A study comparing 618 military veterans who deployed to a combat zone after Sept. 11, 2001, and 2,099 health care workers (HCWs) working during the COVID-19 pandemic found similar levels of potential moral injury (PMI), with 46.1% of veterans and 50.7% of HCWs reporting PMI.
PMI — the strong cognitive and emotional response that can occur following events that violate a person’s moral or ethical code — was assessed in two categories: other-induced and self-induced. Both types were significantly associated with gender, race, enlisted versus officer status and post-battle traumatic experiences among veterans, and with age, race, working in a high COVID-19 risk setting and reported COVID-19 exposure among HCWs.
by Emily Stembridge, VUMC Reporter
PMI was associated with significantly higher depressive symptoms and worse quality of life in both samples and higher rates of burnout among HCWs. “Examples of PMI we saw most were individuals being expected to do things that made them feel questionable about their participation,” said Keith Meador, MD, ThM, MPH, professor of Psychiatry and Health Policy, director of the Vanderbilt Center for Biomedical Ethics and Society, and author on the Journal of General Internal Medicine report.
“In the health care context, that may look like not being able to provide the level of care one would like to provide due to the complexities of the ongoing pandemic. As a result, HCWs were vulnerable to the consequences of potential moral injury and reduced quality of mental health, similarly to what we’ve seen in post 9/11 veterans.”
Meador has worked with colleagues to identify areas for potential improvement in the mental health of HCWs. One area that shows promising results is a collaboration between chaplains and mental health providers. Much of Meador’s work has focused on equipping chaplains to be knowledgeable and aware of PMI in the health care and military settings. On the front lines of both hospitals and wars, people often begin to question their sense of self. Whether someone identifies as religious or not, they often seek out chaplains to answer questions about the crossroads between their professional identity and sense of purpose.
Together with Jason Nieuwsma, PhD, adjoint associate professor in the Practice of Integrative Chaplaincy at Vanderbilt Divinity School and associate professor in the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center, first author on the paper, Meador has established a Doctor of Ministry program at Vanderbilt which equips chaplains in evidence-based practices to be care providers for people with PMI.
“These results are a real message about just how stressful the last couple of years have been for our health care workers, and our need for mindfulness around those issues in order to best support them,” Meador said. “We’re working to transform moral suffering and cultivate even more resilience. We need to utilize all kinds of preventative and primary interventions in support of health care workers.”
A three-time UIC graduate, McFarlin joined the faculty of UIC Nursing in 2005 after delivering more than 4,000 babies in her 35 years as a nurse-midwife. During her tenure at UIC Nursing, she served as head of the Department of Women, Children and Family Health Science (now Human Development Nursing Science).
“Dr. McFarlin has had an enormous influence on our college, and more broadly, in the field of maternal and infant health,” says UIC Nursing Dean Eileen Collins, PhD, RN, ATSF, FAAN. “Her program of research used novel technologies to address stubborn problems in women’s healthcare.”
Driven by the question of what causes preterm births , McFarlin combined her perspective as a midwife and sonographer with her expertise in research.
Her initial line of research was to develop and test an ultrasound method to detect microstructural changes in the tissue of the cervix to signal risk of spontaneous preterm birth.
Collaborating with professors William O’Brien and Aiguo Han at the Bioacoustics Research Laboratory at the University of Illinois at Urbana-Champaign, McFarlin developed a method to use quantitative ultrasound (QUS) to examine cervical changes associated with spontaneous preterm birth, first in pregnant rats, then translating the technique to humans.
McFarlin, O’Brien and Han are completing a study of cervical QUS in more than 500 pregnant people and are finalizing a model to predict people at risk of delivering prematurely.
“This technology has great potential to monitor treatment for preterm birth based on biomarkers, rather than waiting for symptoms of preterm birth when it is too late to intervene,” Collins says.
McFarlin is also a dedicated mentor, facilitating the success of junior faculty and students and her mentees. With research grants from major government agencies and private foundations, she has published 63 peer-reviewed articles during her career. She received the college’s Distinguished Mentor of Faculty and the Distinguished Researcher awards in 2020 and 2021, respectively.
McFarlin was also the recipient of the March of Dimes Jonas Salk Research Award, which is presented to top Illinois healthcare leaders who have facilitated improvements in the health of mothers and infants.
Oftentimes, social or economic disadvantages prevent a person from living their healthiest life. Last year, the American Diabetes Association (ADA) announced grant funding to support projects that focus on the impact of such health disparities on those with diabetes.
Louise Reagan, MS, APRN, ANP-BC, an assistant professor at the University of Connecticut School of Nursing, received one of those grants — called the Health Disparities and Diabetes Innovative Clinical or Transitional Science Award — as her research focuses on people with diabetes who are reentering society from prison.
Reagan says her team has found that people living with diabetes in prison lack critical knowledge and skills regarding managing their diabetes. As these individuals transition to the community, they are required to self-manage diabetes independently and are not prepared to do so.
Diabetes survival and self-management skills include knowing what foods to eat, how to control blood glucose (sugar), when to take insulin, how to manage sick days, and how to access health care. These skills are critical for incarcerated individuals, as their rate of diabetes diagnosis is almost 50% higher than the general population.
“I wanted to figure out what we could do to reach persons with diabetes at this critical transition period when they’re just getting out of prison and into the community, and how we could help them self-manage their illness,” Reagan says. “The Connecticut Department of Correction (CDOC), a community collaborator and advocate for the needs of persons transitioning from prison to the community, and my team don’t want citizens returning to the community from prison to end up in the emergency room being treated for hypoglycemia or dangerously low blood glucose when it can be prevented.”
Reagan worked as an advanced practice registered nurse in Hartford for 16 years, treating underserved populations with multiple comorbid diseases, including diabetes. This clinical work exposed her to the challenges that people released from prison or living in supervised community housing post-prison release face in self-managing their illness when reentering the community, and inspired her research.
She says many social barriers prevent patients from adequately caring for their own health. It can be challenging to provide diabetes education to recently released patients due to their multiple housing locations, desire for anonymity, and limited access to clinical care.
Additionally, she says, the priorities of people recently released from prison are often to avoid reentering prison, to find a job, and reestablish social and family relationships rather than manage their diabetes and other aspects of their health.
“Patients have many other competing needs when integrating into their societal roles,” Reagan says. “The Diabetes LIVE JustICE research provides an opportunity to help them with their health.”
Her study — called Diabetes Learning in Virtual Environments Just in Time for Community reEntry (Diabetes LIVE JustICE) — examines the feasibility and acceptability of a mobile app that provides diabetes education, support, and other resources in a virtual environment to people recently released from prison living in supervised community housing or on parole. Reagan’s goal is to improve health outcomes and reduce health inequities for this vulnerable population.
Reagan’s app, called LIVE Outside, contains live sessions with diabetes educators and instructive games to inform users about self-care.
Over the course of 12 weeks, Reagan will be measuring users’ diabetes knowledge, stress, and self-care after using LIVE Outside and comparing it to typical diabetes care education.
The mobile app is a culmination of projects Reagan has been working on since completing her postdoctoral fellowship at New York University. There, she served as a project director for an R01 study using a personal computer-based virtual environment called Diabetes LIVE, which promoted diabetes education to community-dwelling individuals.
Reagan’s proceeding research project with the CDOC, Diabetes Survival Skills (DSS), was an in-person intervention run within CDOC-managed correctional facilities. However, this project experienced attrition as individuals reentered society and could no longer participate, she says.
With collaboration and support from the Connecticut Department of Correction, Reagan anticipated taking in-person DSS interventions beyond prisons to supervised housing facilities to reach recently released individuals. This intervention, however, was put on hold due to the COVID-19 pandemic.
This forced Reagan to get creative with her work, leading to her innovation and the ADA grant.
“I was thinking about my work, and I wondered, ‘what if we use a virtual environment and adapt it to a mobile environment?’ ” Reagan says. “We could adapt the virtual app, use my program from the Diabetes Survival Skills, and blend them into a mobile app.”
Given the need for diabetes self-management education during the critical transition from prison to the community, the CDOC was excited to work with Reagan again to develop a remote mobile option for the people with diabetes under their care. Reagan then collaborated with her colleagues from Diabetes LIVE — Constance Johnson (UTHealth Houston), Allison Vorderstrasse (University of Massachusetts Amherst), and Stephen Walsh (UConn School of Nursing) — to combine DSS and Diabetes LIVE into a mobile app.
Diabetes LIVE JustICE was created and Reagan applied for the ADA grant to propel her innovation forward.
“My team and I had been talking about making this app mobile,” Reagan says. “The grant allows us to put all our work together to collaborate on this new idea.”
Reagan says she is grateful to have received this grant and for the strong collaboration with and involvement of the CDOC.
“When I received notice that the project was going to be funded, it was just an unbelievable feeling,” she says. “For me, this grant meant I had the opportunity to help underserved populations with their health, and I am so grateful for that. I feel so thankful that we can offer something to these people that sometimes don’t have anything.”
This research is supported by an American Diabetes Association grant #11-21-ICTSHD-05 Health Disparities and Diabetes Innovative Clinical or Translational Science Award. To learn more about the grant program, visit professional.diabetes.org. To learn more about the UConn School of Nursing, visit nursing.uconn.edu and follow the School on Facebook, Instagram, Twitter, or LinkedIn.
The American Association of Critical-Care Nurses (AACN) has honored nurse and bioethicist Cynda Hylton Rushton, PhD, RN, FAAN, with its 2022 Marguerite Rodgers Kinney Award for a Distinguished Career.
Rushton receives the award for her exceptional contributions that enhance the care of critically ill patients and their families and the nurses who care for them, and further AACN’s mission and vision. The presentation will occur during the 2022 National Teaching Institute & Critical Care Exposition in Houston, May 16-18.
An international leader in bioethics and nursing, Rushton is the Anne and George L. Bunting Professor of Clinical Ethics at the Johns Hopkins University Berman Institute of Bioethics and the JHU School of Nursing. She co-chairs Johns Hopkins Hospital’s Ethics Committee and Consultation Service. A founding member of the Berman Institute, she co-led the first National Nursing Ethics Summit that produced a Blueprint for 21st Century Nursing Ethics.
In 2016, she co-led a national collaborative, State of the Science Initiative: Transforming Moral Distress into Moral Resilience in Nursing and co-chaired the American Nurses Association’s professional issues panel that created “A Call to Action: Exploring Moral Resilience Toward a Culture of Ethical Practice.” She was a member of the National Academies of Medicine, Science and Engineering Committee that produced the report “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.”
“Dr. Rushton is an internationally recognized leader in nursing ethics, moral resilience and workforce issues and a longtime contributor to groundbreaking work on these topics,” said AACN President Beth Wathen. “Her work has influenced nursing practice, health policy and patient care.”
A member of AACN since 1979, Rushton is a frequent presenter at NTI and regularly contributes to AACN’s clinical journals.
Rushton is the chief synergy strategist for Maryland’s R3 Resilient Nurses Initiative, a statewide initiative to build resilience and ethical practice in nursing students and novice nurses.
She is a fellow of the Hastings Center bioethics research institute, chair of the Hastings Center Fellows Council and a fellow of the American Academy of Nursing.
She is the editor and author of “Moral Resilience: Transforming Moral Suffering in Healthcare,” the first book to explore the emerging concept of moral resilience from a variety of perspectives including nursing, bioethics, philosophy, psychology, neuroscience and contemplative practice.
She earned her bachelor’s degree in nursing at the University of Kentucky, followed by a master’s degree in nursing at the Medical University of South Carolina and a PhD from Catholic University of America in Washington, D.C.
About the Marguerite Rodgers Kinney Award: Established in 1997 and named for an AACN past president, the Marguerite Rodgers Kinney Award for a Distinguished Career recognizes extraordinary and distinguished professional contributions that further AACN’s mission and vision of a healthcare system driven by the needs of patients and their families where acute and critical care nurses make their optimal contribution. Recipients of this Visionary Leadership Award receive a $1,000 gift to the charity of their choice and a crystal replica of the presidential “Vision” icon. Other Visionary Leadership awards, AACN’s highest honor, include the Lifetime Membership Award and the AACN Pioneering Spirit Award.
Nearly 90% of COVID-19 patients who qualified for, but did not receive, ECMO (extracorporeal membrane oxygenation) due to a shortage of resources during the height of the pandemic died in the hospital, despite being young with few other health issues, according to a study published in the American Journal of Respiratory and Critical Care Medicine.
Approximately 90% of patients for whom health system capacity to provide ECMO was unavailable died in the hospital, compared to 43% mortality for patients who received ECMO, despite both groups having young age and limited comorbidities.
“Even when saving ECMO for the youngest, healthiest and sickest patients, we could only provide it to a fraction of patients who qualified for it,” Gannon said. “I hope these data encourage hospitals and federal authorities to invest in the capacity to provide ECMO to more patients.”
Once a patient was determined to be medically eligible to receive ECMO, a separate assessment was performed of the health system’s resources to provide ECMO.
When health system resources — equipment, personnel and intensive care unit beds —were not available, the patient was not transferred to an ECMO center and did not receive ECMO.
Among 240 patients with COVID-19 referred for ECMO, 90 patients (37.5%) were determined to be medically eligible to receive ECMO and were included in the study. The median age was 40 years and 25 (27.8%) were female.
For 35 patients (38.9%), the health system capacity to provide ECMO at a specialized center was available; for 55 patients (61.1%), the health system capacity to provide ECMO at a specialized center was unavailable.
Death before hospital discharge occurred in 15 of the 35 patients (42.9%) who received ECMO, compared with 49 of the 55 patients (89.1%) who did not receive ECMO.
“Throughout the pandemic, it has been challenging for many outside of medicine to see the real-world impact of hospitals being ‘strained’ or ‘overwhelmed,’” said co-author Matthew Semler, MD, assistant professor of Medicine at VUMC. “This article helps make those effects tangible. When the number of patients with COVID-19 exceeds hospital resources, young, healthy Americans die who otherwise would have lived.”
In total, the risk of death for patients who received ECMO at a specialized center was approximately half of those who did not.
“Because some patients die despite receiving ECMO, there has been debate about how much benefit it provides. This study shows the answer is a huge benefit,” said senior author Jonathan Casey, MD, assistant professor of Medicine at VUMC.
“This data suggests that, on average, providing ECMO to two patients will save a life and give a young person the potential to live for decades,” he said.
The study was funded by NIH National Heart, Lung, and Blood Institute grants K23HL153584 and K23HL143053.
“Exploring the Birth Stories of Women on the Autism Spectrum” has earned Laura Foran Lewis, Ph.D., RN the 2022 Best of The Journal of Obstetric, Gynecologic, & Neonatal Nursing (JOGNN) award. Dr. Lewis, an assistant professor at the University of Vermont (UVM) College of Nursing and Health Sciences will receive the award in June at the 2022 Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) Convention for herself and her co-authors, UVM and UVM nursing graduates Hannah Schirling, Emma Beaudoin, Hannah Scheibner, and Alexa Cestrone.
Lewis and her team explored birth stories of autistic women to understand how they make sense of the experience of childbirth. Accounts of poor communication, untreated pain, and sensory overload dominated the birth narratives, as study participants expressed feelings that their concerns were minimized, their wishes were ignored, and they were left out of critical communication and education during the birth process. Participants also emphasized the struggle they experienced when their own autistic traits, such as sensory sensitivities, were out of balance with the birth environment, impairing their ability to communicate with providers and participate in the birth.
The study concluded that nurses could help improve the birth experiences of autistic women by providing thorough and nonjudgmental education about the birth process; trusting women’s reports of pain and anxiety; and making environmental adjustments to help minimize sensory overload.
The study results pose a new challenge to conclusions of previous research documenting delayed bonding between autistic mothers and their babies, Lewis adds.
“In the past, we’ve just assumed that these early parenting outcomes are directly related to autism, but our study sheds new light on the severe trauma many of these women face during childbirth that may lead to detachment and postpartum depression,” said Lewis.
Lewis’s research contributes important evidence to the practice of inclusive health care, said Nursing Department Chair Rosemary Dale, Ed.D., APRN.
“Professional nurses care for a full spectrum of pregnant individuals. The more we are able to highlight the similarities and the unique needs of groups, then we are able to tailor our care and maximize inclusivity,” said Dale.
Lewis will receive the award at the 2022 Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) Convention in June.
Approximately 90% of patients for whom health system capacity to provide ECMO was unavailable died in the hospital, compared to 43% mortality for patients who received ECMO, despite both groups having young age and limited comorbidities.
