Understanding and mitigating moral injury in nurses

Burnout, moral injury, and suicidal/self-harm ideation among healthcare professionals in Mainland China: Insights from an online survey during the COVID-19 pandemic

OBJECTIVE

This survey explored the relationships between burnout, moral injury, and suicidal/self-harm ideation among Chinese health professionals in mainland China.

METHODS

Health professionals were surveyed online using the Maslach Burnout Inventory-Human Services Survey for Medical Personnel, Patient Health Questionnaire-9, and the Moral Injury Symptom Scale-Health Professional version.

RESULTS

A total of 6,146 health professionals participated in the study. The average age of participants was 34.9 ± 8.5 years, and suicidal/self-harm ideation was present in 2,338 participants (38.0%). The prevalence of suicidal/self-harm ideation was more common among those with severe burnout (vs. mild burnout), particularly in the dimensions of emotional exhaustion, depersonalization, and decreased personal accomplishment. The prevalence of suicidal/self-harm ideation among those with significant moral injury symptoms was higher than in those without moral injury. Unconditional logistic regression analysis demonstrated that those with moderate or severe emotional exhaustion, moderate or severe reduced sense of professional accomplishment, and moderate or severe depersonalization were at increased risk of suicidal/self-harm ideation.Structural equation modelling demonstrated that burnout significantly mediated the relationship between moral injury and suicidal/self-harm ideation. The proportion of mediation (PM) by burnout was 43.0%.

CONCLUSIONS

This study found that burnout and moral injury were significant predictors of suicidal/self-harm ideation among health professionals in China. Both moral injury and burnout had positive and direct effects on suicidal/self-harm ideation, and burnout mediated the relationship between moral injury and suicidal/self-harm ideation. Interventions to address moral injury and subsequent burnout in Chinese healthcare workers may enhance the mental health of these healthcare professionals and increase the quality of care that they provide.

Identifying stigmatizing language in clinical documentation: A scoping review of emerging literature

BACKGROUND

Racism and implicit bias underlie disparities in health care access, treatment, and outcomes. An emerging area of study in examining health disparities is the use of stigmatizing language in the electronic health record (EHR).

OBJECTIVES

We sought to summarize the existing literature related to stigmatizing language documented in the EHR. To this end, we conducted a scoping review to identify, describe, and evaluate the current body of literature related to stigmatizing language and clinician notes.

METHODS

We searched PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Embase databases in May 2022, and also conducted a hand search of IEEE to identify studies investigating stigmatizing language in clinical documentation. We included all studies published through April 2022. The results for each search were uploaded into EndNote X9 software, de-duplicated using the Bramer method, and then exported to Covidence software for title and abstract screening.

RESULTS

Studies (N = 9) used cross-sectional (n = 3), qualitative (n = 3), mixed methods (n = 2), and retrospective cohort (n = 1) designs. Stigmatizing language was defined via content analysis of clinical documentation (n = 4), literature review (n = 2), interviews with clinicians (n = 3) and patients (n = 1), expert panel consultation, and task force guidelines (n = 1). Natural language processing was used in four studies to identify and extract stigmatizing words from clinical notes. All of the studies reviewed concluded that negative clinician attitudes and the use of stigmatizing language in documentation could negatively impact patient perception of care or health outcomes.

DISCUSSION

The current literature indicates that NLP is an emerging approach to identifying stigmatizing language documented in the EHR. NLP-based solutions can be developed and integrated into routine documentation systems to screen for stigmatizing language and alert clinicians or their supervisors. Potential interventions resulting from this research could generate awareness about how implicit biases affect communication patterns and work to achieve equitable health care for diverse populations.

New graduate nurses' delivery of patient care: A focused ethnography

AIM

To explore factors influencing newly graduated nurses' delivery of direct care in acute care hospital settings.

DESIGN

Qualitative study using focused ethnography.

METHODS

During the period from March to June 2022, a total of ten newly graduated nurses were purposively sampled, and data were collected through 96 h of participant observation as well as ten semi-structured interviews. This research took place in a large hospital located in Denmark. Data were analysed using LeCompte and Schensul's ethnographic content analysis.

RESULTS

Three main structures were developed from the data: 'Contrasting Intentions and Actions for care delivery', 'Organizational Constraints Block Interpersonal Aspects of Nursing Care' and 'Newly Graduated Nurses' Suppressed Need for Support Constitutes Delay in Care Actions'.

CONCLUSION

Newly graduated nurses were committed to delivering high-quality care but were aware they sometimes provided compromised care. The paradox between a commitment to care and compromised care delivery was borne out of tensions between newly graduated nurses' professional beliefs and nursing values, a desire to integrate patients' needs and preferences, and organizational constraints on everyday practices where newly graduated nurses often worked alone without the support of a more experienced nurse. Critical reflection on cultural, social and political forces that influence direct care delivery might support newly graduated nurses to deliver direct patient care more intentionally.

RELEVANCE TO CLINICAL PRACTICE

Establishment of onboarding programs and other support activities for newly graduated nurses to cope with contrasting intentions and actions that must address organizational constraints is essential. These development programs should include how critical reflection competency is supported to address value inconsistencies and emotional distress to ensure high-quality patient care.

REPORTING METHOD

The reporting adhered to the COREQ guidelines. PATIENT OR PUBLIC CONTRIBUTION: 'No Patient or Public Contribution'.

Supporting nurse leaders to recognise and mitigate the effects of moral injury

The concept of moral injury has been around for several decades, yet its effect on nurses remains under-recognised. Moral injury is defined as the biopsychosocial harm that arises from a violation of one's moral code, meaning that a person is powerless to uphold and enact what they believe is morally right. The coronavirus disease 2019 (COVID-19) pandemic has brought the issue of moral injury into focus because many nurses and other healthcare professionals have encountered potentially morally injurious events, resulting in increased pressure and emotional demands. It is essential that nurse leaders recognise moral injury if its effects are to be addressed. This article describes moral injury and its effects on nurses, and offers nurse leaders a practical framework for mitigating this issue. The framework aims to support nurse leaders to increase their understanding of moral injury, address any ethical challenges, ensure they are adequately prepared to provide support to nurses, and enhance their awareness of various interventions that can mitigate moral injury.