of you who lasted to the last day of the APA. I know that I have some friends who are also presenting today, and whenever we get the last day of the conference, we're all a little disappointed. But here we are, and I'm glad you're here with us today. So my name's Steve Cuff. I'm the chair of the Department of Psychiatry at the University of Florida College of Medicine in Jacksonville. And we are presenting on moral injury in health care providers, what clinicians and hospital leadership can do. And I have with me two colleagues from the University of Florida College of Medicine Jacksonville, Dr. Lourdes Dale, who's a clinical and research psychologist. She and I are, she's presenting our research on health care providers during COVID. Dr. David Chessire, who's also a clinical psychologist who runs the Center for Healthy Minds and Practice, which has been developed at UF Health Jacksonville for faculty, residents, nurses, and staff to help them with any emotional, behavioral, psychiatric, psychological issues that have come up. So he's going to be describing that. So disclosures, the research Dr. Dale and I did was funded by the University of Florida Clinical and Translational Science Institute, which is supported in part by the NIH National Center for Advancing Translational Sciences. Dr. Dale also receives funding from the SURF Foundation, Somatic Understanding Research Foundation. Ah, that's better. I'm a little tall and I couldn't hold it up. But that has really nothing to do with the current presentation today. So what are we going to do today? We have, we're going to look at the impact of stress on health care providers and the resulting burnout, moral injury, high rates of resignations and retirements. Going to go over the topic of moral injury perpetrated by self and others and the factors associated with that. Discuss how moral injury and other factors may impact the exhaustion and disengagement associated with burnout. Understand what we can do about moral injury and burnout as clinicians and also as leaders. And discuss what leadership can do. So have any of you experienced moral injury? Yeah. So I think it's more common than we have given it credit for. And I'll just describe a couple of things that I've experienced in my career. So in a previous position, I was the head of child psychiatry for the University of South Carolina and the director of the State Hospital for Children. And during the course of that 12 years or so when I did that, the budget would get slashed and slashed and slashed. And we would have moratoriums on hiring. And when I started, we had a plethora of services with two social workers on every unit, a full-time psychologist. We had six different units we were covering. And music therapy, art therapy, occupational speech and language, we had everything. And over the course of time, the only way I could keep any psychology on the unit was to make them the unit director. We lost our music therapy. We lost our art therapy. We were down to one social worker per unit. And so I was feeling like we were hanging on by our fingernails and not treating these kids the way they deserved to be treated, which, of course, is partially why I ended up in Jacksonville as I started looking around because I couldn't take it anymore. Another thing that happened was one of the units was a unit from juvenile justice. So any child with a psychiatric disorder from the Department of Juvenile Justice was transferred to us in our unit. And we gave them all of the treatments. And that meant they went outside. They were doing things. And one of them escaped. I mean, he got like a few blocks. But it freaked out the Department of Mental Health Administration. And they said, you can't let them off the unit. So what would you do in a situation like that? Well, I'll tell you what I did. I said, if you make us do that, I'm resigning today. And they backed off. They did increase the level of security, fine. But sometimes you have to make a stand in situations where you know that you cannot tolerate what's being asked of you. And that happens sometimes in other settings and other psychiatric units. And people lined up in the emergency rooms where you can't really provide the kind of treatment that you want to provide. So in our field, we experience moral injury in multiple different settings. All right. So let's move on. Just a little bit of introduction for what is burnout. What do we mean by burnout? So it's not listed as a diagnosis. It's listed as a cultural idiom of distress in DSM-5. ICD-11 describes it as an occupational phenomenon, not a diagnosis. And it's a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. And I can say that when I was going through all that stuff, I was definitely burning out and had emotional disengagement and multiple other exhaustion and things like that. So burnout is a symptom of a chronic workplace stress Burnout is real. And we have to be really cognizant of that. And if you're a leader, be aware of that and understand your own faculty and your staff and residents. So burnout was first introduced by an analyst, Herbert Freudenberger, in 1975 as his paper. And he described the consequences of severe stress and high ideals in helping professionals, defined as failure or exhaustion because of excessive demands on energy, strength, or resources. Maslach went on to define burnout as being characterized by three dimensions. I'm sure you all are aware of these, feelings of emotional exhaustion, cynicism and depersonalization, and reduced professional efficacy and personal accomplishment. So studies of burnout pre-COVID show high rates in physicians, ranging from 30% to 60%, depending on the population, and private practitioners being more susceptible to burnout than people in academic settings, which kind of makes sense if you're in a single group and you don't have camaraderie. You might be more isolated. Nurses have high rates of burnout. This shows about 40%, but I think it's higher at this point. And it's been associated with lower quality of care, medical errors, malpractice lawsuits, and personal issues like substance abuse, poor relationships, depression, and suicidal ideation. So moral distress. We're going to talk about morally distressing events and then the phenomenon of moral injury. So moral distress occurs when one is aware of the right thing to do, but is unable to do so because of occupational constraints. Examples include being unable to provide enough care, conduct or refer patients for necessary procedures or assessments, belief they are providing inadequate care, discomfort with telemedicine, although I think that's kind of an old thing. I think people are much more comfortable with telemedicine at this point. So if you can't do the things that you know you should do, that is an event that could lead to moral injury. So moral injury is when someone's values and morals are violated by perpetrating, failure to prevent, or bearing witness to acts that transgress deeply held moral beliefs and values. Person feels moral pain involving emotions and cognitions in response to that event. And moral injury is the lasting psychological, biological, spiritual, behavioral, and social impact of the morally injurious events. And of course, this research really started in the military and has been expanded into other areas, particularly health care. So what happened during COVID? Health care providers experienced a lot more stress due to fear of contracting the virus. Initially, during the crisis, there were quite a few health care workers who died after being exposed and contracting COVID. Fortunately, the newer iterations are more infectious but cause less morbidity and mortality, which is a great thing. There were increased professional demands, increased belief that their mental and physical health is disregarded by employers, which leads to systemic distrust. And I must say that part of my own fear during this was the fact that my daughter was working in the MICU and had a MICU full of COVID patients she was dealing with. Fortunately, she did not ever contract the virus. She had the PPE and was able to do the work she needed to do. As a psychiatrist, I would be working on the consult service and going in to try to do consultations on people who were in the MICU or before they get to the ICU. And that in itself was disconcerting, but it's not the same as spending all day on a unit with these patients. So as the research show, health care providers reported high rates of anxiety about spreading the virus to loved ones. They reported mental exhaustion and PTSD symptoms. One in three report high levels of emotional exhaustion. One in four, high levels of depersonalization. There is concern that the burnout in psychiatric symptomatology may affect quality of health care delivery, and these mental health difficulties and the corresponding burnout may relate to moral distress. So traumatic stress has been identified as a significant predictor of moral injury. It's been associated with sleep disturbance and mitigated by a supportive workplace, and that's one of the things that our data showed that Dr. Dale will be discussing later. And moral injury can affect autonomic reactivity. Prior research suggests that mental health and medical adversity may retune the autonomic nervous system and the brain in preparation for stress. And that's the end of the sort of introductory discussion. I'm going to turn the podium over to Dr. Dale, who's going to discuss our research findings. Good morning. Thank you for having me here. So I'm going to be presenting the results of a research project that we did in collaboration. It was a collaboration between the University of Florida in Gainesville, the College of Medicine there. Also, University of Florida in Jacksonville. And we also had some undergraduate students from the University of North Florida who helped out with this research project. So we had some hypothesis and some research questions. We hypothesized, based on the previous literature that was just presented, that health care providers would report significant levels of moral injury and burnout. We thought that those that would report moral injury would obviously have experienced some morally distressing experiences, that we could make that link between the experiences and the moral injury, that these people that were reporting moral injury would be more likely to have had prior adversity in the past that kind of retunes their system potentially and prepares them to be more impacted. They may be less resilient, and they may be feeling less support by hospital leadership. We also thought that health care providers who were experiencing this moral injury would report higher levels or be more likely to have psychiatric symptomatology, anxiety, and depression, and PTSD, and also be more likely to score above the clinical cutoff for burnout. Additional questions were whether health care providers would be more likely to score above the clinical cutoff for burnout if they were experiencing both the moral injury, the psychiatric symptomatology, reporting that they were impacted by the care that they were providing to the COVID patients, and they were experiencing less leadership support. Lastly, we wanted to know if there were any differences depending on the health care role, so between nurses, doctors, and assistant technicians in terms of their level of moral injury and burnout. So the participants were health care providers. The larger study included health care workers, but we focused just on the health care providers because of our interest in moral injury and their experiences in providing health care. The sample came from the Gainesville area, which is more of a mid-sized city, and the Jacksonville area, which is a larger city. And we recruited through flyers, emailed brochures, were also sent out. And we were able to get about 430 participants, and we're focusing on a smaller number here that were the health care providers. So they completed measures via REDCap, and they were compensated for their time. They were paid progressively more, and we collected up to eight months of data. I'm focusing mostly on the first month, but also including data from months one to four to look at the relationship between moral injury and burnout. So here's the characteristics of the sample. There's some obvious problems with the data. We have predominantly females and predominantly individuals that identified as white. We only made the distinction between white and non-white because we just did not have enough in the other groups to be able to look at it as a variable. Most of the sample came from the larger city, and you can see that there's a lot of variability in terms of the income and in terms of education because we did have a good number of physicians and doctoral level people, but we also had a good amount of college educated, so having nurses and technicians and assistants too. So we looked at moral injury via the Moral Injury Event Scale. So this is an instrument that includes actually nine items, and we focused on the six items that have to do with either moral injury perpetrated by the self, so that's asking about things that you did or things that you did not do, and then moral injury by others, which is you see people doing things that you think is morally wrong. So those six items, and four of them are in the self moral injury scale, and two of them are in the others moral injury scale, and so we found that it was really important to make that distinction, and I'll explain to you a little more later. We looked at morally distressing experiences, and this is a measure that we came up on our own. So we wanted to find out if there were some experiences in providing healthcare that seemed to relate to that moral injury variable that we were looking at. So we asked them, in spite of COVID-19, have you been able to provide patients with appropriate frequency of care, conduct necessary assessments procedures, refer patients to specialists, and refer patients for necessary procedures? So these questions were answered on a Likert scale, and if they disagreed, then we viewed them as having experienced that morally distressing experience, and a couple of other questions focused specifically on their experience with telemedicine, so this was a larger, a smaller sample that was just doing telemedicine. We looked at prior adversity, so we used an instrument that I created with other colleagues that's called the Adverse and Traumatic Experiences Scale, and it looks at all different kinds of adversity and trauma that you may experience in your life, and instead of just indicating did you experience it or not, the person says did not occur, occurred and no impact on my life, occurred and minimal impact, some impact, or big impact. So they themselves rate how impactful the different events were, instead of just knowing the frequency or that it occurred or did not occur, okay? And we focused on the items that made up the mental health adversity, and those were specific to medical adversity, because we thought that if they had experienced a lot of medical issues in the past, they would be more concerned about COVID and how it could affect them. We also looked at some COVID-related work factors. So similar to the item I just described, we came up with some specific situations that we thought would impact their work, so like work impact or work adversity. And so we had them fill out the different items with the same scale, and they ranged from simple things like working with a patient who might have COVID, or a patient who was suspected of having COVID, or diagnosed with COVID, or died from COVID, so they got progressively more clear about the risk. So as they went through the items, the risk was higher of contracting the infection, and they reported how impacted they were by that, because we thought that that would likely affect their burnout and potentially their moral injury. We also looked at their worry of being infected, infecting family members, and their concerns about whether they were getting appropriate protection or not. In terms of personal resilience, we used the Brief Resilience Coping Scale, it's four items, and it's pretty straightforward, it asks about their perception that they have the resilience to deal with stressful situations. In terms of leadership support, we used the Leadership Behavior Description Questionnaire, and I have to admit that I wasn't quite sure why we needed to put this in there, but it turned out to be one of the most important variables that we found to be important in our understanding our results. We looked at current psychiatric symptomatology, so depression with the PHQ-9, anxiety with the GAD-7, PTSD symptoms with the PTSD Checklist-5, and workplace burnout. We used the Professional Fulfillment Index. This index has three scales. One of them is professional fulfillment, which we did not focus on here. And then two other scales that relate to burnout, which are work exhaustion, which assesses sense of dread, physical or emotional exhaustion, and lack of enthusiasm. And then there's the interpersonal disengagement, which assesses empathy and connection with others, particularly patients and colleagues. And for each of these scales, we figured out mean scores and used a 1.33 as recommended by the authors as a determination that they scored above the clinical cutoff. So going to the results, what I want you to focus on in this table is just it gives you an opportunity to see the actual questions that related to self-moral injury and others' moral injury. And if you look at the mean scores, you see that they reported a lot more others' moral injury than they did self-moral injury. In terms of burnout, again, here are the questions that relate to each of the scales. The work exhaustion and the interpersonal disengagement, again, the mean scores show that they reported a lot more work exhaustion than they did the interpersonal disengagement. And the work exhaustion that, like, they scored the highest in terms of mean scores was physical exhaustion and emotional exhaustion. So kind of putting the statistics a little together in terms of moral injury and burnout, we found that there was a lot of overlap between the self and others' moral injury. So there was 23% of the individuals that reported both self and others, I'm sorry, 7.9% reported both self and others. But the majority, there was 23% that reported only others' moral injury and 2.3% that reported self-moral injury. So most people that saw themselves as doing something wrong also saw other people as doing something wrong in some way. So there's a lot of overlap there. In terms of burnout, looking at the clinical cutoffs, we have really high numbers of individuals that reported exhaustion. So 63.3% scored above the cutoff for work exhaustion, 32.1% for interpersonal disengagement, and 44.4% the combination of the two. And we did do some multi-level modeling analysis that looked at the first four months and the relationship between moral injury, both the self and the others, and the burnout. And we found that at any given point, there was a high relationship between the self-moral injury and the burnout. So as you will see, although we saw more others' moral injuries, self-moral injury tended to be most predictive. So now in this table, we're just presenting univariable binary logistic regression analysis. So we're looking to see if these morally distressing experiences increase the odds of reporting self-moral injury and others' moral injury. So highlighted in orange are the significant findings. And you can see that being unable to provide frequent care increased the risk of both types of moral injury, and that being unable to provide the necessary assessments or feeling uncomfortable providing telemedicine increased the odds of self-moral injury, whereas being unable to refer for tests, you know, that's—other people aren't able to do what I think they should be doing, so that related to others' moral injury. We found that nurses were more likely to report others' moral injury. And we found that there was a lot of factors that related to others' moral injury that seemed to be like sort of predisposing factors, like if you had experienced a lot of adversity in your life and you were impacted by it. You know, if you were caring for COVID patients, your healthcare worry, your protection, if you'd experienced COVID yourself, and leadership support. So most of the factors predicted others' moral injury. Less factors were predictive of self-moral injury. That was more related to the impact of the care that you were providing to COVID patients, feeling less protection, and less leadership support. Next we looked to see how many of our healthcare providers were scoring above the clinical cutoff for depression, anxiety, and PTSD. And you can see that we have, you know, about a quarter reporting, you know, scoring above the clinical cutoff for depression, anxiety, 11% PTSD, and burnout again was that 44%. So we did some conditional logistic regression analysis, and we found that both self and others' moral injury increased the likelihood of scoring above the clinical cutoff for depression. So both types of moral injury. But when it came to anxiety, PTSD, and burnout, it was only the self-moral injury that was predictive of whether you scored above the clinical cutoff. Next we tried to take it to the next step and see how does self-moral injury and psychiatric symptoms, how does that relate to sort of our burnout? So first I'll explain that we had high levels of exhaustion and disengagement, as I said before, and that although these components of burnout were correlated with each other, they did seem to be tapping something very differently, which is why we chose to focus on them as separate constructs instead of just looking at burnout scores, okay. So we did stepwise linear regression analysis, and we found that the predictors of exhaustion that came out were self-moral injury, depression symptoms, healthcare worry, so being worried about getting sick from COVID, and leadership support. So that was tied to the exhaustion. The predictors of disengagement were, again, self-moral injury and leadership support, but it was more of that COVID work impact. So you're impacted by the care that you're providing to these patients, and you're disengaging more. So we thought that that distinction was really important. And then lastly, we did some conditional binary logistic regression analysis to predict burnout, which again is the combination of the two, and not surprising, we have a lot of the same predictors, self-moral injury, depression symptoms, work impact, and leadership support. We were able to correctly classify 75.3% of the providers based on this information, and if you look at the odds ratios, you can see that actually self-moral injury was the one that had the highest odds, or the greatest likelihood of experiencing burnout. So of course this study has some limitations. You know, we did focus on the area in Florida. I think we did good in being able to hit like a mid-size city and a larger city, but the experiences that we were having with COVID may have been very different from other areas of the country. We did start collecting data in October. October, November was like when most people did the first data collection, and in Jacksonville by December, we did not have enough beds for people. We were putting them in all kinds of different units and making units and all that. So we did collect data at a point where we were having a lot of stress in the system. It's possible that healthcare providers may have been experiencing other morally distressing experiences that we didn't tap into, but we're grateful that we're able to see that link between the experiences and the reported moral injury. And you know, their moral injury may have been impacted by other things that I think we need to investigate in the future, which is things like prior training, and that we also need to be aware that leadership support is really important. And lastly, another limitation is that we're not really sure how much of the psychiatric symptoms and the burnout was going on before we started the pandemic. We can't really say that there was an increase. We're really able to just say what we saw at that point in time. So just to briefly summarize the conclusions and implications, we did find high rates of moral injury and burnout among healthcare providers at those four time points, and we found a connection between the two. We found that self-moral injury and leadership support predicted burnout and the two components of exhaustion and disengagement. And we also found that exhaustion was impacted by worrying about getting COVID and your depression symptoms, and that disengagement was also impacted by the care that you were providing to the COVID patients. And so I think our research really highlights that we need to be aware of what's going on with healthcare providers, and that leadership support really needs to be involved, especially if there's crisis situations. So I'm going to pass this along now. Hi, everybody. I'm Dave Chesire. I'm a psychologist over at the University of Florida College of Medicine Jacksonville campus, and I'm not going to talk about research at all. So that part I'm going to leave entirely in the hands of the people who know it better than I do. And I'm going to tell you right off the bat, speaking of moral injury, normally when I give presentations, I prowl up here like a panther. I'm not used to being stuck behind a podium. This is going to drive me nuts. And I'm also going to say, normally that gets a chocolate from the audience. It doesn't. This one, you guys are going to be a tough crowd, but I've also presented to officers and they're coming to my presentations armed. So game on, folks. So let's talk about what we do with moral injury, specifically from a healthcare standpoint. But essentially, moral injury is all about when individuals are in stressful circumstances. And it's tough to define moral injury against things like burnout, things like PTSD, because there's so much overlap. And moral injury is more of a soulful injury, more of a cognitive dissonance injury. It's more of your relationship with what you're seeing as opposed to the event itself, right? Whereas burnout is typically defined as conditions of workplace, and PTSD is exposure to harmful, stressful events, moral injury is what your relationship is with it. And the way I frequently describe this is when a certain set of events comes into being because of something you either did or failed to do, or witnessed but didn't intervene in, and how you feel about how you supported that event, that's moral injury. And to lead us off, Dr. Cuff mentioned this comes out of the military research, and that really comes into play because the military is frequently put at these really morally ambiguous or tumultuous affairs. One of the clients that I see, and again, I only work with employees of the hospital, but one of the clients I see has come from the Army, and he was in Afghanistan. And the reason he joined the military in the first place was because he wanted to spread democracy. He was one of these kids that was gung-ho about, put a gun in my hands, I'm going to go and take out the bad guys, and the good guys are going to benefit from that, right? A noble endeavor. And one day, there was an attack on a small village in Afghanistan, missiles from afar, because there was a high-level target believed to be in this village, and so they launched the missiles into the village. Now the question is, did we get the guy? Well, does anybody know how you find out if you get the guy or not? You send people in to find out, but the problem is, missiles don't discriminate between the innocent and the guilty. And so there was a lot of collateral damage. And so now our soldiers are being asked, did we get this person, go and look and sort out the good from the bad. But here's the other problem, missiles don't leave a lot of remains behind. And so our soldiers, who are only there to spread democracy, to fight the good fight, are being asked, actually before I say what I'm about to say, I do want to give you a warning. I'm going to be war-torn triggering. If anybody finds this triggering, please forewarn. Our soldiers are being asked to cut off the digits of the survivors, put them in a bag, bring them back with them so we can identify who they were. But that doesn't happen immediately. They had to store those remains right alongside their food. That was morally injurious because it's contrary to what this person saw his role in the military to be. I didn't sign up to hurt innocent people and to have to sort that out. I didn't sign up to do these kind of events where I had to actually do these gruesome kinds of details. And it became very difficult. Yes, the PTSD is about what he saw on the ground. The burnout is about the workplace environment that is just totally intolerable. The moral injury is how on earth can I allow myself to be part of this system? So moral injury is the psychological, behavioral, social, spiritual aftermath of all of this stuff. Now flash forward from that into when we started to apply moral injury into hospital settings, medical care settings, psychiatric settings, psychological settings, social work settings, all of those. Three years, well, yeah, three years ago. Gotta get my dates right. I remember saying to my boss, I'm looking forward to the day when I can do a presentation and I don't utter the words COVID-19. And unfortunately, I'm about to say we haven't gotten to that point yet. But three years ago, when COVID-19 got here, one of the things our hospital had to do was prepare. What happens if we're overrun? We saw what was happening in New York. What are we going to do if we're overrun? We're gonna have to triage people. We only have a finite number of beds. Our walls are only a finite amount of space for our emergency department. We set up tents outside our emergency department to handle the overflow. But what happens if that gets too much? What happens if we are so overrun that we can't take care of people? And administration decided if that happens, everyone is automatically do not resuscitate. Everyone is automatically do not resuscitate. So if someone goes into arrest on our front lawn, that person dies. And then they pointed at the healthcare providers and said, those are your parameters. We never got to that point. But imagine if we did, even having to prepare for that, knowing if I had more resources, more space, more personnel, more medication, more beds, more time, I could save these people, that I have to step over and save the people I can. That is a morally injurious situation, yeah? And again, you can see where PTSD would come from, that the images, the sounds, the smells of all that, but the moral injury is knowing you are a part of the system that cannot adequately care. So again, the overlap between PTSD and moral injury, we're exposed to things that are just utterly horrible. The more awful the situation, the more likely we're gonna experience post-traumatic stress, post-traumatic anxiety from it. But where we overlap with moral injury is the guilt and shame as core features here. That you all are in the mental health field, you know shame is a killer. I liken shame to a seizure, that there is no good outcome from that. If you see a seizure, something's wrong. Seizure is never indicative of normal, neither is shame. Shame is always killer. Shame always gets in the way of us being our best self. And lastly, feelings of betrayal and loss of trust, either in the system, in each other, are within ourselves. Now again, it is possible to have moral injury without PTSD. Lot of symptom overlap, PTSD is mostly got a fear response to it. It's about the dread or the fear of personal injury or survival. Moral injury can be beyond that. Very good friend of mine is an emergency physician, and he and I were talking about moral injury last week. And we're talking about how do we define this thing, this fuzzy concept. And in the emergency department, he said, I'm morally injured. My moral compass is broken. And essentially what he's saying is, I have to work within this field. It's not the sights, it's not the sounds, it's not all of that. It's not having to write in the computer, electronic record for six hours every night after I'm off shift. All of that stuff is tough, but the moral injury is I've got to give some kid Narcan, knowing he's gonna come back next week, probably overdosed if he makes it into the hospital in the first place. And I do that over and over and over again until they don't show up, probably deceased. Is that why I became a physician? And that's the moral injury. That's the tough part of it. And then the question is, how do I fix it? How can I be part of the solution rather than part of the machine, part of the problem? Guys, I've been to San Francisco one time in the past. It was years and years ago. I brought my wife for the first time to this go-round, and we have walked all over this city. And of my Irish descent, you can tell by my nose, I've been outside a lot this week, right? Walked the Golden Gate, walked over to the beach, all walking, that's 40,000 steps on Sunday, guys, 40,000, 20 miles of walking. That's a lot for me. And one, I don't know this town at all, so I've basically hit every street. And there are some streets that are qualitatively different from others in San Francisco, right? Y'all know what I'm talking about. Walking down those streets, if you're like me, is really hard for a lot of different reasons. It's hard seeing the suffering. It's hard seeing the poverty. It's hard seeing the disorders. It's hard seeing the relationships. Saw somebody whipping his dog with a belt. That was hard for me. But it's also hard knowing, I don't feel comfortable here, I wanna get away. We're not going down this street again. And then, after all that thinking, I got no thoughts as to what the solution is. I can't fix that. I don't know what to do. And it's tough. And then again, it's the moral injury that we feel on more of a day-to-day basis. And certainly that intrudes on healthcare, but we catch this just by being empaths. Right? And that's part of your calling. Now there's a certain segment of our population that don't feel that way, and thus don't feel moral injury. I'm hoping that those people don't exist inside this room. But if you happen to be a psychopath, this is kind of a curious lecture for y'all to be in. All right, so what do we do to treat this? Well, there is not a lot of research out there that talks about what is successful for moral injury. For that matter, a few short years ago, we didn't have many effective treatments for PTSD in general, right? And so we've been looking at prolonged exposure in cognitive processing therapy as likely candidates for positive treatment outcomes. And the reason for this is we use those for PTSD. There's so much symptom overlap. That makes sense. We should be able to do this, right? And so in the literature from what I've been able to see, cognitive processing therapy has slightly better results than anything else. Not perfect, but cognitive processing, basically challenging people's beliefs as they come up to say, no, you can still be a good person. You're still making change. You're still doing this and helping people that way. But the problem with this is even with these treatment modalities, we're still likely to have guilt following the treatments. And guilt and shame are the bedrocks of what moral injury is. And so even with these treatments, we don't see a lot of positive outcomes, right? Some, but really what it comes down to is the cognitive dissonance. How can I be who I think I am and be a part of this system to not be treating my patients the way I feel I should, to not be, or to watch other people just do a half-assed job because that's the minimum required, knowing if only they would step up to the plate, maybe we could do some real change, right? So even with these treatments, we still see things fall flat. So in healthcare, what causes moral injury? Making decisions that affect the survival of others or where all options will lead to a negative outcome? We do this on a daily basis. Last night over dinner, we had a conversation about end-of-life care and about our effectiveness of treatment from the last couple of days or weeks of life, right? If you've spent any amount of time in our healthcare system, you know that's when we really fall apart because we have to balance palliative care with length of longevity, basically. I can keep you alive, but you're gonna suffer. And when do we tilt the scales in one direction or the other? And that's murder. That's really tough. Any of us that have had to go through it, and chances are, even if we didn't go through it professionally, we have or will go through it personally because this is in front of us. Balancing those is so tough, so hard. And looking at it from a personal level, looking at our parents, our grandparents or other people in our lives, in these kind of situations, how can I be a good friend, a good son, a good husband, a good wife, a good whatever, and allow this to happen? How do I make the choice? It's time to terminate care, withdraw care, versus no, we want to keep fighting because they may be able to pull out of this. It's really hard, and that's morally injurious. That's when it really becomes a problem. When we fail to heal, so much of what we do, I had a great mentor years ago. Ostensibly, I'm housed in the Department of Surgery. And one of the surgeons that I used to work with when I was working a lot of trauma, his name was Dr. Freiberg. And he had a family come into a waiting room, working out of the ICU, and this particular patient wasn't doing so hot. And the family said, everything you're telling me is so different from what we were doing yesterday. And Dr. Freiberg, a genius surgeon, unfortunately he's passed on since his story, but he said, my job is to come in and evaluate the patient. And then I develop a treatment plan. And I run that treatment plan to the best of my ability. And tomorrow morning, I come in and evaluate the patient and come up with a new treatment plan. Because it's not an exact science, we do the best we can with the data we've got. But oftentimes, that doesn't lead to the outcome that we're really shooting for. And in some cases, despite our best efforts, the patient just isn't responding the way we think they should. And that is draining. That is tough, that is hard, that's morally injurious. And so often, we witness things. A few months ago, I don't know if you guys know this story, a few months ago, in our emergency department, we had a young lady come to the emergency department after a very, very bad car accident. She was pregnant. And she needed an emergent C-section to try to save the child. They did it without anesthesia. That was a tough case for people to see. Now, I wasn't there, I don't know the particulars. I had a lot of people come into my office afterwards. But that was tough, and it was tough because it had to happen fast, the necessary stuff wasn't there. That had to happen, the child died, mother survived. Mercifully, didn't remember much of the event. But that's witnessing things, that we didn't sign up for healthcare. Nobody went into healthcare to do that, nobody. And yet, that happened. And then, experience being betrayed by others. So oftentimes, especially when we work in multiple systems, when one department feels, this is what we need to do for this patient, another department swoops in and says, no, you got it wrong, we need to do this. Now, we're at odds with each other. And God forbid, they tell the family, this is, the other people don't know what they're doing. And all of a sudden, we feel betrayed by our colleagues. That, too, is morally injurious. Or worse yet, that we betray them and feel that we're betraying them and not working as part of a team. So how do we minimize moral injury in healthcare? Well, again, a lot of suspicion as to what we should do. A lot of best practices that we can put out there. Not a lot of good science behind a lot of this. Now, for those of you who know me, you know I like to share stories and anecdotes and things like that. Now, the upside is, I know these stories pretty well by now, the stage of my career. The downside is they don't get any more interesting as you hear them in repetition. So I apologize for that if you've heard this before. But two quick stories on this one. First, when I was a graduate student at the Illinois State University, I was taking a theories and techniques of counseling class. And we were talking about the existential therapies, person-centered therapy and the like of those. And one of the hallmarks of existential therapies is helping people find meaning in their lives. Now, existential therapy, almost by definition, are agnostic or atheist. So we're not looking for meaning that way, though we could use those as tools. But really, how do we find meaning in stuff? And so our professor at the time put this out, and I remember raising my hand, and I asked this question. If you're working with, and I said housewife at the time, I've gotten a little older and wiser. So if you've got a man or a woman doing childcare, maintenance kind of things at home, and they don't have a fulfilling experience with that, whereas their spouse or their partner going off, you end up being the breadwinner. So this person comes to your office and says, I don't feel fulfilled. Is the role of the therapist, this type of therapy, to find the meaning, activities they find meaning in and engage in those, or find meaning in the activities they're engaging in now? And my professor said, that's a good question, David. I have no idea. Probably either one, you choose. I always found that very unfulfilling as an answer. But moral injury is kind of that way, because moral injury is the shame, the disconnect, the cognitive dissonance that we have from what we've seen, what we've done, what we've witnessed, what we haven't done, and who we believe we are at our soul. And if we can bridge those two things by finding meaning in what we do, if we can go into that soldier who had to go into camp and help them find, this is an important part of the process, because by goodness, you are going to affect the lives of millions by doing it. It is unfortunate what you've seen, yes, but here's the meaning, and if they believe that and can hold on to that, that could be a pathway out of moral injury. Or helping them find, this may not be for you. Maybe a better avenue for you to get what you want is through the Peace Corps, or the Red Cross, or something in those neighborhoods. And again, how the person goes, what we think to guide, that's gonna be situation dependent, individual dependent. But most of the therapies that seem to work with, or at least have shown to be helpful, are all about establishing meaning in what we're doing. So, how do we do that? Okay, here's your parable. So, two angels are walking down, this takes place in the Middle Ages. Two angels are walking down some stream, or some path, or woods, or somewhere, all by themselves. An older angel and a younger angel, because evidently in this story, angels have different ages. And night falls upon them, and the angels need to find shelter somewhere. And they see this big mansion in front of them. And one angel says, we should go there, they've got lots of room, they should be able to put us up. And they decide to go up there, they knock on the doors, the sun is falling. Kind of a cantankerous old guy answers the door and says, yeah, what do you want? And the older angel says, well, my companion and I are just traveling along the countryside. We lost track of time, night fell, and we need to find shelter. And we saw that you had this big house and lots of room, we're hoping you could put us up. And the angels kind of wait for it, and the old guy says, I'm not letting you in my house. I don't know who you are, I don't know what you're gonna do. I don't want you anywhere near me. Tell you what, I got that old dilapidated shelter over there, they look across, and it's just kind of this dugout structure that's collapsing and not self-dug into the ground. Because you can sleep there if you want. The angels thank him, and set up camp in this old, busty, underground burrow, really. In the morning, the angels wake up, and the younger angel notes, the older angel woke up before he did, and while he was sleeping, the older angel repaired the wall to the structure. So now it's this nice brick wall, very sturdy. And the younger angel says, hey, that guy was really mean to us. And yet you did this favor for him? What gives? By the way, does anybody know this story? Just, okay. Okay, and the older angel says to the younger angel, all is not as it appears to be. Like, that's something an angel says, evidently. Younger angel's like, all right, whatever, and they go off on their way. So they go along a big, scenic lake this day, it's still through the woods, night falls on them again. And this time, they have to take shelter, and they find this little hobble farmhouse. And they knock on the door, and an old farmer and his wife answer the door, and they say the same thing. We're two travelers, night fell upon us, we need shelter, we're hoping you can help us out. And this time, the older farmer says, hey, we don't have much, but what we have is yours. Please come in, we have one bedroom, it's yours, my wife and I will sleep out here. I can't offer you much by way of food, but we do have a cow, so in the morning, there's fresh milk. The angels think. In the morning, the younger angel wakes up to the sound of the farmer's wife crying. When they get out of their room, they ask what happened. And the farmer says, my friends, I know I promised you fresh milk for breakfast, but unfortunately, overnight, our cow died, and I can't offer it to you. Angels say, that's okay, thank you for your hospitality, and they go on their way. Younger angel says to the older angel, they were so nice. They offered everything to us, and overnight, you allowed their cow to die? And the older angel says, all is not as it appears to be. Okay, that works once, but not so much twice. The younger angel chews on it for a bit and says, no, you gotta give me something more than that. Okay, this is the very definition of moral injury. The younger angel feels that the world is not working the way it's supposed to. There are angels for goodness sake who should be able to prevent some of this stuff so that the wicked are punished and the good are blessed. He says, no. Yesterday you repaired that mean guy's wall and he did nothing but just cause us harm. And today you allowed that cow to die and that's not okay. You gotta give me more. The old angel, somewhat exasperated but in a wisened tone, says, all right. Two nights ago when we were sleeping in that hole, I noticed that through the broken wall there was a seam of gold running. And I didn't think that the farmer, that the house owner deserved that gold. So I repaired the wall so now he'll never find it. Last night while we were sleeping, the angel of death came for the farmer's wife and I convinced him to take the cow instead. All was not as it appeared to be. And guys, that's how we get out of moral injury. Moral injury is when we can't see the meaning. But if we are able to tie ourselves into something bigger, something deeper, something beneficial, that's how we go. And how we work with our clients to be able to find that seems to be a way to get there. These are positive ways to do just that. Help people understand their internal talk, what they're telling themselves. We wanna educate people about what moral injury is and pathways out of it. We wanna connect them to their leaders and get support from their leaders. We want people to be able to get satisfaction from what they are able to do. Remember, personal accomplishment is part of the Maslock instruments for burnout. So that's where our overlap is. And if we can get people to cling to this, we can start to raise them up and out of that despair that comes with, that leads to moral injury. One thing about moral injury, anybody, y'all know what imposter syndrome is? All right, lots of nodding. All right, just curious. How many people in here have experienced imposter syndrome? All right, almost everybody is honest with me. Okay, imposter syndrome is one of those things that we all feel or most of us feel about we feel like we're not good enough or smart enough to do the job that we've got in front of us. And the hell of it is we never talk about it because we don't want other people to know that we're just faking it. Moral injury is like that too. We don't talk about it either from shame or guilt or embarrassment or whatever else have you. But if we can open that up, get rid of the stigma and help people to talk about this and communicate with others, it's our first steps toward getting out and ultimately referrals to healthcare providers. Now, important here too is what should leaders do for their teams? As we were coming in today, Dr. Cuff and I were talking about the early days of COVID and about how our leadership handled that. And we had two very prominent leaders that took decidedly different paths. One was very transparent with our team, our whole hospital and talked about, this is tough. And I don't have the answers right now. We are gonna do the best we can each day. And I will promise, I will communicate with you our latest information about the numbers of COVID patients we have, about what we're expecting on a national scale and a city scale and what we're doing about it. And we encourage other people to reach out for help if they need it, really set up a family-like feel. The other leader was just wanting to take a very strong approach of, I'm captain of this ship, but didn't reach out to the people behind them. And so on the one hand, we really had a lot of people kind of gravitating toward that leader because they felt safe, they felt secure, they felt that this person knew them and knew their pain. And the other person, not so much, both very strong leaders in their own right. But what we really need to do in terms of how to help people not feel burned out, not feel morally injured, not feel post-traumatically disordered, is to have, Dr. Cuff wrote this slide, dramatic or radical transparency. We need to make sure that everybody is completely open in these times of crisis and these times of stress because it makes you feel part of something and there lies meaning. Include a variety of staff in decision-making. You wanna make sure that everybody feels that they have a hand in the solution, that no one's being overlooked. Communicate distinctly, clearly, let people know exactly what you're thinking. Empathy is so important here, too. Establishing a sense of, for those of you around my age, you were there in 1992, you know a guy who said, I feel your pain. Bill Clinton was a master at this. He brought a big portion of the country behind him and he won the election because people felt, he legitimately felt their pain. Nothing more than that. Communicating, I get where you're coming from, can be so powerful. In fact, Carl Rogers called this one of the three necessary and sufficient pieces of therapy, right? Accurate empathy, unconditional positive regard and genuineness. And lastly, create a response system to help staff deal with the stress, burnout and moral injury. Basically, set up, if someone is feeling overwhelmed, give them a place to go. And we did at the University of Florida, just before COVID, in 2000, well, in 2017, we had a physician death by suicide after a medical error in the OR. I'm gonna spare you the details just because I've gone through it so many times, I'm not sure I can make it interesting anymore, but essentially, our physician felt that they were directly responsible for a poor outcome for a minor. And we lost him to suicide in their office. And our leader at the time, Dr. Haley was our dean, said, we can't do this anymore. We have got to have a place where anybody on our team, whether that be the dean, him or herself, all the way down through environmental services and everybody else, medical students, they have a place to go to decompress. And out of that, we put together a task force, and at the time, we were calling it the Work Life Center, now called the Center for Healthy Minds in Practice, the CHAMP Center, which is a free, unlimited, confidential mental health counseling center for everybody. And the way to access it, we basically put it in a building right alongside our clinical center. It's a little bit remote, it's confidential. We do keep notes, but not as a part of the medical record, and it's free. And we've expanded it now to work with couples as well. We don't go beyond the employee, but if the employee is having marital problems or relationship problems, things like that, we'll bring them both in. And the whole point is, if you're suffering, we care enough to give you a place to take care of it, to give you a place to express it, where it's not gonna get back to your boss. And even in those rare occasions when HR gets involved and says, you will go and see David at the CHAMP, and he will give you counseling, and he will report back to us what's going on, I report back attendance and only attendance. And from time to time with residents, it becomes mandated as part of their remediation plan, same thing, all you get back from me is attendance. And even then, we have a signed release. It's a safe place, a safe place to go, because moral injury, burnout, despair, stress, is endemic in our profession, even without COVID. So where we go with it, these are some of the services, we're kind of expanding it to be able to help others. And the thing about it is, outside of salaries, it's myself, two counselors, and a manager for the program. There are no expenses. We just need a place to go and do that. And I can tell you how to shadow death, we have prevented four suicides. I know that because they came to us very, very much in a suicidal place, worked with us, and then later said, if I didn't have you to go to, I wouldn't be around anymore. So whatever price you put on human life, whatever price you put on physician's life, whatever price you put on the lives of the people in the medical team, that's what we say. We have about 7,200 employees. As of February of this year, we've seen 824 of them, in individualized counseling sessions. So we've tackled over 10%, we opened our doors in January of 2019. And so obviously it's utilized, but what makes this work, and it gets back at that slide that I told you Dr. Cuff wrote, leadership is important here. Leadership by, our dean created this program, we work with our chairs, with our directors, with everybody, I'm invited to present to the dean every other week, on our numbers. We have leadership support for this, otherwise it wouldn't have worked. And the hours of therapy that we provide are right there. January 2019 is at the bottom, February of 2023 is at the top. COVID is that second group. We just kind of accelerated, that's three therapists throughout most of it that are providing those hours. Again, tremendously successful program if you look at it in terms of utilization. Successful in preventing at least some suicides. Successful, the feedback that we get is people really value this. Every once in a while we get somebody who didn't like us, but it's gonna happen I guess. But for the most part, this is what we are doing, to try to chip away at moral injury. Now I would suspect, when Dr. Cuff started this and said how many of you feel morally injured, they went on to say it's underrepresented in the research, most of us probably do. I haven't worked with everybody yet. So we're not catching everyone, but this I think is a very, very successful start. And what I really wanna do is make ourselves available. If anybody has any interest in how we did this, this is kind of beyond the scope of our lecture, and set up these kind of programs at your own place, I'll have my cards available up here afterwards. Please don't hesitate to reach out. And with that, my friends, thank you for your time. And we wanna open it up. Thank you. Thank you, Dr. Chessire. I think you can tell that Dean Haley made the right choice to build that program. So we can open things up for any questions or comments. If you go to the mic, I think so people can hear. Yeah. Hi. I guess my question is moral injury. You said one of the main treatments is to find meaning. And so even if you find meaning in these kind of broken and harmful systems, is it kind of just a band-aid until we actually fix the system? It sounds like a job for the chair, so. It's a tough question. Yeah, I should say I'm a psych ER nurse, so it's close to heart. I think we cling to the things that matter to us. And we're gonna be affected by pain and suffering, right? There's no way around that. And at the end of the day, I always used to say when I was working in trauma that I'm good for one compassionate wean a day, and after that, you'll find me huddled up in my office. But what happens if there's two or three? And that's going to crush me. I can find meaning there, that even if we can't save people, we can give them a good passing. And is that a band-aid for the fact that it's gonna take a lot out of me? Maybe, but I think the meaning transcends, and I can cling to it over time. Now, if I've gotta do that today and tomorrow and the next day, I may not be able to do that job. So I think your question is deceptively simple, but in practice, it's very difficult. Fighting meaning is hard, and it's easier, I think, to find meaning in the acute phase, but in the chronic one, it can be more difficult. That's a good distinction. And then my second question is the prolonged exposure as an intervention. Talk more about that. I don't do it. Got it. So that's harder for me. In the research, you all may know more about this than I do for the treatment of PTSD, but prolonged exposure is considered, has for a long time been considered the treatment of choice, which is basically exposing yourself to what hurt you and not being hurt by it. Again, it's not my cup of tea, so I wanna be a little bit careful about how far I go with that. Well, I think that would come down to, is there overlap between this moral injury and PTSD symptoms? And if intrusive memories and things are cueing some of the moral injury and other burnout, then you can potentially ameliorate the situation by treating those PTSD-type symptoms with prolonged exposure. I think finding meaning and really doing therapy around that, looking at more existential issues, as Dr. Chessire was mentioning, but also some cognitive behavioral things, looking at, are these automatic negative thoughts? Are these realistic? Was there something you could do? Does that mean that you are morally responsible? So those are the kinds of other things that you might be doing, sort of a combination of those factors. And one of the things that Dr. Dale is spearheading for us is looking at an intervention with healthcare workers who are experiencing these things and trying to help them with their autonomic regulation, their affective regulation. So we're doing a project trying to recruit nurses from the ED and from the ICU and to help them go with an intervention that Dr. Dale can describe in more detail. I did wanna make another comment about your question because I think it is your first question because I think it is really critical. We all work within systems and dealing with our response to that system and trying to help ourselves be able to function as highly as we can in a difficult situation or in a difficult system, that's our responsibility. But it also doesn't obviate the need for us to be active within that system and advocate for the kind of changes that we need to see the system improve. So I think it's yes and for that question. Thank you. A wonderful talk. I missed the first part of it, but I'm glad I came back. Thank you. More than a question, actually I wanted an impression about things. I worked for 15 years in the military as a civilian and we all know about PTSD and I have this thought in my mind that lots of bad things that happen by the people who suffer from PTSD around them and to themselves, a moral injury plays a big role which has never been clarified. To be on the flip side, I can even give you an example of the movie Rambo. I don't know how many of you have seen it. It's kind of dated now, but he went berserk not because of his PTSD, but due to the moral injury he suffered at the hands of the people who treated him unkindly. We don't give enough importance to it. In fact, during my line of work, I've often come across people, I do yoga and in my groups of yoga that I do with the military, I used to. One day a major came to me and he said, it's easy for you to talk about balance in life. What do you know about being in the front? And when you do things that affect innocent people, how do you live with that? So I said, that's a very, very deep question for me to answer. I always look to a solution when I'm conflicted morally. And even though we belong to different religions, I'll tell you what my tradition tells me. The sacred book that I follow, the Gita, has one tenet which says, you have been put on this earth to do your duty. You have no control over what the outcome of that duty is. If you enjoy the fruits of labor, be happy. If not, don't grumble because it was not for you to enjoy them. But that should not prevent you from doing your duty. He related to that. He came back a couple of weeks later and told me, that sort of normalized what I do. I've been placed in that position. So moral injury, yes. I did recognize that moral injury and provided some sort of explanation. It went well. I can't say that universally. But to me, that is an important aspect. What are your thoughts about PTSD and moral injury? And even if it's not military, about the civilian world, there's plenty of PTSD in the civilian world and moral injury. Do you see any connections? Do we see it? I think we're just, really, moral injury is something that we've just been become much more attuned to over the last several years. So yeah, I think we're looking for it now. So we're seeing it more now. Thank you. Yeah. First, I just want to say thank you for this talk. I find it particularly timely, given everything I think our society has experienced in the last three years and our healthcare workers in particular. So for a little bit of background, my name's Lisa. I'm a CL psychiatrist in Alaska and I serve as our department chair. And I sort of, in the role of CL psychiatry, as I think you mentioned, you do, you sort of get to know a lot of the healthcare workers that you work with in sort of in the context of a pandemic. I fell into a little bit of a sort of a de facto physician for them too, sort of informally. And I appreciate many of the things that you called out in the research that you conducted about sort of contributing factors. I wanted to sort of say a few more that personally affected the groups that I helped care for and then ask a question a little bit related to that. So where I practice, we did run out of the ability to treat people in our community. We were the trauma center for the state. We had all the specialty services for an entire state of people. And we rationed dialysis and people died. We didn't have the ability to take people in to perform cardiac procedures and they died in their villages. And these are people that otherwise we would save very, very easily. And in the context of all this, we had society with very, very loud and vocal speakers telling us we were murderers and questioning science and very anti-science. And that I think was a little bit unique in the last three years, something that hadn't been really felt in that same way before for healthcare workers, right? Like we're all heroes and sort of that's the appreciation and gratitude was there before. And it really was lacking, I think, or at least got to that point in my community. And I guess a lot of the healthcare workers that I spoke with, particularly in the ICU, we spoke a bit about, and I think someone mentioned this, sort of like we weren't trained for this, right? Like we didn't expect this, not even in our wildest dreams would this sort of be the area that we would be practicing. I mean, theoretically, I think we all think about bad pandemics, like when Ebola came to the United States, what that would look like, but it never looked like this. And we never really thought about that. And in thinking that, I think, yes, we need to do a lot of work on all the consequences of what transpired. And I think we all are thinking about like, well, what if this happens again? But the reality I think of that is like day to day, we have moral injury independent of the pandemic, and that existed before and it will continue to exist. And so thinking about what things, not treatment, not fixing the problem that's already happened, but we're all going to experience these potentially morally injurious events, maybe not to the same sort of extreme or the things that we're publishing, but they're gonna continue to happen. We can't prevent all of them. I think speaking to the ER, the nurses that spoke earlier, we can't prevent all of these things that happen. We can certainly improve our medical record systems and fix telemedicine and do things from a systems perspective, but there's still going to be things that happen. So what do leaders do? How can we do it systematically in a way that just isn't performative, that isn't sort of a list of really great attributes that we want our leaders to have, but in a way that actually compels something that can exist in perpetuity, a system that actually exists as primary prevention, when we know potentially morally injurious events are going to happen in order to actually prevent the moral injury, prevent the burnout, potentially prevent the PTSD. What does that look like systematically? Is there anything, what do we do? Wow. That's a really complicated question. Yeah, but just a little one for the end of the talk. I mean, part of what we're dealing with is that it's an evolving process. So, you know, I don't know if in your ED and consult work, you've been seeing what we've been seeing, you know, younger, way younger kids coming in suicidal and catatonic and, you know, the incidence of catatonia in our hospital just went way up. One of our residents did a poster on that earlier during the conference. So the amount of stress in society has caused so much of an influx of patients into our emergency rooms, into our clinics, you know, and so it's a very difficult situation. So, you know, you're faced with things that we weren't expecting. Before COVID, our emergency department was overcrowded. Now, when I go in with my residents to do consults in the ED, and we have one of our residents here right now who's doing that, there are beds. They have the hall lined up with numbers on the side of the wall and beds. And so it's, you know, hallway X, you know, bed 10, you know, they're just everywhere. And so, you know, I've been meeting with the chair of the Department of Emergency Medicine to talk about how can we do better with our psychiatric patients, because it's just, you know, they'll have sometimes 16 patients waiting for beds. And we don't have a place to have them right now. Now, fortunately, we have, we got about $100 million grant from multiple sources to create a new emergency room, and there's gonna be a separate, better psychiatric section to that. But, you know, trying to proactively understand what the needs are gonna be, and sometimes you just can't. You can't know what's coming, but you do the best you can under the circumstances. And you try to advocate within that, you know, meet with the people in the ED, meet with the deans or the hospital CEOs trying to advocate for what your needs are. You know, this is a very difficult time economically for hospitals. So our, we have a safety net hospital. I'm involved on the board, you know, for the hospital. It's really bad time economically for safety net hospitals. And so hospitals losing money, you know, where are we gonna get the funds to do some of these things? So you have to really try to do the best you can to think, you know, where can we get funding for these things? So go into foundations or other aspects. So a very complicated question, a long-winded response that I'm not sure really answered it, but. Basically, I think what you're saying is just none of us are alone in this. So there's that at least. I just wanted to add a little bit. As I've been trying to recruit nurses for our intervention study, I take every opportunity I can to tell them about what we're doing. And one of the nurses I spoke to very briefly said, oh yeah, yeah, we need to hear more about that. And she just throws in there, you know, like last week there was this 10 year old boy that just died and we just said, okay, go to your next patient, go to your next patient. And I thought about what she was telling me and how that kind of relates to the situation. And she was saying that, you know, we didn't process anything, we just moved on. And at the end of the day, they're so exhausted, they just wanna get out of there. So they never really take the time to process as a group what are the difficult things that are happening for them. And they're also, I believe, not really having the time to recognize how this is impacting them. And I think that's a big training component that we need to try to teach them about this. And I know that the CHAMP program has been really working on this. But they also have to make the commitment to try to get better with the burnout and the moral injury and all that. And as much as we're offering them all these great programs, some of them are just like, once I'm done, I'm done. I gotta get out of there. And they have to learn that just getting out of there isn't the best thing in the long run. And they need to sort of process and get past the things that are affecting them and their mental health. When I was a graduate student, my roommate was a recovering alcoholic. And he was part of the program. And on his car, there were these two stickers. One said, one day at a time. The other said, take it easy. He used to share me a lot of stories that I really found invaluable. One of the things, as a mentor, when he would be somebody's sponsor, and I don't know how much y'all, I assume you have some familiarity with AA, you get somebody in their first day and they start looking for a sponsor and say, I don't know how I'm gonna be sober the rest of my life. Do y'all know what the response to that question is? Be sober for today. It's one day at a time. You don't have to be sober forever. You just have to be sober today. And I think at the root of your question, or your observation is, things get really big really fast. And when we work with families in trauma, to say, will he ever be able to walk again? The answer is, that's down the road. Right now, let's get him through the night. And if you think too far down the road, it gets too big, too overwhelming. In our hospitals, in our medical care in this country, and not just our country, but all over, is too big. And if we try to solve it all at once, we are gonna get overwhelmed. But if you, there's an old saying that I once heard that, think globally, but act locally. Which means, think about the big issue stuff, but do what you can right here. And if that means, as Dr. Dale just said, take time out to process if something important needs to happen, then that's what you do. If it means, take time out to breathe for 30 seconds, which is what I always tell all of my clients, if people learn how to breathe, I'm out of a job. But basically, take time out for yourself, and then spread that to other people. And if you can keep your own little corner, good. Let other people take care of their own corner, I think you're golden. And I think that's, again, how we keep from getting overwhelmed and injured. I think we've got one more. I think my question is actually a sub contained within, or is below. So I'm Mark Reagans, I work on street medicine teams in Los Angeles, wandering over the streets, looking for people, mostly a lot of harm reduction. And I think we have a set that would be rather common, that the job we're doing is impossible. And when you try to go to the higher factors, curing homeless, I guess it's hard enough to cure the one person in front of me, let alone cure homeless in Los Angeles. And we have a very poor leadership and administration that does the opposite of everything you said. And they set up a program we can go to, so they can say they care about how we're doing. And if we didn't use it, it was our fault, while they continue to do the opposite of all these things. And as a result, two things have happened. One is tons of people keep leaving. And so the turnover gets bad, and you don't get less and less qualified staff. But the other is we get focused our gripes about the leadership, and never end up talking about how hard it is to help homeless people, or the person who died of the overdose, because we're so busy griping about the 17 things that leadership did along the way. And maybe it's easier to talk about that, but, and of course you can go on forever. And we never seem to get to that one, that the complaints about the leadership obscure or overwhelm the actual difficulty of the job. And so I think to some degree, the answer might be the same as the answer to hers, was about, is there a way that you can say, my leadership is doing as good as they're, this is a reasonable standard. They can't fix my problems, what can I reasonably expect from them? Or what can I send them to to say, can we get these three things at least? Or these, so that we could let go of some of the complaints about them to get back to the stuff on the, how difficult it is for the streets, the other moral things. Because otherwise the moral thing is putting up with a bad leader or something, which is less meaningful. I think that's, I think that's it. One of the gurus in moral injury is Heather Dean. And she presents this and she basically says, leaders need to support the point of the spear. And the point of the spear is who boots on the ground taking care. And those people need to express what I need, and leaders need to hear that. And again, I wanna give Dr. Cuff all the credit for the slide that he put together, because I think it's the most important slide in my presentation for leadership, is we need to include the people that know what they're doing in policy determination. And on us, that means we have to apply ourselves to give the information upward. We don't always do that. Because we get burned out and think nothing matters and all that. But if we're not giving good information to our leaders, leaders have to operate with the information they get. And hopefully the leaders are able to hear what they're getting from below. So it is a bi-directional imperative. Sorry, I'll let you go in a second. I just wanted to make a comment about Dr. Haley, who tragically died in a jet ski accident a couple of years ago. One of the things that was, he was a transformative dean in our hospital, in our medical school, and in our culture. And one of the things that he did that no other dean that I've been with has really done is every single time I met with him, and we met regularly, he said, what is it that I can do for you? What do you need? And how can we get it? And so having that kind of leader is transformative because he was there as a service to us rather than we're as a service to him. And so if we can model that in whatever leadership roles that we have and try to expand that. And so it's, you're there to serve others and to understand them. So Dr. Chessire mentioned Carl Rogers, which I spend a long time with our residents every year because I think that empathy, genuineness, and unconditional positive regard are critical in developing a therapeutic relationship with anyone, whether you're doing therapy or not. That sense of empathy, and some leaders have it and some do not. And you can tell almost immediately whether they do or not. So trying to create the level of empathy and the level of leadership that we need and to try to help engender that in our departments and our universities, I think one thing that we can try to help with. I additionally think that employing debriefing in real time would be beneficial for individuals who are experiencing moral injury. I know that when we have an issue on the unit or in any part of the hospital where someone was harmed, for example, there is a real in time debrief. And doing that in a formalized manner, actually identifying what was morally injurious and what could have been changed if we had certain resources, but can't be changed because of that lack. I think identifying those factors in the moment so we can move forward together in that thought process would be beneficial in the long run too. Okay, she's my resident. Thank you, Camille. I went to a talk a few days ago. It was how moral injury has been addressed in veterans. And then they were seeking to apply that in a healthcare setting. And it led to a discussion around DSM. And it seems like since 2009, there's just a kind of a smattering array of literature regarding moral injury in terms of how it's being measured, in terms of how it's being talked about. And that next step seemed to be kind of unifying the voices so that it can be studied more rigorously and systematically. And a big step of that is obviously potentially in the DSM, having a way of talking about it. And I know there's drawbacks to having it as a disorder potentially and pathologizing what could be a normal part of the human experience in terms of having a moral ideal and then meeting something in the world that causes dissonance. It just seems to happen in many different situations as the literature the last few years is showing. And I wonder just what your thoughts are on where it could be. I know I've heard of potentially as a V code, a condition worthy of consideration, such as like a marital problem is or something like that. So at least it can be there and talked about and increase awareness. Because just like this talk and the discussion it creates is so healthy and positive for moving this forward. That's a really interesting comment. I really appreciate that. And I do think that getting some kind of V code or a condition worthy of future research, something where you can define it and have people who are studying it be sure they're studying the same things. Yeah, I think that would be something to advocate within the APA or the ICD from a World Health perspective. Thanks for that comment. I think that would be really helpful. I feel like that's a whole other presentation. I want to be mindful that we have somebody coming in soon, but I think it's an excellent question. And it's something we're gonna have to look at. And some of us, especially from a research standpoint, the DSM and ICD are so important. From a practitioner standpoint, I don't worry too much about, especially since I don't bill. I don't have to convince the insurance companies to pay me. Thank you all so much. Thank you.

moral injury

healthcare providers

COVID-19 pandemic

burnout

psychological stressors

systemic constraints

ethical violation

leadership support

moral distress

CHAMP program

mental health services

systemic changes

diagnostic manuals