September 2018 Article of the Month
by John Ehman, Editor, ACPE Research Article-of-the-Month
and Manager for Pastoral Care, Penn Presbyterian Medical Center, Philadelphia PA
Drescher, K. D., Currier, J. M., Nieuwsma, J. A., McCormick, W., Carroll, T. D., Sims, B. M. and Cauterucio, C. "A qualitative examination of VA chaplains' understandings and interventions related to moral injury in military veterans." Journal of Religion & Health (2018): 17pp., published online ahead of print, August 9, 2018.
[Editor's Note: Because this article is available ahead of print, no final page numbers can be cited. References are to manuscript [MS] page numbers.]
SUMMARY and COMMENT: This month's selection should be of broad interest even though it focuses on Veterans Administration chaplains, since the concept of moral injury (MI) emerging in the VA and military healthcare literature may be valuable beyond those particular contexts. With one definition being: "...the lasting psychological, biological, spiritual, behavioral and social impact of perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations" [MS p. 2, and see Items of Related Interest, §I, below]; moral injury is a significant risk of the experiences of war. This study offers "initial qualitative evidence as to how [VA] chaplains understand the construct of MI, and about their current approaches to intervention" [MS p. 15]. It should also serve as a convenient and practical introduction to a phenomenon that chaplains in general should find thought-provoking, as "MI sits at the nexus of psychological and spiritual health" [MS p. 14].
The researchers employed a "web-based survey administered on behalf of the National VA Chaplain Center by the National Center for PTSD (Training and Dissemination Division) in collaboration with the National Chaplain Center and the VA Mental Health and Chaplaincy Program" [MS p. 5], and analyzed the responses of 245 chaplains who participated out of a sample of 543 (45.1% response rate). Participants were asked [MS p. 5]:
Answers were limited to 253 characters (which the authors acknowledge as a methodological limitation for the study itself [--see MS p. 14]). Data collection occurred over an eight-week period in 2013.
- What is your current understanding of moral injury?
- How do you intervene with veterans dealing with a moral injury? Please describe your preferred approach(es) for these types of concerns. Please be as specific as possible.
Among the findings, two main themes were identified as especially salient for chaplains' understanding of morally injurious events (MIEs): 1) engaging in behaviors against beliefs (i.e., "being an agent involved in wrong actions" [MS p. 8]), with many respondents not differentiating between acts of commission and omission; and 2) exposure to behaviors/experiences against beliefs, depending upon the degree and direction of culpability (i.e., "culpability might be directed outward toward the perpetrator...[or]...blame might be internalized..." [MS p. 5]).
Regarding mechanisms by which MI might develop, VA chaplains described associated factors according to five themes [--see MS pp. 8-9]:
The authors observe that in these responses to the first of the two survey questions, chaplains' understanding of MI tended to revolve around a sense of events (MIEs) rather than "actual features of MI" [MS p. 13], seeming to reflect the overall state of the research that had heretofore concentrated on MIEs. They state that "it is not surprising that most chaplains in this sample understood MI by certain types of military-related events rather than distinct symptom presentations," but they stress how "it will be important to enhance understandings across health care professions about the primary symptoms of MI" [MS p. 13].
- "The largest proportion described how MI is defined by changes in one's values, beliefs, or morality (n = 88, 35.9%)." One chaplain noted, "It is the realized insult to one's 'moral compass'...."
- "A subset of chaplains conceptualized MI within the construct of spiritual injury (n = 48, 19.6%)." Respondents emphasized changes in the person's spirituality, and one chaplain wrote of "the wounding of the soul.".
- "Some of the chaplains described MI fundamentally as damage to veterans' understandings of themselves (n = 19, 7.8%)." Examples of this included "a breakdown of self-esteem and ability to affirm self-worth and value, as well as give and receive affirmations and confirmations of personal worth or worthiness." One chaplain commented that "the joy of life is damaged."
- "MI was also conceptualized by chaplains more generally as cognitive or emotional distress (n = 18, 7.3%)."
- "For a small subset of the chaplains, MI was conceptualized as significant damage to all facets of life (n = 6, 2.4%)."
Turning to chaplains' intervention strategies for morally injured veterans, coding of the responses revealed three superordinate categories:
- Pastoral/Therapeutic Presence -- "The first superordinate category encapsulated a variety of intervention strategies that emphasized the importance of cultivating a pastoral or therapeutic presence with morally injured veterans (n = 129, 52.7%). From a definitional standpoint, this posture referred to being fully in the moment with a veteran -- physically, emotionally, cognitively, and spiritually -- in a manner that invites the patient to share their pain, feel understood, and move toward healing and wholeness." [MS p. 10]
- Therapeutic Procedures -- identified with five basic themes:
- "Almost half of the chaplains generally reported using some form of psychotherapy in their interventions with morally injured veterans (n = 116, 47.3%). The most frequently cited technique was cognitive therapy interventions (n = 36, 14.7%), consisting of reframing, challenging maladaptive thoughts and beliefs, and other strategies." [MS p. 10] Additional strategies included narrative therapy (13.9%) and emotional processing (10.6%), as well as counseling/dialogue (7.8%), bibliotherapy (2.4%), mindfulness (0.8%), art therapy (0.8%), rational emotive therapy (0.4%), and brief therapy (0.4%).
- Assessment based upon a "detailed history of veterans' spiritual backgrounds" [MS p. 11] was noted by 24.9% of the chaplains, with 22.4% endorsing an assessment of spiritual/moral distress.
- Nearly one in five chaplains also discussed the helpfulness of pastoral care interventions (n = 52, 21.2%), such as spiritual/religious counseling (n = 32, 13.1%), prayer (n = 14, 5.7%), and religious rituals (n = 9, 3.7%).
- Some chaplains wrote about the "format and systematic processes through which their interventions are provided" [MS p. 11], such as group therapy (6.5%) or referrals to mental health care (3.7%).
- "A substantive minority (n = 23, 9.4%) of chaplains also discussed specific exercises" [MS p. 11]: such as education (4.9%), meditation/guided imagery (3.3%), and journaling (1.2%).
- Therapeutic Processes -- identified with four basic themes:
- "Almost a quarter (n = 60, 24.5%) of the chaplains discussed addressing self-directed negative thoughts or emotions" [MS p. 11], looking at self-evaluative processes for forgiveness and/or making amends (17.1%), shame/guilt (9.8%), promoting acceptance (4.5%), and fostering compassion and/or grace (2.4%).
- "The second most frequent therapeutic process (n = 51, 20.8%) focused on promoting accommodation and encouraging adaptive functioning...." [MS p. 11]
- Fostering internal/external resources was important to 20.8% of the chaplains. Examples included "drawing upon existing spiritual resources and/or fostering spiritual growth or connection with God (n = 16, 6.5%), encouraging development or use of existing coping skills (n = 9, 3.7%), and increasing social support (n = 5, 2.0%)." [MS p. 12]
- Addressing emotional dysregulation was discussed by 11.4% or respondents. They attended to fostering hope (4.9%), encouraging grieving/mourning (4.5%), reducing of anxiety/fear (2.9%), and promoting anger management (1.6%).
This great variety of approaches to intervention shows "1) the dearth of established, standardized, evidence-based approaches (as can be expected at this early phase of scientific development); as well as 2) a tendency within clinical chaplaincy for chaplains to develop and utilize personal and faith-tradition informed approaches to spiritual care." [MS pp. 13-14]. They especially press for research here as the basis not only to hone interventions but to facilitate multidisciplinary collaboration.
The authors comment in their introduction on the relevancy to chaplaincy, pointing to "[s]ome of the unique sequela of moral injury," including "changes in moral/ethical attitudes and behavior, change or loss of spirituality, reduced trust in others, and difficulties with meaning making" [MS p. 3]. For this chaplain reader, who does not work in a VA or military setting, the article brought to mind that research into MI could help inform our understanding of such consequential changes in civilian patients, expand our sense of the dynamics of moral distress that is a significant theme in the literature of civilian nursing, and provide a frame for aspects of work in emergency/trauma medicine, perhaps especially in mass casualty situations. Research in this area has the potential to bring together VA/military and civilian chaplains in exploratory partnerships.
Suggestions for Use of the Article for Student Discussion:
The article will likely be read very differently by chaplaincy groups inside VA medical centers than by those in civilian hospitals, even though patients with moral injury may be found at both. For VA chaplains, engaging this research should be straightforward; for other pastoral caregivers, the task will be first to understand the concept of MI and then to consider how the interventions identified here may inform pastoral care elsewhere. MI is an emerging concept, so discussion should focus in part on clarifying a clinical picture. Do the ideas expressed by the survey participants fill out that picture well? How do they understand its relation to PTSD? [On this, see especially the bottom of MS p. 8.] Have any of them cared for patients whom they believe have suffered a moral injury? Next, students could look at the list of interventions on MS pp. 10-12, just to establish which ones seem commonplace and which ones seem unfamiliar to them. What does the group think about the authors' pleas for more research here? What, regarding moral injury, would students like to know more about? Discussion could also address the prospect of chaplains working collaboratively with mental health providers on MI and in general.
Related Items of Interest:
I. The term moral injury is credited to Jonathan Shay, a psychiatrist with the Veterans Administration, who hinted at it in a 1991 article, "Learning about combat stress from Homer's Iliad " [Journal of Traumatic Stress 4, no. 4 (October 1991): 561-579; see esp. p. 563], used the phrase in a 1994 book, Achilles in Vietnam: Combat Trauma and the Undoing of Character, and explicated it in a 2002 book, Odysseus in America: Combat Trauma and the Trials of Homecoming. Shay's definition, arising out of his own work with veterans suffering from PTSD, focused on combatants' experience of a "betrayal of what's right," specifically by their military leaders in critical situations [--see Shay, J., 2014, cited immediately below]. The definition was soon further developed by others focusing on the personal acts of combatants themselves, and while it is still firmly grounded in a military context, the term continues to be expanded, with application in civilian contexts. For more on the background and some of the broader application of the concept, see:
Shay, J. "Moral injury." Psychoanalytic Psychology 31, no. 2 (April 2014): 182–191. [(Abstract:) The term moral injury has recently begun to circulate in the literature on psychological trauma. It has been used in two related, but distinct, senses; differing mainly in the "who" of moral agency. Moral injury is present when there has been (a) a betrayal of "what's right"; (b) either by a person in legitimate authority (my definition), or by one's self—"I did it" (Litz, Maguen, Nash, et al.); (c) in a high stakes situation. Both forms of moral injury impair the capacity for trust and elevate despair, suicidality, and interpersonal violence. They deteriorate character. Clinical challenges in working with moral injury include coping with  being made witness to atrocities and depravity through repeated exposure to trauma narratives,  characteristic assignment of survivor's transference roles to clinicians, and  the clinicians' countertransference emotions and judgments of self and others. A trustworthy clinical community and, particularly, a well-functioning clinical team provide protection for clinicians and are a major factor in successful outcomes with morally injured combat veterans.]
Williamson, V., Stevelink, S. A. M. and Greenberg, N. "Occupational moral injury and mental health: systematic review and meta-analysis." British Journal of Psychiatry 212, no. 6 (June 2018): 339-346. [(Abstract:) BACKGROUND: Many people confront potentially morally injurious experiences (PMIEs) in the course of their work which can violate deeply held moral values or beliefs, putting them at risk for psychological difficulties (e.g. post-traumatic stress disorder (PTSD), depression, etc.).AimsWe aimed to assess the effect of moral injury on mental health outcomes. METHOD: We conducted a systematic review and meta-analysis to assess the association between work-related PMIEs and mental health disorders. Studies were independently assessed for methodological quality and potential moderator variables, including participant age, gender and PMIE factors, were also examined. RESULTS: Thirteen studies were included, representing 6373 participants. PMIEs accounted for 9.4% of the variance in PTSD, 5.2% of the variance in depression and 2.0% of the variance in suicidality. PMIEs were associated with more symptoms of anxiety and behavioural problems (e.g. hostility), although this relationship was not consistently significant. Moderator analyses indicated that methodological factors (e.g. PMIE measurement tool), demographic characteristics and PMIE variables (e.g. military v. non-military context) did not affect the association between a PMIE and mental health outcomes. CONCLUSIONS: Most studies examined occupational PMIEs in military samples and additional studies investigating the effect of PMIEs on civilians are needed. Given the limited number of high-quality studies available, only tentative conclusions about the association between exposure to PMIEs and mental health disorders can be made.]
Also, an extensive bibliography on moral injury has recently been compiled by the Nebraska Psychological Association.
II. For articles (and one dissertation) on moral injury that are pertinent to chaplaincy, see:
Carey, L. B., Hodgson, T. J., Krikheli, L., Soh, R. Y., Armour, A. R., Singh, T. K. and Impiombato, C. G. "Moral injury, spiritual care and the role of chaplains: an exploratory scoping review of literature and resources.." Journal of Religion and Health 55, no. 4 (August 2016): 1218-1245. [(Abstract:) his scoping review considered the role of chaplains with regard to 'moral injury'. Moral injury is gaining increasing notoriety. This is due to greater recognition that trauma (in its various forms) can cause much deeper inflictions and afflictions than just physiological or psychological harm, for there may also be wounds affecting the 'soul' that are far more difficult to heal-if at all. As part of a larger research program exploring moral injury, a scoping review of literature and other resources was implemented utilising Arksey and O'Malley's scoping method (Int J Soc Res Methodol 8(1):19-32, 2005) to focus upon moral injury, spirituality (including religion) and chaplaincy. Of the total number of articles and/or resources noting the term 'moral injury' in relation to spiritual/religious issues (n = 482), the results revealed 60 resources that specifically noted moral injury and chaplains (or other similar bestowed title). The majority of these resources were clearly positive about the role (or the potential role) of chaplains with regard to mental health issues and/or moral injury. The World Health Organization International Classification of Diseases: Australian Modification of Health Interventions to the International Statistical Classification of Diseases and related Health problems (10th revision, vol 3-WHO ICD-10-AM, Geneva, 2002), was utilised as a coding framework to classify and identify distinct chaplaincy roles and interventions with regard to assisting people with moral injury. Several recommendations are made concerning moral injury and chaplaincy, most particularly the need for greater research to be conducted.]
Drescher, K. D. and Foy, D. W. "When they come home: posttraumatic stress, moral injury, and spiritual consequences for veterans." Reflective Practice: Formation and Supervision in Ministry 28 (2008): 85-102. [(Abstract:) Clergy supervisors, as they live out their various roles as models, educators, consultants, and direct providers of pastoral care, have powerful opportunities to influence and shape the responses of religious communities to the needs of returning veterans. Four key suggestions are offered to assist in ministry to/with veterans.] [Available freely online from the journal. Note: This is not a report of article.] [The article is part of a collection in this volume of Reflective Practice, under the heading of "Symposium on Moral Injury and Spirituality" --see the volume 33 table of contents.]
Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Schutz, K. and Litz, B. "An exploration of the viability and usefulness of the construct of moral injury in war veterans." Traumatology 17, no. 1 (March 2011): 8-13. [(Abstract:) It is widely recognized that, along with physical and psychological injuries, war profoundly affects veterans spiritually and morally. However, research about the link between combat and changes in morality and spirituality is lacking. Moral injury is a construct that we have proposed to describe disruption in an individual's sense of personal morality and capacity to behave in a just manner. As a first step in construct validation, we asked a diverse group of health and religious professionals with many years of service to active duty warriors and veterans to provide commentary about moral injury. Respondents were given a semistructured interview and their responses were sorted. The transcripts were used to clarify the range of potentially and morally injurious experiences in war and the lasting sequelae of these experiences. There was strong support for the usefulness of the moral injury concept; however, respondents chiefly found our working definition to be inadequate.]
Harris, J. I., Park, C. L., Currier, J. M., Usset, T. J. and Voecks, C. D. "Moral injury and psycho-spiritual development: considering the developmental context." Spirituality in Clinical Practice 2, no. 4 (December 2015): 256–266. [Research on military mental health has recently begun to explore the construct of “moral injury,” the mental health sequelae of real or perceived violations of deeply held values or beliefs. Moral injury may be a distinctive dimension of combat-related posttraumatic stress disorder and related problems and is therefore critical to understand and attend to. This article considers moral injury from the perspective of psycho-spiritual development, with an emphasis on the interplay of cognitive, social, and faith group culture dimensions to contextualize the construct of moral injury within a theoretical framework. We present a case study to illustrate the utility of this psycho-spiritual framework to understand and treat moral injury. Implications for clinical interventions and suggested directions for future research conclude the article.]
Hodgson, T. J. and Carey, L. B. "Moral injury and definitional clarity: betrayal, spirituality and the role of chaplains." Journal of Religion and Health 56, no. 4 (August 2017): 1212-1228. [(From the abstract:) This article explores the developing definition of moral injury within the current key literature. Building on the previous literature...,this article notes the complexity that has developed due to definitional variations regarding moral injury-particularly with respect to the concepts of 'betrayal' and 'spirituality'. Given the increasing recognition of moral injury and noting the relevance and importance of utilizing a bio-psycho-social-spiritual model, this article argues that betrayal and spirituality should be core components for understanding, defining and addressing moral injury. It also supports the role of chaplains being involved in the holistic care and rehabilitation of those affected by moral injury.] [Note: This is not a report of research.]
Hufford, D. J., Fritts, M. J. and Rhodes, J. E. "Spiritual Fitness." Military Medicine 175, no. 8 supplement (August 2010): 73-87. [This article about the role of spirituality in the "total force fitness" (p. 73) of service members, includes a consideration of moral injury and urges that persons demonstrating risk factors "should be referred immediately to a chaplain or mental health professional for appropriate follow-up, including chaplain-sponsored programs, skills training, and counseling" (p. 78).]
Kopacz, M. S., Ducharme, C., Ani, D. and Atlig, A. "Towards a faith-based understanding of moral injury." Journal of Pastoral Care and Counseling 71, no. 4 (December 2017): 217-219. [(Abstract:) In recent years, the issue of moral injury (MI) has garnered considerable attention, especially as related to the military experiences of Service Members and Veterans. This brief communication is intended to provide an overview of Christian, Jewish, and Islamic understandings of MI. The intent is to draw attention to a faith-based etiology for MI, thereby facilitating dialogue and discussion on the relevance of spiritual and pastoral care to supporting those affected by MI.] [Note: This is not a report of research.]
Meador, K. G. and Nieuwsma, J. A. "Moral injury: contextualized care." Journal of Medical Humanities 39, no. 1 (March 2018): 93-99. [(Abstract:) Amidst the return of military personnel from post-9/11 conflicts, a construct describing the readjustment challenges of some has received increasing attention: moral injury. This term has been variably defined with mental health professionals more recently conceiving of it as a transgression of moral beliefs and expectations that are witnessed, perpetrated, or allowed by the individual. To the extent that morality is a system of conceptualizing right and wrong, individuals' moral systems are in large measure developmentally and socially derived and interpreted. Thus, in seeking to provide care and aid in reintegration for combat veterans, it is necessary to consider communities that have contributed to an individual's formation and that might have participated in the interpretation of his/her suffering. This can take many forms, but given that morality is often complexly intertwined with issues of religion, faith, and spirituality for many individuals, and recognizing that much of the current focus on moral injury is emanating out of healthcare contexts, we devote particular attention to how chaplains might be more intentionally engaged in healthcare systems such as the Veterans Health Administration to provide non-judgmental, person-centered, culturally-relevant care rooted in communities of practice to veterans with moral injury.] [Note: This is not a report of research.]
Price, R. A. "A meta-analytic case study of clinical chaplain care for moral injury in veterans." Dissertation, Regent University (Virginia Beach, VA), September 2017. [(Abstract:) The purpose of this project is to examine clinical chaplain care elements for veterans whom are experiencing moral injury as a result of military service experiences. Persons can experience intense shame and guilt resulting from morally injurious experiences: events in which a "betrayal of what's right" occurs by committing an act, failing to prevent an event or act, learning of such a violation, and/or being or feeling betrayed by an authority.1 What clinical chaplain care elements lessen the symptoms the affected persons experience, particularly in the context of veteran clients receiving said clinical chaplain care? The relevant literature is extensively reviewed, as well as the developing treatment options. The literature reviewed herein suggests that moral injury is an issue resulting in shame and guilt-related symptomatology, which further suggests that a chaplain care/spirituality group strategy would be appropriate, augmented by individual therapy for each participant, provided either by a clinical chaplain or other mental health provider. This author has designed small, closed homogenous spirituality groups for participants that combine psychoeducational elements with group processing of individual experiences and emotional reactions, with the most significant outcome of intentional outcome of converting toxic shame to healthy guilt. While more research is necessary, a reduction in the overall perceived effects of shame and guilt on the participants, along with subsequent changes in quality of life and relationships, was the outcome. Once these benefits are consistently substantiated in the experiences of participants, this clinical chaplain care intervention can not only provide a much-needed care strategy for military veterans, but can equally be relevant to survivors of other traumatic experiences.]
Pyne, J. M., Rabalais. A. and Sullivan, S. "Mental health clinician and community clergy collaboration to address moral injury in veterans and the role of the Veterans Affairs Chaplain." Journal of Health Care Chaplaincy (2018): 19pp., online ahead of print, August 15, 2018. [(Abstract:) Moral injury in veterans with posttraumatic stress disorder includes symptoms of guilt and shame, and these symptoms are often not responsive to evidence-based mental health treatments. Clergy provide a pathway for relieving the guilt and shame. However, there is a long history of mistrust between clergy and mental health clinicians and not enough Veterans Health Administration chaplains to meet this need. The goal of this study was to gather qualitative interview data from relevant stakeholders regarding whether and how Veterans Affairs (VA) mental health clinicians and community clergy could collaborate to address moral injury issues such as guilt and shame in veterans being treated for posttraumatic stress disorder. The stakeholders for this study were veterans, mental health clinicians, and clergy. Qualitative data were organized into three domains: barriers, facilitators, and intervention suggestions. These data were used to develop a new intervention for moral injury that includes a central role for the Veterans Affairs chaplain.]
Van Loenen, G., Korver, J., Walton, M. and De Vries, R. "Case study of 'moral injury': Format Dutch Case Studies Project." Health and Social Care Chaplaincy 5, no. 2 (2017): 281-296. [(Abstract:) The case study "Moral Injury" traces care provided by a chaplain in a mental health institution to a former military marksman named "Hans. " Hans was in care at a specialized unit for military veterans with traumas. He sought contact with a chaplain "to set things right with God" and wanted the chaplain to perform a ritual to that end. The case study traces the care provided in conversations, in the reading of Psalms and in the construction and performance of a ritual.]
III. Moral distress, a concept related to -- and predating -- moral injury, has been explored extensively in the context of civilian health care, especially in nursing. Chaplains interested in moral distress per se may find the following few articles a good entrée to the literature:
Campbell, S. M., Ulrich, C. M. and Grady, C.
"A broader understanding of moral distress." American Journal of Bioethics 16, no. 12 (2016): 2-9. [On the traditional view, moral distress arises only in cases where an individual believes she knows the morally right thing to do but fails to perform that action due to various constraints. We seek to motivate a broader understanding of moral distress. We begin by presenting six types of distress that fall outside the bounds of the traditional definition and explaining why they should be recognized as forms of moral distress. We then propose and defend a new and more expansive definition of moral distress and examine how it can enable the development of a taxonomy of moral distress.]
Guthrie, M. "A health care chaplain's pastoral response to moral distress.." Journal of Health Care Chaplaincy 20, no. 1 (2014): 3-15. [(Abstract:) This article offers health care chaplains a pastoral response to moral distress experienced by health care professionals. The article offers a broad definition, explores its impact on health care professionals, and looks at various interventions to ameliorate its effects. The article goes on to clarify the concept of moral distress by differentiating it from the experience of moral dilemmas, and looking closer at the aspects of initial and reactive distress. After defining moral distress, the article explores two clinical models that create a better context to understand the phenomenon. Finally, the article proposes a pastoral response to moral distress from the integration of the five functions of pastoral care: "healing," "sustaining," "guiding," "reconciling," and "nurturing" based on the work of William Clebsch, Charles Jaekle, and Howard Clinebell. The author then applies the pastoral response to moral distress by illustrating the outcome of a scenario with a critical care nurse.]
Houston, S., Casanova, M. A., Leveille, M., Schmidt, K. L., Barnes, S. A., Trungale, K. R. and Fine, R. L. "The intensity and frequency of moral distress among different healthcare disciplines." Journal of Clinical Ethics 24, no. 2 (2013): 98-112. [This report of a large sample of healthcare providers within the Baylor Health Care System included chaplains. Among the results: "In reviewing our mean moral distress intensity scores across professions, one group stood out with interest: chaplains. When evaluating the mean moral distress intensity for the nine core items, chaplains, physicians, and SWs were tied for first, followed by nurses. In analyzing the nine core items individually, chaplains scored highest in moral distress intensity in four of nine core items and a close second in two of the items." (p. 107, and see also esp. p. 108)]
IV. The findings of what interventional strategies were used by chaplains here speaks to the issue of "What do chaplains do?" For more on that larger question itself, see the March 2017 and the August 2018 Articles-of-the-Month.