The Association of Moral Injury and Healthcare Clinicians' Wellbeing: A Systematic Review

Understanding the Lived Experience of Nurses: A Mixed-Methods Study of Resilience and Burnout

BACKGROUND

During COVID-19, organizations accommodated an increase in critically ill and isolated patients. Rapid changes to workload and the environment consumed daily operations, causing an unrelenting strain on nurses.

OBJECTIVE

This study explored the lived experience of nurses during a pandemic event. Additional objectives were to determine the levels of individual resilience and burnout.

METHODS

This cross-sectional survey used a convergent mixed-methods design. Descriptive and inferential statistics were used to summarize and test differences in resiliency and burnout scores. Constant comparative analysis was used to analyze qualitative responses.

RESULTS

The Brief Resilient Coping Scale indicated medium resilient copers (mean, 15.7 [SD, 2.52]). There was no correlation between burnout and Brief Resilient Coping Scale (r = 0.186). Four themes were identified: (1) mental, physical, and emotional toll; (2) constant change; (3) perceptions of leadership; and (4) burnout.

DISCUSSION

No correlation was found between coping ability and burnout. Nursing burnout was associated with the ongoing tolls, constant change, and leadership challenges.

Moral distress among infection prevention and control professionals: A scoping review

BACKGROUND

The COVID-19 pandemic highlighted the vital role of Infection Prevention and Control Professionals (IPCPs) in safeguarding public health. Amid rapidly evolving guidelines, critical personal protective equipment shortages, and surging workloads, IPCPs encountered unprecedented moral and ethical dilemmas. However, their experiences, ethical challenges, and the resulting moral distress remain understudied.

METHODS

A scoping review following Arksey and O'Malley's methodology was conducted to examine current research on ethical challenges and moral distress among IPCPs. Searches in CINAHL, MEDLINE via OVID, Emcare, Scopus, and Korea Citation Index yielded two extracted articles.

RESULTS

Common themes included high workload, increased recognition, pressure to deliver accurate and timely information, need for peer support, and evidence-based practice. Differences in nationality, role discretion, and administrative systems led to varied experiences. District Medical Officers in Norway experienced more decision-making responsibilities and resulting ethical dilemmas in the context of broader communities and municipalities. The experiences of IPCPs were confined to their respective healthcare facilities.

CONCLUSION

There is a dearth of available research reporting the moral distress experienced by IPCPs whilst there is a plethora for those seen as "frontline" workers. Given the integral decision-making and implementation roles of these health professionals, and the burdens of ethical dilemmas they experienced in pandemic preparedness and response, further research is imperative to inform strategies to build moral resilience in the future.

Understanding moral injury and its predictors among Chinese physicians

BACKGROUND

Moral injury - the betrayal of one's moral and professional values - is a negative factor affecting physicians' wellbeing. However, few studies have examined moral injury and its predictors in healthcare professionals. Therefore, this study aimed to explore the prevalence, associated factors, and predictors of moral injury in Chinese physicians.

METHODS

This study was a cross-sectional survey conducted from September 14 to October 27, 2023, in mainland China. A total of 549 physicians completed the online self-administered questionnaire through the WeChat app. The 10-item Moral Injury Symptom Scale-Health Professional (MISS-HP) was used to assess the severity of moral injury symptoms, and the Moral Injury Events Scale (MIES) was used to measure exposure to potentially morally injurious events (PMIEs).

RESULTS

The results of the study showed a mean score of 42.07 (SD = 13.67) for the MISS - HP, and the prevalence of moral injury among the physicians was 31.6%. The multiple linear regression identified five main predictors of moral injury: exposure to PMIEs, job satisfaction, lack of organizational support, witnessing patient suffering or death, and mental health needs.

CONCLUSIONS

Chinese physicians reported experiencing different types of PMIEs and suffering from moral injury-related symptoms in their clinical practice. It helped to understand modifiable risk factors for moral injury, highlighting the need for systemic interventions. Healthcare institutions can mitigate moral injury and safeguard the wellbeing of healthcare workers by building peer-support networks, improving communication to address workload issues, and implementing recognition systems for ethics.

Factors affecting the retention of healthcare assistants in English mental health services: a qualitative interview study

BACKGROUND

In the UK, healthcare assistants (HCAs) work alongside registered nurses and other clinicians to provide frontline clinical care. HCAs provide a considerable amount of essential direct patient care which, dependent on the setting, can include monitoring of temperature, pulse, respirations and ECGs, support with daily activities, emotional support and facilitating communication with other health professionals. In 2019, the leaver rate of HCAs and support workers in the UK was 13.4%. In many Trusts this was higher than the leaving rate for nurses. The aim of this study was to explore HCAs' experiences and their perceptions of the reasons for poor retention rates.

METHODS

We recruited HCAs from three English mental health Trusts. Recruitment information was circulated using a variety of approaches. 31 participants took part in semi-structured interviews. We explored the factors they considered to affect HCAs' decision to leave their role, and any differences they perceived with registered staff. Interviews were coded and analysed using the framework generated in a previous phase of the study which focused on retention of registered mental health professionals.

FINDINGS

Three key factors impacted HCAs job satisfaction, wellbeing, and motivation to remain in post: (1) high workloads and unclear role boundaries creating stress and concerns for patient care; (2) good relationships with line managers and colleagues providing essential support to cope with both work and personal challenges; (3) feeling undervalued by the wider organisation, with a lack of investment including pay, facilities, and opportunities for development. These factors combined to create a situation of high stress and low job satisfaction, with many HCAs expressing an intention or desire to leave, particularly when the pay is similar to much less demanding jobs in other sectors.

CONCLUSIONS

HCAs are a diverse group but many reported job dissatisfaction and feeling undervalued by the organisations they work for, with some struggling to cope with the cost-of-living crisis. Improved role boundaries, career pathways, and appreciation of the role such as reward and recognition schemes, could help retain this key staff group who provide a large proportion of essential patient care.

Moral injury: State of the Science

In this paper, I provide a concise overview of the state of the scientific study of moral injury (MI). I argue that the state of science is immature, characterized by the lack of a paradigmatic theory and a lack of rigor in terms of construct definition and measurement. Because researchers, clinicians, and the media reify the results of empirical and clinical outcome studies that are chiefly exploratory and fraught with internal validity problems, enthusiasm about MI continues to far outweigh scientific and actionable, practice-based knowledge. I posit that the field needs to have epistemic humility about MI, focus on building a paradigmatic model to generate and test hypotheses that will ultimately create knowledge about the causes and consequences of MI, and employ evidence-based assessment and intervention approaches to mitigate and treat the problem. To facilitate research in this area, I summarize the social-functional theory of moral behavior and a new theory of MI based on it. I also make recommendations for future research to advance the field into a normal science, which requires hypothesis-driven research and valid measurement.

Performance-Based Reimbursement, Illegitimate Tasks, Moral Distress, and Quality Care in Primary Care: A Mediation Model of Longitudinal Data

PURPOSE

We tested for direct and indirect effects that performance-based reimbursement (PBR) in primary care has on perceived individual and organizational quality of care, and the role of illegitimate tasks and moral distress as potential mediators.

METHOD

We used results from the Longitudinal Occupational Health survey in Healthcare Sweden with data collected in 2021, 2022, and 2023. The sample of primary care physicians who answered at all 3 years and were aged 68 or less was 433. Performance-based reimbursement was measured using a single item. The Bern Illegitimate Tasks Scale measured illegitimate tasks, and moral distress was measured with a 10-item scale. Six items from the English National Health Staff Survey were used to measure the quality of individual and organizational care.

RESULT

Of the 433 participants, 70% reported that PBR negatively impacted their work. Performance-based reimbursement was negatively associated with illegitimate tasks (b = -0.160; 95% CI, -0.240 to -0.080) and moral distress (b = -0.134; 95% CI, -0.210 to -0.058). These work factors were in turn associated with both individual and organizational quality of care. Using mediation models, we found an indirect effect (b = 0.011; 95% CI, 0.004 to 0.021) but no direct effect (b = 0.062; 95% CI, -0.019 to 0.143) between PBR on the quality of individual care.

CONCLUSION

Performance-based reimbursement systems should account for the experience of individual primary care physicians to ensure effective, safe, and quality care, as this study shows how the level of illegitimate tasks and moral distress due to a PBR system can undermine care delivery. Consequently, it is imperative for stakeholders to consider how health care systems relate to the health care staff's experience, well-being, and the care being provided.

Moral transgressions, psychological well-being, and family conflict in the context of the COVID-19 pandemic: The role of self-forgiveness

PURPOSE

The COVID-19 pandemic led many individuals to experience moral transgressions, exacerbating feelings of guilt and remorse. This study explored the role of the self-forgiveness of such transgressions in explaining their associations with psychological well-being and family conflict. We hypothesized that (a) higher levels of self-forgiveness would be associated with greater psychological well-being and reduced family conflict, (b) the perceived relevance of moral transgressions would be positively associated with self-forgiveness and indirectly associated with psychological well-being and family conflict through the mediation of self-forgiveness, and (c) the relationships between the variables of interest could vary across age.

METHOD

Adults (N = 277; M age = 30.04) completed anonymous online questionnaires assessing the relevance of transgressions committed, forgiveness and unforgiveness of self, psychological well-being, and family conflict during the first COVID-19 lockdown in Italy.

RESULTS

Structural equation modeling revealed that transgression relevance was positively associated with both forgiveness and unforgiveness of self, and indirectly related to psychological well-being and family conflict via self-forgiveness. Greater forgiveness of self was related to greater eudaimonic well-being, whereas greater unforgiveness of self was linked to increased family conflict and reduced eudaimonic well-being. The findings also indicated that age moderated the relationship between forgiveness of self and hedonic well-being, with the association weakening as age increased.

CONCLUSIONS

The results highlight the importance of promoting self-forgiveness to enhance psychological resilience and familial stability, particularly during challenging times.

Moral injury and mental health in healthcare workers are linked to organizational culture and modifiable workplace conditions: Results of a national, mixed-methods study conducted at Veterans Affairs (VA) medical centers during the COVID-19 pandemic

Using mixed methods, we examined drivers of risk for moral injury, mental health symptoms, and burnout among frontline healthcare workers in high-risk Veterans Affairs (VA) clinical settings during the COVID-19 pandemic. Across 21 VA medical centers, 2,004 healthcare workers completed an online survey assessing potential risk factors for moral injury, posttraumatic stress, depression, and burnout. Assessed risk factors included: pandemic exposures; individual worker characteristics; aspects of workplace/organizational culture; and facility performance on standardized measures of care quality, patient satisfaction, and employee satisfaction (extracted from VA administrative data). Among surveyed workers, 39% were at risk for moral injury, 41% for posttraumatic stress, 27% for depression, and 25% for persistent burnout. In generalized linear mixed models, significant predictors of moral injury risk included perceived lack of management support for worker health/safety, supervisor support, coworker support, and empowerment to make job-related decisions-all modifiable workplace factors. Pandemic-related risk factors for moral injury included prolonged short-staffing, denying patient-family visits, and high work-family conflict. Predictors of posttraumatic stress, depression, and burnout were similar. Forty-six surveyed workers completed a follow-up qualitative interview about experiences of moral distress in the workplace, and interview themes aligned closely with survey findings. Rapid qualitative analysis identified protective factors that may reduce moral injury risk, including a collaborative workplace community, engaged leadership, empowerment to make changes in the workplace, and opportunity to process distressing events. We conclude with recommendations to mitigate moral injury risk in healthcare organizations. These include involving workers in discussions of high-stakes decisions that will affect them, creating consistent and clear channels of communication between the frontlines and leaders of the organization, practicing leadership rounding to improve leaders' understanding of the daily work of frontline teams, and collaborating to understand how existing processes and policies may contribute to safety risks and moral conflict.

Examining the Impact of Moral Injury on Burnout, Impostor Syndrome, and Low Self-Compassion Among Female Medical Trainees: A Secondary Analysis

OBJECTIVE

To examine the prevalence of moral injury and its association with burnout, impostor syndrome, and low self-compassion in physician trainees.

METHODS

This is a secondary analysis of baseline data from 1017 female physician trainees across 26 institutions who volunteered for a randomized controlled trial of a well-being program in 2022. Participants completed the Moral Injury Symptom Scale-Healthcare Professionals (MISS-HP), Maslach Burnout Inventory, Young Impostor Syndrome Scale, and Neff Self-Compassion Scale-Short Form. Univariate and multivariate logistic regressions were used to assess outcomes.

RESULTS

Of 1017 participants, 787 (77.4%) completed the MISS-HP, of whom 600 (76.2%) experienced moral injury (≥36 score). All models adjusted for postgraduate year and race. After additionally controlling for impostor syndrome and self-compassion, moral injury was associated with positive burnout (odds ratio [OR], 3.79; 95% CI, 2.55 to 5.66), high emotional exhaustion (OR, 2.96; 95% CI, 2.04 to 4.32), high depersonalization (OR, 4.28; 95% CI, 2.94 to 6.29), and low personal accomplishment (OR, 1.96; 95% CI, 1.34 to 2.88). Moral injury was also associated with positive impostor syndrome (OR, 1.71; 95% CI, 1.12 to 2.58) after controlling for burnout and self-compassion as well as with low self-compassion (OR, 3.35; 95% CI, 2.15 to 5.34) after controlling for burnout and impostor syndrome.

CONCLUSION

Female medical trainees have a high prevalence of moral injury, which has significant associations with burnout, impostor syndrome, and low self-compassion. Effective interventions require further implementation and analysis to reduce moral injury among medical trainees.

System-based strategies for mitigating burnout in radiology

BACKGROUND

Burnout is a chronic problem prevalent in radiology, with a significant burden on individuals and healthcare systems.

DISCUSSION

A substantial portion of the literature on managing burnout has focused on individual-based remedies. We posit that burnout is a systemic problem and present an overview of some system-based strategies that could be employed to mitigate burnout in radiology. These include managing workload, optimizing work shifts, maximizing autonomy, limiting work-life conflicts, creating opportunities for professional fulfillment, utilizing user-friendly electronic medical records (EMR), deploying efficient picture archiving and communication systems (PACS), building system redundancy, leadership transparency, and fostering a healthy work environment.  CONCLUSION: System-based strategies can help mitigate burnout.

Moral Injury in Correctional Health Care

Due to the complex nature of correctional facilities, correctional health care professionals (CHPs) are at high risk of experiencing the harms of helping such as burnout, vicarious trauma, and post-traumatic stress disorder (PTSD). Although traditionally applied to military populations, the construct of moral injury has gained increasing application to health care and bears relevance to correctional health care. This qualitative study examines the prevalence of moral injury among CHPs while considering the moral dilemmas and ethical challenges of delivering care in a carceral environment. Employing an interpretative phenomenological analysis (IPA), 25 semi-structured interviews were conducted with a diverse sample of CHPs, selected through nonprobability, purposive sampling. Rigorous thematic analysis, guided by IPA principles, was used. The data revealed five key themes: moral injury is an occupational hazard for correctional health care workers; incidental versus cumulative moral injury; role of institutional betrayal; the intersectional relationship among moral injury, PTSD, and burnout; and the road to moral repair. These themes offer insights into the prevalence and effects of moral injury in correctional health care while offering solutions to navigating moral injury. These findings contribute to a deeper understanding of the complex ethical and psychological dynamics within correctional health care settings and explore implications for practice, policy, and future research.

Generational Differences in Moral Injury, Resilience, and Well-Being Among Nurses: Predictors of Intention to Leave Position and Profession

BACKGROUND

The COVID-19 pandemic highlighted the negative impact of moral injury on nurses' well-being. However, there is a lack of research about generational differences among nurses, particularly on newer nurses who have been identified as having a higher rate of intention to leave.

OBJECTIVE

This study examines generational differences among nurses on moral injury, well-being, resilience, and intention to leave their nursing position and profession.

METHODS

This is a secondary analysis of cross-sectional data from registered nurses in clinical practice in Ohio between July and August 2021. Data on demographics, moral injury, resilience, and well-being were collected using an online survey. Participants were categorized into 4 generational groups based on their age in 2021: Baby Boomers (57-75 years old), Generation X (42-56 years old), Generation Y (27-41 years old), and Generation Z (12-26 years old). Descriptive and inferential statistics, including logistic regression and analysis of variance, were employed for analysis.

RESULTS

Significant generational differences were found in years of clinical experience, moral injury, resilience, and well-being. Baby Boomers reported higher well-being and resilience and lower moral injury. Notably, the intention to leave the profession was more strongly associated with well-being and moral injury levels than with the years of experience or generational group.

CONCLUSIONS

The findings suggest that interventions to improve nurse retention should prioritize enhancing well-being and addressing the root causes of moral injury. Tailored strategies addressing the needs of different generations are necessary for mitigating the adverse effects of current healthcare challenges on nurse attrition.

"Working within broken systems": Social workers bridge the fractures of U.S. healthcare: A qualitative inquiry on moral injury

Healthcare social workers (HSWs) in the United States are integral to interdisciplinary teams and health services. HSWs have a unique role in healthcare, as they care for their patients' psychosocial needs, through case management and clinical services. There is a gap in understanding how HSWs are impacted by their healthcare work. This study aims to understand the experience of moral injury, a marker of well-being, amongst HSWs in one state in the United States. Moral injury is the moral transgression (or boundary breaking) by oneself or someone in a position of power in high stakes situations and the negative outcomes of those experiences. Using a qualitative approach, semi-structured interviews were conducted with 24 HSWs in August of 2022. Thematic analysis was used to understand the lived experience of moral injury for HSWs. Three themes emerged: 1) HSWs' definition and examples of moral injury; 2) HSWs situated in the "in-between" of policy and practice; and 3) upholding social work values within the medical model. These findings impact healthcare practice and policy, in delineating what falls within the bounds of social work, changing the workflow of health services, and creating further opportunities for interdisciplinary training, well-being initiatives, and systems-level changes. The findings from this work highlight the importance of understanding the moral impact of healthcare work on social workers, which should be further examined in depth not only amongst HSWs but also across the healthcare workforce.

General practitioner and nurse experiences of type 2 diabetes management and prescribing in primary care: a qualitative review following the introduction of funded SGLT2i/GLP1RA medications in Aotearoa New Zealand

AIM

To explore the views of general practitioners (GPs) and nurses on type 2 diabetes (T2D) management, including the use of recently funded T2D medications in New Zealand (NZ) and their perceived barriers to providing optimal care.

BACKGROUND

T2D is a significant health concern in NZ, particularly among Māori and Pacific adults. Characterised by prolonged hyperglycaemia, T2D is generally a progressive condition requiring long-term care.

METHODS

Semi-structured interviews were conducted between July and December 2022 with 21 primary care clinicians (10 GPs and 11 nurses/nurse prescribers) from nine different general practice clinics across the Auckland and Waikato regions of NZ. Framework analysis was conducted to identify common themes in clinicians' perceptions and experiences with T2D management.

FINDINGS

Three themes were identified: health-system factors, new medications, and solution-based approaches. Lack of clinician time, healthcare funding, staff shortages, and burn-out were identified as barriers to T2D management under health-system factors. The two newly funded medications, empagliflozin and dulaglutide, were deemed to be a positive change for T2D care in that they improved patient satisfaction and clinical outcomes, but several clinicians were hesitant to prescribe these medications. Participants suggested that additional education and specialist diabetes support would be helpful to inform optimal medication prescribing and that better use of a multi-disciplinary team (clinical and support staff) could support T2D care by reducing workload, addressing cultural gaps in healthcare delivery, and reducing burnout. An improved primary care work environment, including appropriate professional development to support prescribing of new medications and the value of collaboration with a non-regulated workforce, may be required to facilitate optimal T2D management in primary care. Future research should focus on interventions to increase support for both clinical teams and patients while adopting a culturally appropriate approach to increase patient satisfaction and improve health outcomes.

The Work-life Check-ins randomized controlled trial: A leader-based adaptive, semi-structured burnout intervention in primary care clinics

BACKGROUND

Burnout in primary care undermines worker well-being and patient care. Many factors contribute to burnout, including high workloads, emotional stress, and unsupportive supervisors. Formative evidence suggests that burnout might be reduced if clinic leaders hold quarterly and brief (∼30 min) one-on-one check-ins with team members to acknowledge and address work-life stressors (e.g., schedules, workflow breakdowns, time off requests). This paper describes the intervention protocol for a randomized controlled trial (RCT) designed to evaluate the effectiveness and process of the check-ins in reducing burnout among primary care professionals.

METHODS

Two-arm RCT conducted at 12 primary care clinics of a healthcare system in the Pacific Northwest. Six clinics received an adaptive design, semi-structured intervention, including predefined training modules with evidence-based tactics to reduce burnout through the check-ins, followed by clinic-specific feedback sessions prior to offering and conducting quarterly leader-employee check-ins. Six clinics were randomized as waitlist controls. Burnout was measured using the Maslach Burnout Inventory (MBI) at baseline and at the 12-month follow-up. Secondary outcomes include organizational constraints, psychological safety, and supervisor support. Multilevel modeling and qualitative methods were applied to evaluate the effects and process of the intervention.

CONCLUSION

By focusing on modifiable work-life factors such as stressors and supervisor support, the check-ins intervention aims to reduce burnout rates among primary care professionals. Findings from this trial will shed light on the conditions upon which check-ins might reduce burnout. Results will also inform policies and interventions aimed at improving mental health and well-being in primary care settings.

CLINICALTRIALS

gov: ID NCT05436548.

Tools for Hospital Medicine Leadership in the Post-Pandemic Era

Leadership in today's hospital medicine environment requires vision, clear goals and importantly, engagement and buy-in from practice members. The phenomenon of "quiet quitting," a form of disengagement can be combatted through the methods of LEAD (Litmus test, Encouragement and Empowerment, Advocacy and Accountability, Discourse and Discrepancies). Leaders striving to be effective must critically examine their own skill sets and find the balance between operational demands of the modern hospital and physicians' need for respect and autonomy in the workplace.