Association of Moral Distress with Anxiety, Depression, and an Intention to Leave among Nurses Working in Intensive Care Units during the COVID-19 Pandemic

Depicting occupational trauma concepts impacting nurse well-being during the COVID-19 pandemic

PURPOSE

The purpose of this concept delineation was to differentiate similar concepts impacting nurse well-being during the COVID-19 pandemic, including: compassion fatigue, burnout, moral injury, secondary traumatic stress, and second victim.

METHODS

A total of 63 articles were reviewed for concept delineation. Morse's (1995) approach to concept delineation was utilized to analyse the articles.

RESULTS

Concepts were described interchangeably but were found to present themselves in a sequence. A nurse may experience moral injury, leading to a second victim experience, synonymous with secondary traumatic stress, then compassion fatigue and/or burnout that can be acute or chronic in nature. An Occupational Trauma Conceptual Model was created to depict how these concepts interact based on concept delineation findings.

CONCLUSION

Nurses are experiencing long-lasting occupational trauma and future intervention research should centre on optimizing nurse well-being to ensure the sustainability of nursing profession.

Why Are Healthcare Providers Leaving Their Jobs? A Convergent Mixed-Methods Investigation of Turnover Intention among Canadian Healthcare Providers during the COVID-19 Pandemic

BACKGROUND

Staffing shortages across the healthcare sector pose a threat to the continuity of the Canadian healthcare system in the post-COVID-19 pandemic era. We sought to understand factors associated with turnover intention as well as Canadian healthcare providers' (HCPs) perspectives and experiences with turnover intention as related to both organizational and professional turnover.

METHOD

A convergent questionnaire mixed-methods design was employed. Descriptive statistics and ordinal logistic regressions were used to analyze quantitative data and ascertain factors associated with turnover intention. Thematic analysis was used to analyze qualitative open-field textbox data and understand HCPs' perspectives and experiences with turnover intention.

RESULTS

Quantitative analyses revealed that 78.6% of HCPs surveyed (N = 398) reported at least a 25% turnover likelihood regarding their organization, with 67.5% reporting at least a 25% turnover likelihood regarding their profession. Whereas regression models revealed the significant impact of years worked, burnout, and organizational support on turnover likelihood for organizations, age, sex, burnout, and organizational support contributed to the likelihood of leaving a profession. Patterns of meaning drawn from participants' qualitative responses were organized according to the following four themes: (1) Content to stay, (2) Drowning and no one cares, (3) Moral stressors, and (4) Wrestling with the costs and benefits.

CONCLUSIONS

Many HCPs described weighing the costs and benefits of leaving their organization or profession during the COVID-19 pandemic. Although challenging working conditions, moral stressors, and burnout may play a significant role in HCPs' experiences of turnover intention, there is ample room to intervene with organizational support.

Moral distress among critical care nurses before and during the COVID-19 pandemic: A systematic review

Moral distress has emerged as a significant concern for critical care nurses, particularly due to the complex and demanding care provided to critically ill patients in critical care units. The ongoing COVID-19 pandemic has introduced new ethical challenges and changes in clinical practice, further exacerbating the experience of moral distress among these nurses. This systematic review compares the factors influencing moral distress among critical care nurses before and during the COVID-19 pandemic to gain a comprehensive understanding of the impact of the pandemic on moral distress. For this systematic review, PubMed, Scopus, ProQuest, Web of Science, medRxiv, bioRxiv, Embase, and Google Scholar were all utilized in the search. The search covered articles published from 2012 to December 2022, encompassing a 10-year timeframe to capture relevant research on moral distress among critical care nurses. In total, 52 articles were included in this systematic review. The findings indicate that personal, caring-related, and organizational factors can influence nurses' moral distress. Before the pandemic, factors including futile and end-of-life care, conflicts with physicians, nurse performance and authority, poor teamwork, decision-making regarding treatment processes and patient care, limited human resources and equipment, medical errors, patient restraints, and nurses' age and work experience affect critical care nurses' moral distress. Similarly, during the COVID-19 pandemic, factors contributing to moral distress include futile and end-of-life care, fear of contracting and spreading COVID-19, decision-making about treatment processes, poor teamwork, and being female. This study revealed that the factors contributing to moral distress were approximately similar in both periods. Futile care and end-of-life issues were critical care nurses' primary causes of moral distress. Implementing prevention strategies and reducing these underlying factors could decrease this major issue and improve the quality of care.

Determinants of intention to leave among nurses and physicians in a hospital setting during the COVID-19 pandemic: A systematic review and meta-analysis

BACKGROUND

The global outbreak of COVID-19 has brought to light the profound impact that large-scale disease outbreaks can have on healthcare systems and the dedicated professionals who serve within them. It becomes increasingly important to explore strategies for retaining nurses and physicians within hospital settings during such challenging times. This paper aims to investigate the determinants of retention among nurses and physicians during the COVID-19 pandemic.

METHOD

A systematic review of other potential determinants impacting retention rates during the pandemic was carried out. Secondly, a meta-analysis on the prevalence of intention to leave for nurses and physicians during the COVID-19 pandemic.

FINDINGS

A comprehensive search was performed within four electronic databases on March 17 2023. Fifty-five papers were included in the systematic review, whereas thirty-three papers fulfilled the eligibility criteria for the meta-analysis. The systematic review resulted in six themes of determinants impacting intention to leave: personal characteristics, job demands, employment services, working conditions, work relationships, and organisational culture. The main determinants impacting the intention to leave are the fear of COVID-19, age, experience, burnout symptoms and support. Meta-analysis showed a prevalence of intent to leave the current job of 38% for nurses (95% CI: 26%-51%) and 29% for physicians (95% CI: 21%-39%), whereas intention to leave the profession for nurses 28% (95% CI: 21%-34%) and 24% for physicians (95% CI: 23%-25%).

CONCLUSION

The findings of this paper showed the critical need for hospital managers to address the concerning increase in nurses' and physicians' intentions to leave during the COVID-19 pandemic. This intention to leave is affected by a complex conjunction of multiple determinants, including the fear of COVID-19 and the confidence in and availability of personal protective equipment. Moreover, individual factors like age, experience, burnout symptoms, and support are maintained in this review. Understanding the influence of determinants on retention during the COVID-19 pandemic offers an opportunity to formulate prospective strategies for retaining nurses and physicians within hospital settings.

Exploring the role of personality, perfectionism, and self-compassion on the relationship between clinical decision-making and nurses' wellbeing

BACKGROUND

Clinical decision-making is a core competency of the nursing role, with nurses having to make decisions surrounding patient care and patient safety daily. With decision-making being linked to psychological outcomes, it is important to consider potential areas that may support or hinder nurses' wellbeing whilst navigating clinical decisions.

AIM

The present study sought to investigate the relationship between clinical decision-making and moral distress, and further explore the role of personality, perfectionism, philotimo (a virtue describing the desire to do right by oneself and others, aligning with one's sense of morality), and self-compassion.

DESIGN

An online cross-sectional survey was conducted using Qualtrics. Associations between clinical decision-making and moral distress, burnout, personality, perfectionism, philotimo, and self-compassion were examined using univariate and multivariate statistics.

METHODS

One hundred and forty-three nurses from the United Kingdom completed an online questionnaire. Eligibility criteria included individuals who had practised in the nursing profession for a minimum of six months. To ensure that all participants were practising across the United Kingdom, the eligibility criteria was made clear in the study advertisement, and the consent form. The consent form required participants to confirm that they reached these criteria to proceed with the study.

RESULTS

Results revealed that clinical decision-making was associated with moral distress experience, and that both openness to experience, and philotimo mediated this relationship, independently. In addition to this, self-compassion was significantly associated with clinical decision-making across senior banded nursing roles, but this was non-significant for junior banded nursing roles.

CONCLUSION

Findings highlight the role of individual differences when looking at the impact of clinical decision-making upon nurses' wellbeing and offers explanation for any variance in moral distress experience across nursing professionals. This research identifies fundamental differences between junior and senior nurses in relation to clinical decision-making and self-compassion that should be considered in future research.

Exposure to moral stressors and associated outcomes in healthcare workers: prevalence, correlates, and impact on job attrition

Introduction: Healthcare workers (HCWs) often experience morally challenging situations in their workplaces that may contribute to job turnover and compromised well-being. This study aimed to characterize the nature and frequency of moral stressors experienced by HCWs during the COVID-19 pandemic, examine their influence on psychosocial-spiritual factors, and capture the impact of such factors and related moral stressors on HCWs' self-reported job attrition intentions.Methods: A sample of 1204 Canadian HCWs were included in the analysis through a web-based survey platform whereby work-related factors (e.g. years spent working as HCW, providing care to COVID-19 patients), moral distress (captured by MMD-HP), moral injury (captured by MIOS), mental health symptomatology, and job turnover due to moral distress were assessed.Results: Moral stressors with the highest reported frequency and distress ratings included patient care requirements that exceeded the capacity HCWs felt safe/comfortable managing, reported lack of resource availability, and belief that administration was not addressing issues that compromised patient care. Participants who considered leaving their jobs (44%; N = 517) demonstrated greater moral distress and injury scores. Logistic regression highlighted burnout (AOR = 1.59; p < .001), moral distress (AOR = 1.83; p < .001), and moral injury due to trust violation (AOR = 1.30; p = .022) as significant predictors of the intention to leave one's job.Conclusion: While it is impossible to fully eliminate moral stressors from healthcare, especially during exceptional and critical scenarios like a global pandemic, it is crucial to recognize the detrimental impacts on HCWs. This underscores the urgent need for additional research to identify protective factors that can mitigate the impact of these stressors.

Moral Distress and Intention to Leave During COVID: A Cross-sectional Study on the Current Nursing Workforce to Guide Nurse Leaders for the Future

OBJECTIVE

The aim of this study was to investigate how the experience of caring for COVID-19 patients, nurses' moral distress, and the current practice environment impact nurses' intention to leave.

BACKGROUND

Caring for COVID-19 patients has been associated with an increase in nurses' moral distress and an increase in nurses' turnover. To date, research has focused on nurses' moral distress, the practice environment, and intentions to leave during the pandemic's peak. The current workplace climate, including those who stayed in their positions, has not been adequately assessed.

METHODS

This cross-sectional correlational study was conducted in a Magnet® hospital.

RESULTS

Moral distress related to team/system (B = 0.64, t = 3.86, P < 0.001), nurses' participation in hospital affairs (B = -2.21, t = -3.52, P < 0.001), and staffing (B = -1.91, t = -5.48, P < 0.001) are strongest predictors for nurses' intention to leave postpandemic.

CONCLUSIONS

Nurses in practice still report experiencing COVID-related moral distress; however; issues related to resources and staffing have the most substantial impact on intention to leave among the current nursing workforce.

Moral Resilience Reduces Levels of Quiet Quitting, Job Burnout, and Turnover Intention among Nurses: Evidence in the Post COVID-19 Era

The aim of the study was to examine the impact of moral resilience on quiet quitting, job burnout, and turnover intention among nurses. A cross-sectional study was implemented in Greece in November 2023. The revised Rushton Moral Resilience Scale was used to measure moral resilience among nurses, the Quiet Quitting Scale to measure levels of quiet quitting, and the single-item burnout measure to measure job burnout. Moreover, a valid six-point Likert scale was used to measure turnover intention. All multivariable models were adjusted for the following confounders: gender, age, understaffed department, shift work, and work experience. The multivariable analysis identified a negative relationship between moral resilience and quiet quitting, job burnout, and turnover intention. In particular, we found that increased response to moral adversity and increased moral efficacy were associated with decreased detachment score, lack of initiative score, and lack of motivation score. Additionally, personal integrity was associated with reduced detachment score, while relational integrity was associated with reduced detachment score, and lack of initiative score. Moreover, response to moral adversity was associated with reduced job burnout. Also, increased levels of response to moral adversity were associated with lower probability of turnover intention. Moral resilience can be an essential protective factor against high levels of quiet quitting, job burnout, and turnover intention among nurses. This study was not registered.

Canadian respiratory therapists who considered leaving their clinical position experienced elevated moral distress and adverse psychological and functional outcomes during the COVID-19 pandemic

INTRODUCTION

Respiratory therapists (RTs) faced morally distressing situations throughout the COVID-19 pandemic, including working with limited resources and facilitating video calls for families of dying patients. Moral distress is associated with a host of adverse psychological and functional outcomes (e.g. depression, anxiety, symptoms of posttraumatic stress disorder [PTSD] and functional impairment) and consideration of position departure. The purpose of this study was to understand the impact of moral distress and its associated psychological and functional outcomes on consideration to leave a clinical position among Canadian RTs during the COVID-19 pandemic.

METHODS

Canadian RTs (N = 213) completed an online survey between February and June 2021. Basic demographic information (e.g. age, sex, gender) and psychometrically validated measures of moral distress, depression, anxiety, stress, PTSD, dissociation, functional impairment, resilience and adverse childhood experiences were collected.

RESULTS

One in four RTs reported considering leaving their position. RTs considering leaving reported elevated levels of moral distress and adverse psychological and functional outcomes compared to RTs not considering leaving. Over half (54.5%) of those considering leaving scored above the cut-off for potential diagnosis of PTSD. Previous consideration to leave a position and having left a position in the past each significantly increased the odds of currently considering leaving, along with system-related moral distress and symptoms of PTSD, but the contribution of these latter factors was small.

CONCLUSIONS

Canadian RTs considering leaving their position reported elevated levels of distress and adverse psychological and functional outcomes, yet these individual-level factors appear unlikely to be the primary factors underlying RTs' consideration to leave, because their effects were small. Further research is required to identify broader, organizational factors that may contribute to consideration of position departure among Canadian RTs.

Levels of burnout and exposure to ethical conflict and assessment of the practice environment in nursing professionals of intensive care

BACKGROUND

Nursing professionals working in Intensive Care Units (ICU) are at high risk of developing negative emotional responses as well as emotional and spiritual problems related to ethical issues. The design of effective strategies that improve these aspects is determined by knowing the levels of burnout and ethical conflict of these professionals, as well as the influence that the practice environment might have on them.

OBJECTIVES

To analyze the relationship between levels of burnout, the exposure to ethical conflicts and the perception of the practice environment among themselves and with sociodemographic variables of the different intensive care nursing professionals.

METHODS

Descriptive, correlational, cross-sectional, observational study in an ICU of a tertiary level university hospital. The level of burnout was evaluated with the Maslach Burnout Inventory Human Services Survey scale; the level of ethical conflict with the Ethical Conflict Questionnaire for Nurses and the perception of the environment with the Practice Environment Scale of the Nursing Work Index. Descriptive and inferential statistics were performed. The association between categorical variables was analyzed using Fisher's exact chi-square test (χ2) RESULTS: 31 nurses and 8 nursing assistants were evaluated, which meant a participation rate of 82,93%. 31,10% of the nursing professionals presented signs of burnout, 14,89% considered that they work in an unfavorable environment and 87,23% presented a medium-high index of exposure to ethical conflict. The educational level (χ2=11.084, p=0.011) and the professional category (χ2=5.007, p=0.025) influenced the level of burnout: nursing assistants presented higher levels of this. When comparing the level of burnout with the environment and the index of ethical conflict, there were no statistically significant differences.

CONCLUSIONS

The absence of association found in the study between Burnout and ethical conflict with the perception of the practice environment suggests that personal factors may influence its development.

The relationship between moral distress, burnout, and considering leaving a hospital job during the COVID-19 pandemic: a longitudinal survey

BACKGROUND

Previous research suggests that moral distress contributes to burnout in nurses and other healthcare workers. We hypothesized that burnout both contributed to moral distress and was amplified by moral distress for hospital workers in the COVID-19 pandemic. This study also aimed to test if moral distress was related to considering leaving one's job.

METHODS

A cohort of 213 hospital workers completed quarterly surveys at six time-points over fifteen months that included validated measures of three dimensions of professional burnout and moral distress. Moral distress was categorized as minimal, medium, or high. Analyses using linear and ordinal regression models tested the association between burnout and other variables at Time 1 (T1), moral distress at Time 3 (T3), and burnout and considering leaving one's job at Time 6 (T6).

RESULTS

Moral distress was highest in nurses. Job type (nurse (co-efficient 1.99, p < .001); other healthcare professional (co-efficient 1.44, p < .001); non-professional staff with close patient contact (reference group)) and burnout-depersonalization (co-efficient 0.32, p < .001) measured at T1 accounted for an estimated 45% of the variance in moral distress at T3. Moral distress at T3 predicted burnout-depersonalization (Beta = 0.34, p < .001) and burnout-emotional exhaustion (Beta = 0.38, p < .008) at T6, and was significantly associated with considering leaving one's job or healthcare.

CONCLUSION

Aspects of burnout that were associated with experiencing greater moral distress occurred both prior to and following moral distress, consistent with the hypotheses that burnout both amplifies moral distress and is increased by moral distress. This potential vicious circle, in addition to an association between moral distress and considering leaving one's job, suggests that interventions for moral distress may help mitigate a workforce that is both depleted and burdened with burnout.

Understanding the mediated relationship between moral distress, depression, and suicide risk in undergraduate nursing students

BACKGROUND

Nursing students are at higher risk for depression, suicide, and other mental health concerns as compared to the general college student population. Moral distress and other ethical issues may be a significant source of psychological harm within nursing student experiences and warrants further attention.

PURPOSE

The purpose of this study was to understand the mediating effect of depression on the relationship between moral distress and suicide risk among undergraduate nursing students.

METHODS

This cross-sectional analysis was derived from a larger sequential mixed methods study. The first phase was an online survey completed by a national sample of N = 679 nursing students in the United States.

FINDINGS

The relationship between moral distress and suicide risk was fully mediated by depression and statistically significant at the alpha = 0.05 level.

CONCLUSION

All three psychological variables (depression, moral distress, suicide risk) impact nursing students and require innovative solutions within nursing and educational programs.

Moral Distress, Organizational Climate, and the Risk of Burnout Among Physician Assistants in Oncology

PURPOSE

Moral distress (MD) is the result of barriers or constraints that prevent providers from carrying out what they believe to be ethically appropriate care. This study was initiated to explore associations between MD, burnout, and the organizational climate (OC) for oncology physician assistants (PAs).

METHODS

A national survey of oncology PAs was conducted to explore the associations between MD, OC, and burnout. The Nurse Practitioner-Primary Care OC Questionnaire was revised for oncology PAs to assess OC for PA practice. MD and burnout were assessed using the Measure of MD-Healthcare Professionals (MMD-HP) and the Maslach Burnout Inventory.

RESULTS

One hundred forty-six oncology PAs are included in the analysis. PAs were mostly female (90%), White/Caucasian (84%), married/partnered (78%), and in medical oncology (73%), with mean age 41.0 years. The mean MMD-HP score for oncology PAs was 71.5 and there was no difference in MD scores on the basis of oncology subspecialty, practice setting, practice type, or hours worked per week. PAs currently considering leaving their position because of MD had significantly higher mean scores on the MMD-HP compared with those not considering leaving their position (108.2 v 64.8; P = .001). PAs with burnout also had significantly higher mean scores for MD compared with PAs without burnout (97.6 v 54.3; P < .001). A negative relationship between OC for PA practice and MD was only found for the PA-administration relations subscale, whereas all subscales were negatively associated with burnout.

CONCLUSION

This study demonstrates that the risk of professional burnout increases significantly with increasing levels of MD. Additional research exploring the relationship between MD and burnout is needed.

American Academy of Nursing Expert Panel Consensus Statement on leveraging equity in policy to improve recognition and treatment of mental health, substance use disorders, and nurse suicide

Rates of nurse mental health and substance use disorders are high. Heightened by the COVID-19 pandemic, nurses are challenged to care for patients in ways that often jeopardize their own health and increase risks for their families. These trends exacerbate the epidemic of suicide in nursing underscored by several professional organization clarion calls to nurses' risk. Principles of health equity and trauma-informed care dictate urgent action. The purpose of this paper is to establish consensus among clinical and policy leaders from Expert Panels of the American Academy of Nursing about actions to address risks to mental health and factors contributing to nurse suicide. Recommendations for mitigating barriers drew from the CDC's 2022 Suicide Prevention Resource for Action strategies to guide the nursing community to inform policy, education, research, and clinical practice with the goals of greater health promotion, risk reduction, and sustainment of nurses' health and well-being are provided.

Psychological distress among healthcare providers in oncology during the COVID-19 pandemic in Japan: The mediating role of moral distress and resilience

Objective

Even though vaccines have become widespread, there is an explosion of infection due to the emergence of new mutant strains, and support for healthcare providers' mental health is necessary. The aims of this study were to explore factors associated with the psychological distress, and to determine the degree of association between moral distress, resilience and psychological distress in order to consider intervention models for psychological distress of healthcare providers involved with cancer patients during the COVID-19 pandemic.

Method

We conducted a cross-sectional survey among healthcare providers at the National Cancer Center, Japan. Psychological distress was assessed by the Hospital Anxiety and Depression Scale. We also assessed moral distress using the Moral Distress Thermometer and resilience using the Connor-Davidson Resilience Scale 10 in April and May 2020 which was the first surge of the epidemic period.

Results

Five hundred sixty-six of 3,900 healthcare providers (14.5%) responded. Sixty-eight percent (385/566) responders were above the Hospital Anxiety and Depression Scale cutoff. Hierarchical regression analyses indicated that nurses, allied health professionals and office workers/engineers (odds ratio = 4.63; 95% confidence interval 1.90-11.29; p < 0.001, odds ratio = 3.88; 95% confidence interval 1.88-8.00; p < 0.001, odds ratio = 2.10; 95% confidence interval 1.06-4.18; p < 0.05) as well as healthcare providers with low resilience (odds ratio = 0.88; 95% confidence interval 0.85-0.91; p < 0.001) were at risk of psychological distress. Moral distress was not significantly associated with prevalence of psychological distress.

Conclusion

During the first surge of the pandemic, a high prevalence of psychological distress was demonstrated among cancer center healthcare providers. The study suggests that mental health care should be available to cancer care providers. Since the COVID-19 pandemic is still going on, in addition to the efforts by our facilities, we should consider interventions that promote resilience and a feasibility study of these interventions.

Measuring moral distress in Swedish intensive care: Psychometric and descriptive results

OBJECTIVES

To investigate the construct validity and psychometric properties of the Swedish version of the Moral Distress Scale-Revised and to describe moral distress in an intensive care context.

RESEARCH METHODOLOGY/DESIGN

The Italian Moral Distress Scale-Revised was translated and semantically adjusted to the Swedish intensive care context. A web survey with 14 moral distress items, as well as three additional and eight background questions was answered by critical care nurses (N = 71) working in intensive care units during the second year of the coronavirus disease pandemic. Inferential and descriptive statistics were used to investigate the Italian four-factor model and to examine critical care nurses' moral distress.

RESULTS

The result shows a factor model of four components differing from the previous model. Critical care nurses demonstrated significant differences in moral distress regarding priorities compared to before the pandemic, type of household; experience as critical care nurses and whether they had supervised students during the pandemic.

CONCLUSION

The component structure might have originated from the specific situation critical care nurses perceived during the pandemic. The health care organisations' role in preventing and healing the effects of moral distress is important for managers to understand.

IMPLICATIONS FOR CLINICAL PRACTICE

Moral distress is common in intensive care and it is necessary to use valid instrument when measuring it. A psychometrical investigation of the Swedish version of the Moral Distress Scale-Revised, adapted for intensive care shows need for further semantic and cultural adaptation. Perceived priorities during the pandemic, household type, supervising during the pandemic and working experience were related to critical care nurses' experience of moral distress and managers need to be aware of conditions that may trigger such a response.

Characterizing the mental health and functioning of Canadian respiratory therapists during the COVID-19 pandemic

Introduction: Healthcare professionals (HCPs) appear to be at increased risk for negative psychological outcomes [e.g. depression, anxiety, post-traumatic stress disorder (PTSD), moral distress] and associated impacts on functioning throughout the COVID-19 pandemic. HCPs working on designated COVID-19 units may be further impacted than their colleagues not on these units given added demands of patient care and risk of contracting COVID-19. Little is known, however, about the mental health and functioning of specific professional groups beyond nurses and physicians, including respiratory therapists (RTs), over the course of the pandemic. Accordingly, the purpose of the present study was to characterize the mental health and functioning of Canadian RTs and compare profiles between RTs working on and off designated COVID-19 units.Methods: Canadian RTs completed an online survey between February and June 2021, including demographic information (e.g. age, sex, gender,) and measures of depression, anxiety, stress, PTSD, moral distress and functional impairment. Descriptive statistics, correlation analyses and between-groups comparisons were conducted to characterize RTs and compare profiles between those on and off COVID-19 units.Results: Two hundred and eighteen (N = 218) RTs participated in this study. The estimated response rate was relatively low (6.2%) Approximately half of the sample endorsed clinically relevant symptoms of depression (52%), anxiety (51%) and stress (54%) and one in three (33%) screened positively for potential PTSD. All symptoms correlated positively with functional impairment (p's < .05). RTs working on COVID-19 units reported significantly greater patient-related moral distress compared to those not on these units (p < .05).Conclusion: Moral distress and symptoms of depression, anxiety, stress and PTSD were prevalent among Canadian RTs and were associated with functional impacts. These results must be interpreted with caution given a low response rate, yet raise concern regarding the long-term impacts of pandemic service among RTs.

Critical care nurses' perception of moral distress in intensive care during the COVID-19 pandemic - A pilot study

OBJECTIVES

To describe critical care nurses' perception of moral distress during the second year of the COVID-19 pandemic.

DESIGN/METHODS

A cross-sectional study involving a questionnaire was conducted. Participants responded to the Italian version of the Moral Distress Scale-Revised, which consists of 14 items divided in dimensions Futile care (three items), Ethical misconduct (five items), Deceptive communication (three items) and Poor teamwork (three items). For each item, participants were also invited to write about their experiences and participants' intention to leave a position now was measured by a dichotomous question. The data were analysed with descriptive statistics and qualitative content analysis. The study followed the checklist (CHERRIES) for reporting results of internet surveys.

SETTING

Critical care nurses (n = 71) working in Swedish adult intensive care units.

RESULTS

Critical care nurses experienced the intensity of moral distress as the highest when no one decided to withdraw ventilator support to a hopelessly ill person (Futile care), and when they had to assist another physician or nurse who provided incompetent care (Poor teamwork). Thirty-nine percent of critical care nurses were considering leaving their current position because of moral distress.

CONCLUSIONS

During the COVID-19 pandemic, critical care nurses, due to their education and experience of intensive care nursing, assume tremendous responsibility for critically ill patients. Throughout, communication within the intensive care team seems to have a bearing on the degree of moral distress. Improvements in communication and teamwork are needed to reduce moral distress among critical care nurses.

Working Conditions and Wellbeing among Prison Nurses during the COVID-19 Pandemic in Comparison to Community Nurses

The psychological health and work challenges of nurses working in prisons during the COVID-19 pandemic are understudied. We evaluated the work and wellbeing characteristics of a California prison nurse group, with a comparison to those of a community nurse group. From May to November 2020, an online survey measured psychosocial and organizational work factors, sleep habits, psychological characteristics, COVID-19 impacts, and pre-pandemic recall among 62 prison nurses and 47 community nurses. Prison nurses had significantly longer work hours (54.73 ± 14.52, p < 0.0001), higher pandemic-related work demands, and less sleep hours (5.36 ± 1.30, p < 0.0001) than community nurses. Community nurses had significantly higher pandemic-related fear levels (work infection: p = 0.0115, general: p = 0.0025) and lower perceived personal protective equipment (PPE) supply (p = 0.0103). Between pre-pandemic and pandemic periods, both groups had significantly increased night shift assignments and decreased sleep hours, but the prison group had increased work hours. Although not statistically significant, both groups had high occupational stress and prevalence of post-traumatic stress symptoms. Our results indicate that prison nurses experienced work and wellbeing challenges during the pandemic. Future research and practice ought to address nurses' workload, PPE, and psychological resources in correctional facilities and healthcare organizations.

Correlates of turnover intention among nursing staff in the COVID-19 pandemic: a systematic review

BACKGROUND

During the COVID-19 pandemic, shortage of nursing staff became even more evident. Nurses experienced great strain, putting them at risk to leave their jobs. Individual and organizational factors were known to be associated with nurses' turnover intention before the pandemic. The knowledge of factors associated with turnover intention during the pandemic could help to foster nurses' retention. Therefore, this review aims to identify factors associated with nurses' turnover intention during the COVID-19 pandemic.

METHODS

After a systematic search of six databases, the resulting records were screened in a two-step process based on pre-defined inclusion and exclusion criteria. The included quantitative studies were synthesized qualitatively due to their methodological heterogeneity.

RESULTS

A total of 19 articles were included in the analysis. Individual factors such as health factors or psychological symptoms and demographic characteristics were associated with nurses' turnover intention. Organizational factors associated with turnover intention were e.g., caring for COVID-19 patients, low job control or high job demands, and moral distress. Resilience and supporting leadership could mitigate adverse associations with turnover intention.

CONCLUSIONS

The results help to identify high-risk groups according to individual factors and to develop possible interventions, such as trainings for nurses and their superiors, addressing individual and organizational factors. Future research should focus on longitudinal designs applying carefully defined concepts of turnover intention.

Resilience, Occupational Stress, Job Satisfaction, and Intention to Leave the Organization among Nurses and Midwives during the COVID-19 Pandemic

The current study on the intention to leave the organization among nurses and midwives aligns with the broader direction of research on the consequences of demanding jobs. This is particularly important in the context of the COVID-19 pandemic, which began in 2020 and is ongoing. The aim of the current study was to identify the levels of intention to leave the organization and job satisfaction in a sample of 390 Polish nurses and midwives. A multiple stepwise linear regression was carried out to establish which variables are predictors of job satisfaction and intention to leave the organization. The following measures were used in the study: Nurses' Occupational Stressor Scale, The Brief Resilience Coping Scale, The Turnover Intention Scale, The Job Satisfaction Scale, and an occupational questionnaire (number of workplaces, weekly number of evening and night shifts, working at a unit dedicated to treating COVID-19, working as a supervisor/executive). The current study showed that almost 25% of the sample reported high turnover intention, and a similar proportion reported low job satisfaction. Resilience was related to nurses' job satisfaction. In the predictive models for job satisfaction, the organizational factor of the number of workplaces was significant (positively related), while job experience was a negative predictor of intention to leave. The practical implications of the results and the need to continue research on this topic are also discussed.

A national study of moral distress among U.S. internal medicine physicians during the COVID-19 pandemic

Background

There have been no studies to date of moral distress during the COVID-19 pandemic in national samples of U.S. health workers. The purpose of this study was to determine, in a national sample of internal medicine physicians (internists) in the U.S.: 1) the intensity of moral distress; 2) the predictors of moral distress; 3) the outcomes of moral distress.

Methods

We conducted a national survey with an online panel of internists, representative of the membership of the American College of Physicians, the largest specialty organization of physicians in the United States, between September 21 and October 8, 2020. Moral distress was measured with the Moral Distress Thermometer, a one-item scale with a range of 0 (“none”) to 10 (“worst possible”). Outcomes were measured with short screening scales.

Results

The response rate was 37.8% (N = 810). Moral distress intensity was low (mean score = 2.4, 95% CI, 2.2–2.6); however, 13.3% (95% CI, 12.1% - 14.5%) had a moral distress score greater than or equal to 6 (“distressing”). In multiple linear regression models, perceived risk of death if infected with COVID-19 was the strongest predictor of higher moral distress (β (standardized regression coefficient) = 0.26, p < .001), and higher perceived organizational support (respondent belief that their health organization valued them) was most strongly associated with lower moral distress (β = -0.22, p < .001). Controlling for other factors, high levels of moral distress, but not low levels, were strongly associated (adjusted odds ratios 3.0 to 11.5) with screening positive for anxiety, depression, posttraumatic stress disorder, burnout, and intention to leave patient care.

Conclusions

The intensity of moral distress among U.S. internists was low overall. However, the 13% with high levels of moral distress had very high odds of adverse mental health outcomes. Organizational support may lower moral distress and thereby prevent adverse mental health outcomes.

Risk Perception of Natural and Human-Made Disasters-Cross Sectional Study in Eight Countries in Europe and Beyond

Each year, emergency and disaster situations claim a heavy toll in human lives and economic loss. Civilian populations that are more aware and prepared for emergencies are more resilient. The aim of this study was to explore similarities and differences in risk perception of emergencies and disasters across different societies and its association with individual resilience. A cross sectional study that explored attitudinal factors, as expressed by diverse samples of target countries across Europe and beyond, took place during the months of January-February 2021. Diverse samples (N ≥ 500) of adults from 8 countries (Italy, Romania, Spain, France, Sweden, Norway, Israel, and Japan) were engaged in this study. This study used the Pictorial Representation of Illness and Self-Measure (iPRISM) tool to assess risk perception. The results suggest that for the overall sample (N = 4,013), pandemics were the risk of which participants showed the highest concern, followed by critical infrastructure fail, social disturbance, natural hazards, and extreme weather events. It was found that religiosity is associated with risk perception, with highly religious and non-religious reporting elevated risk perception (F = 5.735, df = 2, p = 0.003), however country-specific analysis revealed that this finding varies depending on local contexts. The analysis also revealed differences in risk perception depending on age and type of risk. The results of this study present that there are commonalities and differences between societies across Europe and beyond concerning societal resilience at large, including risk perception. The dependency of risk perception on local context suggests that a regional-based approach for disaster risk reduction may be called for to adapt and adjust to local socio-cultural characteristics of each population.

Critical Care Nurse Burnout, Moral Distress, and Mental Health During the COVID-19 Pandemic: A United States Survey

BACKGROUND

The COVID-19 pandemic has and will continue to have a tremendous influence on intensive care unit (ICU) nurses' mental health.

OBJECTIVES

The purpose of this study was to describe the impact of COVID-19 on nurse moral distress, burnout, and mental health.

METHODS

Between October 2020 and January 2021 this descriptive study recruited a national sample of nurses who worked in the ICU during the COVID-19 pandemic through American Association of Critical Care Nurses newsletters and social media.

RESULTS

A total of 488 survey responses were received from critical care nurses working in the U.S. during the COVID pandemic. Over two thirds of respondents experienced a shortage of personal protective equipment (PPE). Nurse respondents reported moderate/high levels of moral distress and burnout. Symptoms of moderate to severe depression and anxiety were reported by 44.6% and 31.1% of respondents, respectively. Forty-seven percent of respondents were at risk for having posttraumatic stress disorder (PTSD). Lack of perceived support from administration and shortage of PPE were associated with higher levels of burnout, moral distress, and PTSD symptoms.

CONCLUSIONS

Respondents had higher anxiety and depression than the general population and higher risk for having PTSD than recent veterans or patients after traumatic injury. High levels of reported burnout and moral distress increase the risk of nurses leaving ICU practice or the profession. This study offers important insights about the mental health of nurses during a global pandemic that can guide the development of customized interventions for ICU nurses related to this health care crisis.