Institutional Courage in Healthcare: An Improvement Project Exploring the Perspectives of Veterans Exposed to Airborne Hazards
Abstract
:1. Introduction
2. Materials and Methods
2.1. Context
2.2. Participants
2.3. Data Collection
2.4. Data Analysis
3. Results
3.1. Experiences of Institutional Betrayal
Absolutely nothing was done and after I filed a…complaint, retaliation ensued and the commander…told me that if I didn’t stop turning in safety violations that I would lose my job. And so I ended up losing my job.Participant 2.
3.2. Defining Institutional Courage
3.3. Characteristics of Courageous Institutions
3.3.1. Being Accountable
I think because we’re never going to get the justice that we were looking for from our branch of service. Matter of fact, you know, anything but it. You know as soon as you get your discharge, you’re done, goodbye…it’s like they don’t want to hear from you. So all we have left is the VA.Participant 1.
3.3.2. Proactive
…if there was a survey that asks you, do you have this symptom, this symptom, this symptom, this symptom?…if you scored over a certain point on that system I think you should automatically be sent for certain testing.Participant 20.
I think every single one of us should have a caseworker, or a social worker who is calling us every 90 days. Whether you’re a healthy vet or not…somebody should be calling me every 90 days going, are you making it to your doctor’s appointments? Are you getting the doctor’s appointments you need? Do you have a safe place to live? Do you have food on your table?—Participant 12.
3.3.3. Mindful of Unique Experiences
Because they don’t fit into their system, they’re not willing to work with them individually to be able to learn how to fit into the system…it’s the same way with the VA, it’s the same way with schools, it’s the same way with other places…I don’t think that a lot of places want to take the, have the courage to expand and help people to thrive in that environment.Participant 17.
I’m not just rushed in and rushed back out. I know I’m one of those trouble cases, you know, a difficult case they call me. I get that. And so sometimes doctors are like, yeah, we’ve heard it all, duh, duh, duh, duh, here’s what you need to do, bye. And the ones that are like, okay, tell me all of it, what more can I do? I think those are the ones that do have that institutional courage.Participant 12.
3.3.4. Value and Support Advocacy
I needed to take charge of my destiny and self-advocate. And that I was not in a situation I thought I was in. I thought I was in a meritocracy, where everyone’s treated equally and fairly and that people cared about me, loved me and valued me. And none of that turned out to be true.Participant 8.
I’ll never say anything that’s universally bad or universally good…There are pockets of hope, and that makes things a little easier to deal with. You know, I get it’s a big bureaucracy, gets in its own way, but there are those who work in, within the confines of the bureaucracy that really do try to work for the benefit of the veteran.Participant 11.
3.3.5. Support a Cultural Shift around Social Welfare
It is better in some parts of the country—they think they’re doing you a favor and don’t believe in entitlement—systemic prejudice in helping veterans when it comes to money—don’t even think that its conscious.Participant 3.
3.3.6. Offer Safety
[my provider] called me to tell me to stop taking that medicine right away, and if I had any further issues I needed to go to the nearest emergency room…she’s doing her job, she’s doing what’s expected of her to do. So there are two sides of that, one is that she took the initiative to call me to say, hey this could be life threatening stop taking it right away. On the other side, basically she was admitting that they are giving me a medicine that I didn’t need for a diagnosis that I did not have.
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- Smith, C.P.; Freyd, J.J. Institutional betrayal. Am. Psychol. 2014, 69, 575–587. [Google Scholar] [CrossRef] [PubMed]
- Bloeser, K.; McCarron, K.K.; Merker, V.L.; Hyde, J.; Bolton, R.E.; Anastasides, N.; Petrakis, B.A.; Helmer, D.A.; Santos, S.; Litke, D.; et al. “Because the country, it seems though, has turned their back on me”: Experiences of institutional betrayal among veterans living with Gulf War Illness. Soc. Sci. Med. 2014, 284, 114–211. [Google Scholar] [CrossRef] [PubMed]
- Holliday, R.; Monteith, L.L. Seeking help for the health sequelae of military sexual trauma: A theory-driven model of the role of institutional betrayal. J. Trauma Dissociatio. 2019, 20, 340–356. [Google Scholar] [CrossRef] [PubMed]
- Monteith, L.L.; Bahraini, N.H.; Matarazzo, B.B.; Soberay, K.A.; Smith, C.P. Perceptions of institutional betrayal predict suicidal self-directed violence among veterans exposed to military sexual trauma. J. Clin. Psychol 2016, 72, 743–755. [Google Scholar] [CrossRef]
- Monteith, L.L.; Holliday, R.; Schneider, A.L.; Miller, C.N.; Bahraini, N.H.; Forster, J.E. Institutional betrayal and help-seeking among women survivors of military sexual trauma. Psychol. Trauma-US 2021, 13, 814–823. [Google Scholar] [CrossRef]
- McAndrew, L.M.; Teichman, R.F.; Osinubi, O.Y.; Jasien, J.V.; Quigley, K.S. Environmental exposure and health of Operation Enduring Freedom/Operation Iraqi Freedom veterans. J. Occup. Environ. Med. 2012, 54, 665–669. [Google Scholar] [CrossRef]
- Freyd, J.J. Sexual Harassment: Moving from Institutional Betrayal to Institutional Courage. Invited Presentation to the National Academies of Sciences, Engineering, and Medicine, Workshop on Impact of Sexual Harassment in Academia 2017, June. Available online: https://livestream.com/accounts/7036396/events/7512102/videos/158530621 (accessed on 15 May 2023).
- Gómez, J.M.; Smith, C.P.; Gobin, R.L.; Tang, S.S.; Freyd, J.J. Collusion, torture, and inequality: Understanding the actions of the American Psychological Association as institutional betrayal. J. Trauma Dissociatio. 2016, 17, 527–544. [Google Scholar] [CrossRef]
- Aschengrau, A.; Winter, M.R.; Gallagher, L.G.; Vieira, V.M.; Butler, L.J.; Fabian, M.P.; Carwile, J.L.; Wesselink, A.K.; Mahalingaiah, S.; Januleqicz, P.A.; et al. Reproductive and developmental health effects of prenatal exposure to tetrachloroethylene-contaminated drinking water. Environ. Sci-Proc. Imp. 2020, 22, 555–566. [Google Scholar] [CrossRef]
- Bove, F.J.; Ruckart, P.Z.; Maslia, M.; Larson, T.C. Evaluation of mortality among marines and navy personnel exposed to contaminated drinking water at USMC base Camp Lejeune: A retrospective cohort study. Environ. Health Glob. 2014, 13, 1–14. [Google Scholar] [CrossRef]
- Anderko, L.; Pennea, E. Exposures to per-and polyfluoroalkyl substances (PFAS): Potential risks to reproductive and children’s health. Curr. Prob. Pediatr. Ad. 2020, 50, 100760. [Google Scholar] [CrossRef]
- National Academies of Sciences, Engineering, and Medicine. Veterans and Agent Orange: Update 11; The National Academies Press: Washington, DC, USA, 2018. [Google Scholar] [CrossRef]
- Haley, R.W.; Kramer, G.; Xiao, J.; Dever, J.A.; Teiber, J.F. Evaluation of a gene–environment interaction of PON1 and low-level nerve agent exposure with Gulf War illness: A prevalence case–control study drawn from the US military health survey’s national population sample. Environ. Health Persp. 2020, 130, 057001. [Google Scholar] [CrossRef]
- Fukuda, K.; Nisenbaum, R.; Stewart, G.; Thompson, W.W.; Robin, L.; Washko, R.M.; Noah, D.L.; Barrett, D.H.; Randall, B.; Herwaldt, B.L.; et al. Chronic multisymptom illness affecting Air Force veterans of the Gulf War. JAMA 1998, 280, 981–988. [Google Scholar] [CrossRef]
- Steele, L. Prevalence and patterns of Gulf War illness in Kansas veterans: Association of symptoms with characteristics of person, place, and time of military service. Am. J. Epidemiol. 2000, 152, 992–1002. [Google Scholar] [CrossRef]
- Falvo, M.J.; Osinubi, O.Y.; Sotolongo, A.M.; Helmer, D.A. Airborne hazards exposure and respiratory health of Iraq and Afghanistan veterans. Epidemiol. Rev. 2015, 37, 116–130. [Google Scholar] [CrossRef]
- Liu, J.; Lezama, N.; Gasper, J.; Kawata, J.; Morley, S.; Helmer, D.; Ciminera, P. Burn pit emissions exposure and respiratory and cardiovascular conditions among airborne hazards and open burn pit registry participants. J. Occup. Environ. Med. 2016, 58, e249–e255. [Google Scholar] [CrossRef]
- Both-Melander, P.; Ratliff, J.; Poisson, C.; Jindal, C.; Choi, Y.M.; Efird, J.T. Slow burns: A qualitative study of burn pit and toxic exposures among military veterans serving in Afghanistan, Iraq, and throughout the Middle East. Ann. Psychiatry Clin. Neurosci. 2021, 4, 1042. [Google Scholar]
- Richard, B.W.; Miller, R.F. The Honoring Our PACT Act: An improved commitment to Veterans’ health. Ann. Am. Thorac. Soc. 2023, 20, 508–509. [Google Scholar] [CrossRef]
- Zavestoski, S.; Brown, P.; McCormick, S.; Mayer, B.; D’Ottavi, M.; Lucove, J.C. Patient activism and the struggle for diagnosis: Gulf War illnesses and other medically unexplained physical symptoms in the US. Soc. Sci. Med. 2008, 58, 161–175. [Google Scholar] [CrossRef]
- Monteith, L.L.; Schneider, A.L.; Holliday, R.; Bahraini, N.H. Assessing institutional betrayal among female veterans who experienced military sexual trauma: A Rasch analysis of the Institutional Betrayal Questionnaire. J. Interpers. Violence 2021, 36, 10861–10883. [Google Scholar] [CrossRef]
- Andresen, F.J.; Monteith, L.L.; Kugler, J.; Cruz, R.A.; Blais, R.K. Institutional betrayal following military sexual trauma is associated with more severe depression and specific posttraumatic stress disorder symptom clusters. J. Clin. Psychol. 2019, 75, 1305–1319. [Google Scholar] [CrossRef]
- Kelly, U.A. Barriers to PTSD treatment-seeking by women veterans who experienced military sexual trauma decades ago: The role of institutional betrayal. Nurs. Outlook 2021, 69, 458–470. [Google Scholar] [CrossRef] [PubMed]
- Monteith, L.L.; Gerber, H.R.; Brownstone, L.M.; Soberay, K.A.; Bahraini, N.H. The phenomenology of military sexual trauma among male veterans. Psychol. Men Masculin. 2019, 20, 115–127. [Google Scholar] [CrossRef]
- Howard, R.E.; Rabin, A.S.; Heaney, D.S.; Osterholzer, J.J. A Sacred Obligation: Meeting the Needs of Veterans with Airborne Hazard Exposures. Ann. Am. Thorac. Soc. 2022, 20, 3. [Google Scholar] [CrossRef] [PubMed]
- Smidt, A.M.; Freyd, J.J. Government-mandated institutional betrayal. J. Trauma Dissociatio. 2018, 19, 491–499. [Google Scholar] [CrossRef]
- US Department of Veterans Affairs. Federal Benefits for Veterans, Dependents and Survivors 2021 Edition. US Department of Veterans Affairs. Available online: https://www.va.gov/opa/publications/benefits_book/2021_Federal_Benefits_for_Veterans_Dependents_and_survivors.pdf (accessed on 5 May 2023).
- Fried, D.A.; Rajan, M.; Tseng, C.L.; Helmer, D. Impact of presumed service-connected diagnosis on the Department of Veterans Affairs healthcare utilization patterns of Vietnam-Theater Veterans: A cross-sectional study. Medicine 2018, 97, e0662. [Google Scholar] [CrossRef]
- Stellman, J.M.; Stellman, S.D. Agent Orange during the Vietnam War: The lingering issue of its civilian and military health impact. AJPH 2018, 108, 726–728. [Google Scholar] [CrossRef]
- Lange, G.; McAndrew, L.; Ashford, J.W.; Reinhard, M.; Peterson, M.; Helmer, D.A. War Related Illness and Injury Study Center (WRIISC): A multidisciplinary translational approach to the care of veterans with chronic multisymptom illness. Mil. Med. 2013, 178, 705–707. [Google Scholar] [CrossRef]
- Rodriguez, A.; Smith, J. Phenomenology as a healthcare research method. Evid. Based Nurs. 2018, 21, 96–98. [Google Scholar] [CrossRef]
- Kvale, S.; Brinkmann, S. Interviews: Learning the Craft of Qualitative Research Interviewing; Sage: Thousand Oaks, CA, USA, 2009. [Google Scholar]
- Shook, A.G.; Tordoff, D.M.; Clark, A.; Hardwick, R.; St. Pierre Nelson, W.; Kantrowitz-Gordon, I. Trans Youth Talk Back: A Foucauldian Discourse Analysis of Transgender Minors’ Accounts of Healthcare Access. Qual. Health Res. 2022, 32, 1672–1689. [Google Scholar] [CrossRef]
- Birks, M.; Chapman, Y.; Francis, K. Memoing in qualitative research: Probing data and processes. J. Res. Nurs. 2008, 13, 68–75. [Google Scholar] [CrossRef]
- Ogrinc, G.; Davies, L.; Goodman, D.; Batalden, P.B.; Davidoff, F.; Stevens, D. SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Qual. Saf. 2016, 25, 986–992. [Google Scholar] [CrossRef]
- Burks, D.J. Lesbian, gay, and bisexual victimization in the military: An unintended consequence of “Don't Ask, Don't Tell”? Am. Psychol 2011, 66, 604. [Google Scholar] [CrossRef]
- Kerrigan, M.F. Transgender discrimination in the military: The new don't ask, don't tell. Psychol. Public Pol. L 2012, 18, 500. [Google Scholar] [CrossRef]
- Numminen, O.; Repo, H.; Leino-Kilpi, H. Moral courage in nursing: A concept analysis. Nurs. Ethics 2017, 24, 878–891. [Google Scholar] [CrossRef]
- Kleemola, E.; Leino-Kilpi, H.; Numminen, O. Care situations demanding moral courage: Content analysis of nurses’ experiences. Nurs. Ethics 2020, 27, 714–725. [Google Scholar] [CrossRef]
- Thorup, C.B.; Rundqvist, E.; Roberts, C.; Delmar, C. Care as a matter of courage: Vulnerability, suffering and ethical formation in nursing care. Scand. J. Caring Sci. 2012, 26, 427–435. [Google Scholar] [CrossRef]
- Dzeng, E.; Curtis, J.R. Understanding ethical climate, moral distress, and burnout: A novel tool and a conceptual framework. BMJ Qual. Saf. 2018, 27, 766–770. [Google Scholar] [CrossRef]
- Shoorideh, F.A.; Ashktorab, T.; Yaghmaei, F.; Alavi Majd, H. Relationship between ICU nurses’ moral distress with burnout and anticipated turnover. Nurs. Ethics 2015, 22, 64–76. [Google Scholar] [CrossRef]
- Dolansky, M.A.; Barg-Walkow, L.; Barnsteiner, J.; McGaffigan, P.; Oster, C.A.; Schumann, M.J.; Spencer, T.; Chenot, T.; Johnson, L.E.; Burke, K.G. A Call to Action Following the RaDonda Vaught Case: A Culture of Safety and High-Reliability Organizations. J. Nurses Prof. Dev. 2022, 38, 329–332. [Google Scholar] [CrossRef]
- Lusk, C.; DeForest, E.; Segarra, G.; Neyens, D.M.; Abernathy, J.H.; Catchpole, K. Reconsidering the application of systems thinking in healthcare: The RaDonda Vaught case. Brit. J. Anaesth. 2022, 129, e61–e62. [Google Scholar] [CrossRef]
- Kelman, B.; Norman, H. Why nurses are raging and quitting after the RaDonda Vaught verdict. Biomed. Saf. Stand. 2022, 52, 81–83. [Google Scholar] [CrossRef]
- Barkell, N.P.; Snyder, S.S. Just culture in healthcare: An integrative review. Nurs. Forum. 2021, 1, 103–111. [Google Scholar] [CrossRef] [PubMed]
- Burns, J.; Miller, T.; Weiss, J.M.; Erdfarb, A.; Silber, D.; Goldberg-Stein, S. Just culture: Practical implementation for radiologist peer review. J. Am. Coll. Radiol. 2019, 16, 384–388. [Google Scholar] [CrossRef] [PubMed]
- Spinola, S.; Fenton, B.T.; Meshberg-Cohen, S.; Black, A.C.; Rosen, M.I. Comparison of attitudes towards the service connection claims process among veterans filing for PTSD and veterans filing for musculoskeletal disorders. Medicine 2021, 100, e27068. [Google Scholar] [CrossRef] [PubMed]
- Murdoch, M.; Kehle-Forbes, S.; Spoont, M.; Sayer, N.A.; Noorbaloochi, S.; Arbisi, P. Changes in post-traumatic stress disorder service connection among veterans under age 55: An 18-year ecological cohort study. Mil. Med. 2019, 184, 715–722. [Google Scholar] [CrossRef]
- Murdoch, M.; Spoont, M.R.; Sayer, N.A.; Kehle-Forbes, S.M.; Noorbaloochi, S. Reversals in initially denied Department of Veterans Affairs’ PTSD disability claims after 17 years: A cohort study of gender differences. BMC Women's Health 2021, 21, 1–8. [Google Scholar] [CrossRef]
- Stuber, J.; Schlesinger, M. Sources of stigma for means-tested government programs. Soc. Sci. Med. 2006, 63, 933–945. [Google Scholar] [CrossRef]
- Dickstein, B.D.; Vogt, D.S.; Handa, S.; Litz, B.T. Targeting self-stigma in returning military personnel and veterans: A review of intervention strategies. Mil. Psychol. 2010, 22, 224–236. [Google Scholar] [CrossRef]
- Corcoran, B.C.; Brandt, L.; Fleming, D.A.; Gu, C.N. Fidelity to the healing relationship: A medical student's challenge to contemporary bioethics and prescription for medical practice. J. Med. Ethics 2016, 42, 224–228. [Google Scholar] [CrossRef]
- Giosa, J.; Holyoke, P. Caregiving is not a disease: Moving from reactive to proactive supports for family caregivers across the healthcare system. Healthc. Q. 2014, 17, 36–41. [Google Scholar] [CrossRef]
- Purcell, N.; Zamora, K.; Bertenthal, D.; Abadjian, L.; Tighe, J.; Seal, K.H. How VA whole health coaching can impact veterans’ health and quality of life: A mixed-methods pilot program evaluation. Glob. Adv. Health Med. 2021, 10, 2164956121998283. [Google Scholar] [CrossRef]
- Haun, J.N.; Melillo, C.; Cotner, B.A.; McMahon-Grenz, J.; Paykel, J.M. Evaluating a Whole Health Approach to Enhance Veteran Care: Exploring the Staff Experience. J. Veterans Stud. 2021, 7, 163–173. [Google Scholar] [CrossRef]
- Jackson, D.; Peters, K.; Andrew, S.; Edenborough, M.; Halcomb, E.; Luck, L.; Salamonson, Y.; Wilkes, L. Understanding whistleblowing: Qualitative insights from nurse whistleblowers. J. Adv. Nurs. 2020, 66, 2194–2201. [Google Scholar] [CrossRef]
- Mannion, R.; Davies, H.T. Cultures of silence and cultures of voice: The role of whistleblowing in healthcare organisations. Int. J. Health Policy Manag. 2015, 4, 503. [Google Scholar] [CrossRef]
- Finlay, S.; Sandall, J. “Someone's rooting for you”: Continuity, advocacy and street-level bureaucracy in UK maternal healthcare. Soc. Sci. Med. 2009, 69, 1228–1235. [Google Scholar] [CrossRef]
- Looi, J.C.; Allison, S.; Kisely, S.R.; Bastiampillai, T. Stiffen the sinews, summon up the blood, and strain upon the start: Enfranchising the medical profession for clinically proximate advocacy of improved healthcare. Australas. Psychiatry 2021, 29, 672–675. [Google Scholar] [CrossRef]
- The Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022. H.R 3967, 117th Congress. Available online: https://www.congress.gov/bill/117th-congress/senate-bill/3373 (accessed on 5 May 2023).
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2023 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/).
Share and Cite
Bloeser, K.; McAdams, M.; McCarron, K.K.; Varon, S.; Pickett, L.; Johnson, I. Institutional Courage in Healthcare: An Improvement Project Exploring the Perspectives of Veterans Exposed to Airborne Hazards. Behav. Sci. 2023, 13, 423. https://doi.org/10.3390/bs13050423
Bloeser K, McAdams M, McCarron KK, Varon S, Pickett L, Johnson I. Institutional Courage in Healthcare: An Improvement Project Exploring the Perspectives of Veterans Exposed to Airborne Hazards. Behavioral Sciences. 2023; 13(5):423. https://doi.org/10.3390/bs13050423
Chicago/Turabian StyleBloeser, Katharine, Mikayla McAdams, Kelly K. McCarron, Samantha Varon, Lisa Pickett, and Iman Johnson. 2023. "Institutional Courage in Healthcare: An Improvement Project Exploring the Perspectives of Veterans Exposed to Airborne Hazards" Behavioral Sciences 13, no. 5: 423. https://doi.org/10.3390/bs13050423