A Scoping Review of Moral Stressors, Moral Distress and Moral Injury in Healthcare Workers during COVID-19

Examining moral distress and injury resulting from the COVID-19 pandemic: Insights from the Ghanaian radiography workforce

BACKGROUND

Moral distress has been an issue under consideration in healthcare practice. The COVID-19 pandemic became a critical factor that contributed to heightened moral distress and injury among healthcare professionals, including radiographers. Despite the substantial engagement of radiographers in the management of COVID-19 patients, the consequent moral distress and injury states experienced by this critical frontline workforce have not been widely explored. This study investigated the level of moral distress and the coping mechanisms employed by radiographers in Ghana during the pandemic to provide valuable information to support radiographers and prepare the workforce better against any future pandemics.

METHODS

Utilising a cross-sectional design, a survey approach was employed for data collection between June 2023 and August 2023 from clinically-active radiographers who worked before and during the pandemic in Ghana. Both descriptive and inferential statistics were generated using Microsoft Excel 2019 and the Statistical Package for the Social Sciences (v.26).

RESULTS

Hundred (100) radiographers participated in the study. The result demonstrated that the COVID-19 pandemic escalated the risk of moral distress among radiographers from 22 % (n = 22) to 43 % (n = 43), with 33 % (n = 33) exhibiting signs of moral injury. This escalation impacted the mental health of 12 % (n = 12) of respondents and was reported as a contributor to career-changing decisions among radiographers. Notably, many of those affected did not seek formal support but relied on personal coping strategies and family support. Inadequate resources (69 %, n = 69), particularly regarding consumables, emerged as the primary cause of moral distress. The study underscored that the most effective means of mitigating moral distress in radiographers was through the provision of resources and additional staff support (66 %, n = 66).

CONCLUSION

This study sheds light on the state of moral distress and injury among radiographers during the COVID-19 pandemic, impacting the mental health of a minority and contributing to career-changing decisions. The findings emphasise the importance for healthcare institutions to proactively implement systems, such as resource provision, improved staffing, and emotional support, now and during similar future pandemics. This is crucial to address moral distress and cater to the mental health needs of radiographers, ensuring a resilient clinical radiography workforce.

A mixed-methods analysis of moral injury among healthcare workers during the COVID-19 pandemic

During the COVID-19 pandemic, healthcare workers faced grave responsibilities amidst rapidly changing policies and material and staffing shortages. Moral injury, psychological distress following events where actions transgress moral beliefs/ expectations, increased among healthcare workers. We used a sequential mixed methods approach to examine workplace and contextual factors related to moral injury early in the pandemic. Using a Total Worker Health® framework, we 1) examined factors associated with moral injury among active healthcare professionals (N = 14,145) surveyed between May-August 2020 and 2) qualitatively analyzed open-ended responses from 95 randomly selected participants who endorsed moral injury on the survey. Compared to inpatient hospital, outpatient (OR = 0.74 [0.65, 0.85]) or school clinic settings (OR = 0.37 [0.18, 0.75]) were associated with lower odds of moral injury; while group care settings increased odds (OR = 1.36 [1.07, 1.74]). Working with COVID+ patients (confirmed+ OR = 1.27 [1.03, 1.55]), PPE inadequacy (OR = 1.54 [1.27, 1.87]), and greater role conflict (OR = 1.57 [1.53, 1.62]) were associated with greater odds of moral injury. Qualitative findings illustrate how outside factors as well as organizational policies and working conditions influenced moral injury. Moral injury experiences affected staff turnover and patient care, potentially producing additional morally injurious effects. Worker- and patient-centered organizational policies are needed to prevent moral injury among healthcare workers. The generalizability of these findings may be limited by our predominantly white and female sample. Further research is indicated to replicate these findings in minoritized samples.

Navigating the decision-making landscape of AI in risk finance: Techno-accountability unveiled

The integration of artificial intelligence (AI) systems has ushered in a profound transformation. This conversion is marked by revolutionary extrapolative capabilities, a shift toward data-centric decision-making processes, and the enhancement of tools for managing risks. However, the adoption of these AI innovations has sparked controversy due to their unpredictable and opaque disposition. This study employs the transactional stress model to empirically investigate how six technological stressors (techno-stressors) impact both techno-eustress (positive stress) and techno-distress (negative stress) experienced by finance professionals and experts. To collect data for this research, an e-survey was distributed to a diverse group of 251 participants from various sources. The findings, particularly the identification and development of techno-accountability as a significant factor, contribute to the risk analysis domain by improving the failure mode and effect analysis framework to better fit the rapidly evolving landscape of AI-driven innovations.

Moral distress among physicians in Norway: a longitudinal study

OBJECTIVES

To explore and compare physicians' reported moral distress in 2004 and 2021 and identify factors that could be related to these responses.

DESIGN

Longitudinal survey.

SETTING

Data were gathered from the Norwegian Physician Panel Study, a representative sample of Norwegian physicians, conducted in 2004 and 2021.

PARTICIPANTS

1499 physicians in 2004 and 2316 physicians in 2021.

MAIN OUTCOME MEASURES

The same survey instrument was used to measure change in moral distress from 2004 to 2021. Logistic regression analyses examined the role of gender, age and place of work.

RESULTS

Response rates were 67% (1004/1499) in 2004 and 71% (1639/2316) in 2021. That patient care is deprived due to time constraints is the most severe dimension of moral distress among physicians, and it has increased as 68.3% reported this 'somewhat' or 'very morally distressing' in 2004 compared with 75.1% in 2021. Moral distress also increased concerning that patients who 'cry the loudest' get better and faster treatment than others. Moral distress was reduced on statements about long waiting times, treatment not provided due to economic limitations, deprioritisation of older patients and acting against one's conscience. Women reported higher moral distress than men at both time points, and there were significant gender differences for six statements in 2021 and one in 2004. Age and workplace influenced reported moral distress, though not consistently for all statements.

CONCLUSION

In 2004 and 2021 physicians' moral distress related to scarcity of time or unfair distribution of resources was high. Moral distress associated with resource scarcity and acting against one's conscience decreased, which might indicate improvements in the healthcare system. On the other hand, it might suggest that physicians have reduced their ideals or expectations or are morally fatigued.

Overestimating prevalence? Rethinking boundaries and confounders of moral distress

Moral distress denotes a negative reaction to a morally challenging situation. It has been associated with adverse outcomes for healthcare professionals, patients and healthcare institutions. We argue that existing definitions, along with measures of moral distress, compromise the validity of empirical research. First, the definition and measurement of moral distress conflate moral events and psychological distress, even though they are distinct phenomena that should be assessed independently. Second, in many studies, there is a lack of clarity in distinguishing between moral and non-moral events. Finally, prior research on moral distress often overlooks the substantial body of evidence demonstrating the impact of diverse work-related factors, beyond moral events, on both distress and job retention. These challenges might undermine the effectiveness of interventions aimed at alleviating moral distress. We outline a comprehensive research agenda that encompasses conceptual clarifications, the refinement of data collection instruments, the design of studies and the application of appropriate statistical methods.

From Crisis to Opportunity: A Qualitative Study on Rehabilitation Therapists' Experiences and Post-Pandemic Perspectives

Rehabilitation therapists (RTs) have developed substantial mental health problems since the pandemic. Our study aimed to understand the experience of COVID-19 on occupational therapists and physiotherapists practicing in Canada, how the pandemic may have affected care delivery, and to identify new learnings articulated by RTs. A qualitative descriptive study design guided data collection through one-on-one interviews, dyadic interviews, and focus groups. We recruited active RTs across Canada, advertising on professional practice networks and social media platforms and using snowball sampling. Forty-nine RTs representing seven Canadian provinces participated. The four overarching themes developed using thematic analysis were (1) navigating uncertainty along with ever-changing practices, policies, and attitudes, (2) morphing roles within a constrained system, (3) witnessing patients suffering and experiencing moral distress, and (4) recognizing the personal toll of the pandemic on self and others, as well as lessons learned. Our study demonstrated that many RTs suffered moral distress, poor mental health, and some from challenging financial situations, especially those in the private sector. They also expressed a resilient attitude in response to these stressors. Implications in the future include identifying promising communication strategies that could act as protective factors, addressing workforce constraints and diminishing resources through innovative models of care.

Original Research: Exploring U.S. Nurses' Perceived Duty to Care During the COVID-19 Pandemic

BACKGROUND

Duty to care is both an integral concept in health care and a fundamental nursing obligation. But nurses' perceptions of duty to care can be moderated by their experiences in the practice setting. Research examining nurses' perceptions of their duty to care during the COVID-19 pandemic could shed light on how the pandemic is affecting the nursing workforce.

PURPOSE

This study aimed to examine nurses' sense of duty to care during the early months of the pandemic, using the Nash Duty to Care Scale (NDCS), and to compare the high-scoring nurses with the low-scoring nurses.

METHODS

This quantitative study used a descriptive, cross-sectional design. It was conducted among licensed RNs enrolled at two accredited nursing programs in the Northeast region of the United States. Data were collected via a demographics questionnaire and the NDCS. A two-step cluster procedure was used to categorize participants into two groups: those with high perceived duty to care (HPDC) and those with low perceived duty to care (LPDC). Independent t tests were performed to compare NDCS results between the two groups.

RESULTS

Nearly two-thirds (61%) of the participants had total NDCS scores indicating an HPDC, while 39% had scores indicating an LPDC. Of the NDCS's four subscales, perceived obligation and perceived risk were the most important in separating participants into the low- and high-scoring groups.

CONCLUSIONS

This study adds to the literature about the components that affected nurses' perceived duty to care and willingness to report to work during the early months of the pandemic. Just as nurses have a duty to care, health care organizations have an obligation to provide a safe working environment so that nurses can fulfill that duty without sacrificing personal safety. The study findings may guide health care leaders, systems, and organizations regarding how to create safer work environments that support the nurse's duty to care during disasters.

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).

Implementation of the Dementia Isolation Toolkit in long-term care improves awareness but does not reduce moral distress amongst healthcare providers

BACKGROUND

Healthcare providers may experience moral distress when they are unable to take the ethically or morally appropriate action due to real or perceived constraints in delivering care, and this psychological stressor can negatively impact their mental health, leading to burnout and compassion fatigue. This study describes healthcare providers experiences of moral distress working in long-term care settings during the COVID-19 pandemic and measures self-reported levels of moral distress pre- and post-implementation of the Dementia Isolation Toolkit (DIT), a person-centred care intervention designed for use by healthcare providers to alleviate moral distress.

METHODS

Subjective levels of moral distress amongst providers (e.g., managerial, administrative, and front-line employees) working in three long-term care homes was measured pre- and post-implementation of the DIT using the Moral Distress in Dementia Care Survey and semi-structured interviews. Interviews explored participants' experiences of moral distress in the workplace and the perceived impact of the intervention on moral distress.

RESULTS

A total of 23 providers between the three long-term care homes participated. Following implementation of the DIT, subjective levels of moral distress measured by the survey did not change. When interviewed, participants reported frequent experiences of moral distress from implementing public health directives, staff shortages, and professional burnout that remained unchanged following implementation. However, in the post-implementation interviews, participants who used the DIT reported improved self-awareness of moral distress and reductions in the experience of moral distress. Participants related this to feeling that the quality of resident care was improved by integrating principals of person-centered care and information gathered from the DIT.

CONCLUSIONS

This study highlights the prevalence and exacerbation of moral distress amongst providers during the pandemic and the myriad of systemic factors that contribute to experiences of moral distress in long-term care settings. We report divergent findings with no quantitative improvement in moral distress post-intervention, but evidence from interviews that the DIT may ease some sources of moral distress and improve the perceived quality of care delivered. This study demonstrates that an intervention to support person-centred isolation care in this setting had limited impact on overall moral distress during the COVID-19 pandemic.

"Like not having an arm": a qualitative study of the impact of visitor restrictions on cancer care during the COVID-19 pandemic

PURPOSE

Visitor restriction policies to prevent the spread of COVID-19 among patients and clinicians were widespread during the pandemic, resulting in the exclusion of caregivers at key points of cancer care and treatment decision-making. The aim of this study was to explore how visitor restrictions impacted cancer treatment decision-making and care from patient and physician perspectives.

METHODS

Sixty-seven interviews, including 48 cancer patients and 19 cancer and palliative care physicians from four academic cancer centers in the USA between August 2020 and July 2021.

RESULTS

Visitor restrictions that prevented caregivers from participating in clinic appointments and perioperative hospital care created challenges in cancer care that spanned three domains: practical, social, and informational. We identified eight themes that characterized challenges within the three domains across all three groups, and that these challenges had negative emotional and psychological consequences for both groups. Physicians perceived that patients' negative experiences due to lack of support through the physical presence of caregivers may have worsened patient outcomes.

CONCLUSIONS

Our data demonstrate the tripartite structure of the therapeutic relationship in cancer care with caregivers providing critical support in the decision-making and care process to both patients and physicians. Caregiver absences led to practical, psychosocial, and informational burdens on both groups, and likely increased the risk of burnout among physicians. Our findings suggest that the quality of cancer care can be enhanced by engaging caregivers and promoting their physical presence during clinical encounters.

Impact of COVID-19 first wave on the mental health of healthcare workers in a Front-Line Spanish Tertiary Hospital: lessons learned

Healthcare workers (HCWs) were at high risk of experiencing psychological distress during COVID-19 pandemic. The objective of this study was to evaluate the impact on HCWs' mental health in a Spanish hospital. Cross-sectional study of HCW, active between May and June 2020. A web-based survey assessed probable current mental disorders (major depressive disorder [PHQ-8 ≥ 10], generalized anxiety disorder [GAD-7 ≥ 10], panic attacks, post-traumatic stress disorder [PTSD; PLC-5 ≥ 7], or substance use disorder [CAGE-AID ≥ 2]). The Sheehan Disability Scale (SDS) was used to assess severe impairment and items taken from the modified self-report version of the Columbia Suicide Severity Rating Scale (C-SSRS) assessed suicidal thoughts and behaviors. A total of 870 HCWs completed the survey. Most frequent probable mental disorders were major depressive disorder (33.6%), generalized anxiety disorder (25.5%), panic attacks (26.9%), PTSD (27.2%), and substance use disorder (5.0%). Being female, having aged 18-29 years, being an auxiliary nurse, direct exposure to COVID-19-infected patients, and pre-pandemic lifetime mental disorders were positively associated with mental issues. Hospital HCWs presented a high prevalence of symptoms of mental disorders, especially depression, PTSD, panic attacks, and anxiety. Younger individuals and those with lifetime mental disorders have been more vulnerable to experiencing them.

Gendered and racial experiences of moral distress: A scoping review

AIM

To inform efforts to integrate gender and race into moral distress research, the review investigates if and how gender and racial analyses have been incorporated in such research.

DESIGN

Scoping review.

METHODS

The PRISMA (Preferred Reporting Items for Systematic and Meta-Analysis) Extension for Scoping Reviews was adopted.

DATA SOURCES

Systematic literature search was conducted through PubMed, CINAHL and Web of Science databases. Boolean operators were used to identify moral distress literature which included gender and/or race data and published between 2012 and 2022.

RESULTS

After screening and full-text review, 73 articles reporting on original moral distress research were included. Analysis was conducted on how gender and race were incorporated in research and interpretation of moral distress experiences among healthcare professionals.

IMPACT

This study found that while there is an upward trend in including gender and race-disaggregated data in moral distress research, over half of such research did not conduct in-depth analysis of such data. Others only highlighted differential experiences such as moral distress levels of women vis-à-vis men. Only about 20% of publications interrogated how experiences of moral distress differed and/or explored factors behind their findings.

CONCLUSION

There is a need to not only collect disaggregated data in moral distress research but also engage this data through gender and race-based analysis. Particularly, we highlight the need for intersectional analysis, which can elucidate how social identities and categories (such as gender and race) and structural inequalities (such as those sustained by sexism and racism) interact to influence moral experiences.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Moral distress as experienced by healthcare professionals is increasingly recognized as an important area of research with significant policy implications in the healthcare sector. This study offers insights for nuanced and targeted policy approaches.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Structural Equation Modeling Analysis on Associations of Moral Distress and Dimensions of Organizational Culture in Healthcare: A Cross-Sectional Study of Healthcare Professionals

OBJECTIVE

Moral distress is a complex phenomenon experienced by healthcare professionals. This study examined the relationships between key dimensions of Organizational Culture in Healthcare (OCHC)-perceived psychological safety, ethical climate, patient safety-and healthcare professionals' perception of moral distress.

DESIGN

Cross-sectional survey.

SETTING

Pediatric and adult critical care medicine, and adult hospital medicine healthcare professionals in the United States.

PARTICIPANTS

Physicians (n = 260), nurses (n = 256), and advanced practice providers (n = 110) participated in the study.

MAIN OUTCOME MEASURES

Three dimensions of OCHC were measured using validated questionnaires: Olson's Hospital Ethical Climate Survey, Agency for Healthcare Research and Quality's Patient Safety Culture Survey, and Edmondson's Team Psychological Safety Survey. The perception of moral distress was measured using the Moral Distress Amidst a Pandemic Survey. The hypothesized relationships between various dimensions were tested with structural equation modeling (SEM).

RESULTS

Adequate model fit was achieved in the SEM: a root-mean-square error of approximation =0.072 (90% CI 0.069 to 0.075), standardized root mean square residual = 0.056, and comparative fit index =0.926. Perceived psychological safety (β= -0.357, p <.001) and patient safety culture (β = -0.428, p<.001) were negatively related to moral distress experience. There was no significant association between ethical climate and moral distress (β = 0.106, p = 0.319). Ethical Climate, however, was highly correlated with Patient Safety Culture (factor correlation= 0.82).

CONCLUSIONS

We used structural equation model to test a theoretical model of multi-dimensional organizational culture and healthcare climate (OCHC) and moral distress.Significant associations were found, supporting mitigating strategies to optimize psychological safety and patient safety culture to address moral distress among healthcare professionals. Future initiatives and studies should account for key dimensions of OCHC with multi-pronged targets to preserve the moral well-being of individuals, teams, and organizations.

Causes and solutions to workplace psychological ill-health for nurses, midwives and paramedics: the Care Under Pressure 2 realist review

Background

Nurses, midwives and paramedics are the largest collective group of clinical staff in the National Health Service and have some of the highest prevalence of psychological ill-health. Existing literature tends to be profession-specific and focused on individual interventions that place responsibility for good psychological health with nurses, midwives and paramedics themselves.

Aim

To improve understanding of how, why and in what contexts nurses, midwives and paramedics experience work-related psychological ill-health; and determine which high-quality interventions can be implemented to minimise psychological ill-health in these professions.

Methods

Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards' reporting guidelines.

Data sources

First round database searching in Medical Literature Analysis and Retrieval System Online Database ALL (via Ovid), cumulative index to nursing and allied health literature database (via EBSCO) and health management information consortium database (via Ovid), was undertaken between February and March 2021, followed by supplementary searching strategies (e.g. hand searching, expert solicitation of key papers). Reverse chronology screening was applied, aimed at retaining 30 relevant papers in each profession. Round two database searches (December 2021) targeted COVID-19-specific literature and literature reviews. No date limits were applied.

Results

We built on seven key reports and included 75 papers in the first round (26 nursing, 26 midwifery, 23 paramedic) plus 44 expert solicitation papers, 29 literature reviews and 49 COVID-19 focused articles in the second round. Through the realist synthesis we surfaced 14 key tensions in the literature and identified five key findings, supported by 26 context mechanism and outcome configurations. The key findings identified the following: (1) interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; (2) it is difficult to promote staff psychological wellness where there is a blame culture; (3) the needs of the system often override staff well-being at work ('serve and sacrifice'); (4) there are unintended personal costs of upholding and implementing values at work; and (5) it is challenging to design, identify and implement interventions to work optimally for diverse staff groups with diverse and interacting stressors.

Conclusions

Our realist synthesis strongly suggests the need to improve the systemic working conditions and the working lives of nurses, midwives and paramedics to improve their psychological well-being. Individual, one-off psychological interventions are unlikely to succeed alone. Psychological ill-health is highly prevalent in these staff groups (and can be chronic and cumulative as well as acute) and should be anticipated and prepared for, indeed normalised and expected. Healthcare organisations need to (1) rebalance the working environment to enable healthcare professionals to recover and thrive; (2) invest in multi-level system approaches to promote staff psychological well-being; and use an organisational diagnostic framework, such as the NHS England and NHS Improvement Health and Wellbeing framework, to self-assess and implement a systems approach to staff well-being.

Future work

Future research should implement, refine and evaluate systemic interventional strategies. Interventions and evaluations should be co-designed with front-line staff and staff experts by experience, and tailored where possible to local, organisational and workforce needs.

Limitations

The literature was not equivalent in size and quality across the three professions and we did not carry out citation searches using hand searching and stakeholder/expert suggestions to augment our sample.

Study registration

This study is registered as PROSPERO CRD42020172420. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172420.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129528) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 9. See the NIHR Funding and Awards website for further award information.

Moral Injury Among Interventional Radiologists

RATIONALE AND OBJECTIVES

To evaluate moral injury (MI) among interventional radiologists using validated assessment tools.

MATERIALS AND METHODS

An anonymous 29-question online survey was distributed to interventional radiologists using the Society of Interventional Radiology Connect Open Forum website, Twitter, Facebook, LinkedIn, and electronic mail. The survey consisted of demographic and practice environment questions, a global quality of life (QoL) scale (scored 1-100), the MI Symptom Scale‑Healthcare Professional (MISS-HP) (scored 1-100), and two open-ended questions. A MISS-HP score ≥ 36 was indicative of experiencing MI. P < .05 was considered statistically significant for all two-sided tests.

RESULTS

Beginning on March 30, 2023, 365 surveys were completed over 5 days. Of the respondents, 299 (81.9%) were male, 65 (17.8%) were female, and one preferred not to disclose gender. The respondents included practicing interventional radiologists (299; 81.9%) and interventional radiologists-in-training (66; 18.1%). Practice settings included academic (146; 40.0%), community (121; 33.2%), hybrid (84; 23.0%), or other (14; 3.8%) centers. Mean QoL was 71.1 ± 17.0 (range: 0-100) suggestive of "good" QoL. Mean QoL in the MI subgroup was significantly different from that for the rest of the group (67.6 ± 17.0 vs. 76.6 ± 16.0; P < 0.05). 223 (61.1%) respondents scored ≥ 36 on the MISS-HP, and thus were categorized as having profession-related MI. Mean MISS-HP was 39.9 ± 12.6 (range: 10-83). Mean MISS-HP in the MI subgroup was significantly different from that for the rest of the group (47.4 ± 9.6 vs. 28.0 ± 5.7; P < 0.05). There was a negative correlation between MI and QoL (r = -0.4; P < 0.001). Most common themes for greatest contribution to MI were ineffective leadership, barriers to patient care, corporatization of medicine, non-physician administration, performing futile procedures, turf battles, and reduced resources. Most common themes for ways to reduce MI were more autonomy, less bureaucracy, more administrative support, physician-directed leadership, adequate staffing, changes to the medical system, physician unionization, transparency with insurance companies, more time off, and leaving medicine/retirement.

CONCLUSION

MI is prevalent among interventional radiologists, and it negatively correlates with QoL. Future work should investigate causative factors and mitigating solutions.

Impact of the Work Environment on Nurse Outcomes: A Mediation Analysis

BACKGROUND

The nursing workforce remains in a vulnerable state post pandemic as working conditions are difficult and exacerbated by a global nursing shortage. Identifying factors leading to turnover intentions are thus critical for health care system recovery.

PURPOSE

The purpose of this study was to examine the impact of nurses' work environment and the pandemic on missed nursing care, scope of practice, emotional exhaustion, and intent to leave.

METHODS

This study was a cross-sectional, self-reporting online survey, sent to hospital-based nurses in a Canadian province (n = 419). Mediation analysis was used to examine both direct and indirect effects of work environment and COVID-19 impact on nurse outcomes (emotional exhaustion and intent to leave) through missed care and scope of practice.

RESULTS

The results showed that 73% of nurses were considering leaving the profession. Several direct and indirect pathways predicted emotional exhaustion and intent to leave. A better work environment was related to both decreased emotional exhaustion and intent to leave. Nurses' scope of practice partially mediated the relationship between work environment and intent to leave. On the other hand, missed care did not mediate emotional exhaustion or intent to leave.

CONCLUSIONS

While considering the global nursing shortage, it is imperative to implement strategies to promote nurses' well-being and their retention within the health care system.

Measuring moral distress and moral injury: A systematic review and content analysis of existing scales

BACKGROUND

Moral distress (MD) and moral injury (MI) are related constructs describing the negative consequences of morally challenging stressors. Despite growing support for the clinical relevance of these constructs, ongoing challenges regarding measurement quality risk limiting research and clinical advances. This study summarizes the nature, quality, and utility of existing MD and MI scales, and provides recommendations for future use.

METHOD

We identified psychometric studies describing the development or validation of MD or MI scales and extracted information on methodological and psychometric qualities. Content analyses identified specific outcomes measured by each scale.

RESULTS

We reviewed 77 studies representing 42 unique scales. The quality of psychometric approaches varied greatly across studies, and most failed to examine convergent and divergent validity. Content analyses indicated most scales measure exposures to potential moral stressors and outcomes together, with relatively few measuring only exposures (n = 3) or outcomes (n = 7). Scales using the term MD typically assess general distress. Scales using the term MI typically assess several specific outcomes.

CONCLUSIONS

Results show how the terms MD and MI are applied in research. Several scales were identified as appropriate for research and clinical use. Recommendations for the application, development, and validation of MD and MI scales are provided.

"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.

Bearing witness poetically in a pandemic: documenting suffering and care in conditions of physical isolation and uncertainty

The COVID-19 crisis is still affecting millions of people worldwide. However, government and mass media attention to the continuing loss of life, severe illness and prolonged effects of COVID-19 has subsided, rendering the suffering of those who have become ill or disabled, or who have lost loved ones to the disease, largely hidden from view. In this article, we employ autoethnographic poetic inquiry from the perspective of a mother/carer whose young adult daughter became critically ill and hospitalised after becoming infected while the mother herself was isolating at home due to her own COVID-19 diagnosis. The first author created a poem from notes she had made in a journal from telephone conversations and messages with the healthcare providers caring for her daughter. The second author responded to the poem, identifying the feelings and meanings it surfaced. Together, the authors draw on scholarship discussing concepts of uncertainty, liminality, moral distress, bearing witness and illness narratives to reflect on how autoethnographic poetic inquiry can document and make visible COVID-19-related suffering.

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.

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.

Moral failure, moral prudence, and character challenges in residential care during the Covid-19 pandemic

In many high-income countries, an initial response to the severe impact of Covid-19 on residential care was to shield residents from outside contacts. As the pandemic progressed, these measures have been increasingly questioned, given their detrimental impact on residents' health and well-being and their dubious effectiveness. Many authorities have been hesitant in adapting visiting policies, often leaving nursing homes to act on their own safety and liability considerations. Against this backdrop, this article discusses the appropriateness of viewing the continuation of the practice of shielding as a moral failure. This is affirmed and specified in four dimensions: preventability of foreseeable harm, moral agency, moral character, and moral practice (in MacIntyre's sense). Moral character is discussed in the context of prudent versus proportionate choices. As to moral practice, it will be shown that the continued practice of shielding no longer met the requirements of an (inherently moral) practice, as external goods such as security thinking and structural deficiencies prevented the pursuit of internal goods focusing on residents' interests and welfare, which in many places has led to a loss of trust in these facilities. This specification of moral failure also allows a novel perspective on moral distress, which can be understood as the expression of the psychological impact of moral failure on moral agents. Conclusions are formulated about how pandemic events can be understood as character challenges for healthcare professionals within residential care, aimed at preserving the internal goods of residential care even under difficult circumstances, which is understood as a manifestation of moral resilience. Finally, the importance of moral and civic education of healthcare students is emphasized to facilitate students' early identification as trusted members of a profession and a caring society, in order to reduce experiences of moral failure or improve the way to deal with it effectively.

A theoretical framework for Acute Care Nurse Stress Appraisal: Application of the transactional model of stress and coping

AIM

To develop a framework for understanding the stress appraisal process among acute care nurses during the COVID-19 pandemic.

DESIGN

A secondary analysis of open-ended responses from a cross-sectional survey of 3030 frontline, acute care nurses in New Jersey and the effect of burnout during the COVID-19 pandemic.

METHODS

Lazarus and Folkman's transactional model of stress and coping guided the study. Thematic analysis was used to analyse 1607 open-ended responses.

RESULTS

Nine themes emerged during the secondary appraisal of stress. Five themes contributed to distress and burnout including (1) high patient acuity with scarce resources, (2) constantly changing policies with inconsistent messaging, (3) insufficient PPE, (4) unprepared pandemic planning and (5) feeling undervalued. Four themes led to eustress and contributed to post-traumatic growth including (1) team nursing to ensure sufficient resource allocation, (2) open channels of communication, (3) sense- of-duty and (4) personal strength from new possibilities.

CONCLUSION

The COVID-19 pandemic was a traumatic event for patients and the nursing workforce. Internal and external demands placed on acute care nurses increased burnout, however, a subset of nurses with adequate support experienced personal growth.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Beyond mental health interventions for acute care nurses, organizational interventions such as reevaluation of emergency action plans to optimize resource allocation, and work environment strategies such as improved communication and decision-making transparency are necessary.

IMPACT

To better understand how frontline acute care nurses experienced stress during COVID-19, a data-informed framework was developed that included a primary and secondary appraisal of stress. Themes contributing to distress and burnout were identified, and themes leading to eustress and post-traumatic growth were also identified. These findings can assist nurse leaders in optimizing strategies to reduce burnout and promote post-traumatic growth in the post-COVID years.

REPORTING METHOD

No patient or public contribution.

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.

Improving modelling for epidemic responses: reflections from members of the UK infectious disease modelling community on their experiences during the COVID-19 pandemic

Background

The COVID-19 pandemic both relied and placed significant burdens on the experts involved from research and public health sectors. The sustained high pressure of a pandemic on responders, such as healthcare workers, can lead to lasting psychological impacts including acute stress disorder, post-traumatic stress disorder, burnout, and moral injury, which can impact individual wellbeing and productivity.

Methods

As members of the infectious disease modelling community, we convened a reflective workshop to understand the professional and personal impacts of response work on our community and to propose recommendations for future epidemic responses. The attendees represented a range of career stages, institutions, and disciplines. This piece was collectively produced by those present at the session based on our collective experiences.

Results

Key issues we identified at the workshop were lack of institutional support, insecure contracts, unequal credit and recognition, and mental health impacts. Our recommendations include rewarding impactful work, fostering academia-public health collaboration, decreasing dependence on key individuals by developing teams, increasing transparency in decision-making, and implementing sustainable work practices.

Conclusions

Despite limitations in representation, this workshop provided valuable insights into the UK COVID-19 modelling experience and guidance for future public health crises. Recognising and addressing the issues highlighted is crucial, in our view, for ensuring the effectiveness of epidemic response work in the future.

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.

"I haven't really gone through things like this": Young long-term care workers' experiences of working during the COVID-19 pandemic

BACKGROUND

Long-term care (LTC) facilities were hard hit by the COVID-19 pandemic in Canada. Using life course theory concepts, we looked for conditions that led to worker moral distress -i.e. pain or anguish over not being able to take right action - and how life stage may influence experiences.

OBJECTIVE

To illuminate the experiences of adults under the age of 30 who stepped into, and/or persevered in, working in LTC during the pandemic, recognizing that this emerging workforce represents the future of LTC in Canada.

METHODS

This secondary analysis uses interview data from a sub-sample of 16 young workers between 18 and 29 years of age who had been working in Canadian LTC facilities for between 8 months and 7 years.

RESULTS

Young workers expressed feeling guilt about mourning the loss of socially significant milestones as these milestones paled by comparison to the loss of life and consequences of resident isolation they witnessed at work. To manage feelings of moral distress, young workers attempted to maintain high standards of care for LTC residents and engaged in self-care activities. For some workers, this was insufficient and leaving the field of LTC was their strategy to respond to their mental health needs.

CONCLUSION

The life stage of young LTC workers influenced their experiences of working during the COVID-19 pandemic. Interventions are needed to support young workers' wellbeing and job retention.

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.

Civilian Moral Injury and Amygdala Functional Connectivity During Attention to Threat

BACKGROUND

Moral injury references emotional and spiritual/existential suffering that may emerge following psychological trauma. Despite being linked to adverse mental health outcomes, little is known about the neurophysiological mechanisms of this phenomenon. In this study, we examined neural correlates of moral injury exposure and distress using the Moral Injury Exposure and Symptom Scale for Civilians. We also examined potential moderation of these effects by race (Black vs. White individuals) given the likely intersection of race-related stress with moral injury.

METHODS

Forty-eight adults ages 18 to 65 years (mean age = 30.56, SD = 11.93) completed the Moral Injury Exposure and Symptom Scale for Civilians and an affective attentional control measure, the affective Stroop task (AS), during functional magnetic resonance imaging; the AS includes presentation of threat-relevant and neutral distractor stimuli. Voxelwise functional connectivity of the bilateral amygdala was examined in response to threat-relevant versus neutral AS distractor trials.

RESULTS

Functional connectivity between the right amygdala and left postcentral gyrus/primary somatosensory cortex was positively correlated with the Moral Injury Exposure and Symptom Scale for Civilians exposure score (voxelwise p < .001, cluster false discovery rate-corrected p < .05) in response to threat versus neutral AS distractor trials. Follow-up analyses revealed significant effects of race; Black but not White participants demonstrated this significant pattern of amygdala-left somatosensory cortex connectivity.

CONCLUSIONS

Increased exposure to potentially morally injurious events may lead to emotion-somatosensory pathway disruptions during attention to threat-relevant stimuli. These effects may be most potent for individuals who have experienced multilayered exposure to morally injurious events, including racial trauma. Moral injury appears to have a distinct neurobiological signature that involves abnormalities in connectivity of emotion-somatosensory paths, which may be amplified by race-related stress.

Psychometric properties of the Persian version of the nursing moral disengagement scale

Moral disengagement is a set of cognitive mechanisms through which a person violates his/her moral standards without losing his/her dignity. Therefore, a tool has been designed to measure moral disengagement in nurses. This study aims to determine the psychometric properties of the Nursing Moral Disengagement scale. In this methodological study, 440 nurses working in hospitals of Mashhad were selected by the availability sampling method. The translation was carried out using the forward-backward method. The final version of the tool was psychometrically tested for validity (exploratory and confirmatory factor analysis) and reliability (internal consistency and relative stability). Four factors were extracted in the exploratory factor analysis, and since the factor loadings of all the tool items were higher than 0.3, they were all retained. The tool's general fit indices indicated the model's confirmation and optimal fit. Cronbach's alpha and relative stability coefficients for the whole questionnaire were 0.90 and 0.89, respectively. The study results showed that this tool has good validity and reliability and can therefore measure behaviors related to moral disengagement in nurses, so that appropriate interventions can be designed to reduce these harmful behaviors.

Moral distress and moral courage among Iraqi nurses during the COVID-19 pandemic: a cross-sectional study

In the years following its outbreak in 2019, COVID-19 changed the health-care system structures, the context of professional activity, and nurses' moral performance. The present study aimed to examine the moral distress and moral courage of Iraqi nurses during the COVID-19 pandemic. This cross-sectional and correlational study was conducted in 2021 on 168 nurses selected by convenience sampling methods. Data were collected by self-reported instruments including a demographic questionnaire, the Professional Moral Courage (PMC), and the Moral Distress Scale (MDS). Data were analysed using descriptive statistics, the Spearman, Mann-Whitney and Kruskal-Wallis tests, and SPSS version 22. Most nurses showed a moderate level of moral distress (98.80%) and a high level of moral courage (99.40%). The dimension of multiple values had the highest mean (12.45 ± 1.47) and endurance of threats had the lowest mean (9.15 ± 1.79). There was a statistically significant correlation between moral distress and moral courage (P = 0.007, r = - 0.2), and moral distress and the dimensions of endurance of threat (P < 0.001, r = - 0.26), going beyond compliance (P < 0.001, r = - 0.037), and moral goals (P < 0.001, r = - 0.173). A statistically significant relationship was also found between moral distress and work shift, position and gender (P < 0.05), and between moral courage and position (P < 0.05). We concluded that nurses need more organizational support in terms of protective facilities, job security and organizational incentives to be able to show ethical behaviors.

In critique of moral resilience: UK healthcare professionals' experiences working with asylum applicants housed in contingency accommodation during the COVID-19 pandemic

This research explores the experiences of UK NHS healthcare professionals working with asylum applicants housed in contingency accommodation during the COVID-19 pandemic. Using a critical understanding of the concept of moral resilience as a theoretical framework, we explore how the difficult circumstances in which they worked were navigated, and the extent to which moral suffering led to moral transformation. Ten staff from a general practice participated in semistructured interviews. Encountering the harms endured by people seeking asylum prior to arrival in the UK and through the UK's 'Hostile Environment' caused healthcare staff moral suffering. They responded to this in several ways, including: (1) feeling grateful for their own fortunes; (2) defining the limitations of their professional obligations; (3) focusing on the rewards of work and (4) going above and beyond usual care. Although moral resilience is reflected in much of the data, some participants described how the work caused ideological transformations and motivated challenges to systems of oppression. We show how current moral resilience theory fails to capture these transformative political and social responses, warning of how, instead, it might encourage healthcare staff to maintain the status quo. We caution against the widespread endorsement of current formulations of moral resilience in contemporary social and political climates, where the hostile and austere systems causing suffering are the result of ideological political decisions. Future work should instead focus on enabling working conditions to support, and developing theory to capture, collective resistance.

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.

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.

Bedside Politics and Precarious Care: New Directions of Inquiry in Critical Nursing Studies

Health care systems are facing soaring workforce shortages, challenging their ability to secure timely access to good-quality care. In this context, nurses make difficult decisions about which patients to deliver care to, transfer to other providers, or strategically ignore. Yet, we still know little about how nurses engage in situated practices of bedside rationing. Building on the work of Giorgio Agamben and Judith Butler, we have developed a research agenda that homes in on a politics of bedside rationing. We argue that this agenda is essential to better understand the implications of scarcity for nursing and to explore new ways to cope with challenges faced.

Is nurses' clinical competence associated with their moral identity and injury?

BACKGROUND

The enhancement of nursing care quality is closely related to the clinical competence of nurses, making it a crucial component within health systems.

OBJECTIVE

The present study investigated the relationship between nurses' clinical competence, moral identity, and moral injury during the COVID-19 outbreak.

RESEARCH DESIGN

This cross-sectional study was carried out among frontline nurses, using the Moral Identity Questionnaire (MIQ), the Moral Injury Symptom Scale-Healthcare Professionals version (MISS-HP), and the Competency Inventory for Registered Nurse (CIRN) as data collection tools.

PARTICIPANTS

and research context: The research population for this study consisted of all frontline nurses (n = 251) employed in a hospital in southern Iran. Sampling was conducted between May 1, 2021 and September 30, 2021, during the COVID-19 outbreak.

ETHICAL CONSIDERATIONS

The present study received approval from the research ethics committee of Rafsanjan University of Medical Sciences, with project No. 99267 and code of ethics ID No. IR. RUMS.REC.1399.262, dated 15.02.2021.

RESULTS

According to the study findings, 42.2% of the nurses demonstrated high clinical competence, while 51.4% exhibited moderate clinical competence. The results indicated a positive correlation between moral identity and clinical competence but a negative correlation between moral injury and clinical competence. Furthermore, the variables of moral identity and moral injury were found to predict 10% of the variance in clinical competence.

CONCLUSION

According to the results, moral identity and moral injury had an impact on the clinical competence of nurses. Therefore, implementing a program aimed at enhancing moral identity and providing training strategies to address moral injury during crises like the COVID-19 pandemic can lead to improvements in nurses' clinical competence and the overall quality of care they provide.

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.

Predictors and consequences of moral distress in home-care nursing: A cross-sectional survey

BACKGROUND

Nurses frequently face situations in their daily practice that are ethically difficult to handle and can lead to moral distress.

OBJECTIVE

This study aimed to explore the phenomenon of moral distress and describe its work-related predictors and individual consequences for home-care nurses in Germany.

RESEARCH DESIGN

A cross-sectional design was employed. The moral distress scale and the COPSOQ III-questionnaire were used within the framework of an online survey conducted among home-care nurses in Germany. Frequency analyses, multiple linear and logistic regressions, and Rasch analyses were performed.

PARTICIPANTS AND RESEARCH CONTEXT

The invitation to participate was sent to every German home-care service (n = 16,608).

ETHICAL CONSIDERATIONS

The study was approved by the Data Protection Office and Ethics Committee of the German Federal Institute for Occupational Safety and Health.

RESULTS

A total of 976 home-care nurses participated in this study. Job characteristics, such as high emotional demands, frequent work-life-conflicts, low influence at work, and low social support, were associated with higher disturbance caused by moral distress in home-care nurses. Organizational characteristics of home-care services, such as time margin with patients, predicted moral distress. High disturbance levels due to moral distress predicted higher burnout, worse state of health, and the intention to leave the job and the profession, but did not predict sickness absence.

CONCLUSIONS

To prevent home-care nurses from experiencing severe consequences of moral distress, adequate interventions should be developed. Home-care services ought to consider family friendly shifts, provide social support, such as opportunities for exchange within the team, and facilitate coping with emotional demands. Sufficient time for patient care must be scheduled and short-term takeover of unknown tours should be prevented. There is a need to develop and evaluate additional interventions aimed at reducing moral distress, specifically in the home-care nursing sector.

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

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.

"Actually, the psychological wounds are more difficult than physical injuries:" a qualitative analysis of the impacts of attacks on health on the personal and professional lives of health workers in the Syrian conflict

INTRODUCTION

Attacks on healthcare in armed conflict have far-reaching impacts on the personal and professional lives of health workers, as well as the communities they serve. Despite this, even in protracted conflicts such as in Syria, health workers may choose to stay despite repeated attacks on health facilities, resulting in compounded traumas. This research explores the intermediate and long-term impacts of such attacks on healthcare on the local health professionals who have lived through them with the aim of strengthening the evidence base around such impacts and better supporting them.

METHODS

We undertook purposive sampling of health workers in northwest and northeast Syria; we actively sought to interview non-physician and female health workers as these groups are often neglected in similar research. In-depth interviews (IDIs) were conducted in Arabic and transcribed into English for framework analysis. We used an a priori codebook to explore the short- and long-term impacts of attacks on the health workers and incorporated emergent themes as analysis progressed.

RESULTS

A total of 40 health workers who had experienced attacks between 2013 and 2020 participated in IDIs. 13 were female (32.5%). Various health cadres including doctors, nurses, midwives, pharmacists, students in healthcare and technicians were represented. They were mainly based in Idlib (39.5%), and Aleppo (37.5%) governorates. Themes emerged related to personal and professional impacts as well as coping mechanisms. The key themes include firstly the psychological harms, second the impacts of the nature of the attacks e.g. anticipatory stress related to the 'double tap' nature of attacks as well as opportunities related to coping mechanisms among health workers.

CONCLUSION

Violence against healthcare in Syria has had profound and lasting impacts on the health workforce due to the relentless and intentional targeting of healthcare facilities. They not only face the challenges of providing care for a conflict-affected population but are also part of the community themselves. They also face ethical dilemmas in their work leading to moral distress and moral injury. Donors must support funding for psychosocial support for health workers in Syria and similar contexts; the focus must be on supporting and enhancing existing context-specific coping strategies.

Ethical issues experienced by nurses during COVID-19 pandemic: Systematic review

BACKGROUND

Frontline nurses who care for patients with COVID-19 work in stressful environments, and many inevitably struggle with unanticipated ethical issues. Little is known about the unique, ethically sensitive issues that nurses faced when caring for patients with COVID-19.

AIM

To better understand how frontline nurses who care for patients with COVID-19 experience ethical issues towards others and themselves.

METHODS

Systematic review of qualitative evidence carried out according to the Preferred Reporting Items for Systematic reviews and Meta-analyses on ethical literature (PRISMA-Ethics). The electronic databases PubMed, Embase, Cinahl, Web of Science, Philosopher's Index, and Scopus were queried to identify candidate articles. Articles appearing from March 1, 2020 to December 31, 2022 were considered if they met the following inclusion criteria: (1) Published qualitative and mixed method studies and (2) ethical issues experienced by nurses caring for patients with COVID-19. We appraised the quality of included studies, and data analysis was guided by QUAGOL principles.

FINDINGS

Twenty-six studies meeting our inclusion criteria for how nurses experience ethical issues were characterised by two key themes: (1) the moral character of nurses as a willingness to respond to the vulnerability of human beings and (2) ethical issues nurses acted as barriers sometimes, impeding them from responding to requests of vulnerable human beings for dignified care.

CONCLUSION

Our review provides a deeper understanding of nurses' experiences of ethically sensitive issues, while also highlighting the critical need for adjustments to be made at organisational and societal levels. Ethical issues that emerged in situations where organisational and situational constraints impeded nurses' ethical responses to patients' appeals suggests that early practical support should be made available to resolve ethical issues recognised by nurses. Such support contributes to protecting and promoting not only the dignity of patients with COVID-19 but also of fellow humans in need during crisis.

The mediating roles of workplace support and ethical work environment in associations between leadership and moral distress: a longitudinal study of Canadian health care workers during the COVID-19 pandemic

Introduction

The COVID-19 pandemic has resulted in heightened moral distress among health care workers (HCWs) worldwide. Past research has shown that effective leadership may mitigate potential for the development of moral distress. However, no research to date has considered the mechanisms by which leadership might have an influence on moral distress. We sought to evaluate longitudinally whether Canadian HCWs' perceptions of workplace support and ethical work environment would mediate associations between leadership and moral distress.

Methods

A total of 239 French- and English-speaking Canadian HCWs employed during the COVID-19 pandemic were recruited to participate in a longitudinal online survey. Participants completed measures of organizational and supervisory leadership at baseline and follow-up assessments of workplace support, perceptions of an ethical work environment, and moral distress.

Results

Associations between both organizational and supervisory leadership and moral distress were fully mediated by workplace supports and perceptions of an ethical work environment.

Discussion

To ensure HCW well-being and quality of care, it is important to ensure that HCWs are provided with adequate workplace supports, including manageable work hours, social support, and recognition for efforts, as well as an ethical workplace environment.

Coping, Supports and Moral Injury: Spiritual Well-Being and Organizational Support Are Associated with Reduced Moral Injury in Canadian Healthcare Providers during the COVID-19 Pandemic

Healthcare providers (HCPs) have described the onset of shame- and trust-violation-related moral injuries (MI) throughout the COVID-19 pandemic. Previous research suggests that HCPs may turn to various coping methods and supports, such as spirituality/religiosity, substance use, friends/family or organizational support, to manage workplace stress. It remains unknown, however, if similar coping methods and supports are associated with MI among this population. We explored associations between MI (including the shame and trust-violation presentations individually) and coping methods and supports. Canadian HCPs completed an online survey about their mental health and experiences during the COVID-19 pandemic, including demographic indices (e.g., sex, age, mental health history) and measures of MI, organizational support, social support, spiritual well-being, self-compassion, alcohol use, cannabis use and childhood adversity. Three hierarchical multiple linear regressions were conducted to assess the associations between coping methods/supports and (i) MI, (ii) shame-related MI and (iii) trust-violation-related MI, when controlling for age, mental health history and childhood adversity. One hundred and seventy-six (N = 176) HCPs were included in the data analysis. Spiritual well-being and organizational support were each significantly associated with reduced total MI (p's < 0.001), shame-related MI (p = 0.03 and p = 0.02, respectively) and trust-violation-related MI (p's < 0.001). Notably, comparison of the standardized beta coefficients suggests that the association between trust-violation-related MI and both spiritual well-being and organizational support was more than twice as great as the associations between these variables and shame-related MI, emphasizing the importance of these supports and the trust-violation outcomes particularly. Mental health history (p = 0.02) and self-compassion (p = 0.01) were additionally related to shame-related MI only. Our findings indicate that heightened levels of spiritual well-being and organizational support were associated with reduced MI among HCPs during the COVID-19 pandemic. Rather than placing sole responsibility for mental health outcomes on HCPs individually, organizations can instead play a significant role in mitigating MI among staff by implementing evidence-informed organizational policies and interventions and by considering how supports for spiritual well-being may be implemented into existing models of care where relevant for employees.

Mental Health Status, Risk and Protective Factors for Healthcare Staff Prior to the First Major COVID-19 Outbreak in Western Australia

Objectives: Western Australia's unique public health response delayed the first wave of community COVID-19 transmission for 2 years. We aimed to determine the status of post-traumatic stress (PTSS), depressive, and anxiety symptoms among healthcare staff in major tertiary hospitals, together with associated risk and protective factors prior to the first substantial outbreak of COVID-19. Methods: A cross-sectional study was conducted with 431 healthcare staff immediately prior to the Western Australian border re-opening in 2022. Staff were recruited via notices in email newsletters, at four tertiary hospitals and a public mental health clinic in metropolitan Perth. Validated and original questionnaires were administered via Qualtrics. Results: Moderate levels of PTSS (22.3%), depression (21.9%), and anxiety (25.9%) were reported. Pathway analyses indicated that sleep difficulties, workplace stressors, and infectious disease training were associated with higher PTSS, depression and anxiety symptoms, and younger age was associated with higher levels of depression and anxiety. Nursing roles were associated with higher PTSS. Social support and workplace support were associated with lower levels of depression and anxiety but were not associated with PTSS. Conclusion: The findings illustrate high levels of resilience, but indicate a need for structural supports within the health system to foster staff mental health prior to the onset of emergencies.

Day to Day and Environmental Risk Factors for Psychological Distress Among Healthcare Workers: A Mixed Methods Analysis

OBJECTIVE

Despite a growing literature on mental health among clinical staff during COVID-19, factors shaping distress for nonclinical staff are understudied and may be driven by inequalities at work. We aimed to discuss the role of workplace factors in shaping psychological distress for a diverse group of clinical, nonclinical, and other health and hospital workers (HHWs).

METHODS

This convergent parallel mixed-methods study with HHWs in a US hospital system included an online survey ( n = 1127) and interviews ( n = 73) collected from August 2020 to January 2021. We thematically analyzed interviews; findings informed log binomial regression estimating risk factors for severe psychological distress (Patient Health Questionnaire - 4 item version [PHQ-4] scores of 9 or greater).

RESULTS

Qualitatively, day-to-day stressors fostered fear and anxiety, and concerns about work environments manifest as betrayal and frustration with leadership. Distress was associated with burnout, financial concerns, and feeling betrayed or unsupported by the institution and leadership. Staff in service versus clinical roles had higher risk for severe distress (adjusted prevalence ratio = 2.04, 95% confidence interval = 1.13-2.66); HHWs receiving workplace mental health support had lower risk (adjusted prevalence ratio = 0.52, 95% confidence interval = 0.29-0.92.

CONCLUSIONS

Our mixed-methods study underscores how the pandemic brought inequalities to the surface to increase distress for vulnerable HHWs. Workplace mental health activities can support HHWs now and during future crises.

Good death disrupted: Nurses' moral emotions navigating clinical and public health ethics during the first wave of COVID-19 pandemic

AIM

To explore the moral emotions that frontline nurses navigated in endeavouring to ensure a 'good death' for hospital patients and care home residents during the first wave of the COVID-19 pandemic.

BACKGROUND

Under normal circumstances, frontline staff are focused on clinical ethics, which foreground what is best for individuals and families. Public health crises such as a pandemic require staff to adapt rapidly to focus on what benefits communities, at times compromising individual well-being and autonomy. Visitor restrictions when people were dying provided vivid exemplars of this ethical shift and the moral emotions nurses encountered with the requirement to implement this change.

METHODS

Twenty-nine interviews were conducted with nurses in direct clinical care roles. Data were analysed thematically informed by the theoretical concepts of a good death and moral emotions.

RESULTS

The data set highlighted that moral emotions such as sympathy, empathy, distress and guilt were integral to the decisions participants described in striving for a good palliative experience. Four themes were identified in the data analysis: nurses as gatekeepers; ethical tensions and rule bending; nurses as proxy family members; separation and sacrifice.

CONCLUSIONS

Participants reflected on morally compromising situations and highlighted agency through emotionally satisfying workarounds and collegial deliberations that enabled them to believe that they were party to painful but morally justifiable decisions.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Nurses are required to implement national policy changes that may disrupt notions of best practice and therefore be experienced as a moral wrong. In navigating the moral emotions accompanying this shift, nurses benefit from compassionate leadership and ethics education to support team cohesion enabling nurses to prevail.

PUBLIC CONTRIBUTION

Twenty-nine frontline registered nurses participated in the qualitative interviews that inform this study.

REPORTING METHOD

The study adhered to the Consolidated Criteria for Reporting Qualitative Research checklist.