Moral injury in healthcare professionals: A scoping review and discussion

Development and validation of the Moral Injury Symptom Scale - Clinician Version - Short Form (MISS-CV-SF)

BACKGROUND

Moral injury occurs when one witnesses or perpetrates an act that transgresses strongly held moral beliefs and expectations. First documented among active military and veterans, moral injury is increasingly studied in healthcare personnel impacted by the coronavirus pandemic. Measurement of moral injury among this population, particularly nurses, is still in its infancy.

OBJECTIVE

To develop the Moral Injury Symptom Scale - Clinician-Short Form and validate it among United States based acute care nurses. .

METHODS

The Moral Injury Symptom Scale - Military Version was modified for a healthcare audience. 174 acute care nurses responded to a survey package including the scale and related instruments. Reliability and validity, including convergent and discriminant validities, were assessed, and a cutoff score was calculated using the area under the receiver operating characteristic curve.

RESULTS

Reliability (Cronbach α = .75) and validity were established and a cutoff score of 41, based on functional impairment caused by moral injury, demonstrated 86.4% sensitivity and 69.6% specificity. Nurses who screened positive for moral injury experienced higher depression, anxiety, work exhaustion, interpersonal disengagement, emotional exhaustion, and depersonalization. .

CONCLUSIONS

The Moral Injury Symptom Scale - Clinician Version - Short Form is a valid and reliable instrument with strong psychometric properties that can assess moral injury in acute care nurses, a population at risk due to the challenges of providing care during the pandemic. Appropriate measurement and establishing prevalence should prompt support and intervention from healthcare organizations. .

COVID-19 and nurses' ethical issues: Comparisons between two European countries

BACKGROUND

The global pandemic raised ethical issues for nurses about caring for all patients, not just those with COVID-19. Italy was the first European country to be seriously affected by the first wave, while Estonia's infection and death rates were among the lowest in Europe. Did this raise different ethical issues for nurses in these two countries as well?

AIM

The aim was to describe and compare ethical issues between nurses working during the first wave of the COVID-19 pandemic in Estonia and Italy.

RESEARCH DESIGN

A cross-sectional survey study with a self-administered questionnaire. The impact of COVID-19 emergency on nursing care questionnaire was used.

PARTICIPANTS AND RESEARCH CONTEXT

Convenience sampling was used to recruit 1098 nurses working during the first wave of the pandemic in 2020: 162 from Estonia and 936 from Italy.

ETHICAL CONSIDERATIONS

Research ethics approvals were obtained, and the nurses provided informed consent.

RESULTS

The most frequent ethical issues for Estonian nurses were professional communication and ensuring access to care for patients without COVID-19, and for Italian nurses, the end-of-life care and the risk of them getting the virus and transmitting it to their loved ones. There were no statistically significant differences in the frequency of ethical issues between Estonian nurses working with patients with and without COVID-19. Italian nurses caring for COVID-19 patients faced statistically significantly more (both p < .001) issues around prioritising patients and end-of-life. Nurses working with patients without COVID-19 in Italy faced more issues about access to care (p < .001).

CONCLUSIONS

Estonian and Italian nurses, working in different clinical contexts during the first wave of the pandemic, faced different ethical issues. Local contextual aspects need to be considered to support nurses' ethical decision-making in providing care during future crises and to ensure ethical care for patients.

Addressing Nurse Burnout: Moving Beyond the Conversation

BACKGROUND

Nurse burnout is a widespread issue in the health care industry, jeopardizing the well-being of both health care professionals and the patients they serve, manifesting as an intense sense of exhaustion, depersonalization, and a diminished sense of personal achievement.

METHOD

In nursing, professionals are exposed to an extraordinary array of challenges and demands that increase their likelihood of experiencing burnout and resulting mental health issues. Although burnout has been aggressively discussed and studied in recent years, strategies for preventing and mitigating burnout have been underreported.

RESULTS

This article highlights leading causes of burnout, delves into its alarming prevalence, and underscores the critical need for comprehensive strategies to address and prevent it.

CONCLUSION

This article highlights several initiatives established by a resilience program at a college of nursing that can be implemented within health care systems to directly address both individual and organizational burnout. [J Contin Educ Nurs. 202x;5x(x):xx-xx.].

Sense of failure in end of life care: Perspectives from physicians and nurses

Limited knowledge exists regarding sensed failure resulting provision of end-of-life (EOL) care. Among medical health professionals (MHP), a sense of failure is associated with impaired patientcare and reduced worker wellbeing, including higher rates of burnout and secondary traumatic stress. As part of a larger mixed-methods study on the effects of EOL-care provision on MHP in general hospitals, semi-structured in-depth interviews were conducted with 22 physicians and nurses at three tertiary Israeli hospitals, representing a wide range of medical specialties, training, experience, and cultural backgrounds. Qualitative thematic analysis of the interviews led to the identification of the theme 'sense of failure' with the sub-themes 'sources' and 'lived meanings' of the sensed failure. Apart from the source 'losing a patient' all other identified sources were recognized as work-related risk factors, including 'unsupportive environments' and 'shortcomings of the medical practice.' Two of the lived meaning 'sense of personal responsibility' and 'moral injury' were also recognized as work-related risk factors. Surprisingly, albeit the adverse context of EOL-care, the two remaining lived meanings 'learning from failure' and 'sense of purpose' were recognized as protective resilience factors. Changes in workplace norms by focusing on leadership and mentoring programs and implementation of evidence based interventions aimed at reducing the sense of failure and enhancing feelings of purpose are recommended. Finally, the findings described in the study would benefit from continued studies on larger scales.

Worth a try or a last resort: Healthcare professionals' experiences and opinions of above cuff vocalisation

BACKGROUND

Above cuff vocalisation (ACV) involves the application of an external flow of air via the subglottic port of a tracheostomy. ACV can facilitate vocalisation and may improve swallowing and quality of life for patients with a tracheostomy. A recent systematic review highlighted the limited evidence available for the acceptability, effectiveness, safety or optimal implementation of ACV.

AIMS

To explore the experience of healthcare professionals (HCPs) using ACV and their perceptions of best practice.

METHODS AND PROCEDURES

Semi-structured interviews were conducted with a range of HCPs with experience using ACV. Topics included: experiences with ACV, management of ACV, opinions about ACV, impact of COVID-19, future directions for ACV and impact on length of stay. Interviews were conducted online from December 2020 to March 2022. Data were analysed using reflexive thematic analysis.

OUTCOMES AND RESULTS

Twenty-four HCPs were interviewed from seven countries and five professional groups. Four interconnected themes were developed: (1) moral distress amplifying the need to fix patients; (2) subjectivity and uncertainty leading to variations in practice and purpose; (3) knowledge and experience leading to control and caution; and (4) worth a try or a last resort. Theme four contained three sub-themes: (a) part of the toolbox; (b) useful but limited tool; and (c) following the patient's lead. The moral distress experienced by HCPs and their essential 'need to fix' patients seems to underpin the varied opinions of ACV. These opinions appear to be formed primarily on the basis of experience, because of the underlying subjectivities and uncertainties. As knowledge and experience with ACV increased, and adverse events were experienced, most HCPs became more cautious in their approach to ACV.

CONCLUSIONS AND IMPLICATIONS

More research is needed to reduce the subjectivities and uncertainties surrounding ACV. The implementation of standardised procedures, processes, and competencies may help to reduce the frequency of adverse events and support a more controlled approach. Widening the focus of the purpose of ACV to include swallowing may help to maximise the potential benefits.

WHAT THIS PAPER ADDS

What is already known on the subject There is limited and low-quality evidence for above cuff vocalisation (ACV) and clinical application and practice varies substantially. However, the reasons for this variation in practice and healthcare professionals' (HCPs') opinions of ACV were unclear. What this study adds HCPs' experiences and opinions of ACV vary as a result of the uncertainty and subjectivity surrounding ACV compounded by their personal experiences with it. A need for caution also appears to emerge as HCPs become more familiar and experienced with using ACV. What are the clinical implications of this work? Implementing standardised procedures, safety processes and competencies may help to compensate for the uncertainty and subjectivity surrounding ACV and may reduce the frequency of adverse events. Widening the focus of purpose of ACV, including swallowing in addition to communication, may increase the number of potential candidates and increase the potential benefits of ACV. Using multidisciplinary team (MDT) simulation training for ACV competency development might help to improve MDT working and ACV implementation.

A mixed methods study of moral distress among frontline nurses during the COVID-19 pandemic

OBJECTIVE

The study's purpose was to develop an understanding of factors affecting moral distress among nurses during the COVID-19 pandemic.

METHOD

California-licensed, registered nurses who cared for COVID-19 patients for at least 3 months were recruited for an explanatory concurrent mixed methods study. Data are derived from the first of two surveys administered 3 months apart, including open-ended questions.

RESULTS

Variables with significant bivariate correlations were included as simultaneous predictors in a linear regression model predicting moral distress. The overall model was significant, explaining a substantial portion of the variance in moral distress, but results showed only organizational support and institutional betrayal uniquely predicted moral distress. Three qualitative themes were identified: Ethical Violations in Care, Institutional Betrayal, and Traumatic Strain. The impacts of organizational support and institutional betrayal on nurses' moral distress are important findings in both datasets.

CONCLUSIONS

Findings provide insights into how nurses' experiences affected their feelings about work. Participants indicated feeling disregarded by management and institutional structures, indicating potential means of slowing the rates at which nurses plan to leave bedside practice. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Psychological Group Interventions for Reducing Distress Symptoms in Healthcare Workers: A Systematic Review

Healthcare workers exposed to emergencies and chronic stressors are at high risk of developing mental health problems. This review synthesized existing studies of group psychological therapy to reduce distress symptoms in healthcare workers (i.e., as complex and heterogeneous emotional states, characterized by the presence of symptoms associated with post-traumatic stress disorder, burnout, anxiety, depression and moral injury). Searches were conducted using PRISMA guidelines and databases such as PubMed, PsycINFO, Medline and Web of Science, along with manual searches of reference lists of relevant articles. The search returned a total of 1071 randomized trials, of which 23 met the inclusion criteria. Of the total studies, nine were mindfulness interventions, seven were cognitive behavioural programmes, one was a programme based on acceptance and commitment therapy, one was an EMDR protocol and two focused on systemic and art therapy. Most studies aimed to reduce burnout, anxiety and depression; only three focused on post-traumatic stress disorder, and no studies were found that addressed moral injury. The results suggested that group interventions could be an effective tool to improve the mental health of healthcare workers and reduce their symptoms of distress, although many of the studies have methodological deficiencies. Limitations and future directions are discussed.

Investigating the relationship between compassion fatigue and moral injury in nurses

Background: Compassion fatigue and professional quality of life are important in health and professional ethics. Aim: This study aimed to determine the relationship between compassion satisfaction, compassion fatigue, secondary traumatic stress, and moral injury in nurses. Research design: This research is a cross-sectional descriptive-analytical study. The research community of this research was all the nurses of the teaching hospitals of Ardabil city. Three questionnaires on demographic characteristics, the Professional Quality of Life Scale (ProQOL), and the Moral Injury Events Scale were used to collect data. SPSS (version 22) software was used for data analysis. Participants and research context: The study recruited 297 nurses randomly selected from five teaching hospitals in Ardabil city. Ethical considerations: Ethical approval was obtained from the Ardabil University of Medical Sciences ethics committee (with the code of ethics IR.ARUMS.REC.1401.198). Informed consent was obtained from the participants. Results: The results showed that the mean compassion satisfaction score of this study's participants was 37.61 ± 8.86, the mean compassion fatigue score of this study's participants was 28.73 ± 7.04, and the mean secondary traumatic stress score of this study's participants was 29.95 ± 7.84. The mean score of moral injury among nurses was 31.19 ± 8.54. The results showed a negative significant relationship between compassion satisfaction and moral injury (p < 0.001). Also, there is a positive significant relationship between compassion fatigue and secondary traumatic stress with moral injury (p < 0.001). Conclusion: The results of this study show a negative relationship between compassion satisfaction and moral injury. According to the results of the present study, nurse managers should implement educational interventions, create ethical processes, and clear ethical guidelines to reduce moral injury and increase compassion satisfaction.

What's up doc? Physicians' reflections on their sustainable employability throughout careers: a narrative inquiry

BACKGROUND

Physicians have complex and demanding jobs that may negatively affect their sustainable employability (SE) and quality of care. Despite its societal and occupational relevance, empirical research on physicians' SE is scarce. To further advance our understanding of physicians' SE, this study explores how physicians perceive their employment context to affect their SE, how physicians self-regulate with the intent to sustain their employability, and how self-regulations affect physicians' SE and their employment context.

METHODS

Twenty Dutch physicians from different specialisms were narratively interviewed between March and September 2021 by a researcher with a similar background (surgeon) to allow participants to speak in their own jargon. The interviews were analyzed collaboratively by the research team in accordance with theory-led thematic analysis.

RESULTS

According to the interviewees, group dynamics, whether positive or negative, and (mis)matches between personal professional standards and group norms on professionalism, affect their SE in the long run. Interviewees self-regulate with the intent to sustain their employability by (I) influencing work; (II) influencing themselves; and (III) influencing others. Interviewees also reflect on long-term, unintended, and dysfunctional consequences of their self-regulations.

CONCLUSIONS

We conclude that physicians' SE develops from the interplay between the employment context in which they function and their self-regulations intended to sustain employability. As self-regulations may unintentionally contribute to dysfunctional work practices in the employment context, there is a potential for a vicious cycle. Insights from this study can be used to understand and appraise how physicians self-regulate to face complex challenges at work and to prevent both dysfunctional work practices that incite self-regulation and dysfunctional consequences resulting from self-regulations.

Unraveling attrition and retention: A qualitative study with rehabilitation professionals

BACKGROUND

Health human resources are scarce worldwide. In occupational therapy (OT), physical therapy (PT), and speech-language pathology (S-LP), attrition and retention issues amplify this situation and contribute to the precarity of health systems.

OBJECTIVE

To investigate the phenomena of attrition and retention with OTs, PTs and S-LPs who stayed in, or left their profession.

METHODS

Cultural-historical activity theory provided the theoretical scaffolding for this interpretive description study. We used purposeful sampling (maximum variation approach) to recruit OTs, PTs, and S-LPs from Quebec, Canada. Individual interviews were conducted with 51 OTs, PTs, and S-LPs from Quebec, Canada, in English or French (2019-2020). Inductive and deductive approaches, and constant comparative techniques were used for data analysis.

RESULTS

Six themes were developed: 1) characteristics of work that made it meaningful; 2) aspects of work that practitioners appreciate; 3) factors of daily work that weigh on a practitioner; 4) factors that contribute to managing work; 5) relationships with different stakeholders that shape daily work; and 6) perceptions of the profession. Meaningfulness was tied to participants' sense that their values were reflected in their work. Factors outside work shaped participants' work experiences. Recurrent negative experiences led some to leave their profession.

CONCLUSION

Findings underscore a critical need to address contributing factors to attrition and retention which are essential to ensuring the availability of OTs, PTs and SLPs for present and future rehabilitation needs.

'Physical well-being is our top priority': Healthcare professionals' challenges in supporting psychosocial well-being in stroke services

BACKGROUND

Following stroke, a sense of well-being is critical for quality of life. However, people living with stroke, and health professionals, suggest that well-being is not sufficiently addressed within stroke services, contributing to persistent unmet needs. Knowing that systems and structures shape clinical practice, this study sought to understand how health professionals address well-being, and to examine how the practice context influences care practice.

METHODS

Underpinned by Interpretive Description methodology, we interviewed 28 health professionals across multiple disciplines working in stroke services (acute and rehabilitation) throughout New Zealand. Data were analysed using applied tension analysis.

RESULTS

Health professionals are managing multiple lines of work in stroke care: biomedical work of investigation, intervention and prevention; clinical work of assessment, monitoring and treatment; and moving people through service. While participants reported working to support well-being, this could be deprioritised amidst the time-oriented pressures of the other lines of work that were privileged within services, rendering it unsupported and invisible.

CONCLUSION

Stroke care is shaped by biomedical and organisational imperatives that privilege physical recovery and patient throughput. Health professionals are not provided with the knowledge, skills, time or culture of care that enable them to privilege well-being within their work. This has implications for the well-being of people with stroke, and the well-being of health professionals. In making these discourses and culture visible, and tracing how these impact on clinical practice, we hope to provide insight into why well-being work remains other to the 'core' work of stroke, and what needs to be considered if stroke services are to better support people's well-being.

PATIENT OR PUBLIC CONTRIBUTIONS

People with stroke, family members and people who provide support to people with stroke, and health professionals set priorities for this research. They advised on study conduct and have provided feedback on wider findings from the research.

Trauma-Informed Care Education Initiative Explores Impact on Perinatal Nurse Secondary Traumatic Stress and Workforce Challenges

BACKGROUND

Psychological trauma refers to long-lasting adverse effects on well-being precipitated by the experience of a distressing event or a combination of events. High rates of psychological birth trauma in patients contribute to secondary traumatic stress (STS) in perinatal nurses, creating workplace challenges and resulting in dissatisfaction, apathy, and attrition. Perinatal nurses experience high rates of STS, and researchers have called for a universal standard of trauma-informed care (TIC). However, there is a lack of published results on effectively creating TIC education in this nurse population.

METHODS

A pre/posttest design evaluated an online pilot evidence-based practice project addressing a perinatal nurse education initiative on STS and its correlation with nurse attitudes toward TIC. Participants include perinatal nurses in the United States (n = 29). Two scales measured the program's effect on nurses: the Secondary Traumatic Stress Scale (STSS) and the Attitudes Related to Trauma-Informed Care (ARTIC) scale.

RESULTS

A paired t test evaluating pre- and postprogram levels of the STSS showed a decrease in STS (t28 = -3.28, P = .003, Cohen's d = 0.609), the ARTIC scale results showed an increased receptiveness to TIC (t28 = 3.8, P < .001, Cohen's d = 0.706], and a not significant correlation was found between pretest STS and ARTIC scores (Spearman' ρ = -0.248, P = .194).

CONCLUSION

This program supported a significant reduction in nurses' identification of STS. Future perinatal nurse education can expand to build a standard of TIC that is patient-centered and reduces nurse STS.

"Entonces, Como Promotores, Pues, No Somos Intérpretes": Reconciling Medical Interpretation & Community Health Work in Indiana and South Carolina

Community health workers (CHWs) and promotores de salud are frontline health workers who typically come from the communities they serve. Despite providing crucial services, they are not institutionalized (or integrated) within much of the U.S. health care system. Many work, either officially or unofficially, as medical interpreters-restricting their full impact as CHWs/ promotores . In this paper, we detail the misemployment and its effects among a subsample of CHWs/ promotores in two geographically distinct, exploratory projects. We encourage that collaborative research with CHWs/ promotores continue and that fidelity to the CHW model be ensured to realize their true potential.

Organizational response to the COVID-19 pandemic and its association with moral distress in community mental health teams in the UK: A qualitative study

In March 2020, Coronavirus-19 (COVID-19) rapidly spread across the globe impacting the mental health of the population and putting an overwhelming pressure on health services. Much has been written about the impact of the pandemic on health-care workers working in hospital settings but less attention has been paid to its effect on community mental health teams (CMHTs). This study is based on 21 remote interviews with community mental health professionals during the first wave of the COVID-19 pandemic. Interviews were transcribed and analysed using a thematic analysis whereby codes of similar meaning were grouped into main themes. Analysis identified three major contributors to moral distress; changes in the nature of contact with service users, changes to the place of work, and difficulties of balancing risks to the families of CMHT staff and service users. This study demonstrates that necessary organizational changes instituted to minimize the spread of COVID-19, required different ways of working which were not perceived to be in the best interests of service users or the families of CMHT staff. In order to comply with Government directives, CMHT staff were forced to behave in a way which did not match their moral values causing them to experience moral distress.

Compassionate care during the COVID-19 pandemic

BACKGROUND

There was a substantial documented call for healthcare professionals to provide compassionate care during the COVID-19 pandemic and significant criticism voiced when it was lacking. This study aimed to explore perspectives on compassionate care among healthcare professionals providing care during the COVID-19 pandemic. The study focuses on healthcare professionals who participated in a wide range of COVID-19 measures, including testing, quarantine, diagnosis, and care provision (patients with COVID-19 or patients with other illnesses and comorbid with COVID-19).

METHODS

A qualitative design with an interpretative phenomenological analysis approach was used. Twenty frontline healthcare professionals (15 nurses and five physicians) who had worked in COVID-19 facilities in China were interviewed individually.

RESULTS

Participants stated that a commitment to 'offering oneself' and 'balancing the advantages/disadvantages' in providing care during the pandemic were key to alleviate population-level suffering. On a personal level, they described a desire for obtaining 'mutual support' and improving 'professional competencies' to safeguard their physical and mental well-being. Two professional competencies were notable: coping with grief and implementing infection control across the organization. Additionally, they emphasized the importance of receiving support from the health care organization, the public, and leaders in creating an 'environment conducive to fostering compassionate care.'

CONCLUSION

Healthcare professionals recognized the centrality of compassionate care during the pandemic which entailed a commitment to offering themselves, the balancing of advantages and disadvantages in order to find the best solution, as well as the need to safeguard themselves using professional competencies. Such findings can enrich the contemporary understanding of compassion, including when it is lacking. Support from the healthcare organization, the public, and leadership were crucial in fostering compassionate care in healthcare professionals during the pandemic and in moving the field forward in the future.

Canadian intensive care unit nurses' responses to moral distress during the COVID-19 pandemic, and their recommendations for mitigative interventions

AIMS

To describe intensive care unit nurses' experiences of moral distress during the COVID-19 pandemic, and their recommendations for mitigative interventions.

DESIGN

Interpretive description.

METHODS

Data were collected with a purposeful sample of 40 Canadian intensive care unit nurses between May and September 2021. Nurses completed a demographic questionnaire, the Measure of Moral Distress-Healthcare Professionals survey and in-depth interviews. Quantitative data were analysed using descriptive statistics. Qualitative data were categorized and synthesized using reflexive thematic analysis and rapid qualitative analysis.

RESULTS

Half of the nurses in this sample reported moderate levels of moral distress. In response to moral distress, nurses experienced immediate and long-term effects across multiple health domains. To cope, nurses discussed varied reactions, including action, avoidance and acquiescence. Nurses provided recommendations for interventions across multiple organizations to mitigate moral distress and negative health outcomes.

CONCLUSION

Nurses reported that moral distress drove negative health outcomes and attrition in response to moral events in practice. To change these conditions of moral distress, nurses require organizational investments in interventions and cultures that prioritize the inclusion of nursing perspectives and voices.

IMPLICATIONS FOR THE PROFESSION

Nurses engage in a variety of responses to cope with moral distress. They possess valuable insights into the practice issues central to moral distress that have significant implications for all members of the healthcare teams, patients and systems. It is essential that nurses' voices be included in the development of future interventions central to the responses to moral distress.

REPORTING METHOD

This study adheres to COREQ guidelines.

IMPACT

What Problem did the Study Address? Given the known structural, systemic and environmental factors that contribute to intensive care unit nurses' experiences of moral distress, and ultimately burnout and attrition, it was important to learn about their experiences of moral distress and their recommendations for organizational mitigative interventions. Documentation of these experiences and recommendations took on a greater urgency during the context of a global health emergency, the COVID-19 pandemic, where such contextual influences on moral distress were less understood. What Were the Main Findings? Over half of the nurses reported a moderate level of moral distress. Nurses who were considering leaving nursing practice reported higher moral distress scores than those who were not considering leaving. In response to moral distress, nurses experienced a variety of outcomes across several health domains. To cope with moral distress, nurses engaged in patterns of action, avoidance and acquiescence. To change the conditions of moral distress, nurses desire organizational interventions, practices and culture changes situated in the amplification of their voices. Where and on Whom Will the Research Have an Impact on? These findings will be of interest to: (1) researchers developing and evaluating interventions that address the complex phenomenon of moral distress, (2) leaders and administrators in hospitals, and relevant healthcare and nursing organizations, and (3) nurses interested in leveraging evidence-informed recommendations to advocate for interventions to address moral distress. What Does this Paper Contribute to the Wider Global Community? This paper advances the body of scientific work on nurses' experiences of moral distress, capturing this phenomenon within the unique context of a global health emergency. Nurses' levels of moral distress using Measure of Moral Distress-Healthcare Professional survey were reported, serving as a comparator for future studies seeking to measure and evaluate intensive care unit nurses' levels of moral distress. Nurses' recommendations for mitigative interventions for moral distress have been reported, which can help inform future interventional studies.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

The Impact of Moral Injury on Self-reported Work Performance in Hospital Nurses Following the Global Pandemic Surge

OBJECTIVE

The aim of this study was to determine relationships between moral injury (MI) and self-reported nurse work performance (NWP) among hospital nurses after the COVID-19 pandemic surges.

BACKGROUND

Previously studied in the military, nurse MI became evident due to the pandemic. No previous studies have examined the impact of MI on NWP. Few studies have attended to how MI in nurses can be addressed by nursing leadership.

METHODS

A convenience sample of 191 nurses from 7 hospitals in Southern California participated in a multisite correlational survey-design study.

RESULTS

Significant levels of MI occurred in 57% (n = 114) of participants. Increased levels of MI were a significant predictor of decreased levels of self-reported NWP. Younger and less experienced nurses reported greater levels of MI.

CONCLUSIONS

This study relates MI in nurses to NWP. There is a need for further research to assist nursing administrators in ameliorating MI in nurses and in preparing for the impact of MI on the nursing workforce in future emergent situations.

Ethical value conflicts in healthcare and their effects on nurses' health, turnover intent, team effectiveness, and patient safety: a longitudinal questionnaire study

OBJECTIVE

Moral distress emanating from value conflicts comprising ethical dimensions pose a threat to nurses' health and retention, as well as to the quality of care. The aim of the present study was to investigate the relationships between the frequency of ethical value conflicts (EVC), and the perceived distress when they occur, respectively, and nurses' work-related stress, burnout symptoms, turnover intent, team effectiveness, and patient safety.

METHODS

A two-wave longitudinal cohort questionnaire study was performed among registered nurses at six hospitals in two Swedish regions. Cross-sectional analyses (T1) were based on 1817 nurses in 228 care units (CU), and longitudinal analyses (T1 - T2) on 965 nurses in 190 CU. Hypothesis testing was performed using multilevel controlled regression modeling.

RESULTS

The results indicated that nurses who were often exposed to EVC also to a higher extent tended to report these conflicts as stressful. Frequent exposure to EVC induced by insufficient resources, inapt organizational structures or interpersonal staff relations were cross-sectionally associated with work-related stress, burnout symptoms, turnover intent, and team effectiveness. The longitudinal analyses indicated that EVC induced by a lack of resources primarily had negative effects on nurses' health and well-being. At the CU level, such conflicts also impaired team effectiveness. At the individual level, EVC induced by organizational constraints or interpersonal relations negatively affected care effectiveness.

CONCLUSIONS

EVC are related to negative consequences in healthcare, and such processes take place both on the individual and organizational levels.

Moral Injury Post-COVID-19: More Than Military? A Theological Perspective

The author of this article considers moral distress theologically, as a potential shattering of core sustaining belief systems, hope, securities, self-identities, and organizing principles of one's existence. Shattering of individual moral expectations can occur in both medical and military moral injury.

Uncertainty in serious illness: A national interdisciplinary consensus exercise to identify clinical research priorities

BACKGROUND

Serious illness is characterised by uncertainty, particularly in older age groups. Uncertainty may be experienced by patients, family carers, and health professionals about a broad variety of issues. There are many evidence gaps regarding the experience and management of uncertainty.

AIM

We aimed to identify priority research areas concerning uncertainty in serious illness, to ensure that future research better meets the needs of those affected by uncertainty and reduce research inefficiencies.

METHODS

Rapid prioritisation workshop comprising five focus groups to identify research areas, followed by a ranking exercise to prioritise them. Participants were healthcare professionals caring for those with serious illnesses including geriatrics, palliative care, intensive care; researchers; patient/carer representatives, and policymakers. Descriptive analysis of ranking data and qualitative framework analysis of focus group transcripts was undertaken.

RESULTS

Thirty-four participants took part; 67% female, mean age 47 (range 33-67). The highest priority was communication of uncertainty, ranked first by 15 participants (overall ranking score 1.59/3). Subsequent priorities were: 2) How to cope with uncertainty; 3) healthcare professional education/training; 4) Optimising clinical approaches to uncertainty; and 5) exploring in-depth experiences of uncertainty. Research questions regarding optimal management of uncertainty were given higher priority than questions about experiences of uncertainty and its impact.

CONCLUSIONS

These co-produced, clinically-focused research priorities map out key evidence gaps concerning uncertainty in serious illness. Managing uncertainty is the most pressing issue, and researchers should prioritise how to optimally manage uncertainty in order to reduce distress, unlock decision paralysis and improve illness and care experience.

"Definitely a Dark Time:" professional and ethical issues in post-acute care physical therapy during the COVID-19 pandemic

BACKGROUND

Disproportionate effects of the SARS-CoV-2 (COVID-19) pandemic on older adults in post-acute care settings created many professional and ethical challenges for patients and healthcare providers.

OBJECTIVE

The purpose of this study was to examine the professional and ethical issues of physical therapists (PTs) and physical therapist assistants (PTAs) in providing facility-based post-acute care in residential settings (skilled nursing facilities, inpatient rehabilitation facilities, and long-term acute care hospitals) during the COVID-19 pandemic.

METHODS

A qualitative descriptive research design was used to explore professional and ethical issues during the COVID-19 pandemic. PTs and PTAs described their experiences during semi-structured interviews conducted virtually. Interview data was analyzed with reflexive thematic analysis.

RESULTS

Thematic analysis produced 4 themes: facility-wide battle against infection and death, doing the best you can to provide care amidst COVID-19 constraints, promoting ethical good and doing the right thing, and a dark intense time.

CONCLUSIONS

Professional and ethical constraints on providing care faced by PTs and PTAs during the COVID-19 pandemic can inform current and future clinical practice. Although some of the challenges faced by PTs and PTAs were unique to COVID-19, many problems represent preexisting systemic and organizational issues that were exacerbated by the pandemic.

Listening to the Voices of Health Care Workers During the COVID-19 Pandemic: A Qualitative Study Providing In-Depth Insights Into Ethical and Individual Challenges

In their daily practice, health care workers (HCWs) experience the effects of tensions between professional ethos and work realities, which can lead to ethical dilemmas. We aim to explore the ethical dilemmas that affected HCWs in Germany during the COVID-19 pandemic and to understand these in the context of the German health system. Between April and December 2022, we interviewed HCWs from various levels of care and key informants responsible for decisions related to HCWs in Germany. Three themes were identified in the data analyzed from 78 participants. The first highlighted the potency of pre-existing health system problems during the COVID-19 pandemic. The second captured the ethical dilemmas that were described as having arisen due to the tension between professional ethos and structural constraints. The third included factors related to increasing or diminishing the implications of ethical dilemmas. A lack of opportunities for HCWs to participate in political and managerial decisions was suggested to result in policies that do not meet the needs of HCWs and patients. Positive interpersonal interactions were described as helpful when coping with dilemmatic decision-making situations. In order to avoid negative consequences caused by unresolved ethical dilemmas, including moral distress, among HCWs, staff shortages and decision-making in the German health system urgently need to be addressed. HCWs' working conditions regularly evoke ethical dilemmas, particularly during public health emergencies. Together with HCWs, decision-makers must develop new models for working in health care settings that are in line with HCWs' professional ethos.

Too good for this world: moral bioenhancement and the ethics of making moral misfits

Persson and Savulescu argue that moral bioenhancement is not only morally permissible; in some cases, it is morally obligatory. In this article, I introduce a new reason to worry about moral enhancement. I adapt the disability concept of misfit to show how moral enhancement could cause extreme moral disempowerment to those enhanced, which would result in moral injury. I argue that any safety framework that guides the development of moral bioenhancement must be sensitive to the problem of moral misfitting. I present the best case for moral bioenhancement before turning to my own worry concerning the development of moral bioenhancement and its practical implications. Finally, I consider a series of objections and responses.

The independent and combined impact of moral injury and moral distress on post-traumatic stress disorder symptoms among healthcare workers during the COVID-19 pandemic

Background: Healthcare workers (HCWs) across the globe have reported symptoms of Post-Traumatic Stress Disorder (PTSD) during the COVID-19 pandemic. Moral Injury (MI) has been associated with PTSD in military populations, but is not well studied in healthcare contexts. Moral Distress (MD), a related concept, may enhance understandings of MI and its relation to PTSD among HCWs. This study examined the independent and combined impact of MI and MD on PTSD symptoms in Canadian HCWs during the pandemic.Methods: HCWs participated in an online survey between February and December 2021, with questions regarding sociodemographics, mental health and trauma history (e.g. MI, MD, PTSD, dissociation, depression, anxiety, stress, childhood adversity). Structural equation modelling was used to analyze the independent and combined impact of MI and MD on PTSD symptoms (including dissociation) among the sample when controlling for sex, age, depression, anxiety, stress, and childhood adversity.Results: A structural equation model independently regressing both MI and MD onto PTSD accounted for 74.4% of the variance in PTSD symptoms. Here, MI was strongly and significantly associated with PTSD symptoms (β = .412, p < .0001) to a higher degree than MD (β = .187, p < .0001), after controlling for age, sex, depression, anxiety, stress and childhood adversity. A model regressing a combined MD and MI construct onto PTSD predicted approximately 87% of the variance in PTSD symptoms (r2 = .87, p < .0001), with MD/MI strongly and significantly associated with PTSD (β = .813, p < .0001), after controlling for age, sex, depression, anxiety, stress, and childhood adversity.Conclusion: Our results support a relation between MI and PTSD among HCWs and suggest that a combined MD and MI construct is most strongly associated with PTSD symptoms. Further research is needed better understand the mechanisms through which MD/MI are associated with PTSD.

The Impact of COVID-19 Visitor Restrictions on Clinical Cancer Nurses

OBJECTIVES

To explore the impact of visitor restrictions on clinical cancer nurses, their roles and duties, and the coping strategies used to address the impact.

DATA SOURCES

Semistructured qualitative interviews were conducted through purposive sampling with nurses working in a clinical role within cancer services at the study site for at least 1 year. Interviews were recorded and transcribed. Textual data transcribed from interviews were analyzed for themes using NVivo version 12 software, following Braun and Clarke's six phases of thematic analysis.

CONCLUSION

Visitor restrictions implemented due to COVID-19 had a significant impact on clinical cancer nurses. The study found evidence of moral injury and conflict-within the role of the nurse, the implementation of organizational policies, and nurses' professional identity and personal beliefs. Despite this adversity, nurses remained committed to their clinical practice.

IMPLICATIONS FOR NURSING PRACTICE

Changes to nurses' roles and the practice environment have potentially significant impact on well-being and retention. To ensure that nurses can continue to provide high-quality nursing care in challenging environments, organizations must minimize this impact. Consistent communication and support activities, including recognizing and responding appropriately to situations, may be used in the reduction of potential moral injury and stress.

Applicability and Validity of Second Victim Assessment Instruments among General Practitioners and Healthcare Assistants (SEVID-IX Study)

BACKGROUND

The second victim phenomenon and moral injury are acknowledged entities of psychological harm for healthcare providers. Both pose risks to patients, healthcare workers, and medical institutions, leading to further adverse events, economic burden, and dysfunctionality. Preceding studies in Germany and Austria showed a prevalence of second victim phenomena exceeding 53 percent among physicians, nurses, emergency physicians, and pediatricians. Using two German instruments for assessing moral injury and second victim phenomena, this study aimed to evaluate their feasibility for general practitioners and healthcare assistants.

METHODS

We conducted a nationwide anonymous online survey in Germany among general practitioners and healthcare assistants utilizing the SeViD (Second Victims in Deutschland) questionnaire, the German version of the Second Victim Experience and Support Tool Revised Version (G-SVESTR), and the German version of the Moral Injury Symptom and Support Scale for Health Professionals (G-MISS-HP).

RESULTS

Out of 108 participants, 67 completed the survey. In G-SVESTR, the collegial support items exhibited lower internal consistency than in prior studies, while all other scales showed good-quality properties. Personality traits, especially neuroticism, negatively correlated to age, seem to play a significant role in symptom count and warrant further evaluation. Multiple linear regression indicated that neuroticism, agreeableness, G-SVESTR, and G-MISS-HP were significant predictors of symptom count. Furthermore, moral injury partially mediated the relationship between second victim experience and symptom count.

DISCUSSION

The results demonstrate the feasible use of the questionnaires, except for collegial support. With respect to selection bias and the cross-sectional design of the study, moral injury may be subsequent to the second victim phenomenon, strongly influencing symptom count in retrospect. This aspect should be thoroughly evaluated in future studies.

Providing compassionate care via eHealth

BACKGROUND

eHealth was widely used during the COVID-19 pandemic. Much attention was given to the technical aspects of eHealth, such as infrastructure and cost, while the soft skill of compassion remained underexplored. The wide belief in compassionate care is more compatible with in-person interactions but difficult to deliver via e-platforms where personal and environmental clues were lacking urges studying this topic.

PURPOSE

to explore the experience of delivering compassionate care via an eHealth platform among healthcare professionals working to contain the COVID-19 pandemic.

METHODS

A qualitative study design with an interpretative phenomenological analysis approach was used. Twenty healthcare professionals (fifteen nurses and five physicians) who provided care using technology platforms, such as telephone hotlines, mobile apps, and social media, were interviewed individually.

ETHICAL CONSIDERATIONS

Permission to conduct the study was obtained from the Institutional Review Board.

RESULTS

Participants stated that "eHealth enabled compassionate care during the pandemic" by ensuring patient care availability and accessibility. They shared experiences of "communicating compassionate care via eHealth" with suggestions of addressing patients' needs with empathy, adopting a structured protocol to guide eHealth communication, and using more advanced visual-media methods to promote human-to-human interaction. They recommended "setting realistic mutual expectations" considering the limitations of eHealth in handling complex health situations and staffing shortages. Participants considered "low eHealth literacy hinders compassion." Additionally, they recommended the need for "institutional/system-level support to foster compassionate care."

CONCLUSION

Participants recognized the importance of integrating compassion into eHealth services. Promotion of compassionate care requires standardization of eHealth services with institutional and system-level support. This also includes preparing adequate staffing who can communicate compassionate care via eHealth, set realistic expectation, and adjust communication to eHealth literacy level while meeting the needs of their patients.

"Who Takes Care of Carers?": Experiences of Intensive Care Unit Nurses in the Acute Phase of the COVID-19 Pandemic

Introduction: The COVID-19 pandemic caused an international health emergency situation where nursing took on a fundamental role. The high number of patients in hospital ICUs led to a shift in nurses' working conditions and workload. Objective: The objective of this study was to describe the experiences of nurses who worked in ICUs during the acute phase of the COVID-19 pandemic. Methodology: A qualitative, descriptive study was carried out, with the participation of 21 nurses who worked in the ICU during the pandemic. Data collection took place between May and July 2021 through 21 in-depth interviews. Results: Three main themes emerged: (1) COVID-19 in ICUs: nurses on the frontline. (2) United against adversity: teamwork. (3) New optics of critical care and the nursing profession. COVID-19 was perceived with harshness, and the lack of knowledge about the virus generated confusion, anxiety and fear due to the risk of transmission to family members and relatives. The pandemic marked a shift in the management of human, material and economic resources. Novice nurses learned critical care at an accelerated pace, with significant physical and psychological strain. Expert nurses carried the burden of training new nurses. Although there were tense situations, experiencing these adverse situations as a team led to feelings of increased belonging, togetherness and professional bonding for nurses. While the participants noted an increase in motivation to continue in their profession, they also had a feeling of not having been cared for as they deserve by healthcare institutions.

Digital Interventions for Stress Among Frontline Health Care Workers: Results From a Pilot Feasibility Cohort Trial

BACKGROUND

The COVID-19 pandemic has challenged the mental health of health care workers, increasing the rates of stress, moral distress (MD), and moral injury (MI). Virtual reality (VR) is a useful tool for studying MD and MI because it can effectively elicit psychophysiological responses, is customizable, and permits the controlled study of participants in real time.

OBJECTIVE

This study aims to investigate the feasibility of using an intervention comprising a VR scenario and an educational video to examine MD among health care workers during the COVID-19 pandemic and to use our mobile app for longitudinal monitoring of stress, MD, and MI after the intervention.

METHODS

We recruited 15 participants for a compound intervention consisting of a VR scenario followed by an educational video and a repetition of the VR scenario. The scenario portrayed a morally challenging situation related to a shortage of life-saving equipment. Physiological signals and scores of the Moral Injury Outcome Scale (MIOS) and Perceived Stress Scale (PSS) were collected. Participants underwent a debriefing session to provide their impressions of the intervention, and content analysis was performed on the sessions. Participants were also instructed to use a mobile app for 8 weeks after the intervention to monitor stress, MD, and mental health symptoms. We conducted Wilcoxon signed rank tests on the PSS and MIOS scores to investigate whether the VR scenario could induce stress and MD. We also evaluated user experience and the sense of presence after the intervention through semi-open-ended feedback and the Igroup Presence Questionnaire, respectively. Qualitative feedback was summarized and categorized to offer an experiential perspective.

RESULTS

All participants completed the intervention. Mean pre- and postintervention scores were respectively 10.4 (SD 9.9) and 13.5 (SD 9.1) for the MIOS and 17.3 (SD 7.5) and 19.1 (SD 8.1) for the PSS. Statistical analyses revealed no significant pre- to postintervention difference in the MIOS and PSS scores (P=.11 and P=.22, respectively), suggesting that the experiment did not acutely induce significant levels of stress or MD. However, content analysis revealed feelings of guilt, shame, and betrayal, which relate to the experience of MD. On the basis of the Igroup Presence Questionnaire results, the VR scenario achieved an above-average degree of overall presence, spatial presence, and involvement, and slightly below-average realism. Of the 15 participants, 8 (53%) did not answer symptom surveys on the mobile app.

CONCLUSIONS

Our study demonstrated VR to be a feasible method to simulate morally challenging situations and elicit genuine responses associated with MD with high acceptability and tolerability. Future research could better define the efficacy of VR in examining stress, MD, and MI both acutely and in the longer term. An improved participant strategy for mobile data capture is needed for future studies.

TRIAL REGISTRATION

ClinicalTrails.gov NCT05001542; https://clinicaltrials.gov/study/NCT05001542.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/32240.

Moral injury and mental health among health-care workers during the COVID-19 pandemic: meta-analysis

Background: During the COVID-19 pandemic, health-care workers (HCWs) may have been confronted with situations that may culminate in moral injury (MI). MI is the psychological distress that may result from perpetrating or witnessing actions that violate one's moral codes. Literature suggests that MI can be associated with mental health problems.Objective: We aimed to meta-analytically review the literature to investigate whether MI is associated with symptoms of posttraumatic stress disorder (PTSD), anxiety, depression, burnout, and suicidal ideation among active HCWs during the COVID-19 pandemic.Method: We searched eight databases for studies conducted after the onset of the COVID-19 pandemic up to 18 July 2023, and performed random-effects meta-analyses to examine the relationship between MI and various mental health outcomes.Results: We retrieved 33 studies from 13 countries, representing 31,849 individuals, and pooled 79 effect sizes. We found a positive association between MI and all investigated mental health problems (rs = .30-.41, all ps < .0001). Between-studies heterogeneity was significant. A higher percentage of nurses in the samples was associated with a stronger relationship between MI and depressive and anxiety symptoms. Samples with a higher percentage of HCWs providing direct care to patients with COVID-19 exhibited a smaller effect between MI and depressive and anxiety symptoms. We observed a stronger effect between MI and PTSD symptoms in US samples compared to non-US samples.Conclusion: We found that higher MI is moderately associated with symptoms of PTSD, anxiety, depression, burnout, and suicidal ideation among HCWs during the COVID-19 pandemic. Our findings carry limitations due to the array of MI scales employed, several of which were not specifically designed for HCWs, but underscore the need to mitigate the effect of potentially morally injurious events on the mental health of HCWs.

Development of a hybrid point-of-care ultrasound curriculum for first year medical students in a rural medical education program: a pilot study

BACKGROUND

The field of point-of-care ultrasound (POCUS) has advanced in recent decades due to the benefits it holds for medical providers. However, aspiring POCUS practitioners require adequate training. Unfortunately, there remains a paucity of resources to deliver this training, particularly in rural and underserved areas. Despite these barriers, calls for POCUS training in undergraduate medical education are growing, and many medical schools now deliver some form of POCUS education. Our program lacked POCUS training; therefore, we developed and implemented a POCUS curriculum for our first-year medical students.

METHODS

We developed a POCUS curriculum for first year medical students in a rural medically underserved region of the United States. To evaluate our course, we measured learning outcomes, self-reported confidence in a variety of POCUS domains, and gathered feedback on the course with a multi-modal approach: an original written pre- and post-test, survey tool, and semi-structured interview protocol, respectively.

RESULTS

Student (n=24) knowledge of POCUS significantly increased (pre-test average score = 55%, post-test average score = 79%, P<0.0001), and the course was well received based on student survey and interview feedback. In addition, students reported increased confidence toward a variety of knowledge and proficiency domains in POCUS use and their future clinical education and practice.

CONCLUSIONS

Despite a lack of consensus in POCUS education, existing literature describes many curricular designs across institutions. We leveraged a combination of student initiatives, online resources, remote collaborations, local volunteers, and faculty development to bring POCUS to our institution in a rural and medically underserved region. Moreover, we demonstrate positive learning and experiential outcomes that may translate to improved outcomes in students' clinical education and practice. Further research is needed to evaluate the psychomotor skills, broader learning outcomes, and clinical performance of students who take part in our POCUS course.

Treatment of Posttraumatic Stress Disorder: A State-of-the-art Review

This narrative state-of-the-art review paper describes the progress in the understanding and treatment of Posttraumatic Stress Disorder (PTSD). Over the last four decades, the scientific landscape has matured, with many interdisciplinary contributions to understanding its diagnosis, etiology, and epidemiology. Advances in genetics, neurobiology, stress pathophysiology, and brain imaging have made it apparent that chronic PTSD is a systemic disorder with high allostatic load. The current state of PTSD treatment includes a wide variety of pharmacological and psychotherapeutic approaches, of which many are evidence-based. However, the myriad challenges inherent in the disorder, such as individual and systemic barriers to good treatment outcome, comorbidity, emotional dysregulation, suicidality, dissociation, substance use, and trauma-related guilt and shame, often render treatment response suboptimal. These challenges are discussed as drivers for emerging novel treatment approaches, including early interventions in the Golden Hours, pharmacological and psychotherapeutic interventions, medication augmentation interventions, the use of psychedelics, as well as interventions targeting the brain and nervous system. All of this aims to improve symptom relief and clinical outcomes. Finally, a phase orientation to treatment is recognized as a tool to strategize treatment of the disorder, and position interventions in step with the progression of the pathophysiology. Revisions to guidelines and systems of care will be needed to incorporate innovative treatments as evidence emerges and they become mainstream. This generation is well-positioned to address the devastating and often chronic disabling impact of traumatic stress events through holistic, cutting-edge clinical efforts and interdisciplinary research.

Psychotherapy's Role in Evaluating the Invisible Wounds of Moral Injury

Moral injury is a relatively new concept with varying definitions that attempts to define a profound and lasting insult to one's conscience caused by perpetration of or directly witnessing harm to another person in a high-pressure situation. This entity is separate from posttraumatic stress disorder (PTSD), but it can coexist with PTSD. This article provides psychotherapeutic examples of the diagnosis of moral injury from a psychodynamic perspective, focusing on morally challenging situations related to warfare and the healthcare system.

Factors Associated With Healthcare Clinician Stress and Resilience: A Scoping Review

GOAL

Clinician stress and resilience have been the subjects of significant research and interest in the past several decades. We aimed to understand the factors that contribute to clinician stress and resilience in order to appropriately guide potential interventions.

METHODS

We conducted a scoping review (n = 42) of published reviews of research on clinician distress and resilience using the methodology of Peters and colleagues (2020). Our team examined these reviews using the National Academy of Medicine's framework for clinician well-being and resilience.

PRINCIPAL FINDINGS

We found that organizational factors, learning/practice environment, and healthcare responsibilities were three of the top four factors identified in the reviews as contributing to clinician distress. Learning/practice environment and organizational factors were two of the top four factors identified in the reviews as contributing to their resilience.

PRACTICAL APPLICATIONS

Clinicians continue to face numerous external challenges that complicate their work. Further research, practice, and policy changes are indicated to improve practice environments for healthcare clinicians. Healthcare leaders need to promote resources for organizational and system-level changes to improve clinician well-being.

Beyond burnout: Moral suffering among healthcare workers in the first COVID-19 surge

The U.S. is facing a national shortage of healthcare workers, as waves of clinicians quit their jobs or leave the profession entirely. Much of the public discourse around this exodus characterizes it as the result of widespread "burnout." This study draws on in-depth interviews with 22 healthcare workers in New York City to gain deeper understanding of what is leading them to abandon their roles despite the abundant need for their services. It finds that "burnout" in healthcare may be largely explained by moral distress and moral injury inflicted on healthcare workers struggling to care for patients during the COVID-19 pandemic. After presenting a review of the recent literature on moral injury and moral distress, this study lays out five kinds of experiences that emerged during the interviews as the most salient contributors to moral distress, on the one hand, and moral injury, on the other, among healthcare workers. Taken together, these experiences are referred to as "moral suffering." The key finding from this research is that moral suffering, even when undiagnosed and unnamed, affects HCWs' ability to provide care and influences their decisions to leave the healthcare profession. Ultimately, this article suggests a need to rethink the ways in which moral distress and moral injury are applied in social scientific research and concludes by indicating how future research can promote the transformation of networks of injury in healthcare into networks of care.

Moral Injury Among Transplant Providers: Evaluating the Effects of Training in End-of-Life Counseling

Introduction

Ethical issues are pervasive in healthcare, but few specialties rival the moral complexity of transplant medicine. Transplant providers must regularly inform patients that they are no longer eligible to receive a potentially life-saving operation and the stress of these conversations poses a high risk of moral injury. Training in end-of-life counseling (EOLC) has proven to significantly reduce provider stress and burnout. The purpose of this study was to determine whether training in EOLC reduces levels of moral injury among transplant providers.

Methods

This was a mixed methods study. We interviewed 10 patient participants and administered a survey to staff in the solid organ transplant department at the University of Kansas Health System. Respondents indicated whether they had received training in EOLC and completed the standardized Moral Injury Symptom Scale-Healthcare Professionals version (MISS-HP). A two-sample, one-sided t-test compared levels of moral injury between trained and untrained staff. Subsequently, we conducted semi-structured interviews with transplant providers, then performed inductive coding followed by thematic network analysis.

Results

Thirty-seven percent (14/38) of respondents reported a moral injury score at or above the threshold for psychosocial dysfunction associated with moral injury. Analysis revealed no difference in moral injury scores between the trained and untrained groups (p = 0.362, power (1-β) = 0.842). Thematic network analysis demonstrated high-level themes of "challenges", "training", and "stress relief".

Conclusions

Our study demonstrated a concerning prevalence of moral injury among transplant staff and suggested that EOLC training did not significantly mitigate the threat of moral injury.

Exploring the lived experiences of participants and facilitators of an online mindfulness program during COVID-19: a phenomenological study

The coronavirus pandemic (COVID-19) has placed incredible demands on healthcare workers (HCWs) and adversely impacted their well-being. Throughout the pandemic, organizations have sought to implement brief and flexible mental health interventions to better support employees. Few studies have explored HCWs' lived experiences of participating in brief, online mindfulness programming during the pandemic using qualitative methodologies. To address this gap, we conducted semi-structured interviews with HCWs and program facilitators (n = 13) who participated in an online, four-week, mindfulness-based intervention program. The goals of this study were to: (1) understand how participants experienced work during the pandemic; (2) understand how the rapid switch to online life impacted program delivery and how participants experienced the mindfulness program; and (3) describe the role of the mindfulness program in supporting participants' mental health and well-being. We utilized interpretive phenomenological analysis (IPA) to elucidate participants' and facilitators' rich and meaningful lived experiences and identified patterns of experiences through a cross-case analysis. This resulted in four main themes: (1) changing environments; (2) snowball of emotions; (3) connection and disconnection; and (4) striving for resilience. Findings from this study highlight strategies for organizations to create and support wellness programs for HCWs in times of public health crises. These include improving social connection in virtual care settings, providing professional development and technology training for HCWs to adapt to rapid environmental changes, and recognizing the difference between emotions and emotional states in HCWs involved in mindfulness-based programs.

Light Personality Style and Moral Injury Among Chinese Health Professionals

Moral injury has attracted attention widely in various occupations, particularly health professionals. Personality traits involve the professional values in clinical decision-making associated with mental outcomes. The current study examines the relationship between "light personality" style and moral injury. Scores on three subscales of the Light Triad Scale were negatively correlated with the Moral Injury Symptoms Scale-Health Professional. Health professionals more likely to have light personality styles may be less likely to suffer from moral injury under high-stake situations. The findings provide evidence to better understand the inner core of the moral injury, suggesting a potential pathway to improve the moral well-being of health professionals by strengthening key elements of light personality.

Moral Distress and Moral Injury in Pharmacy and Why the Academy Needs to Care

Pharmacists and other pharmacy personnel are experiencing job stress and burnout, and in some instances, suicidal ideation and death by suicide. However, the described lived experiences of pharmacists and other pharmacy personnel are not defined by burnout. Thus, consideration of and research about whether pharmacy personnel are possibly experiencing moral distress or moral injury is necessary and urgent. The pharmacy academy is served by considering workplace conditions and lived experiences of pharmacists because of the potential, negative impact on prospective student recruitment, quality of experiential sites and preceptors, sites for clinical faculty placement, and the well-being of alumni. Understanding phenomena occurring for pharmacy personnel and determining how they impact the pharmacy academy can lend itself to the future development of solutions.

Financial medicine as a source of moral distress: An unrecognised pathway to moral injury in the South African EMS systems

Introduction

The phenomenon of Financial Medicine is a wide spread practice within the South African prehospital domain, which remains poorly researched. Similarly the impact of this phenomenon is not well understood, with many healthcare providers grappling with the moral dilemmas introduced into the work systems through the effects of the practice of Financial Medicine. Persisting, repetitive moral dilemmas can lead to instances of Moral Distress and Moral Injury. The practice of Financial Medicine in the South African prehospital domain proves to introduce many moral dilemmas and subsequently can serve as a source of Moral Distress and Moral Injury.

Methods

This study used a qualitative research methodology in the form of a constructivist grounded theory design. Participants voluntarily consented to be enrolled into one-on-one in-depth interviews, and were selected using purposive and theoretical sampling techniques. Data was subjected to validated coding procedures and analysed using the constant comparative analysis approach, analytical diagramming, and supported by researcher theoretical sensitivity.

Results

The sub-category presented in this study stems from the development of 6 final analytical labels that were abstracted in the process of a theory construction, not presented in this article. This sub-category is nested under 1 of the final analytical labels, and comprised of 3 preliminary analytical labels and an associated code and proposition list.

Conclusion

Understanding the sources of Moral Distress and Moral Injury within the South African prehospital domain are key steps in promoting and supporting the adoption and sustainability of ethical practices. This article presents a key finding that demonstrates a link between the experience of the phenomenon of Financial Medicine and the suffering of a Moral Injury by South African prehospital personnel.

Exploring experiences of moral injury and distress among health care workers during the Covid-19 pandemic

OBJECTIVE

Health care workers have been exposed to a variety of practical and emotional challenges because of the Covid-19 pandemic, leaving them vulnerable to experiencing moral injury and distress. However, there is currently sparse research which directly explores such experiences. This study aimed to explore and characterise the experiences and impacts of moral injury and distress among health care workers during the pandemic.

METHODS

Twenty semi-structured interviews were conducted with health care workers employed across both mental and physical health care services. Interviews were analysed from a critical realist perspective using thematic analysis.

RESULTS

Three key themes were identified: attitudes towards moral injury, experiences of moral injury and consequences of moral injury. Participants appeared to identify with the idea of acting against their morals to varying extents based on their job roles. Participants experienced a range of potentially morally injurious and distressing events throughout the pandemic and many ultimately felt that they provided sub-standard levels of care due to extreme pressures on services. Detrimental impacts upon wellbeing were commonly reported, including high levels of emotional distress and feelings of guilt and shame. Some reported a loss of enthusiasm for their job and a desire to leave the profession entirely.

CONCLUSION

Moral injury and distress presents a real concern for staff wellbeing and retention within the profession. During and beyond the Covid-19 pandemic, there is an urgent need for health care providers to implement wider strategies to target moral injury and distress, and support staff within health care settings.

Moral Distress, Moral Resilience, Moral Courage, and Moral Injury Among Nurses in the Philippines During the COVID-19 Pandemic: A Mediation Analysis

Investigations about moral resilience and moral courage as mediators between moral distress and moral injury remain underreported among nurses during the COVID-19 pandemic. Nurses (n = 412) from the Philippines were conveniently recruited via social media platforms and completed four self-report scales. The mediation model depicts that moral distress negatively impacts moral resilience and moral courage while positively affecting moral injury. Moral resilience and moral courage negatively impact moral injury, whereas moral resilience directly impacts moral courage. Finally, moral resilience and moral courage demonstrated a mediating effect between moral distress and moral injury. Findings indicate that healthcare organizations and nurse managers should nurture morally resilient and courageous therapeutic practices among frontline healthcare professionals to mitigate the negative effects of moral distress and moral injury.

Understanding Moral Injury in Frontline Health Care Professionals 2 Years After the Onset of COVID-19

ABSTRACT

Throughout the COVID-19 pandemic, health care professionals have worked in morally challenging situations. The aim of this research was to investigate the predictors of moral injury in United Kingdom frontline health care professionals working in a variety of roles 2 years after the onset of the pandemic. A cross-sectional survey was conducted January 25-February 28, 2022. A total of 235 participants answered sociodemographic, employment, health, COVID-19-related questions, and the 10-item Moral Injury Symptom Scale-Healthcare Professional version. Nearly three quarters had experienced moral injury. Twelve significant predictors of moral injury were entered into a backward elimination binominal logistic regression. The final model included five independent predictors that explained 25.4% variance in moral injury (χ 2 [5, N = 235] = 45.7, p < 0.001). Odds of moral injury were significantly raised in young health care professionals (<31 years), smokers, and those reporting low workplace confidence, not feeling appreciated, and feeling burned out. The findings support interventions to relieve moral injury in frontline health care professionals.

Moral injury and its mental health consequences among protesters: findings from Israel's civil protest against the government's judicial reform

Background: Government actions and participating in protracted-duration protests against it affect protesters' mental health, leading to high distress levels, such as posttraumatic and depressive symptoms. Aside from exposure to violence and other issues, protest participation can pose unique challenges to the protesters as they may be exposed to potentially morally injurious events (PMIEs), such as the betrayal of leaders they once trusted. This study's primary objective was to examine the extent of psychological difficulties among civilians participating in long-duration protests in Israel. More specifically, the study aimed to understand the contribution of exposure to protest-related PMIEs to psychological difficulties such as posttraumatic and depressive symptoms.Method: Participants comprised 4036 Israelis who were actively involved in the unfolding civil protest movement against the government-led judicial overhaul between January 2023 and August 2023. The protesters completed validated self-report questionnaires that included measures of PMIE exposure, PTSD and depressive symptoms.Results: About half (44.3%) of the sample met the criteria for self-report diagnosis of major depression and 10.6% for PTSD. Most of the protesters indicated their exposure to at least one moral injury event, with 63.9% reporting exposure to PMIE-Betrayal. Protesters exposed to PMIEs reported significantly higher levels of both PTSD and depression than non-PMIE-exposed protesters. Hierarchical regression analyses revealed that, beyond demographics and protest-related characteristics such as exposure to violence, PMIE dimensions significantly contributed to both PTSD and depression levels.Conclusions: The findings highlight the mental burden of protesters during the civil protests against the judicial overhaul in Israel. More central to the present research, the findings highlight the critical contribution of PMIEs exposure to this burden. Clinicians treating protesters coping with depression and PTSD following the civil actions should attend to their exposure to PMIEs, which may relate to the deleterious psychological effects among protesters.

Bringing mental health to the frontlines: A proactive team-based model for healthcare workers during the COVID-19 pandemic

OBJECTIVE

A novel team-based service was developed at the beginning of the pandemic in which sixty liaisons were assigned to provide proactive, tailored psychological support for healthcare workers (HCWs) across three of NewYork-Presbyterian's Weill Cornell affiliated hospitals.

METHOD

The program took the proactive approach of bringing mental health awareness to every department and major division that interfaced with COVID-19 patients. Virtual and in-person team-based "town hall" meetings were offered to provide psychoeducation, facilitate discussion, foster adaptive coping and social cohesion, and identify employees who would benefit from further individualized support.

RESULTS

The program's success was reflected in the number of town halls (1000+) and attendees (6000+) and in qualitative feedback from departments who requested ongoing services.

CONCLUSIONS

This article presents the development, implementation, challenges, and opportunities in designing a team-based support model for HCWs. This model may be useful for organizations that seek to develop similar programs.

Examining moral injury in clinical practice: A narrative literature review

Healthcare workers experience moral injury (MI), a violation of their moral code due to circumstances beyond their control. MI threatens the healthcare workforce in all settings and leads to medical errors, depression/anxiety, and personal and occupational dysfunction, significantly affecting job satisfaction and retention. This article aims to differentiate concepts and define causes surrounding MI in healthcare. A narrative literature review was performed using SCOPUS, CINAHL, and PubMed for peer-reviewed journal articles published in English between 2017 and 2023. Search terms included "moral injury" and "moral distress," identifying 249 records. While individual risk factors predispose healthcare workers to MI, root causes stem from healthcare systems. Accumulation of moral stressors and potentially morally injurious events (PMIEs) (from administrative burden, institutional betrayal, lack of autonomy, corporatization of healthcare, and inadequate resources) result in MI. Individuals with MI develop moral resilience or residue, leading to burnout, job abandonment, and post-traumatic stress. Healthcare institutions should focus on administrative and climate interventions to prevent and address MI. Management should ensure autonomy, provide tangible support, reduce administrative burden, advocate for diversity of clinical healthcare roles in positions of interdisciplinary leadership, and communicate effectively. Strategies also exist for individuals to increase moral resilience, reducing the impact of moral stressors and PMIEs.

[The second victim phenomenon-What personnel in anesthesiology should know about it]

Adverse events can occur at any time during medical treatment of patients. These adverse events not only negatively impact patients but also the medical personnel involved. The impairment of medical personnel after an adverse event is known as the second victim phenomenon (SVP). Although the concept of second victims is relatively unknown, the chances to become a second victim during the course of one's professional carrier are high. Effective measures to support second victims are peer support programs within medical institutions, which also benefit economically from the implementation of these programs. Supporting second victims is also beneficial to future patients and finally healthcare systems as a whole.