Prioritizing spiritual health and moral injury (MI) science for service persons
Originally published December 2020 on https://broadcastedge.blogspot.com/
Spiritual health is a priority and inclusion in total health must be treated as precedence for service persons. Simultaneously, moral injury (MI) should be championed, inclusive of spirituality and not contingent to spirituality.
A commitment to spiritual health and a dedicated focus to MI are responsibilities to be embraced. As we face the reality of who we are and what we are in healthcare, we must commit to total health partnership. It is dedication to healthcare and science that compels us to incorporate spiritual health and MI in medicine. It is compassionate professionalism that presses us to support military healthcare leadership, for MI scientific advancement and service person health equity.
Militaries should partner with the greater healthcare industry, spiritual wellness and spiritual fitness should be organized into military medicine, and military leadership must be supported for advancement of MI science.
1. To get spiritual health details right, militaries should partner with the greater healthcare industry.
Spiritual wellness and spiritual fitness belong in medicine. These components to health are not new; we observe patients’ cultures and wishes at every step. Acute care welcomes chaplaincy and space is made for religious observations in long term care. Additionally, spirituality may be a daily consideration for individuals, whether it is practiced in formal prayer or through meditation, even if individuals are not classifying actions to definition. Incorporating the conversations into routine care should not be depreciated by lack of training, liticaphobia or any other barrier.
* Define spirituality and religiosity (S/R) for health industries, inclusive of international consensus, with applicable coding and operational components. Medical, psychosocial and military research on S/R all include international work, and there should be international consensus for healthcare.
* Acknowledge spiritual health in healthcare governance operations. There is ongoing individual country consideration to S/R worldwide. There is also increasing interest for spirituality as a quality component to healthcare, and accreditation such as Joint Commission has initiated inclusion. There is also identified need and ask in literature, such as publications that specifically state paucity of spiritual health scientific structure in some Eastern Europe countries (1). Despite movement to advance spiritual health inclusion, global collaborations remain out of touch. In fact, the World Health Organisation has yet to specialize S/R and has yet to organize decades of research on the subjects.
* Include clinician training, syllabus standards and ongoing staff development for clinicians. Not only do clinicians at the US Department of Veterans Affairs report that they are underprepared for spiritual health assessment(2), clinicians worldwide are observed to be undertrained. Studies in China, South Africa and Iran all demonstrate underpreparedness of nurses to address patient spirituality (3,4,5). Physicians and clinicians are often provided multiple tools for spiritual health assessment of patients, without structure or standardization (6,7,8). Competencies for spiritual health have been identified and trialed, including one from the Netherlands (9), yet there remains no professional consensus on training and competency expectations for any medical profession. Additionally, respect to religious tolerance is underreported. A recent Iranian military nursing readiness and acceptance study on spiritual health, demonstrating similarities to spiritual health readiness research worldwide, omitted discussion or assurance of respect to religious tolerance (10).
* Refine operations and tie outcomes and quality to patient spiritual healthcare needs. Incorporation of spiritual health at wellness and primary care levels remains without structure (11). Spiritual health deficiencies in current operations are not even tied to regulatory or evidence basis. Competencies to spiritual health at the clinician and care delivery levels remain without outcome indicators as well. We do not know how patients are affected, nor if they are satisfied, nor how the care affects their health-related quality of life (HRQOL). Studies have shown that staff education interventions increase spiritual health competency (12), yet these studies do not ties competency to the patients themselves. International work that recommends structure to nursing spiritual health considerations (13), including partnered work between Irish and Portuguese professionals, has flexibility for follow up research to tie outcome data (14). Additionally, there is a lack of data around patient satisfaction and S/R opportunities in routine care, in acute care and in disability-related care. Finally, there is a lack of S/R indicators at the international level and sincerity to this major component to healthcare is left out of governance, from SDG to global citizenry to Healthy People objectives. While some countries have started to examine acknowledgement of spiritual health at the public health level, including for the Czech Republic (15), public acknowledgment of spiritual health as a component to total health remains poorly understood. Individual spiritual health studies link spirituality with physical and mental outcomes, including a Bulgarian study of depression (16) and a Lithuanian study that considered pain and physical limitations (17). All of these details can be fine-tuned for research, for care delivery and for international action. Additionally, these details can and should be partly shouldered by reimbursement agencies, from government and private insurers. Research details should be shouldered in part by the publication agencies responsible.
* Create transparent standards to chaplaincy credentialing (18, 19). Credentials to military chaplaincy should require spiritual health standards worldwide.
* Incorporate a country's spiritual health considerations from government, academia and social scientist considerations. Consider how any metrics can be qualified and consistent globally. In example, would considerations of a country engagement with religiousinstitutions, such as this Russian work on spirituality (20) be supported with citizen identification or non-denominational spirituality metrics? What concepts are priorities to the public and spirituality, and is there a way to connect literature to objective health metrics? In example, literature on spirituality and social justice in Russia (21) could be supported with health indicators and advanced in international inclusion/leadership.
* Provide cross walks on healthcare laws and government policies around religious tolerance in a country's medical delivery. This is an area where global healthcare governance can and must walk the walk.
2. Spiritual wellness and spiritual fitness should be organized in military medicine.
Spiritual health should be a component to healthcare, with matched funding. Given the occupational nature, intimate connection to morality and deeply intimate connection to service, addressing spiritual health as military and veteran healthcare should be routine.
* Message spiritual fitness and spiritual health consistently across military departments. While spiritual health is defined on public sites for the VA (22), and S/R delineated in military spiritual health research (23), spiritual health in military healthcare is not ubiquitously transparent. Messaging is not easily identifiable in NATO health considerations, for example. This leaves us guessing as to how common spiritual health is addressed in military units, and to what degree.
* Commit to a scientific organization of literature. Organize data, research, limitations and opportunities for quality in military spiritual health science. Identify what is known between spirituality and service person mental health (24, 25, 26), spirituality and the military, and the quality of military spirituality research. Organize this cross walk internationally, with responsibilities to continued systematic reviews. Identify low and high quality in military spirituality research (27) and fund accordingly.
* Organize current operations around military spiritual health, with international standards a goal. Identify policies, assessments, staffing, chaplaincy credentialing, customs and norms, referrals, spiritual health reimbursement, leadership training and interventions. Note similarities, differences and opportunities for cohesive moves forward.
* Prioritize service person satisfaction, customer service and preference data. What does this population want in regards to spiritual health assessment and resource (28), and what emphasis do they place of spiritual fitness to their HRQOL?
* Acknowledge previous military leadership perception and response, and build from it (29).
* Acknowledge potential correlations, and potentials of independent variance. If military fitness is inclusive of spirituality (30), spirituality is correlated to some components of suicide and mental health, and outcomes of suicide and/or mental health are not optimal, are there opportunities for spiritual health improvement? Is there correlation with interventions?
* Let the data do the steering. Take the research, crosswalks, international consensus and individual military satisfaction data and drive operations. Standardize military health assessments for spiritual fitness, inclusive of non-spiritual preference to wellbeing, consistently.
* Identify risks and hazards associated with poor spiritual fitness, and incorporate this into healthcare. Assess terminology and apply to care operations and risk management. In example, researchers could note the danger terminology applied for German service person research in advancing risk management of spiritual health science (31).
* Include military families in spirituality research, formally. Military families who participate in research should be identified by occupational connection. In example, a Brazilian study identified health status associated with spirituality, and insight into participant military connection could have furthered the data reach (32). Additionally, the incorporation of spirituality in family dynamic research is important and should be standard(33).
* Seek to quantify and qualify the informal caregiving of spiritual health in the military, with consideration to churches, social networks, meditation, outdoor recreation categorization, teleconnection, etc. Consider how this is already factored into living decisions, demographics and deployment geography, and how factoring could improve.
* Define spirituality within complementary and alternative medicine. Determine if there is overlap with formal traditional medicine.
* Remain holistic in spirituality definition and health categorization for the non religious and self-identified non-spiritual. * Support NATO and similar allied military coordination in efforts of total health (34). Provide several indicators, interventions and considerations. This may include chaplain ratios, mental health provider standards and training consistency (35,36). This may include spiritual assessment quality audits and service person satisfaction data. This may also include informal spiritual health caregiving definitions and metrics, and this may also include metrics on spiritual fitness training.
* Support dissimilar military inclusion, such as with spirituality insight on child soldiers (37).
* Standardize spiritual fitness assessments. Timing of assessments should follow the science and is not likely not tied to borders. Identify where spirituality is not included and could be included in current assessments (38), including upon entry to military, throughout service person career (39, 40) and after career. Be accountable to deployment and spirituality, where there remains a paucity of data. Find consensus in post-deployment, decompression and TLD data around spirituality (41, 42) and find consensus with re-deployment and spiritual fitness needs (43). Concepts such as minimizing compounding, stress, and moral injury are necessary for international militaries to work together around.
3. Choose military leadership for Moral Injury (MI) scientific structure.
MI is necessary to prioritize in healthcare and should become commonplace in medicine, with consensus. International collaboration through military leadership should lead the way. Spirituality should be defined, quantified and qualified in degree of inclusion alongside MI.
* Collect military actions around moral injury assessments, tools and definitions used internationally. MIES, MIQ-M and other assessments (44, 45) should be in consensus and clarified.
* Collect international comparisons on military moral injury metrics, inclusive of details. These comparisons should include identification of exposure versus actual moral injury measures (46). Additionally, comparisons should identify if moral injury risk is assessed and when (basic training, deployment, post-deployment), and they should identify if psychological and spiritual aspects of moral injury are specified (47).
* Examine current military application of literature around moral injury and mental health (48, 49), and initiate evidence-based conversations with the objective of graded evidence tiers (50).
* Determine how to align a country's navigation of baseline equity in S/R, potentially morally injurious events (PHIE) and MI. In example, Canadian researchers have identified inequities in teen spiritual health (51), differences in PHIE and Afghanistan deployed soldiers (52), and insight into MI for Canadian military personnel (53). How does the baseline inequity affect military personnel for a country, and how can this be addressed before deployment? Additionally, some researchers feel PHIE should not be a priority focus at this time. Is there international consensus to lead the way?
* Create a strategic agenda for moral injury science. Determine where supportive funding will go. Decide who will be tasked with what aspects of research, data, dissemination and implementation. Determine objectives and goals for mental health specialties and military health specialities, and determine international collaboration.
* Outline synthesis of moral injury and spiritual work. Some data indicates S/R mitigation while other data indicates S/R exacerbation with MI (53,54). Some literature supports inclusion of moral efficacy and courage concepts (55) other literature supports faith groups inclusion with MI insight (56).
* Outline synthesis of moral injury and non-spiritual work. Assistance for non-spiritual individuals or for those with other MI intervention needs should be evidence-based and ongoing in study. The evidence for Acceptance and Commitment Therapy (57), positive moral emotion interventions (58, 59) and cultural considerations such as work with Latino service persons (60). Additionally, concepts of personal values and decision making, such as European border agent MI with migration (61) and social infrastructure security should be reviewed. If scientifically supported, interventions should be funded.
* Create structure for clinicians and moral injury, inclusive of operational codes, definitions, referrals, primary care inclusion and reimbursement. This is important for all countries, for clinician development, for partnered contracts and for developing universal care (62).
* Specify weak data and low quality research, and create pathways for assurance to high quality (63). Require commitment to standards with transparency and consistency of transgression items (60).
* Standardize definitions of complimentary and alternative medicine regarding moral injury (64).
* Provide international coordination for the definition of betrayal and how it is incorporated into MI assessment, research and intervention (60, 65). Provide international coordination for moral injuries that alter a service person’s perception of the military as a whole (66).
* Quantify moral injury burden as any other health burden is quantified, with global governance at the table. Consider moral injury and spiritual health burden inclusion with military intervention estimates. These are real costs for individuals and society, and it is our responsibility to include these costs in geopolitical conversations.
Our responsibility to a service person's health includes consideration of spirituality, religiosity and moral injury. For an individual, these concepts may or may not be mutually exclusive. For healthcare, these concepts are a part of total health. It is dedication to healthcare and science that compels us to incorporate spiritual health and MI in medicine. It is compassionate professionalism that presses us to support military healthcare leadership, for MI scientific advancement and service person health equity. Supporting military health requires encouragement of military leadership in MI science as well as committed healthy industry partnership in securing spiritual health equity. We will accomplish spiritual health equity, as well as and inclusion of MI into medicine, with international expectations and international collaboration.
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