance of care-seeking. Other barriers, such as concerns around confidentiality, career impact, and deployability persist, however, and may account for some remaining unmet need. To address these barriers, new initiatives that are more evidence-based, theoretically-driven, and culturally-sensitive, are therefore needed, and must be rigorously evaluated to ensure they bring about additional improvements in pathways to care.

Published
2022

29. Mental health disorders and alcohol misuse among UK military veterans and the general population : a comparison study

Author

Rhead, R, MacManus, D, Jones, M, Greenberg, N, Fear, NT, Goodwin, L, Rhead, R, MacManus, D, Jones, M, Greenberg, N, Fear, NT, and Goodwin, L

Abstract

Background For a small minority of personnel, military service can have a negative impact on their mental health. Yet no studies have assessed how the mental health of UK veterans (who served during the recent operations in Afghanistan or Iraq) compares to non-veterans, to determine if they are at a disadvantage. We examine the prevalence of mental disorders and alcohol misuse in UK veterans compared to non-veterans. Methods Veteran data were taken from the third phase of the King's Centre for Military Health Research cohort study (n = 2917). These data were compared with data on non-veterans taken from two large general population surveys: 2014 Adult Psychiatric Morbidity Survey (n = 5871) and wave 6 of the UK Household Longitudinal Study (UKHLS, n = 22 760). Results We found that, overall, UK veterans who served at the time of recent military operations were more likely to report a significantly higher prevalence of common mental disorders (CMD) (23% v. 16%), post-traumatic stress disorder (PTSD) (8% v. 5%) and alcohol misuse (11% v. 6%) than non-veterans. Stratifying by gender showed that the negative impact of being a veteran on mental health and alcohol misuse was restricted to male veterans. Being ill or disabled was associated with a higher prevalence of CMD and PTSD for both veterans and non-veterans. Conclusion Whilst the same sociodemographic groups within the veteran and non-veteran populations seemed to have an increased risk of mental health problems (e.g. those who were unemployed), male veterans, in particular, appear to be at a distinct disadvantage compared to those who have never served.

Published
2022

30. Climate change effects on mental health: are there workplace implications?

Author

Brooks, S K and Greenberg, N

Subjects
*CLIMATE change & health, *JOB stress, *HEALTH behavior, *EXTREME weather, *PSYCHOLOGICAL factors, *MENTAL health
Abstract

Background Climate change can negatively affect mental health, and poor mental health can negatively affect work. However, less is known about the relationship between mental health and workplace behaviours within the climate change context. Aims To explore existing literature relating to climate-induced mental ill-health as a potential predictor of workplace behaviours. Methods Scoping review, searching five databases for relevant literature using two separate search strategies. Results Only five studies with any relevant data were found. Results could not be easily synthesized because each of the five considered different work-related outcomes. However, the available data suggest that the psychological impact of extreme events could lead to increased job tension, higher turnover intentions and workplace hostility. Stress about extreme weather could also impede the ability to make essential work-related decisions and, for those who work in the environmental sector, concerns about climate could lead to overcommitment to work. There was some evidence that social support might lessen the effects of climate-induced stress on work outcomes. Conclusions Very little literature considers the impacts of climate change on employees' mental health and associated workplace function. The available evidence suggests there are potential negative impacts which may be mitigated by social support. It is important for future research to explore ways of supporting staff and fostering resilience. [ABSTRACT FROM AUTHOR]

Published
2023
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41. Prostate Cancer in a Transgenic Mouse

Author

Greenberg, N. M., DeMayo, F., Finegold, M. J., Medina, D., Tilley, W. D., Aspinall, J. O., Cunha, G. R., Donjacour, A. A., Matusik, R. J., and Rosen, J. M.

Published
1995

45. Family and occupational functioning following military trauma exposure and moral injury

Author

Williamson, Victoria, Murphy, D, Stevelink, S AM, Jones, E, Allen, S, and Greenberg, N

Abstract

IntroductionEvidence is growing regarding the impact of potentially morally injurious events (PMIEs) on mental health; yet how moral injury may affect an individual’s occupational and familial functioning remains poorly understood.MethodThirty male veterans who reported exposure to either traumatic or morally injurious events and 15 clinicians were recruited for semi-structured qualitative interviews.ResultsWhile many veterans experienced psychological distress postevent, those who experienced PMIEs especially reported social withdrawal and engagement in aggressive, risk-taking behaviours. This was highly distressing for family members and created a tense, volatile home and workplace environment that was difficult for others to navigate. Following PMIEs, employment could be used as a cognitive avoidance strategy or as a means to atone for transgressive acts. In cases of moral injury, clinicians considered that targeted support for spouses and accessible guidance to help children to better understand how their military parent may be feeling would be beneficial.ConclusionsThis study provides some of the first evidence of the pervasive negative impact of PMIEs on veterans’ familial and occupational functioning. These findings highlight the need to comprehensively screen for the impact of moral injury on daily functioning in future studies that goes beyond just an assessment of psychological symptoms.

Published
2023
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