Serving on multiple fronts: A grounded theory model of complex decision-making in military mental health care

• Published in: Social science & medicine (1982) 2020-04, Vol.250, p.112865-112865, Article 112865
• Main Authors: King, Erika L., Snowden, David L.
• Format: Article
• Language: English
• Subjects: Complex care; Decision making; Ethics; Grounded theory; Mental health; Military; Qualitative; Role strain
• ISSN: 0277-9536; 1873-5347
• DOI: 10.1016/j.socscimed.2020.112865

Military mental health providers must navigate multiple competing professional boundaries when delivering care in complex cases. Currently no clear policy exists to balance clinical professional obligations to do no harm with potentially-contradictory military policies. Thusly, military providers may face Catch-22 situations where they must choose to seemingly neglect either their duty to the military or their duty to clinical professional standards. Recognizing such situations as emblematic of role strain (Goode, 1960), this study employed a grounded theory approach to examine military mental health providers' decision-making in the face of competing professional demands. An evolving, semi-structured interview guide steered discussions with 20 active duty and civilian mental health providers across 16 Air Force/Department of Defense facilities. Using a symbolic interactionism framework, three rounds of coding enabled increasing levels of abstraction, ultimately revealing a grounded theory model of complex decision-making. The final model includes four antecedents - training, resources, consultation, and clinic climate. Those antecedents influence development of three different role views: clinical professional, agent of the client, and agent of the military. Role views impact decision-making and provider behaviors that may either enhance or detract from quality care. Decision-making and provider behaviors link to consequences at the patient, provider, clinic, and community levels. The model offers insights into military mental health providers' growth versus burnout, and engagement in quality-enhancing versus -detracting behaviors. It also illuminates strategies military leaders might leverage to normalize and relieve provider role strain as a means to improve individual and community trust, wellness, and helpseeking. •Grounded theory decision-making model accounts for military-unique role strains.•Antecedents influence role views—the most influential facet of decision-making.•Decision-making impacts engagement in quality-enhancing and -detracting behaviors.•A table of extracted quality-related behaviors offers clinical goalposts/targets.•Behavioral consequences reverberate across client, provider, clinic and community.