Prevalence, Predictors, and Experience of Moral Suffering in Nursing and Care Home Staff during the COVID-19 Pandemic: A Mixed-Methods Systematic Review.

(1) Background: Nursing and care home staff experienced high death rates of older residents and increased occupational and psychosocial pressures during the COVID-19 pandemic. The literature has previously found this group to be at risk of developing mental health conditions, moral injury (MI), and moral distress (MD). The latter two terms refer to the perceived ethical wrongdoing which contravenes an individual's moral beliefs and elicits adverse emotional responses. (2) Method: A systematic review was conducted to explore the prevalence, predictors, and psychological experience of MI and MD in the aforementioned population during the COVID-19 pandemic. The databases CINAHL, APA PsychINFO, APA PsychArticles, Web of Science, Medline, and Scopus were systematically searched for original research studies of all designs, published in English, with no geographical restrictions, and dating from when COVID-19 was declared a public health emergency on the 30 January 2020 to the 3 January 2022. Out of 531 studies screened for eligibility, 8 studies were selected for review. A thematic analysis was undertaken to examine the major underpinning themes. (3) Results: MI, MD, and related constructs (notably secondary traumatic stress) were evidenced to be present in staff, although most studies did not explore the prevalence or predictors. The elicited major themes were resource deficits, role challenges, communication and leadership, and emotional and psychosocial consequences. (4) Conclusions: Our findings suggest that moral injury and moral distress were likely to be present prior to COVID-19 but have been exacerbated by the pandemic. Whilst studies were generally of high quality, the dearth of quantitative studies assessing prevalence and predictors suggests a research need, enabling the exploration of causal relationships between variables. However, the implied presence of MI and MD warrants intervention developments and workplace support for nursing and care home staff.

A pulmonary rehabilitation shared decision-making intervention for patients living with COPD: PReSent: protocol for a feasibility study.

Background: Despite the variety of pulmonary rehabilitation programmes for patients living with COPD, uptake remains low. To improve this, it is recommended that health professionals engage patients in informed decisions about pulmonary rehabilitation. Shared decision-making (SDM) facilitates informed and value-based decision-making between patients and health professionals. This protocol describes the development and evaluation of a complex SDM intervention for patients living with COPD, who are referred for pulmonary rehabilitation, and their pulmonary rehabilitation health professional. Methods and analysis: We are developing a complex SDM intervention involving a patient decision aid (PtDA) and a decision coaching workshop. Prior to patient recruitment, pulmonary rehabilitation health professionals will attend the workshop. Upon referral to pulmonary rehabilitation, patients will receive the PtDA to support their decision-making prior to and during their pulmonary rehabilitation assessment with a health professional. The intervention will be evaluated in a one-arm exploratory study to investigate its feasibility and acceptability for patients and health professionals, with an integrated fidelity assessment. The primary outcome is recruitment feasibility, data collection feasibility and intervention fidelity. Secondary outcomes include routine pulmonary rehabilitation data, decisional conflict, patient activation, intervention attendance/attrition and patient and pulmonary rehabilitation health professional experience of the intervention. Quantitative outcomes will be evaluated using the most appropriate statistical test, dependent on the sample distribution. Qualitative outcomes will be evaluated using reflexive thematic analysis. Fidelity will be assessed using the Observer OPTION 5 scale. Conclusion: This intervention will provide structure for an informed and values-based decision-making consultation between a patient with COPD and a pulmonary rehabilitation health professional with the potential for optimising pulmonary rehabilitation decision-making.

Organizational perspectives on outdoor talking therapy: Towards a position of 'environmental safe uncertainty'.

OBJECTIVES: There is growing support within the therapy professions for using talking therapy in alternative environments, such as outdoor spaces. The aim of the present study was to further understand how the organizational culture in clinical psychology may prevent or enable practitioners to step outside the conventional indoor consulting room. DESIGN: Informed grounded theory methodology was used within a pragmatist philosophy. METHODS: Participants (N = 15; nine male, six female) were identified using theoretical sampling. The sample consisted of experts and leaders within the profession of clinical psychology (e.g., heads of services, training programme directors, chairs of professional bodies, and developers of therapy models; M years in the profession = 34.80, SD = 9.77). One-to-one interviews and analysis ran concurrently over 9 months (April-December 2020). Mason's model of safe uncertainty was drawn upon to illuminate and organize themes. RESULTS: The main themes comprised organizational factors that either support a practitioner in maintaining a position of curiosity and flexibility towards the environment where therapy is located ('environmental safe uncertainty'), or push them towards adopting a more fixed position ('environmental certainty'). Themes included influences from therapy traditions, accessibility of alternative environments, internalized risk, workplace subcultures, business models, biomedical approaches, and the COVID-19 pandemic. CONCLUSIONS: Whether therapy is located in a consulting room, outdoors, clients' homes, or digitally, practitioners, clients, and services are encouraged to maintain a position of environmental safe uncertainty. PRACTITIONER POINTS: The therapy process and outcomes are influenced by the physical environment in which talking therapy is situated. Practitioners have often remained fixed in their preferred therapy environment, such as the indoor consulting room, without exploring the potential benefits of alternative environments or involving the client in this decision-making (i.e., 'environmental certainty'). Outdoor environments, as well as other alternatives to the consulting room (e.g., digital, home visits, and public places), can support access to therapy, subsequent engagement, and therefore health care equity. Practitioners and clients are encouraged to adopt a position of 'environmental safe uncertainty', which is defined as having openness, critical curiosity, and collaboration regarding the therapy environment and the possibility of other environments being more conducive to therapy.