Moral injury and mental health outcomes in nurses: A systematic review

Introduction: Moral injury involves the adverse psychological, biological, spiritual, behavioural, and social consequences of actions that violate moral values. It can lead to anxiety, depression, burnout, and post-traumatic stress disorder. Nurses, who often face ethical dilemmas, are particularly vulnerable. Despite its significance, the relationship between moral injury and mental health outcomes in nurses remains underexplored. Aim: This systematic review aimed to describe the associations among moral injury, anxiety, depression, and quality of life in nurses. Methods: The review was registered in PROSPERO (CRD42023438731) and was conducted following the PRISMA guidelines. A literature search was performed in December 2023 across PubMed, CINAHL, Scopus, and Web of Science. Peer-reviewed primary research involving nurses, published in English or Italian, without time restrictions, was considered eligible. The risk of bias and the quality of evidence were assessed using the Joanna Briggs Institute checklist and the GRADE approach. Results: Out of 4730 articles identified, eight met the inclusion criteria. The analysis revealed significant positive associations between moral injury, anxiety, and depression, along with a significant negative association with quality of life. Conclusion: These findings highlight the need for healthcare systems to implement strategies that mitigate moral injury among nurses. Future research should prioritize longitudinal studies to explore causal relationships and develop targeted interventions. Additionally, standardizing the concept and measurements of moral injury is crucial for enhancing the comparability and understanding of this phenomenon.

Understanding nurse suicide using an ideation-to-action framework: An integrative review

OBJECTIVE

The purpose of this integrative review was to explore, appraise and synthesize the current literature on correlates of suicide risk in nurses.

DESIGN

Integrative literature review.

DATA SOURCES

Cumulative Index to Nursing and Allied Health Literature (CINAHL), Joanna Briggs Institute, PubMed, PsycInfo and Scopus electronic databases were searched for abstracts published between 2005 and 2020. Reference lists were hand searched.

REVIEW METHODS

The integrative review was based on the Whittemore and Knafl review methodology. Primary qualitative and quantitative studies about suicidal behaviour in nurses published in peer-reviewed journals were included. The methodological quality of included articles was assessed using the Mixed Methods Assessment Tool.

RESULTS

Separate correlates of risk and protective factors were identified for suicidal ideation, suicide attempt and death by suicide in nurses.

IMPLICATIONS

Due to a number of factors at the individual, interpersonal and work levels, nurses are uniquely positioned to be at risk of dying by suicide. The ideation-to-action framework provides a theoretical guide to understand the interplay between correlates and the effect it has on increasing a nurses' capability for suicide.

CONCLUSIONS

This review integrates the empirical literature to elucidate the concept of suicidal behaviour as it applies to nurses.

The Prevalence and Correlation of Suicidal Ideation Among Nurses in King Saud University Medical City

Objectives The aim of the study is to measure the prevalence of suicidal ideation among nurses at King Saud University Medical City, compare its prevalence between male and female nurses, and identify the potential risk factors. Methods We conducted a cross-sectional study. The questionnaire was distributed to nurses via email. It consisted of demographics, Depression, Anxiety and Stress Scale (DASS21), and Suicidal Ideation Scale (SIS). We used the Statistical Package for the Social Sciences (SPSS) statistical software for analysis. Results The total number of participants was 419. The estimated prevalence of suicidal ideation among nurses was 24.58%. The prevalence among female and male nurses was 24.67% and 23.68%, respectively. Moreover, we found that nurses who are non-Muslim, single, and living by themselves are highly correlated with suicidal ideation. Depression, stress, and anxiety are also significantly associated with suicidality, with depression being the most significantly related to suicidal ideation. Conclusion Nurses who experienced depression, anxiety, and stress had an increased likelihood of suicidal ideation. This study demonstrates the need to raise awareness of depression, anxiety, and stress in order to prevent suicidal ideation among nurses. Further research is needed to develop measures of successful monitoring and prevention.

Suicide, self-harm, and suicide ideation in nurses and midwives: A systematic review of prevalence, contributory factors, and interventions

BACKGROUND

Nurses have been identified as an occupational group at increased risk of suicide. This systematic review examines the prevalence of, and factors influencing, suicide and related behaviours among nurses and midwives (PROSPERO pre-registration CRD42021270297).

METHODS

MEDLINE, PsycINFO, and CINAHL were searched. Articles published from 1996 onwards exploring suicidal thoughts and behaviours among nurses and midwives were included. Quality of included studies was assessed. Articles were subjected to narrative synthesis informed by suicide data examined, study design, and quality. PRISMA guidelines were followed.

RESULTS

A total of 100 studies were eligible for inclusion in the review. Articles examining suicide exclusively among midwives were absent from the literature. Several studies confirmed that nursing professionals, especially female, are at increased risk of suicide, particularly by self-poisoning. Factors contributing to risk include psychiatric disorders, alcohol and substance misuse, physical health problems, and occupational and interpersonal difficulties. In studies of non-fatal suicidal behaviours, including during the COVID-19 pandemic, psychiatric, psychological, physical and occupational factors were contributory. There has been little investigation of interventions for prevention of suicide in nurses.

LIMITATIONS

Only articles published in English language were reviewed.

CONCLUSIONS

The findings highlight the risk of suicide in nurses. They also show a combination of factors contribute to suicide and non-fatal suicidal behaviour in nurses, with psychiatric, psychological, physical health, occupational and substance misuse (especially alcohol) problems being particularly important. The limited evidence regarding prevention measures indicates a major need to develop primary and secondary interventions for this at-risk occupational group, for example, education regarding enhancing wellbeing and safe alcohol use, alongside accessible psychological support.

Suicidal behaviours among Ugandan university students: a cross-sectional study

BACKGROUND

Suicide remains the leading cause of death among university students often resulting from multiple physical and psychological challenges. Moreover, suicidal behaviours among students appear to have increased due to the COVID-19 pandemic according to some studies.

OBJECTIVE

To explore the prevalence and associated factors for suicidal ideation, suicide plans, and suicide attempts among university students in Uganda.

METHODS

Cross-sectional study data were collected from May to September 2021 from 540 undergraduate university students in south-western Uganda (363 males, mean age 23.3 years). Questions from the General Health Questionnaire (GHQ-28) were used to assess suicidal ideation, while other bespoke questions were used to assess suicide plans and attempts. The survey also investigated the suicide attempt/plan method, location of the suicidal activity, and reason for not enacting the suicide plan. Three independent regression analyses were used to determine the factors associated with different forms of suicidal behaviours.

RESULTS

The prevalence of past-year suicidal behaviours was 31.85% for suicidal ideation, 8.15% for suicide plans, and 6.11% for suicide attempts. Having a chronic physical medical condition increased the likelihood of having all forms of suicidal behaviours. Suicidal ideation was associated with having difficulty paying university tuition fees. However, being in the fifth year of university education, and feeling satisfied with current academic grades reduced the likelihood of suicidal ideation. Individuals feeling satisfied with academic performance appeared to be a protective factor against having suicide plans. Suicide attempts were associated with having a history of sexual abuse and having difficulty paying university tuition fees. The most common method used for attempted suicide was a drug overdose, and the most common location for attempted suicide was their homes.

CONCLUSION

University students have prevalent suicide behaviours especially among students with a chronic physical medical condition, a history of sexual abuse, and problems paying university tuition fees. Based on the present study, for students at risk, universities should provide appropriate interventions such as life skills education and suicide prevention techniques.

Factors associated with suicide risk among nurses and physicians: a cross-section study

OBJECTIVE

to estimate the prevalence and factors associated with suicide risk among nurses and physicians.

METHOD

a cross-sectional study carried out at a university hospital with 216 health professionals, who answered a socio-demographic-labor questionnaire, the Mini International Neuropsychiatric Interview (MINI) for assessing suicide risk, and the Depression, Anxiety and Stress Scale (DASS 21). The Poisson Regression Model was used for multiple analysis.

RESULTS

it was identified that variables such as not having a partner, history of attempted suicide, stress and depression symptoms were statistically associated with suicide risk. The prevalence of lifelong suicide attempts among nurses was 9.41%, and among physicians, 2.29%.

CONCLUSION

the findings of this investigation enable the understanding of suicidal behavior among hospital nurses and physicians, in addition to enabling the development of prevention strategies in order to reduce suicide risk prevalence in this population group.

Suicidal ideation among nurses: Unique and cumulative effects of different subtypes of sleep problems

BACKGROUND

Nurses have high rates of sleep problems, and higher risk of suicide than the general population. However, there is no empirical evidence showing the extent to which sleep problems among nurses are related to suicidal ideation.

METHODS

Multistage stratified cluster sampling was performed to recruit nurses from tertiary hospitals in Shandong, China. Item 9 of the Patient Health Questionnaire-9 was used to assess suicidal ideation. The Pittsburgh Sleep Quality Index was used to assess different subtypes of sleep problems.

RESULTS

Overall prevalence of suicidal ideation among the sample was 10.8%. Nurses with sleep problems were at high risk for suicidal ideation (^bOR = 1.79, 95% CI = 1.20-2.65). Among different sleep problem subtypes, only "cannot breathe comfortably" was independently related to suicidal ideation. Different subtypes of sleep problems had cumulative effects on suicidal ideation: the more subtypes of sleep problems nurses experienced, the higher the likelihood of suicidal ideation.

LIMITATIONS

The cross-sectional study design prevents inferring causation, and the use of self-report measures may lead to recall bias. Other physical/mental conditions, besides depression, were not assessed. Statistical power may have been insufficient due to the small sub-sample who reported suicidal ideation. Also, the generalizability of the results is limited, as the sample only comprised nurses in tertiary hospitals.

CONCLUSIONS

Nurses experiencing sleep problems were associated with increased likelihood of suicidal ideation. It may be beneficial to incorporate sleep problems into routine screening and intervention for suicide prevention in clinical practice.

A Call to Intervene: Suicide Risk Among Nursing Students

Researchers have found that nursing students are experiencing stress and mental health issues at higher rates than the general college student population. Emphasis should be placed on assessing nursing student stress, with increased efforts toward early detection of depression, before these students experience academic failure. Nurse educators must be the first line in addressing students' mental health problems, being the "eyes and ears" in the classroom as they advocate for students. Faculty have a responsibility to be aware of warning signs of and risk factors for suicide in nursing students, and how to locate resources for at-risk students. Suicide is a preventable public health concern, and nurse educators can make a difference.

Protocol for a phase III wait-listed cluster randomised controlled trial of an intervention for mental well-being through enhancing mental health literacy and improving work friendliness in Hong Kong

BACKGROUND

Mental health has long been recognised as a major global health issue. Some work-related characteristics have been identified to be associated with common mental health problems, and thus the workplace is an important venue for the prevention of mental health problems and promoting mental wellness. Burnout is one of the important aspects of workplace organisational stressors and, in recent years, the lack of mental health literacy has also been identified as a fundamental issue. Studies have demonstrated that an improvement in mental health literacy is an effective measure for enhancing mental well-being. It would be prudent to combine an organisation-directed component and the enhancement of mental health literacy in an intervention programme. This trial will examine the novel approach of an intervention aiming to provide an evidence-based prevention programme.

METHODS

This study utilised a wait-listed cluster randomised control trial design. Using branch offices as the primary sampling units, employees from three large companies in different industries will be recruited. Upon enrolment and after the baseline assessment of the outcome measures, participants nested in the branch offices will be allocated to the intervention or wait-listed arms. The intervention programme comprises of two main elements: an organisation-directed component and individual-directed psychoeducation training. This intervention will be delivered by a senior social worker well-versed in workplace issues over a period of 3 months. The trial will determine whether an integrated workplace mental health literacy and well-being programme is effective in increasing the mental health literacy scores and reducing burnout and stress scores, as measured by standardised and validated scales.

DISCUSSION

If the trial results are in line with the hypothesis that supports the efficacy of the intervention programme, this will provide an evidence-based approach for an effective workplace mental well-being intervention programme that could not only enhance the understanding of mental health issues, but also reduce work-related burnout and stress as well as increase workers' quality of life.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12619000464167. Registered prospectively on 20 March 2019.

Prevalence and correlates of depression, anxiety and symptoms of stress in vocational college nursing students from Sichuan, China: a cross-sectional study

Nursing students from vocational college programs contribute to over 60% of the nursing student population in China. However, there remains a lack of systematic, quantitative studies examining the prevalence of mental health problems in this population. The purpose of this study was to explore the prevalence of depression, anxiety and stress symptoms and associated factors in vocational college nursing students in Sichuan, China. A total of 554 nursing students from vocational colleges participated in this cross-sectional study. Outcomes were measured with the Depression, Anxiety and Stress Scale 21 (DASS 21). Logistic regressions analysis was performed to examine correlates of mental health problems. The prevalence rates of depression, anxiety and stress symptoms among vocational college nursing students in China were 28.7% (95% CI 24.9%-32.5%), 41.7% (95% CI 37.6%-45.9%) and 20.2% (95% CI 16.8%-23.6%). Mental health problems were elevated as compared to a reference population of Chinese college students of all majors. However, only two percent indicated to seek treatment. The most consistent correlates of mental health problems were reduced engagement in physical and other leisure activities, poor sleep quality, experience of negative life events and poor self-perceived mental health.