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Background: Nurses are exposed to potentially psychologically traumatic events which can lead to operational stress injuries (OSI). Workplace reintegration after an OSI can be challenging, especially with repeated exposure to potentially traumatic scenarios and workplace demands. A workplace reintegration program (RP) originally developed for police officers may be of benefit for nurses returning to work after an OSI. The purpose of this study is to investigate the perceived need for an RP for nurses, and its potential contextualization and implementation in the nursing context using an implementation science approach. Methods: This mixed-methods study collected data via questionnaires and focus groups from acute care nurses in Canada (N = 19). Data analysis was conducted using descriptive statistics, thematic analysis, and an organizational readiness assessment. Results: Study participants indicated that formalized processes were rarely used to support nurses returning to work after time off due to mental health challenges. Themes included (1) “The Perfect Storm”: the current state of return-to-work, (2) Integral Needs, and (3) A Break in the Clouds: hope for health. Conclusions: Exploration of innovative programs such as the RP may provide additional support to nurses affected by OSIs. Further research is needed regarding workplace reintegration for nurses, and contextualization and evaluation of the RP.

LAY SUMMARY In 2015, the Canadian Armed Forces (CAF) implemented Operation HONOUR to eliminate sexual misconduct (SM) in the military. Sexual assault, inappropriate sexual behaviours, sexual harassment, and gender discrimination are all types of SM. Experiencing SM can result in depression, substance abuse, physical health problems, and even posttraumatic stress disorder (PTSD). Despite Operation HONOUR, SM still happens in the CAF. At this time, many groups are working together to address SM and to support those who have experienced SM. Canadian-based researchers, policy makers, military members, Veterans, and clinicians are collaborating to identify new approaches to training, culture change, research, and treatment relating to SM in the CAF. The end goal of working together is to minimize SM in the CAF and ensure the health and safety of all CAF members and Veterans.

Public safety personnel (PSP) are at increased risk of developing operational stress injuries. Peer-led reintegration programs (RPs) for PSP, evidence-based research is lacking. This study explored the experiences of PSP participating in a Reintegration Program Facilitator Training (RPFT) program. Participant ( n = 57) responses were collected from surveys, satisfaction and knowledge questionnaires, and a World Cafe. Four themes emerged: (1) traits of an ideal RF; (2) holistic/complementary workplace reintegration approach; (3) necessary features of the reintegration program; and (4) culture-specific considerations. While RPs hold promise, it is essential that evidence-based research be used to guide RPFT and RP spread and sustainability.

Various forms of assistance are offered to help US Veterans achieve success in their post-military lives in recognition of their service. Despite the many successes, a significant number of Veterans continue to remain at risk for negative mental health outcomes, including suicidality and low levels of life satisfaction. These findings may be due to challenges arising from cultural identity dissonance. Problematic strategies used by Veterans to reduce this dissonance can result in a lack of belongingness, a key component in Joiner’s Interpersonal Theory of Suicide. The authors suggest that research on the immigrant experience of acculturation may provide a new perspective to better understand issues of identity and sense of belonging in Veterans. Given that most Veterans return to the culture in which they grew up, the authors offer the term “reculturation.” The authors propose clinical psychology focus on exploring the reculturation process of Veterans to support program engagement and suicide prevention.

© 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/). Background—Public safety personnel (PSP) are at heightened risk of developing mental health challenges due to exposures to diverse stressors including potentially psychologically traumatic experiences. An increased focus on protecting PSP mental health has prompted demand for interventions designed to enhance resilience. While hundreds of available interventions are aimed to improve resilience and protect PSPs’ mental health, research evidence regarding intervention effectiveness remains sparse. Methods—Focus groups with PSP elicited a discussion of psychoeducational program content, preferred modes of program delivery, when such training should occur, and to whom it ought to be targeted. Results—The results of thematic analyses suggest that PSP participants feel that contemporary approaches to improving mental health and resilience are lacking. While welcomed, the provision of sporadic one-off mental health and resilience programs by organizations was seen as insufficient, and the available organizational mental health supports were perceived as being questionable. The available programs also left participants feeling insufficiently prepared to deal with personal mental health problems and in discussing mental health concerns with co-workers. Conclusions—Participants reported needing more engaging methods for delivering information, career-long mental health knowledge acquisition, and a systems approach to improve the workplace culture, particularly regarding mental health. This research work was supported by a Canadian Institute for Health Research (CIHR) Public Safety Personnel Catalyst Grant (FRN: 162528) and by an Alberta Health, Mental Health and Addiction COVID-19 Community Funding Grant (Grant: 011530). Faculty yes

Background: Exposure to trauma and potentially morally injurious events may lead to moral injury (MI). The link between MI and posttraumatic stress disorder (PTSD) may have particularly relevant implications for treatment-resistant PTSD (TR-PTSD). Multi-modal Motion-Assisted Memory Desensitization and Reconsolidation (3MDR), a technology-assisted exposure-based trauma therapy that has been used in the treatment of PTSD, may also be an acceptable modality for patients in the treatment of TR-PTSD and MI. This proof-of-concept study aimed to investigate (1) whether MI co-occurs in military members (MMs) and veterans with TR-PTSD, and (2) the perspectives of MMs and veterans with TR-PTSD utilizing 3MDR for MI. Methods: This study employed a mixed-methods clinical trial. Military Members and veterans participated in this study (N = 11) through self-reported questionnaires, video recordings of treatment sessions, and semi-structured interviews post-session and post-intervention, with longitudinal follow-up to 6 months. Results: MI scores correlated with self-reported measures of mental health symptoms related to PTSD. The thematic analysis revealed three emergent themes: (1) Realities of War, (2) Wrestling Scruples, and (3) Moral Sensemaking. Conclusion: MI was highly correlated with TR-PTSD and themes regarding MI. This result, while preliminary, allows for the postulation that MI may be contributing to the continuation of PTSD symptoms in TR-PTSD, and that 3MDR may be an acceptable modality for addressing these symptoms in MMs and veterans.

The COVID-19 pandemic has underscored the essential role of public safety personnel in serving and protecting all Canadians. Public safety personnel were reporting challenges with mental health and well-being before the COVID-19 pandemic; accordingly, the new stressors may mean public safety personnel need additional resources to sustainably help them help us. This article suggests elements of support that may be attainable avenues for supporting the well-being of public safety personnel during the protracted stress caused by the COVID-19 pandemic. Sustained self-care may be critical for maintaining the mental health and well-being of public safety personnel during the COVID-19 pandemic.La pandémie de COVID-19 a mis en évidence le rôle essentiel du personnel de sécurité publique dans le service et la protection de l’ensemble des Canadiens. Le personnel de sécurité publique signalant déjà des problèmes de santé mentale et de bien-être avant même la pandémie de COVID-19, les nouveaux facteurs de stress pourraient augmenter les besoins en ressources supplémentaires chez ce personnel afin qu’il soit capable de nous aider à long terme. Cet article propose divers éléments de soutien pouvant constituer des pistes pertinentes en vue de favoriser le bien-être du personnel de sécurité publique pendant la période de stress prolongé provoqué par la pandémie de COVID-19. Les autosoins peuvent s’avérer essentiels au maintien de la santé mentale et du bien-être du personnel de sécurité publique pendant la pandémie de COVID-19.

BACKGROUND Background: Childhood sexual abuse (CSA) is a key health area that needs new and innovative treatment options for both caregivers and children. Although there are few existing treatment options for the CSA survivors, there have been studies targeting inventions for children’s mental health issues as well as for caregiver-child dyads. For CSA survivors, there is some recent evidence for the effectiveness of multimodal treatment. However, no prior study has identified long term findings over the full year of programming in a multimodal program and there has been no analysis of the role of caregivers in treatment outcomes. OBJECTIVE Objective: The aim of this study was to evaluate the effectiveness of a complex multimodal treatment program for child sexual abuse (CSA) survivors. The secondary aim was to qualitatively evaluate the attitudes and opinions of caregivers. METHODS Methods: Children (CSA survivors) completed quantitative self-report surveys before and after each of the four treatment rounds in a comprehensive year long program (n=15). 86.7% identified as female and 13.3% identified as transgender (mean age 10.2 ± 1.6). Measures included validated self-report surveys related to anxiety, depression, PTSD, quality of life, and self-esteem. Changes in mean outcome scores were analyzed for statistical significance. Caregivers of CSA survivors participated in two innovative hybrid webinar focus groups with staff at a residential treatment facility (n=11). Sessions were recorded, transcribed, and thematically analyzed. RESULTS Results: For CSA survivors, statistically significant improvements were observed on PTSD, depression, anxiety, and quality of life. For caregivers of CSA survivors, 20 participants contributed to the data and three themes arose from our thematic analysis: (1) Challenges of starting and maintaining treatment, (2) Therapeutic benefits of specialized treatment, and (3) Barriers and facilitators of treatment. CONCLUSIONS Conclusions: The present mixed methods study supports effectiveness of a complex multimodal program designed for CSA survivors in terms of improving children’s mental health outcomes as well as supporting caregiver well-being. Future studies are warranted with a larger sample size to replicate these preliminary long-term findings. Several benefits and gaps in wellness support arose during our thematic analysis.

Background Military members (MMs) and public safety personnel (PSP) are vulnerable to occupational stress injuries because of their job demands. When MMs and PSP transition out of these professions, they may continue to experience mental health challenges. The development and implementation of resilience-building mobile health (mHealth) apps as an emergent mental health intervention platform has allowed for targeted, cost-effective, and easily accessible treatment when in-person therapy may be limited or unavailable. However, current mHealth app development is not regulated, and often lacks both clear evidence-based research and the input of health care professionals. Objective This study aims to evaluate the evidence-based quality, efficacy, and effectiveness of resilience-building mobile apps targeted toward the MMs, PSP, and veteran populations via a scoping literature review of the current evidence base regarding resilience apps for these populations and an evaluation of free resilience apps designed for use among these populations. Methods The studies were selected using a comprehensive search of MEDLINE, CINAHL Plus, PsycINFO, SocINDEX, Academic Search Complete, Embase, and Google and were guided by PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). A narrative synthesis of the resulting papers was performed. The Alberta Rating Index for Apps was used to conduct a review of each of the identified apps. The inclusion criteria consisted of apps that were free to download in either the Google Play Store or the Apple App Store; updated within the last 3 years; available in English and in Canada; and intended for use by MMs, veterans, and PSP. Results In total, 22 apps met the inclusion criteria for evaluation. The resilience strategies offered by most apps included psychoeducation, mindfulness, cognitive behavioral therapy, and acceptance and commitment therapy. Overall, 50% (11/22) of apps had been tested in randomized controlled trials, 7 (32%) apps had been evaluated using other research methods, and 5 (23%) apps had not been studied. Using the Alberta Rating Index for Apps, the app scores ranged from 37 to 56 out of 72, with higher rated apps demonstrating increased usability and security features. Conclusions The mHealth apps reviewed are well-suited to providing resilience strategies for MMs, PSP, and veterans. They offer easy accessibility to evidence-based tools while working to encourage the use of emotional and professional support with safety in mind. Although not intended to function as a substitute for professional services, research has demonstrated that mHealth apps have the potential to foster a significant reduction in symptom severity for posttraumatic stress disorder, depression, anxiety, and other mental health conditions. In clinical practice, apps can be used to supplement treatment and provide clients with population-specific confidential tools to increase engagement in the treatment process.

The work of public safety personnel (PSP) is inherently moral, however, the ability of PSP to do what is good and right can be impeded and frustrated, leading to moral suffering. Left unresolved, moral suffering may develop into moral injury (MI) and potential psychological harm. The current study was designed to examine if MI is relevant to frontline public safety communicators, firefighters, and paramedics. Semi-structured interviews (n = 3) and focus groups (n = 3) were conducted with 19 participants (public safety communicators (n = 2), paramedics (n = 7), and firefighters (n = 10)). Interviews and focus groups were audio-recorded, transcribed, coded, and constantly compared in accordance with the grounded theory method. A conceptual theory of “frustrating moral expectations” emerged, with participants identifying three interrelated properties as being potentially morally injurious: chronic societal problems, impaired systems, and organizational quagmires. Participants navigated their moral frustrations through both integrative and disintegrative pathways, resulting in either needing to escape their moral suffering or transforming ontologically. The current study results support MI as a relevant concept for frontline PSP. Given the seriousness of PSP leaving their profession or committing suicide to escape moral suffering, the importance of the impact of MI on PSP and public safety organizations cannot be ignored or underestimated. Understanding the similarities and differences of morally injurious exposures of frontline PSP may be critical for determining mental health and resilience strategies that effectively protect PSP.

Multi-modal Motion-assisted Memory Desensitization and Reprocessing Therapy (3MDR), an interactive, virtual-reality assisted, exposure-based intervention for PTSD, has shown promising results for treatment-resistant Posttraumatic Stress Disorder (TR-PTSD) among military members (MMs) and Veterans in Randomized Controlled Trials. Previous research has suggested that emotional regulation (ER) and emotional dysregulation (ED) may be factors which are correlated with symptom severity and maintenance of TR-PTSD. This embedded mixed-methods pilot study (n=9) sought to explore the impact of 3MDR on ER and ED of MMs and Veterans. Difficulties in Emotional Regulation Scale (DERS-18) data was collected at baseline, prior to each session, and at 1 week, 1 month and 3 months post-intervention and analyzed using a Wilcoxon signed-ranks test. Qualitative data collected from sessions, debriefs, and follow-up interviews were transcribed and descriptively analyzed. Results demonstrated statistically significant decreases in DERS-18 scores from pre-intervention to post-intervention at each timepoint. Qualitatively, participants perceived improvements in ER within specified DERS-18 domains. We describe how 3MDR’s unique and novel approach may address ED through cognitive-motor stimulation, narration, divergent thinking, reappraisal of aversive stimuli, dual-task processing, and reconsolidation of traumatic memories. Further investigation is underway to better understand the underlying neurobiological mechanisms by which 3MDR addresses ER and PTSD.

BACKGROUND Public safety personnel (PSP) impacted by operational stress injuries can find themselves needing both time off work and support reintegrating back into the workforce. Work reintegration programs have been introduced in PSP organizations to support those who aim to return to work. One such peer-led workplace reintegration program (RP) was created in 2009 by members of the Edmonton Police Service (EPS). The primary goal of the EPSRP is to assist PSP in returning to work as soon as possible following a critical incident, illness, or injury while diminishing the potential for long-term psychological injury. The EPSRP is delivered by peers through 3 interrelated components: (1) the Reintegration Program Facilitator Training (RPFT) Program; (2) a short-term Critical Incident RP; and (3) a long-term RP. There is a dire need for research that incorporates strong study designs to the determine long-term effectiveness of the program on increasing workplace reintegration, improving mental health knowledge, and creating culture change within PSP organizations. Simultaneously, the efficacy, effectiveness, and fidelity of the RPFT in providing the tools, mental health knowledge, and skills the RP peer facilitators will need for the RP must be evaluated. OBJECTIVE The purpose of this quasi-experimental pre-post pilot cohort study is to evaluate the effectiveness of the EPSRPFT course on influencing mental health knowledge and attitudes of RPFT attendees who will be future RP peer facilitators. METHODS This pre-post cohort study collected data via 2 questionnaires from RPFT participants (N=60) which included the Mental Health Knowledge Survey (MAKS) and the Open Minds Survey of Workplace Attitudes (OMSWA). Descriptive, parametric (sample t tests), and nonparametric (Wilcoxon signed rank tests) statistics were used to compare the pre- and post-RPFT results and to analyze results by gender and profession. RESULTS Statistically significant changes were observed in pre-post questionnaire scores in the domains of mental health attitudes and knowledge. CONCLUSIONS Although results are explorative, the RPFT may facilitate positive changes in workplace mental health attitudes and knowledge among PSP. It is hoped these findings will contribute to a broader evidence base that can inform changes to the program, practices, and policies, and inform decision-making regarding the EPSRP.

BACKGROUND In recent years, the delivery of evidence-based therapies targeting posttraumatic stress disorder (PTSD) has been the focus of the Departments of Defense in countries such as Canada, the Netherlands, and the United States. More than 66% of military members continue to experience symptoms of PTSD that significantly impact their daily functioning and quality of life after completing evidence-based treatments. Innovative, engaging, and effective treatments for PTSD are needed. Multimodal motion-assisted memory desensitization and reconsolidation (3MDR) is an exposure-based, virtual reality–supported therapy used to treat military members and veterans with treatment-resistant PTSD. Given the demonstrated efficacy of 3MDR in recently published randomized control trials, there is both an interest in and a need to adapt the intervention to other populations affected by trauma and to improve accessibility to the treatment. OBJECTIVE We aimed to further innovate, develop, and validate new and existing hardware and software components of 3MDR to enhance its mobility, accessibility, feasibility, and applicability to other populations affected by trauma, including public safety personnel (PSP), via international collaboration. METHODS This study used a modified Delphi expert consultation method and mixed methods quasi-experimental validation with the purpose of software validation among PSP (first responders, health care providers) participants (N=35). A team of international experts from the Netherlands, the United States, and Canada met on the web on a weekly basis since September 2020 to discuss the adoption of 3MDR in real-world contexts, hardware and software development, and software validation. The evolution of 3MDR hardware and software was undertaken followed by a mixed methods software validation study with triangulation of results to inform the further development of 3MDR. RESULTS This study resulted in the identification, description, and evolution of hardware and software components and the development of new 3MDR software. Within the software validation, PSP participants widely acknowledged that the newly developed 3MDR software would be applicable and feasible for PSP affected by trauma within their professions. The key themes that emerged from the thematic analysis among the PSP included the desire for occupationally tailored environments, individually tailored immersion, and the applicability of 3MDR beyond military populations. CONCLUSIONS Within the modified Delphi consultation and software validation study, support for 3MDR as an intervention was communicated. PSP participants perceived that 3MDR was relevant for populations affected by trauma beyond military members and veterans. The resulting hardware and software evolution addressed the recommendations and themes that arose from PSP participants. 3MDR is a novel, structured, exposure-based, virtual reality–supported therapy that is currently used to treat military members and veterans with PTSD. Going forward, it is necessary to innovate and adapt 3MDR, as well as other trauma interventions, to increase effectiveness, accessibility, cost-effectiveness, and efficacy among other populations affected by trauma.

BACKGROUND Military members and veterans exhibit higher rates of injuries and illnesses such as posttraumatic stress disorder (PTSD) because of their increased exposure to combat and other traumatic scenarios. Novel treatments for PTSD are beginning to emerge and increasingly leverage advances in gaming and other technologies, such as virtual reality. Without assessing the degree of technology acceptance and perception of usability to the end users, including the military members, veterans, and their attending therapists and staff, it is difficult to determine whether a technology-based treatment will be used successfully in wider clinical practice. The Unified Theory of Acceptance and Use of Technology model is commonly used to address the technology acceptance and usability of applications in 5 domains. OBJECTIVE Using the Unified Theory of Acceptance and Use of Technology model, the purpose of this study was to determine the technology acceptance and usability of multimodal motion-assisted memory desensitization and reconsolidation (3MDR) on a virtual reality system in the primary user group (military members and veterans with treatment-resistant PTSD, 3MDR therapists, and virtual reality environment operators). METHODS This mixed methods embedded pilot study included military members (n=3) and veterans (n=8) with a diagnosis of combat-related PTSD, as well as their therapists (n=13) and operators (n=5) who completed pre-post questionnaires before and on completion of 6 weekly sessions of 3MDR. A partial least squares structural equation model was used to analyze the questionnaire results. Qualitative data from the interviews were assessed using thematic analysis. RESULTS Effort expectancy, which was the most notable predictor of behavioral intention, increased after a course of 3MDR with the virtual reality system, whereas all other constructs demonstrated no significant change. Participants’ expectations of the technology were met, as demonstrated by the nonsignificant differences in the pre-post scores. The key qualitative themes included feasibility and function, technical support, and tailored immersion. CONCLUSIONS 3MDR via a virtual reality environment appears to be a feasible, usable, and accepted technology for delivering 3MDR to military members and veterans who experience PTSD and 3MDR therapists and operators who facilitate their treatment.

Background Exposure to occupational stressors and potentially psychologically traumatic events experienced by public safety personnel (eg, paramedics, police, fire, and correctional officers), military members, and veterans can lead to the development of posttraumatic stress injuries and other mental health disorders. Providing emergency services during COVID-19 has intensified the challenges. Owing to COVID-19 restrictions, mental health service providers offering support to these populations have had to rapidly pivot to use digital versus in-person methods of service delivery. Objective This paper aims to explore the experience of mental health service providers regarding digital health service delivery, including the current state of digital mental health service delivery, barriers to and facilitators of the use of digital health for mental health service delivery experienced during the pandemic, and recommendations for implementing and integrating digital health into regular mental health service delivery. Methods This embedded mixed-methods study included questionnaires and focus groups with key stakeholders (N=31) with knowledge and experience in providing mental health services. Data analysis included descriptive, quantitative, and qualitative thematic analyses. Results The following three themes emerged: being forced into change, daring to deliver mental health services using digital health, and future possibilities offered by digital health. In each theme, participants’ responses reflected their perceptions of service providers, organizations, and clients. The findings offer considerations regarding for whom and at what point in treatment digital health delivery is appropriate; recommendations for training, support, resources, and guidelines for digitally delivering trauma therapy; and a better understanding of factors influencing mental health service providers’ perceptions and acceptance of digital health for mental health service delivery. Conclusions The results indicate the implementation of digital health for mental health service delivery to military members, public safety personnel, and veterans. As the COVID-19 pandemic continues, remote service delivery methods for trauma therapy are urgently needed to support the well-being of those who have served and continue to serve.

BACKGROUND Military members (MMs) and public safety personnel (PSP) are vulnerable to occupational stress injuries because of their job demands. When MMs and PSP transition out of these professions, they may continue to experience mental health challenges. The development and implementation of resilience-building mobile health (mHealth) apps as an emergent mental health intervention platform has allowed for targeted, cost-effective, and easily accessible treatment when in-person therapy may be limited or unavailable. However, current mHealth app development is not regulated, and often lacks both clear evidence-based research and the input of health care professionals. OBJECTIVE This study aims to evaluate the evidence-based quality, efficacy, and effectiveness of resilience-building mobile apps targeted toward the MMs, PSP, and veteran populations via a scoping literature review of the current evidence base regarding resilience apps for these populations and an evaluation of free resilience apps designed for use among these populations. METHODS The studies were selected using a comprehensive search of MEDLINE, CINAHL Plus, PsycINFO, SocINDEX, Academic Search Complete, Embase, and Google and were guided by PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). A narrative synthesis of the resulting papers was performed. The Alberta Rating Index for Apps was used to conduct a review of each of the identified apps. The inclusion criteria consisted of apps that were free to download in either the Google Play Store or the Apple App Store; updated within the last 3 years; available in English and in Canada; and intended for use by MMs, veterans, and PSP. RESULTS In total, 22 apps met the inclusion criteria for evaluation. The resilience strategies offered by most apps included psychoeducation, mindfulness, cognitive behavioral therapy, and acceptance and commitment therapy. Overall, 50% (11/22) of apps had been tested in randomized controlled trials, 7 (32%) apps had been evaluated using other research methods, and 5 (23%) apps had not been studied. Using the Alberta Rating Index for Apps, the app scores ranged from 37 to 56 out of 72, with higher rated apps demonstrating increased usability and security features. CONCLUSIONS The mHealth apps reviewed are well-suited to providing resilience strategies for MMs, PSP, and veterans. They offer easy accessibility to evidence-based tools while working to encourage the use of emotional and professional support with safety in mind. Although not intended to function as a substitute for professional services, research has demonstrated that mHealth apps have the potential to foster a significant reduction in symptom severity for posttraumatic stress disorder, depression, anxiety, and other mental health conditions. In clinical practice, apps can be used to supplement treatment and provide clients with population-specific confidential tools to increase engagement in the treatment process. CLINICALTRIAL

BackgroundPublic Safety Personnel (e.g., firefighters, paramedics, and police officers) are routinely exposed to human suffering and need to make quick, morally challenging decisions. Such decisions can affect their psychological wellbeing. Participating in or observing an event or situation that conflicts with personal values can potentially lead to the development of moral injury. Common stressors associated with moral injury include betrayal, inability to prevent death or harm, and ethical dilemmas. Potentially psychologically traumatic event exposures and post-traumatic stress disorder can be comorbid with moral injury; however, moral injury extends beyond fear to include spiritual, cognitive, emotional or existential struggles, which can produce feelings of severe shame, guilt, and anger.ObjectiveThis scoping review was designed to identify the extant empirical research regarding the construct of moral injury, its associated constructs, and how it relates to moral distress in firefighters, paramedics, and police officers.MethodsA systematic literature search of peer-reviewed research was conducted using databases MEDLINE, EMBASE, APA PsychInfo, CINHAL PLUS, Web of Science, SCOPUS, and Google Scholar. Included studies were selected based on the inclusion criteria before being manually extracted and independently screened by two reviewers.ResultsThe initial database search returned 777 articles, 506 of which remained after removal of duplicates. Following review of titles, abstracts, and full texts, 32 studies were included in the current review. Participants in the articles were primarily police officers, with fewer articles focusing on paramedics and firefighters. There were two studies that included mixed populations (i.e., one study with police officers, firefighters, and other emergency service workers; one study with paramedic and firefighter incident commanders). Most studies were qualitative and focused on four topics: values, ethical decision-making, organizational betrayal, and spirituality.ConclusionPublic safety organizations appear to recognize the experience of moral distress or moral injury among public safety personnel that results from disconnects between personal core values, formal and informal organizational values, vocational duties, and expectations. Further research is needed to better understand moral distress or moral injury specific to public safety personnel and inform training and treatment in support of public safety personnel mental health.

BACKGROUND Exposure to occupational stressors and potentially psychologically traumatic events experienced by public safety personnel (eg, paramedics, police, fire, and correctional officers), military members, and veterans can lead to the development of posttraumatic stress injuries and other mental health disorders. Providing emergency services during COVID-19 has intensified the challenges. Owing to COVID-19 restrictions, mental health service providers offering support to these populations have had to rapidly pivot to use digital versus in-person methods of service delivery. OBJECTIVE This paper aims to explore the experience of mental health service providers regarding digital health service delivery, including the current state of digital mental health service delivery, barriers to and facilitators of the use of digital health for mental health service delivery experienced during the pandemic, and recommendations for implementing and integrating digital health into regular mental health service delivery. METHODS This embedded mixed-methods study included questionnaires and focus groups with key stakeholders (N=31) with knowledge and experience in providing mental health services. Data analysis included descriptive, quantitative, and qualitative thematic analyses. RESULTS The following three themes emerged: being forced into change, daring to deliver mental health services using digital health, and future possibilities offered by digital health. In each theme, participants’ responses reflected their perceptions of service providers, organizations, and clients. The findings offer considerations regarding for whom and at what point in treatment digital health delivery is appropriate; recommendations for training, support, resources, and guidelines for digitally delivering trauma therapy; and a better understanding of factors influencing mental health service providers’ perceptions and acceptance of digital health for mental health service delivery. CONCLUSIONS The results indicate the implementation of digital health for mental health service delivery to military members, public safety personnel, and veterans. As the COVID-19 pandemic continues, remote service delivery methods for trauma therapy are urgently needed to support the well-being of those who have served and continue to serve. CLINICALTRIAL

BackgroundMild traumatic brain injury (mTBI) occurs at a higher frequency among military personnel than among civilians. A common symptom of mTBIs is cognitive dysfunction. Health care professionals use neuropsychological assessments as part of a multidisciplinary and best practice approach for mTBI management. Such assessments support clinical diagnosis, symptom management, rehabilitation, and return-to-duty planning. Military health care organizations currently use computerized neurocognitive assessment tools (NCATs). NCATs and more traditional neuropsychological assessments present unique challenges in both clinical and military settings. Many research gaps remain regarding psychometric properties, usability, acceptance, feasibility, effectiveness, sensitivity, and utility of both types of assessments in military environments.ObjectiveThe aims of this study were to explore evidence regarding the use of NCATs among military personnel who have sustained mTBIs; evaluate the psychometric properties of the most commonly tested NCATs for this population; and synthesize the data to explore the range and extent of NCATs among this population, clinical recommendations for use, and knowledge gaps requiring future research.MethodsStudies were identified using MEDLINE, Embase, American Psychological Association PsycINFO, CINAHL Plus with Full Text, Psych Article, Scopus, and Military & Government Collection. Data were analyzed using descriptive analysis, thematic analysis, and the Randolph Criteria. Narrative synthesis and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews) guided the reporting of findings. The psychometric properties of NCATs were evaluated with specific criteria and summarized.ResultsOf the 104 papers, 33 met the inclusion criteria for this scoping review. Thematic analysis and NCAT psychometrics were reported and summarized.ConclusionsWhen considering the psychometric properties of the most commonly used NCATs in military populations, these assessments have yet to demonstrate adequate validity, reliability, sensitivity, and clinical utility among military personnel with mTBIs. Additional research is needed to further validate NCATs within military populations, especially for those living outside of the United States and individuals experiencing other conditions known to adversely affect cognitive processing. Knowledge gaps remain, warranting further study of psychometric properties and the utility of baseline and normative testing for NCATs.

BACKGROUND Mild traumatic brain injury (mTBI) occurs at a higher frequency among military personnel than among civilians. A common symptom of mTBIs is cognitive dysfunction. Health care professionals use neuropsychological assessments as part of a multidisciplinary and best practice approach for mTBI management. Such assessments support clinical diagnosis, symptom management, rehabilitation, and return-to-duty planning. Military health care organizations currently use computerized neurocognitive assessment tools (NCATs). NCATs and more traditional neuropsychological assessments present unique challenges in both clinical and military settings. Many research gaps remain regarding psychometric properties, usability, acceptance, feasibility, effectiveness, sensitivity, and utility of both types of assessments in military environments. OBJECTIVE The aims of this study were to explore evidence regarding the use of NCATs among military personnel who have sustained mTBIs; evaluate the psychometric properties of the most commonly tested NCATs for this population; and synthesize the data to explore the range and extent of NCATs among this population, clinical recommendations for use, and knowledge gaps requiring future research. METHODS Studies were identified using MEDLINE, Embase, American Psychological Association PsycINFO, CINAHL Plus with Full Text, Psych Article, Scopus, and Military & Government Collection. Data were analyzed using descriptive analysis, thematic analysis, and the Randolph Criteria. Narrative synthesis and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews) guided the reporting of findings. The psychometric properties of NCATs were evaluated with specific criteria and summarized. RESULTS Of the 104 papers, 33 met the inclusion criteria for this scoping review. Thematic analysis and NCAT psychometrics were reported and summarized. CONCLUSIONS When considering the psychometric properties of the most commonly used NCATs in military populations, these assessments have yet to demonstrate adequate validity, reliability, sensitivity, and clinical utility among military personnel with mTBIs. Additional research is needed to further validate NCATs within military populations, especially for those living outside of the United States and individuals experiencing other conditions known to adversely affect cognitive processing. Knowledge gaps remain, warranting further study of psychometric properties and the utility of baseline and normative testing for NCATs.

Background Military members are at elevated risk of operational stress injuries, including posttraumatic stress disorder (PTSD) and moral injury. Although psychotherapy can reduce symptoms, some military members may experience treatment-resistant PTSD. Multimodular motion-assisted memory desensitization and reconsolidation (3MDR) has been introduced as a virtual reality (VR) intervention for military members with PTSD related to military service. The 3MDR intervention incorporates exposure therapy, psychotherapy, eye movement desensitization and reconsolidation, VR, supportive counselling, and treadmill walking. Objective The objective of this study is to investigate whether 3MDR reduces PTSD symptoms among military members with combat-related treatment-resistant PTSD (TR-PTSD); examine the technology acceptance and usability of the Computer Assisted Rehabilitation ENvironment (CAREN) and 3MDR interventions by Canadian Armed Forces service members (CAF-SMs), veterans, 3MDR clinicians, and operators; and evaluate the impact on clinicians and operators of delivering 3MDR. Methods This is a mixed-methods waitlist controlled crossover design randomized controlled trial. Participants include both CAF-SMs and veterans (N=40) aged 18-60 years with combat-related TR-PTSD (unsuccessful experience of at least 2 evidence-based trauma treatments). Participants will also include clinicians and operators (N=12) who have been trained in 3MDR and subsequently utilized this intervention with patients. CAF-SMs and veterans will receive 6 weekly 90-minute 3MDR sessions. Quantitative and qualitative data will be collected at baseline and at 1, 3, and 6 months postintervention. Quantitative data collection will include multiomic biomarkers (ie, blood and salivary proteomic and genomic profiles of neuroendocrine, immune-inflammatory mediators, and microRNA), eye tracking, electroencephalography, and physiological data. Data from outcome measures will capture self-reported symptoms of PTSD, moral injury, resilience, and technology acceptance and usability. Qualitative data will be collected from audiovisual recordings of 3MDR sessions and semistructured interviews. Data analysis will include univariate and multivariate approaches, and thematic analysis of treatment sessions and interviews. Machine learning analysis will be included to develop models for the prediction of diagnosis, symptom severity, and treatment outcomes. Results This study commenced in April 2019 and is planned to conclude in April 2021. Study results will guide the further evolution and utilization of 3MDR for military members with TR-PTSD and will have utility in treating other trauma-affected populations. Conclusions The goal of this study is to utilize qualitative and quantitative primary and secondary outcomes to provide evidence for the effectiveness and feasibility of 3MDR for treating CAF-SMs and veterans with combat-related TR-PTSD. The results will inform a full-scale clinical trial and stimulate development and adaptation of the protocol to mobile VR apps in supervised clinical settings. This study will add to knowledge of the clinical effectiveness of 3MDR, and provide the first comprehensive analysis of biomarkers, technology acceptance and usability, moral injury, resilience, and the experience of clinicians and operators delivering 3MDR. Trial Registration ISRCTN Registry 11264368; http://www.isrctn.com/ISRCTN11264368. International Registered Report Identifier (IRRID) DERR1-10.2196/20620

Background A necessary shift from in-person to remote delivery of psychotherapy (eg, teletherapy, eHealth, videoconferencing) has occurred because of the COVID-19 pandemic. A corollary benefit is a potential fit in terms of the need for equitable and timely access to mental health services in remote and rural locations. Owing to COVID-19, there may be an increase in the demand for timely, virtual delivery of services among trauma-affected populations, including public safety personnel (PSP; eg, paramedics, police, fire, correctional officers), military members, and veterans. There is a lack of evidence on the question of whether digital delivery of trauma-therapies for military members, veterans, and PSP leads to similar outcomes to in-person delivery. Information on barriers and facilitators and recommendations regarding digital-delivery is also scarce. Objective This study aims to evaluate the scope and quality of peer-reviewed literature on psychotherapeutic digital health interventions delivered remotely to military members, veterans, and PSP and synthesize the knowledge of needs, gaps, barriers to, and facilitators for virtual assessment of and virtual interventions for posttraumatic stress injury. Methods Relevant studies were identified using MEDLINE (Medical Literature Analysis and Retrieval System Online), EMBASE (Excerpta Medica dataBASE), APA (American Psychological Association) PsycINFO, CINAHL (Cumulative Index of Nursing and Allied Health Literature) Plus with Full Text, and Military & Government Collection. For collation, analysis, summarizing, and reporting of results, we used the CASP (Critical Skills Appraisal Program) qualitative checklist, PEDro (Physiotherapy Evidence Database) scale, level of evidence hierarchy, PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews), and narrative synthesis. Results A total of 38 studies were included in this review. Evidence for the effectiveness of digital delivery of prolonged exposure therapy, cognitive processing therapy, behavioral activation treatment with therapeutic exposure to military members, veterans, and PSP was rated level 1a, whereas evidence for cognitive behavioral therapy was conflicting. The narrative synthesis indicated that virtual delivery of these therapies can be as effective as in-person delivery but may reduce stigma and cost while increasing access to therapy. Issues of risk, safety, potential harm (ie, suicidality, enabling avoidance), privacy, security, and the match among the therapist, modality, and patient warrant further consideration. There is a lack of studies on the influences of gender, racial, and cultural factors that may result in differential outcomes, preferences, and/or needs. An investigation into other therapies that may be suitable for digital delivery is needed. Conclusions Digital delivery of trauma therapies for military members, veterans, and PSP is a critical area for further research. Although promising evidence exists regarding the effectiveness of digital health within these populations, many questions remain, and a cautious approach to more widespread implementation is warranted.

BACKGROUND Military members are at elevated risk of operational stress injuries, including posttraumatic stress disorder (PTSD) and moral injury. Although psychotherapy can reduce symptoms, some military members may experience treatment-resistant PTSD. Multimodular motion-assisted memory desensitization and reconsolidation (3MDR) has been introduced as a virtual reality (VR) intervention for military members with PTSD related to military service. The 3MDR intervention incorporates exposure therapy, psychotherapy, eye movement desensitization and reconsolidation, VR, supportive counselling, and treadmill walking. OBJECTIVE The objective of this study is to investigate whether 3MDR reduces PTSD symptoms among military members with combat-related treatment-resistant PTSD (TR-PTSD); examine the technology acceptance and usability of the Computer Assisted Rehabilitation ENvironment (CAREN) and 3MDR interventions by Canadian Armed Forces service members (CAF-SMs), veterans, 3MDR clinicians, and operators; and evaluate the impact on clinicians and operators of delivering 3MDR. METHODS This is a mixed-methods waitlist controlled crossover design randomized controlled trial. Participants include both CAF-SMs and veterans (N=40) aged 18-60 years with combat-related TR-PTSD (unsuccessful experience of at least 2 evidence-based trauma treatments). Participants will also include clinicians and operators (N=12) who have been trained in 3MDR and subsequently utilized this intervention with patients. CAF-SMs and veterans will receive 6 weekly 90-minute 3MDR sessions. Quantitative and qualitative data will be collected at baseline and at 1, 3, and 6 months postintervention. Quantitative data collection will include multiomic biomarkers (ie, blood and salivary proteomic and genomic profiles of neuroendocrine, immune-inflammatory mediators, and microRNA), eye tracking, electroencephalography, and physiological data. Data from outcome measures will capture self-reported symptoms of PTSD, moral injury, resilience, and technology acceptance and usability. Qualitative data will be collected from audiovisual recordings of 3MDR sessions and semistructured interviews. Data analysis will include univariate and multivariate approaches, and thematic analysis of treatment sessions and interviews. Machine learning analysis will be included to develop models for the prediction of diagnosis, symptom severity, and treatment outcomes. RESULTS This study commenced in April 2019 and is planned to conclude in April 2021. Study results will guide the further evolution and utilization of 3MDR for military members with TR-PTSD and will have utility in treating other trauma-affected populations. CONCLUSIONS The goal of this study is to utilize qualitative and quantitative primary and secondary outcomes to provide evidence for the effectiveness and feasibility of 3MDR for treating CAF-SMs and veterans with combat-related TR-PTSD. The results will inform a full-scale clinical trial and stimulate development and adaptation of the protocol to mobile VR apps in supervised clinical settings. This study will add to knowledge of the clinical effectiveness of 3MDR, and provide the first comprehensive analysis of biomarkers, technology acceptance and usability, moral injury, resilience, and the experience of clinicians and operators delivering 3MDR. CLINICALTRIAL ISRCTN Registry 11264368; http://www.isrctn.com/ISRCTN11264368. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/20620