Background:In the post-pandemic recovery era, addressing moral injury is critical due to high prevalence and impact on mental and occupational health. Interventions that address moral injury in hospital settings are limited. Further, engaging HCWs in any mental health interventions has proven challenging for a variety of reasons and exacerbated by factors such as a rural setting. Implementation science aimed at understanding barriers and facilitators to interventions is needed in order to build and offer interventions that are usable, feasible, acceptable, and effective. The current study aimed to understand such barriers and facilitators to building moral injury interventions for nurses on the medical intensive care unit (MICU). Methods:We conducted semi-structured qualitative interviews using the Consolidated Framework for Implementation Science Research (CFIR) and Peer and Academic Model of Community Engagement with 25 participants in a rural hospital system, 19 nurses currently working in the MICU and six nurses who left their MICU employment. Interviews were transcribed and analyzed using a thematic analysis approach. Results:There were five CFIR domains and 14 associated CFIR constructs that impacted intervention implementation in this population. Barriers included resource costs, skepticism regarding the effectiveness of new resources, lack of support from leaders, concerns that emotions affect professional image, inability to take breaks, and a disconnect between nurses' lived experiences and community perceptions. Facilitators included interventions specifically tailored for the MICU, strengths in teaming and social support among fellow nurses, and a desire for change because of factors such as a high turnover rate. Participants also highlighted a strong motivation to provide the best care possible and a desire to build resilience by supporting each other. Conclusion:Analysis of barriers and facilitators suggests value in improving the opportunities for HCWs to process morally injurious experiences with interventions specific to a particular unit and resources such as peer support and chaplains. There is a demonstrated need for high-level organizational change to address the dynamic needs of our nurses.

AIM:To provide a description of nurses' experiences related to moral injury, including Potentially Morally Injurious Events and factors related to the impact of those events. DESIGN:Reflexive thematic analysis of nurse interviews. METHOD:Nurses were recruited from an ongoing study within a large academic medical centre. Nurses who enrolled in the present study participated in semi-structured individual interviews using an interview guide based on Litz's conceptualisation of moral injury. Themes were identified in the recorded and transcribed interviews. RESULTS:Interviews were conducted with 12 nurses in May and June 2023 and coded for themes within three broad categories: (a) Nursing Values, (b) Experiences of Potentially Morally Injurious Events and (c) Stressors and Supports. Within these categories, we pinpointed 8 themes and 3 subthemes, which highlight the nurses experience of potentially morally injurious events related to challenging care, strained relationships with physicians, and treatment inequity, which conflict with their nursing values. We identified team and organisational factors, including senior leadership behaviours, team dynamics and access to resources that appear to intensify or lessen the impact of these events. CONCLUSION:Potentially Morally Injurious Events contribute to the occupational stress experienced by nurses, particularly when systemic organisational factors and demands prevent them from providing the value-driven and ethically necessary healthcare. Limiting Potentially Morally Injurious Events and providing supportive environments following stressors requires organisational-level changes within healthcare environments to prevent and alleviate nurses' occupational stress. IMPACT:This research highlights the need for healthcare organisations to implement systemic interventions aimed both at reducing Potentially Morally Injurious Events and creating system and team-level supports to lessen the impact of unavoidable events. These results pinpoint specific areas for prevention, intervention and support. PATIENT OR PUBLIC CONTRIBUTION:No Patient or Public Contribution.

Throughout the COVID-19 pandemic, teachers risked their physical and mental health to continue providing educational services to students. This study examined the prevalence of mental health distress and risk factors among a sample of teachers from the mid-Atlantic United States. PreK-12 educators (N = 1295) completed online cross-sectional quantitative surveys between October 2020 and January 2021. After obtaining descriptive statistics on rates of posttraumatic stress, depression, anxiety, risky alcohol use, and insufficient sleep, logistic regressions were conducted to examine risk factors for screening positive for clinically meaningful distress. The majority of respondents (65%) screened positive for clinically significant mental health distress on at least one condition, with specific prevalence as follows: traumatic stress (51%), depression (36%), anxiety (50%), risky alcohol use (34%), insufficient sleep (56%). Teachers (vs. other school personnel) had a significantly higher chance of screening positive. Greater chances of screening positive for mental health distress was also associated with having an immunocompromising medical condition, teaching remotely, working more hours, and being younger, female, and/or being a racial and ethnic minoritized-identifying educator. K-12 teachers had high risk for mental health distress, increased by risk factors in educational, demographic, and COVID-19 specific dimensions that have implications for policy and intervention.

Objective We examined the impact of health care workers’ (HCWs) adjustment to the COVID-19 pandemic on their work-related attitudes and behaviors. Methods HCWs (n = 1468) participated in an observational longitudinal study in which they completed surveys of anxiety and occupational health between 2020 and 2021. Results Most HCWs reported anxiety that was consistently below the diagnostic threshold (68%) or fell below the threshold within a year (16%). Others reported consistently high (14%) or increasing (2%) anxiety, especially women, younger HCWs, those with a weakened immune system, and allied health professionals. Consistently high or increasing anxiety was associated with poorer job satisfaction, work engagement, perceived supervisor support, burnout, and turnover intentions. Conclusions Resources to support HCWs may be focused on those who report consistently high or increasing anxiety to minimize the effects of crises and disasters on the workforce.

Moral injury has emerged as a construct of interest in healthcare workers' (HCW) occupational stress and health. We conducted one of the first multidisciplinary, longitudinal studies evaluating the relationship between exposure to potentially morally injurious events (PMIEs), burnout, and turnover intentions. HCWs (N = 473) completed surveys in May of 2020 (T1) and again in May of 2021 (T2). Generalized Linear Models (robust Poisson regression) were used to test relative risk of turnover intentions, and burnout at T2 associated with PMIE exposure, controlling for T1 covariates. At T1, 17.67% reported they had participated in a PMIE, 41.44% reported they witnessed a PMIE and 76.61% reported feeling betrayed by healthcare or a public health organization. In models including all T1 PMIE exposures and covariates, T2 turnover intentions were increased for those who witnessed a PMIE at T1 (Relative Risk [RR] = 1.66, 95% Confidence Interval [CI] 1.17-2.34) but not those that participated or felt betrayed. T2 burnout was increased for those who participated in PMIE at T1 (RR = 1.38, 95%CI 1.03-1.85) but not those that witnessed or felt betrayed. PMIE exposure is highly prevalent among HCWs, with specific PMIEs associated with turnover intentions and burnout. Organizational interventions to reduce and facilitate recovery from moral injury should account for differences in the type of PMIE exposures that occur in healthcare work environments.

Objective: The current studies explored associations between exposure to potentially morally injurious events (PMIEs) and mental health outcomes among frontline workers affected by the coronavirus pandemic. Method: We administered online self-report surveys to emergency responders (N = 473) and hospital personnel (N = 854) in the Rocky Mountain region of the United States between April and June of 2020. Surveys assessed frequency and intensity of exposure to PMIEs alongside psychological and functional outcomes. Results: Between 20% and 30% of frontline workers reported exposure to PMIEs of at least moderate frequency and intensity. Exposure to more intense PMIEs was associated with greater psychological symptoms (i.e., stress, depression, and anxiety) and functional impairment (i.e., professional burnout), especially among emergency responders who reported frequent exposure but also hospital workers who reported few exposures. Conclusion: Efforts to facilitate and maintain the well-being of the public health workforce should specifically address critical incidents encountered by frontline workers that have embedded moral and ethical challenges. Clinical Impact Statement This study suggests that up to 30% of emergency responders and hospital personnel encounter perceived transgressions of their internalized moral beliefs in the context of providing care during disasters and crises. Those exposed to more frequent and intense ethical challenges are more likely than those not exposed to report symptoms of burnout, depression, anxiety, and stress. Efforts to maintain the well-being of essential personnel should therefore address critical incidents encountered by frontline workers that have embedded moral and ethical challenges.

Studies of moral injury among nonmilitary samples are scarce despite repeated calls to examine the prevalence and outcomes of moral injury among civilian frontline workers. The purpose of this study was to describe the prevalence of moral injury and to examine its association with psychosocial functioning among health care workers during the COVID-19 pandemic. We surveyed health care workers (N = 480), assessing exposure to potentially morally injurious events (PMIEs) and psychosocial functioning. Data were analyzed using latent class analysis (LCA) to explore patterns of PMIE exposure (i.e., classes) and corresponding psychosocial functioning. The minimal exposure class, who denied PMIE exposure, accounted for 22% of health care workers. The moral injury-other class included those who had witnessed PMIEs for which others were responsible and felt betrayed (26%). The moral injury-self class comprised those who felt they transgressed their own values in addition to witnessing others' transgressions and feeling betrayed (11%). The betrayal-only class included those who felt betrayed by government and community members but otherwise denied PMIE exposure (41%). Those assigned to the moral injury-self class were the most impaired on a psychosocial functioning composite, followed by those assigned to the moral injury-other and betrayal-only classes, and finally the minimal exposure class. Moral injury is prevalent and impairing for health care workers, which establishes a need for interventions with health care workers in organized care settings. Impact Statement Health care workers experienced stressors that transgressed their moral beliefs during the COVID-19 pandemic. Those who were troubled by their own actions or failures to act had the most severe work, relationship, and personal care problems, followed by those troubled by the actions of others or of their institutions.

First responders are at high risk for disorders that arise from repeat exposure to stress and trauma (Post Traumatic Stress Disorder, depression, and problematic alcohol use). Although mental health treatments are available, first responders often do not access them, anchored by barriers that include: lack of knowledge, stigma, negative experience with mental health providers, and time-based burdens. In this study, we designed an intervention to address these barriers, extending a Planned-Action framework. Step 1 involved self-report screening for four mental health risks (PTSD, depression, anxiety, and alcohol use risk), delivered to all personnel electronically, who were free to either consent and participate or opt-out. The detection of risk(s) in Step 1 led to scheduling a Step 2 telehealth appointment with a trained clinician. We report descriptive statistics for participation/attrition/utilization in Steps 1 and 2, rates of risk on four mental health variables, and rate of adherence to follow-up treatment recommendations. Step 1: In total, 53.3% of personnel [229 of 429 full-time employees (221 males; eight females; 95% White; 48% paramedic or Emergency Medical Technician; 25% captain; 19% engineer; 7% other)] initially opted-in by consenting and completing the brief remote screening survey. Among those who opted-in and completed (n = 229), 43% screened positive for one or more of the following mental health risks: PTSD (7.9%); depression (9.6%); anxiety (13.5%); alcohol use (36.7%). Step 2: A maximum of three attempts were made to schedule "at risk" individuals into Step 2 (n = 99). Among the 99 who demonstrated a need for mental health treatment (by screening positive for one or more risk), 56 (56.6%) engaged in the telehealth appointment. Of the 56 who participated in Step 2 clinical appointments, 38 were recommended for further intervention (16.6% of full-time personnel who participated). Among the 38 firefighters who were recommended to seek further mental health services, 29 were adherent/followed through (76.3% of those who received recommendations for further services). Taken together, evidence-based, culturally conscious, stepped care models delivered via the virtual/telehealth medium can promote access, utilization, and cost-effective mental health services for first responders. Implications are for informing larger, more rigorous dissemination and implementation efforts.

Purpose Healthcare workers are at increased risk for mental health problems during disasters such as the COVID-19 pandemic. Identifying resilience mechanisms can inform development of interventions for this population. The current study examined pathways that may support healthcare worker resilience, specifically testing enabling (social support enabled self-efficacy) and cultivation (self-efficacy cultivating support) models. Methods Healthcare workers ( N = 828) in the Rocky Mountain West completed self-report measures at four time points (once per month from April to July of 2020). We estimated structural equation models to explore the potential mediating effects that received social support and coping self-efficacy had (at time 2 and time 3) between traumatic stress symptom severity (at time 1 and time 4). Models included covariates gender, age, minority status, and time lagged co-variations between the proposed mediators (social support and coping self-efficacy). Results The full model fit the data well, CFI = .993, SRMR = .027, RMSEA = .036 [90% CIs (0.013, 0.057)]. Tests of sequential mediation supported enabling model dynamics. Specifically, the effects of time 1 traumatic stress severity were mediated through received social support at time 2 and time 3 coping self-efficacy, in sequential order to reduce time 4 traumatic stress severity. Conclusions Findings show the importance of received social support and coping self-efficacy in mitigating psychopathology risk. Interventions can support mental health by focusing on social resource engagement that facilitates coping empowerment, which may decrease risk for mental health job-related problems among frontline healthcare workers exposed to highly stressful events.

The mental health of healthcare workers (HCWs) is critical to their long-term well-being and future disaster preparedness. Goal 1 of this study was to identify rates of mental health problems experienced by HCWs. Goal 2 was to test a model of risk stemming from pandemic-related stressors and vulnerability factors.This cross-sectional study included HCWs (N ​= ​2,246 [1,573 clinical providers; 673 non-clinical staff]) in the Rocky Mountain West who voluntarily completed an online survey in April/May 2020. Respondents completed measures for traumatic stress symptoms, depression, anxiety, alcohol use, and sleep. Logistic regressions stratified by professional role (clinical versus non-clinical) were specified to predict clinical screening cutoff (positive/negative) as a function of five pandemic-related stressors (immunocompromised self; immunocompromised household member; care provision to infected patients; clinical management role; positive cases).Results showed that more than half of HCWs surveyed (52.5%) screened positive (above cutoff) for traumatic stress, depression, or anxiety, with ~20% reporting problematic alcohol use, and variable insufficient sleep from ~10% off shift to ~50% on shift. Clinical employees with an immunocompromised household member had increased odds of screening positive for a mental health problem. Non-clinical HCWs who were immunocompromised were at elevated risk for screening positive a mental health problem. Being female, minority status, and younger increased odds for mental health problems.Implications include alleviating a portion of the mental health burden of HCWs involved in response to the SARS-CoV-2 pandemic by considering policies to protect immunocompromised HCWs and their families (e.g., vaccine priorities, telework options).

Students in high school or secondary school face challenges that too often lead them to drop out of school. Administrators and staff in many of these schools have attempted to address this challenge by adopting a framework of Positive Behavior Interventions and Supports (PBIS) that offers graduated tiers of intervention suited to students’ needs. One such intervention that has been used in some parts of the US, was developed by the School of Life Foundation (SOLF). The intervention consists of a life-skills curriculum that supports students by addressing factors related to increased probability of dropping out of school. This article provides a case report, from the United States, of the SOLF intervention in the context of a PBIS framework.

The mental health of frontline workers is critical to a community's ability to manage crises and disasters. This study assessed risks for mental health problems (traumatic stress, depression, anxiety, alcohol use, insomnia) in association with pandemic-related stressors in a sample of emergency and hospital personnel (N = 571). Respondents completed self-report surveys online from April 1st to May 7th, 2020 in the Rocky Mountain region of the United States. Results showed that roughly fifteen to thirty percent of respondents screened positive for each disorder. Odds of screening positive were similar between groups for probable acute traumatic stress, depressive disorder, anxiety disorder, and alcohol use disorder; emergency personnel reported significantly higher rates of insufficient sleep than healthcare workers. Logistic regressions showed that respondents who reported having an immunocompromised condition had higher odds of acute traumatic stress, anxiety, and depression. Having an immunocompromised household member was associated with higher odds of insufficient sleep and anxiety. Being in a direct care provision role was associated with higher odds of screening positive for risky alcohol use. Being in a management role over direct care providers was associated with higher odds of screening positive for anxiety, risky alcohol use, and insufficient sleep. There was an inverse relationship between number of positive COVID-19 cases and anxiety, such that as positive cases went up, anxiety decreased. Overall, the mental health risks that we observed early in the COVID-19 pandemic are elevated above previous viral outbreaks (SARS) and comparable to rates shown in disasters (9/11 attacks; Hurricane Katrina).

What might the field of counseling psychology in the United States of America look like 10 years from now? In a Delphi Poll, an expert panel, consisting of 28 training directors from APA-accredited counseling psychology programs, made predictions regarding the future of counseling psychology 10 years from now in relation to three domains (core features, research and training, and professional training) and 32 specific areas within those domains. The strongest core feature of counseling psychology was viewed as a continuing commitment to issues of diversity (M = 4.64, SD = .63); the research and training theme predicted to attract the most attention in the next 10 years was a commitment to evidence-based practice (M = 4.71, SD = 1.20); and the professional training theme predicted to gain the greatest focus was attention to professional competence (M = 4.43, SD = .65). Results were compared with a previous Delphi Poll conducted in 2001, and recommendations are outlined for future research designed to contribute to the ongoing development of the field of counseling psychology.