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Delgado-Ron JA, Tiwana MH, Murage A, Morgan R, Purewal S, Smith J. Moral distress, coping mechanisms, and turnover intent among healthcare providers in British Columbia: a race and gender-based analysis. BMC Health Serv Res 2024; 24:925. [PMID: 39138558 PMCID: PMC11321194 DOI: 10.1186/s12913-024-11377-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 07/30/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND This study explores intersectionality in moral distress and turnover intention among healthcare workers (HCWs) in British Columbia, focusing on race and gender dynamics. It addresses gaps in research on how these factors affect healthcare workforce composition and experiences. METHODS Our cross-sectional observational study utilized a structured online survey. Participants included doctors, nurses, and in-home/community care providers. The survey measured moral distress using established scales, assessed coping mechanisms, and evaluated turnover intentions. Statistical analysis examined the relationships between race, gender, moral distress, and turnover intention, focusing on identifying disparities across different healthcare roles. Complex interactions were examined through Classification and Regression Trees. RESULTS Racialized and gender minority groups faced higher levels of moral distress. Profession played a significant role in these experiences. White women reported a higher intention to leave due to moral distress compared to other groups, especially white men. Nurses and care providers experienced higher moral distress and turnover intentions than physicians. Furthermore, coping strategies varied across different racial and gender identities. CONCLUSION Targeted interventions are required to mitigate moral distress and reduce turnover, especially among healthcare workers facing intersectional inequities.
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Affiliation(s)
- Jorge Andrés Delgado-Ron
- Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
| | - Muhammad Haaris Tiwana
- Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
| | - Alice Murage
- Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
| | - Rosemary Morgan
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, 615 N Wolfe St Suite E8527, Baltimore, Baltimore, MD, 21205, USA
| | - Simran Purewal
- Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
| | - Julia Smith
- Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada.
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Beadle ES, Walecka A, Sangam AV, Moorhouse J, Winter M, Munro Wild H, Trivedi D, Casarin A. Triggers and factors associated with moral distress and moral injury in health and social care workers: A systematic review of qualitative studies. PLoS One 2024; 19:e0303013. [PMID: 38935754 PMCID: PMC11210881 DOI: 10.1371/journal.pone.0303013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 04/17/2024] [Indexed: 06/29/2024] Open
Abstract
OBJECTIVE At some point in their career, many healthcare workers will experience psychological distress associated with being unable to take morally or ethically correct action, as it aligns with their own values; a phenomenon known as moral distress. Similarly, there are increasing reports of healthcare workers experiencing long-term mental and psychological pain, alongside internal dissonance, known as moral injury. This review examined the triggers and factors associated with moral distress and injury in Health and Social Care Workers (HSCW) employed across a range of clinical settings with the aim of understanding how to mitigate the effects of moral distress and identify potential preventative interventions. METHODS A systematic review was conducted and reported according to recommendations from Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches were conducted and updated regularly until January 2024 on 2 main databases (CENTRAL, PubMed) and three specialist databases (Scopus, CINAHL, PsycArticles), alongside hand searches of study registration databases and other systematic reviews reference lists. Eligible studies included a HSCW sample, explored moral distress/injury as a main aim, and were written in English or Italian. Verbatim quotes were extracted, and article quality was assessed via the CASP toolkit. Thematic analysis was conducted to identify patterns and arrange codes into themes. Specific factors like culture and diversity were explored, and the effects of exceptional circumstances like the pandemic. RESULTS Fifty-one reports of 49 studies were included in the review. Causes and triggers were categorised under three domains: individual, social, and organisational. At the individual level, patients' care options, professionals' beliefs, locus of control, task planning, and the ability to make decisions based on experience, were indicated as elements that can cause or trigger moral distress. In addition, and relevant to the CoVID-19 pandemic, was use/access to personal protection resources. The social or relational factors were linked to the responsibility for advocating for and communication with patients and families, and professionals own support network. At organisational levels, hierarchy, regulations, support, workload, culture, and resources (staff and equipment) were identified as elements that can affect professionals' moral comfort. Patients' care, morals/beliefs/standards, advocacy role and culture of context were the most referenced elements. Data on cultural differences and diversity were not sufficient to make assumptions. Lack of resources and rapid policy changes have emerged as key triggers related to the pandemic. This suggests that those responsible for policy decisions should be mindful of the potential impact on staff of sudden and top-down change. CONCLUSION This review indicates that causes and triggers of moral injury are multifactorial and largely influenced by the context and constraints within which professionals work. Moral distress is linked to the duty and responsibility of care, and professionals' disposition to prioritise the wellbeing of patients. If the organisational values and regulations are in contrast with individuals' beliefs, repercussions on professionals' wellbeing and retention are to be expected. Organisational strategies to mitigate against moral distress, or the longer-term sequalae of moral injury, should address the individual, social, and organisational elements identified in this review.
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Affiliation(s)
- Emily S. Beadle
- Department of Psychology, Sport and Geography, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | | | - Amy V. Sangam
- Intensive Care Unit, Royal Free Hospital, London, United Kingdom
| | | | - Matthew Winter
- Department of Psychology, Sport and Geography, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Helen Munro Wild
- Department of Psychology, Sport and Geography, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Daksha Trivedi
- Centre for Research in Public Health and Community Care, School of Health and Social Work, The University of Hertfordshire, Hatfield, United Kingdom
| | - Annalisa Casarin
- Department of Psychology, Sport and Geography, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
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Lebold M. Exploring feminist political economy and feminist critical discourse analysis as methodologies in critical nursing research. J Adv Nurs 2024; 80:958-970. [PMID: 37811676 DOI: 10.1111/jan.15875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/03/2023] [Accepted: 09/05/2023] [Indexed: 10/10/2023]
Abstract
AIMS This paper explores two critical feminist methodologies for nursing research: feminist political economy and feminist critical discourse analysis. The aim was to appreciate varied methodological approaches available for nurses to understand complexities in healthcare environments, above and beyond socially normative ways of knowing. DESIGN Discursive paper. DATA SOURCES Published articles from nursing databases (CINAHL and ProQuest; no date restrictions) and interdisciplinary databases (Women's Studies International, Sociological Abstracts and Ovid MEDLINE; publication dates between 2017 and 2022). METHODS A discursive paper exploring and critically synthesizing the literature on feminist political economy and feminist critical discourse analysis to demonstrate how each methodological approach can be used in nursing. RESULTS The findings of this discursive paper suggest there is an opportunity to draw on interdisciplinary studies for creative insights into how these methodologies may be helpful for nurses' scholarship and programmes of research. Although few nursing studies explicitly name a feminist political economy or feminist critical discourse analysis approach, several studies apply principles of these methodological approaches. CONCLUSION There is an opportunity for these methodologies to be applied within the same project when there is a fit between the research questions and aims of both methodologies (studies where notions of gender and power are considered central and there are potential insights from exploring social progress, structures and the material, along with the social relations of discourses). IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE Feminist political economy and feminist critical discourse analysis offer novel options for methodological analyses. IMPACT Application of these methodologies may benefit critical nursing scholars looking for diverse critical methodological avenues to explore and to broaden nursing's methodological toolbox towards meeting social justice aims. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution.
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Affiliation(s)
- Margaret Lebold
- School of Nursing, York University, Toronto, Ontario, Canada
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Jaarsma P. Two cases of nursing older nursing home residents during COVID-19. Nurs Ethics 2024; 31:256-267. [PMID: 37597000 PMCID: PMC11181722 DOI: 10.1177/09697330231185944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/21/2023]
Abstract
INTRODUCTION Two ethical challenges of nursing home nurses during the COVID-19 pandemic in Sweden are discussed in this paper. BACKGROUND Historically, the nurse's primary concern is for the person who is ill, which is the core of nurses' moral responsibility and identity. In Sweden, person-centered care is generally deemed important in nursing older nursing home residents. OBJECTIVE To chart moral responsibilities of nursing home nurses in two cases involving older residents during the COVID-19 pandemic in Sweden. METHODS We used Margaret Urban Walker's framework for moral responsibilities and the International Council of Nurses (ICN) code of ethics for nurses (2021) for our normative analysis. ETHICAL CONSIDERATIONS Written and verbal consent was obtained before the interviews, and information was given that participation was entirely voluntary and possible to cancel at any time before the work was published. The Swedish Ethical Review Agency gave an advisory opinion stating that there were no ethical objections to this research project (Dnr. 2020-05649). FINDINGS Case #1: a palliative older nursing home resident who was coercively tested for COVID-19, and case #2: a COVID-19-infected resident with dementia who was isolated using sedation. The decision that was finally made in the respective case was analyzed in the light of either consequentialist/utilitarian or non-consequentialist/deontological reasons. DISCUSSION Empowerment of nurses as moral agents is required for the application of practical wisdom in the balancing of different care relationships (responsibilities), moral identities (professional virtues), and competing moral values. This requires resources and opens possibilities for profound ethical reflection in nursing education and at work. CONCLUSION During the COVID-19 pandemic, the moral and professional responsibility of nursing home nurses to deliver person-centered care was sometimes problematically abandoned in favor of a more utilitarian manner of ethical decision-making.
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Affiliation(s)
- Pier Jaarsma
- Department of Health, Medicine and Caring Sciences, Linköping University, Sweden
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Phillips G, Kendino M, Brolan CE, Herron LM, Kὃrver S, Motofaga S, Cox M. Women on the frontline: exploring the gendered experience for Pacific healthcare workers during the COVID-19 pandemic. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 42:100961. [PMID: 38022711 PMCID: PMC10658397 DOI: 10.1016/j.lanwpc.2023.100961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/24/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023]
Abstract
Background Women comprise 90% of patient-facing global healthcare workers (HCWs), yet remain underpaid, undervalued, and under-represented in leadership and decision-making positions, particularly across the Pacific region. The COVID-19 pandemic has exacerbated these health workplace inequalities. We sought to understand Pacific women HCWs experience from the COVID-19 frontline to contribute to policies aimed at addressing gendered gaps in regional health systems. Methods Our interpretative phenomenological study used critical feminist and social theory, and a gendered health systems analytical framework. Data were collected using online focus groups and in-depth interviews with 36 Pacific regional participants between March 2020 and July 2021. Gender-specific content and women's voices were privileged for inductive analysis by Pacific and Australian women researchers with COVID-19 frontline lived experience. Findings Pacific women HCWs have authority and responsibility resulting from their familial, biological, and cultural status, but are often subordinate to men. They were emancipatory leaders during COVID-19, and as HCWs demonstrated compassion, situational awareness, and concern for staff welfare. Pacific women HCWs also faced ethical challenges to prioritise family or work responsibilities, safely negotiate childbearing, and maintain economic security. Interpretation Despite enhanced gendered power differentials during COVID-19, Pacific women HCWs used their symbolic capital to positively influence health system performance. Gender-transformative policies are urgently required to address disproportionate clinical and community care burdens and to protect and support the Pacific female health workforce. Funding Epidemic Ethics/World Health Organization (WHO), Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding: Australasian College for Emergency Medicine Foundation, International Development Fund Grant.
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Affiliation(s)
- Georgina Phillips
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Emergency Department, St Vincent's Hospital Melbourne, Melbourne, Australia
| | | | - Claire E. Brolan
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Lisa-Maree Herron
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Sarah Kὃrver
- TB Elimination, and Implementation Science, Burnet Institute, Papua New Guinea and Australia
| | - Silina Motofaga
- Clinical Services Program, Public Health Division, Pacific Community, Suva, Fiji
| | - Megan Cox
- Faculty of Medicine and Health, The University of Sydney, Australia
- The Sutherland Hospital, NSW, Australia
- NSW Ambulance, Sydney, Australia
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Smith J, Tiwana MH, Samji H, Morgan R, Purewal S, Delgado-Ron JA. An Intersectional Analysis of Moral Distress and Intention to Leave Employment Among Long-Term Care Providers in British Columbia. J Aging Health 2023:8982643231212981. [PMID: 37943505 DOI: 10.1177/08982643231212981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
Objectives: In this study, we aimed to explore the relationship between intersectional inequities and moral distress among those working in Long-Term Care (LTC) in British Columbia, Canada. Methods: This was a cross-sectional and retrospective study. We assessed moral distress, of 1678 respondents, using a modified Moral Distress Scale, and an equivalent distress mitigation score, at the intersections of gender and racial/ethnic identity. Then, we explored which worker attributes were more predictive of intention to leave work. Results: We found notable difference in experiences of moral distress across intersecting identities, including high moral distress scores among Indigenous men and women, and white women. Significant differences in mitigation scores were also found by intersectional identities. Discussion: Moral distress was the most important predictor of intention to leave work. The differences across racial and gender identity groups suggest the need for tailored interventions to address moral distress among LTC providers.
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Affiliation(s)
- Julia Smith
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | | | - Hasina Samji
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Rosemary Morgan
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Simran Purewal
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
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Fino E, Daniels JK, Micheli G, Gazineo D, Godino L, Imbriaco G, Antognoli M, Sist L, Regnano D, Decaro R, Guberti M, Mazzetti M. Moral injury in a global health emergency: a validation study of the Italian version of the Moral Injury Events Scale adjusted to the healthcare setting. Eur J Psychotraumatol 2023; 14:2263316. [PMID: 37815082 PMCID: PMC10566389 DOI: 10.1080/20008066.2023.2263316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/11/2023] [Indexed: 10/11/2023] Open
Abstract
Background: When exposed to events that transgress one's moral beliefs, a plethora of negative consequences may follow, which are captured by the concept of moral injury (MI). Despite its relevance to experiences of healthcare workers during a global health emergency, there is lack of validated MI instruments adapted to the healthcare setting.Objective: The present study aims to provide a validation of the Italian version of the Moral Injury Events Scale (MIES) adjusted to the healthcare setting by assessing its factor structure, internal consistency and construct validity.Methods: A sample of 794 healthcare workers (46% nurses, 51% female) engaged in hospital facilities during the COVID-19 pandemic in Italy completed measures of MI, PTSD, anxiety, depression, burnout, meaning in life and positive affect.Results: Using an exploratory structural equation modelling (ESEM) we assessed the scale factor structure for the entire sample and separately for nurse professional and female healthcare worker groups. Findings support a three-factor solution: Factor 1 'perceived transgressions by others'; Factor 2 'perceived transgressions by self'; and Factor 3 'perceived betrayals by others'. Findings also indicate some level of convergence with measures of PTSD, anxiety, depression and burnout.Conclusion: Results suggest that the MIES may be useful in capturing unique experiences of moral injury amongst healthcare workers engaged in a global health emergency. The low range correlations with measures of psychological distress might potentially indicate that MI, which captures cognitive value judgements rather than manifest symptomatology, may uniquely explain a certain amount of variance. Implications for the development of new empirically derived and theoretical guided tools are discussed, highlighting the need for future research to examine the role of individualising and social binding moral principles in gaining a more nuanced understanding of moral injury experiences amongst healthcare professionals across different socio-cultural settings.
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Affiliation(s)
- Edita Fino
- Department of Psychology “Renzo Cannestrari”, Alma Mater Studiorum - Università di Bologna, Bologna, Italy
| | - Judith K. Daniels
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, the Netherlands
| | - Giulia Micheli
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, the Netherlands
| | - Domenica Gazineo
- Governo Clinico e Qualità, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Lea Godino
- Medical Genetics Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Guglielmo Imbriaco
- UO Centrale Operativa 118 Emilia Est, Ospedale ‘Maggiore’, Bologna, Italy
| | | | - Luisa Sist
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum - Università di Bologna, Bologna, Italy
| | - Domenico Regnano
- Team accessi vascolari, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Roberta Decaro
- UO Deg. Percorso fegato e vie biliari/Medicina interna trattamento gravi insufficienze d’organo/TI post-operatoria/TI trapianti, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Michela Mazzetti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - Università di Bologna, Bologna, Italy
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