AimsMoral injury (MI) refers to psychological distress resulting from witnessing or participating in events which violate an individual's moral code. Originating from military experiences, the phenomenon also has relevance for healthcare professionals dealing with wars, natural disasters and infectious diseases. The deontological basis of medicine prioritises duty to the individual patient over duty to wider society. These values may place healthcare professionals at increased risk of moral injury, particularly in crisis contexts where they may be party to decisions to withdraw or divert care based on resource availability.We conducted a systematic review of medical literature to understand the extent and clinical and socio-demographic correlates of moral injury during the COVID-19 pandemic.MethodWe conducted a systematic review of reports included in MEDLINE, PsycINFO, BNI, CINAHL, EMBASE, EMCARE and HMIC databases using search terms: “moral injury” AND “covid” OR “coronavirus” OR “pandemic”. We also searched Google Scholar and Ovid Database and conducted reference searching. We searched for published quantitative primary research as well as advance online publications and pre-print research. Findings are reported in line with Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA). Two authors independently assessed the included studies’ methodological quality using a seven-item checklist.ResultOur databases search identified 498 records and other sources identified 4 records. We screened 391 records after removing duplicates. 4 reports met our protocol requirements.Three papers used cross-sectional designs. One reported longitudinal outcomes of their sample already described in one of the three papers. Only one study used a MI scoring system validated for healthcare professionals. Others used scoring validated in military populations. These papers reported outcomes from 3334 subjects, with a higher proportion of females. The largest study (3006 subjects) reported MI in 41.3% of their sample. Overall, factors associated with greater MI included: providing direct care to COVID-19 patients; sleep troubles; being unmarried; aged <30 years; female gender; and Buddhist/Taoist faith. Nurses reported a greater severity of MI than physicians. MI significantly correlated with anxiety, depression and burnout. The longitudinal study reported that more stressful and less supportive work environments predicted greater MI at 3 months follow-up.The average quality assessment score of these studies was 4/7.ConclusionIt is important that we are able to address moral injury awareness training as part of workforce preparedness and burnout prevention during the COVID-19 pandemic and other disaster responses across the globe.
AimsNeuropsychiatry Service in East Kent typically receives referrals for patients with brain injury, progressive neurological conditions, epilepsy specific neuropsychiatric conditions, rare forms of dementia, and functional neurological conditions. COVID-19 pandemic disrupted routine functioning of the service requiring multiple service innovations including introduction of remote access assessments, skills development clinics, and video-conferencing based psychoeducation groups. We conducted a service evaluation with governance approval to understand the impact of COVID-19 work model changes on referral sources, patient attendance, discharge destinations and the mental health professionals’ involvement in the management of the patients referred to the service.MethodsWe applied to Service Evaluation and Audit Group of Kent and Medway NHS Partnership Trust for permission to collect service data using routinely collected clinical and business administration information. We used an approved data collection form for anonymized data collection. We analysed data for new patient assessments conducted over one-year prior to COVID-19 lockdown announced on 23rd March 2020 and compared it with one-year post-COVID lockdown period ending on 22 March 2021. We used Statistical Package for Social Sciences (SPSS) to carry out descriptive and statistical analysis of the data from two service evaluation period.ResultsThe total number of new patient assessments conducted during the two designated service evaluation periods was 365. 233 new patient assessments (64%) were conducted during the one-year pre-COVID-19 lockdown and 132 (36%) new patient assessments were conducted during the one-year post-COVID-19 lockdown.Neurology teams in the local area were the main source of referrals during the two study periods, referring 59% and 51% of total referrals during the two evaluation periods respectively. Other referral sources included local memory service, inpatient psychiatric units, community mental health teams, neuropsychology, neurorehabilitation, palliative care and acute medicine. The primary management model was multidisciplinary. 49% of assessment contacts were made by specialist nursing during the first evaluation period. 48% of assessment contacts were made by the medical staff during the post-lockdown period. 13.3% of patients did not attend their appointments during the first period, dropping to 9.8% in the Post-Lockdown period.Most patients who completed treatment were discharged to GP care (89% pre-COVID-19 and 94% post-lockdown). 12% patients from Pre-Lockdown period were still receiving care at the end of one year and 35% were still receiving care in at the end of post-lockdown period.ConclusionThe service evaluation identifies systemic differences in service use characteristics during Pre-lockdown and Post-lockdown periods.
AimsHealth comorbidities contribute significantly to the development and maintenance of illness in patients with Functional Neurological Disorder (FND). As part of a service evaluation project, we investigated the physical and mental health comorbidities of people referred to a community neuropsychiatry service in East Kent, in one-year periods preceding and following the March 2020 lockdown due to COVID-19.MethodsWe included all people accepted to the service between 23rd March 2019 and 23rd March 2021, where the reason for referral was Functional Neurological Disorder (FND) or Non-Epileptic Attack Disorder (NEAD). Referrals to the service for other reasons were excluded, as were declined referrals. Routinely collected data sources were reviewed and data stored in anonymized fashion. Data were analysed using Statistical Package for Social Sciences (SPSS).ResultsTotal number of referrals for FND in the 2-year period was 260, with 161 referrals for NEAD and 99 for other FND.In the pre-lockdown period, 163 patients were referred due to FND (101 with NEAD, 62 for other FND). There were fewer FND referrals in the post-lockdown period: 60 referrals for NEAD and 37 for other FND. The majority were female (74% pre-lockdown, 81% post-lockdown). Where ethnicity was recorded, White British was the most common (94% pre-lockdown, 90% post-lockdown), with a small number of people from other ethnic groups (3.5% White Other, 1.4% BAME, 1.4% Mixed pre-lockdown; 5.4% White Other, 3.2% BAME and 1.1% Mixed post-lockdown). Ethnicity was not specified in 21 cases (13%).Of the pre-lockdown group, 15 patients had prior contact with Child and Adolescent Mental Health Services (9%), with 7 patients (7%) in the post-lockdown group. Many patients had previous contact with mental health services (47% pre-lockdown, 53% post-lockdown). The majority of patients had at least one physical illness (69% pre-lockdown, 73% post-lockdown). Most had 1–3 physical comorbidities but 9% (pre-lockdown, 7% post-lockdown) had more than 4. Fibromyalgia (14% pre-lockdown, 12% post-lockdown), chronic pain (23% pre-lockdown, 21% post-lockdown), and epilepsy (11%, 9%) were common. Over 90% had psychiatric illness in both periods. Most patients had 1–3 psychiatric illnesses; a few had more than 4 (6.1% pre-lockdown, 1.4% post-lockdown). Depressive disorder was the most common comorbidity in both groups (41% pre-lockdown, 44% post-lockdown), followed by anxiety (35% pre-lockdown, 36% post-lockdown). PTSD was present in 8% pre-lockdown and 8.2% post-lockdown.ConclusionPhysical and psychiatric comorbidities are common in people with FND; multidisciplinary working and liaison between services is crucial for care of these patients.
AimsPatients with Functional Neurological Disorder (FND) often endure low quality of life. Understanding the diagnosis is critical to management, but patients with FND do not always receive appropriate information about their condition. The patient journey through healthcare services can be complex, with often long waits for specialist attention. Creating psychoeducation resources for patients is important to improve patient experience and outcomes. We developed a symptom self-management patient education booklet with an FND symptom recording template, using a co-production model, in a community neuropsychiatry setting.MethodsWe used co-production as part of a quality improvement project (QIP) at East Kent Neuropsychiatry Service, to produce a patient education booklet with symptom self-management information and a symptom recording template. The QIP cycle involved input from 11 participants. Initially, 3 medical students and 4 multi-disciplinary team members adapted an existing booklet, removing medical jargon and simplifying diagrams. The adapted booklet was distributed to patients with FND who were attending psychoeducation/Cognitive Behavioural Therapy group sessions. One week later, four patients discussed the booklet with a medical student facilitator; both quantitative and qualitative feedback was obtained. Feedback was gathered using an adapted 20 point Ensuring Quality of Information for Patients (EQIP) tool. Patient responses were recorded, and qualitative themes identified.ResultsFour themes were found from qualitative feedback during co-production: need for a glossary; an expanded resource list; more diagrams to simplify text; and for the booklet to also address family, friends, and carers. The EQIP questionnaire feedback emphasised that the booklet contained too much medical jargon and that it didn't personally address the reader. On average patients scored the booklet 53.33% using the EQIP questionnaire.The booklet was further adapted and a glossary, further diagrams and a section addressing family, friends, and carers was added. Further resources were added and the text was simplified for clarity.ConclusionThis QIP shows the value of co-producing information for an underserved patient population. Patient psychoeducation is a key part of treatment; involving patients at an early stage of the development of information and self-management tools will increase their acceptability to patients and improve the accessibility of patient psychoeducation.
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