Implementation of Innovative Treatment for Moral Injury Syndrome: A Hybrid Type 2 Study

背景：精神伤害综合征是由经历的心理和行为后遗症组成的 挑战与道德、精神或价值观相关的信仰。管理信息系统的症状可能包括绝望， 无助，失去以前持有的精神信仰，与更高的力量抗争，难以原谅， 缺乏意义或目标，对自己或他人的信任降低，或顽固的内疚、羞愧或愤怒。个人 管理信息系统的人考虑和试图自杀的可能性是同龄人的两倍，而获得的好处更少 从心理治疗中脱身。很少有基于证据的对精神伤害的干预；一种这样的干预是 人性化的团体干预被称为“建立精神力量(BSS)”。在之前的随机对照中 试验表明，BSS可以减少创伤后应激障碍和精神痛苦的症状。这项临床试验将是 的第一个衡量症状作为主要结果的管理信息系统。假设是：假设1：与 PCGT、BSS能显著降低精神损伤综合征的症状(主要疗效结果)。 假设2：与PCGT相比，BSS能显著减轻抑郁症状，减少自杀倾向 思维，并减少功能障碍。(二次效果结果)。 意义：到目前为止，还没有评估和处理管理信息系统的标准程序，所以很可能 未经治疗的管理信息系统导致了包括自杀在内的不良结局。开发一个实现工具包，以便 退伍军人管理信息系统在退伍军人设施中的广泛应用可以减少管理信息系统对退伍军人心理健康的影响。 创新和影响：到目前为止，还没有资助关于管理信息系统治疗的实施研究 退伍军人和极少数退伍军人医院为管理信息系统提供循证护理。这项研究可以为 在退伍军人管理局系统中更容易获得对管理信息系统的循证护理。 具体目标：1.进行混合方法实施前评估，以确定障碍和 在每个地点协助实施业务支助战略，并制定当地实施战略。特定的 根据Proctor和循证质量改进(EBQI)评估实施变量 模型包括可接受性、适当性和可行性。要评估的具体变量将包括a) 业务支助系统对利益攸关方的可接受性，b)可用的执行资源，以及c)组织对 添加新的EBP。 2.进行一项随机对照试验，比较BSS和目前的中心小组疗法(PCGT)对 在精神伤害后果量表上得分超过分界点(14分)的退伍军人。有效性和功能性 结果将由管理信息系统的心理螺旋发展模型来告知。 3.进行混合方法的实施后评估，以比较各教区的结果 管理与心理健康管理的BSS计划。Proctor20，21模型结果将包括采用率、保真度、 渗透性和可持续性。与这一框架有关的具体成果包括a)成功的BSS 实施，b)实施BSS的保真度，c)提供商意识到并愿意参考BSS， 以及d)在研究完成后维持BSS计划的意向的定性报告。 方法：这将是一项第二类混合研究，将实施前和实施后的评估与 在4个不同文化背景的退伍军人事务部进行随机临床试验。 下一步和实施：关于障碍和促进者的数据将用于开发工具包和 与我们在心理健康和自杀预防办公室的合作伙伴以及国家牧师合作 为制定广播卫星系统的全国传播计划提供服务。我们将与现有的临床工作人员在我们的 研究网站，以便这些网站可以在研究结束后继续提供BSS服务。此外，在 完成这项研究后，BSS领导人将有资格在其他地点培训BSS领导人，为以下方面创造资源 培训和全国传播。

Background: Moral injury syndrome (MIS) consists of the psychological and behavioral sequelae of experiences that challenge moral, spiritual, or values related beliefs. Symptoms of MIS may include hopelessness, helplessness, loss of previously held spiritual beliefs, struggle with a Higher Power, difficulty with forgiveness, lack of meaning or purpose, reduced trust in self or others, or intractable guilt, shame or anger. Individuals managing MIS are up to twice as likely as their peers to consider and attempt suicide, and derive less benefit from psychotherapy. There are few evidence-based interventions for moral injury; one such intervention is a manualized, group intervention called "Building Spiritual Strength (BSS)." In previous randomized controlled trials BSS has been shown to reduce both symptoms of PTSD and spiritual distress. This clinical trial will be one of the first to measure symptoms of MIS as a primary outcome. Hypotheses are: Hypothesis 1: Compared to PCGT, BSS will significantly decrease symptoms of moral injury syndrome (primary effectiveness outcome). Hypothesis 2: Compared to PCGT, BSS will significantly decrease symptoms of depression, decrease suicidal ideation, and reduce functional impairment. (secondary effectiveness outcomes). Significance: To date there are not standard procedures for assessing and treating MIS, so it is likely that untreated MIS is contributing to poor outcomes, including suicides. Developing an implementation toolkit so that BSS is widely available in VA facilities could reduce the impact of MIS on Veterans’ mental health. Innovation and Impact: To date there have not been funded implementation studies on treatments for MIS in Veterans, and very few VA facilities provide evidence-based care for MIS. This study can clear the way to make evidence-based care for MIS more accessible in the VA system. Specific Aims: 1.Conduct a mixed methods pre-implementation evaluation to identify barriers and facilitators for BSS implementation at each site, and to develop local implementation strategies. Specific implementation variables assessed, based on the Proctor and Evidence Based Quality Improvement (EBQI) models include acceptability, appropriateness, and feasibility. Specific variables to be assessed will include a) acceptability of BSS to stakeholders, b) available implementation resources, and c) organizational openness to adding a new EBP. 2. Conduct a randomized controlled trial comparing BSS to Present Centered Group Therapy (PCGT) for Veterans who score above cutoff (score >14) on the Moral Injury Outcomes Scale. Effectiveness and functional outcomes will be informed by the psychospiritual developmental model of MIS. 3. Conduct a mixed methods post-implementation evaluation to compare outcomes across chaplaincy managed vs. mental health managed BSS programs. Proctor20,21model outcomes will include adoption, fidelity, penetration, and sustainability. Specific outcomes related to this framework include a) successful BSS implementation, b) fidelity in implementation of BSS, c) provider awareness of, and willingness to refer to BSS, and d) qualitative reports of intent to maintain the BSS program when the study is complete. Methodology: This will be a type 2 hybrid study, combining pre- and post-implementation evaluations with a randomized clinical trial at 4 culturally diverse VA sites. Next Steps and Implementation: Data on barriers and facilitators will be used to develop a toolkit and collaborate with our partners at the Office of Mental Health and Suicide Prevention and the National Chaplain Service to develop a national dissemination plan for BSS. We will work with existing clinical staffing at our study sites, so that those sites can continue to provide BSS services after the study. Furthermore, after completing this study, BSS leaders will be qualified to train BSS leaders at other sites, creating resources for training and national dissemination.