Reliability and validity of the revised Rushton Moral Resilience Scale for healthcare workers.

AIM: To refine the Rushton Moral Resilience Scale (RMRS) by creating a more concise scale, improving the reliability, particularly of the personal integrity subscale and providing further evidence of validity. BACKGROUND: Healthcare workers are exposed to moral adversity in practice. When unable to preserve/restore their integrity, moral suffering ensues. Moral resilience is a resource that may mitigate negative consequences. To better understand mechanisms for doing so, a valid and reliable measurement tool is necessary. DESIGN: Cross-sectional survey. METHODS: Participants (N = 1297) had completed ≥1 items on the RMRS as part of the baseline survey of a larger longitudinal study. Item analysis, confirmatory factor analyses, reliability analyses (Cronbach's alpha), and correlations were used to establish reliability and validity of the revised RMRS. RESULTS: Item and confirmatory factor analysis were used to refine the RMRS from 21 to 16 items. The four-factor structure (responses to moral adversity, personal integrity, relational integrity and moral efficacy) demonstrated adequate fit in follow-up confirmatory analyses in the initial and hold-out sub-samples. All subscales and the total scale had adequate reliabilities (α ≥ 0.70). A higher-order factor analysis supports the computation of either subscale scores or a total scale score. Correlations of scores with stress, anxiety, depression and moral distress provide evidence of the scale's validity. Reliability of the personal integrity subscale improved. CONCLUSION AND IMPLICATIONS: The RMRS-16 demonstrates adequate reliability and validity, particularly the personal integrity subscale. Moral resilience is an important lever for reducing consequences when confronted with ethical challenges in practice. Improved reliability of the four subscales and having a shorter overall scale allow for targeted application and will facilitate further research and intervention development. PATIENT/PUBLIC CONTRIBUTION: Data came from a larger study of Canadian healthcare workers from multiple healthcare organizations who completed a survey about their experiences during COVID-19.

The Impact of Transitional Shock on Newer Nurses in a Contemporary Healthcare Environment.

OBJECTIVE: The aim of this study was to understand newer nurses' perception and expectations of their work environment, professional and institutional satisfaction, and motivating/decision-making factors around nursing and intent to leave their positions. BACKGROUND: Studies have shown newly graduated nurses face many challenges transitioning from a student to an independently practicing nurse. The COVID pandemic complicated this transition and created new stressors resulting in discouragement and turnover for newer nurses. METHODS: This study used a qualitative approach through purposive sampling, semistructured qualitative interviews, and content analytic techniques. Transitional Shock Theory was used as the theoretical framework. RESULTS: Four themes emerged from the study: 1) confronting the reality; 2) betrayal/mistrust; 3) relational integrity; and 4) enablers of clinical competence. CONCLUSIONS: The findings will help nurse leaders understand the importance of organizational-level supports to improve the transition of newer nurses in typical periods and in times of additional stress.

Betrayal-Based Moral Injury and Mental Health Problems Among Healthcare and Hospital Workers Serving COVID-19 Patients.

One factor potentially driving healthcare and hospital worker (HHW)'s declining mental health during the COVID-19 pandemic is feeling betrayed by institutional leaders, coworkers, and/or others' pandemic-related responses and behaviors. We investigated whether HHWs' betrayal-based moral injury was associated with greater mental distress and post-traumatic stress disorder (PTSD) symptoms related to COVID-19. We also examined if these associations varied between clinical and non-clinical staff. From July 2020 to January 2021, cross-sectional online survey data were collected from 1,066 HHWs serving COVID-19 patients in a large urban US healthcare system. We measured betrayal-based moral injury in three groups: institutional leaders, coworkers/colleagues, and people outside of healthcare. Multivariate logistic regression analyses were performed to investigate whether betrayal-based moral injury was associated with mental distress and PTSD symptoms. Approximately one-third of HHWs reported feeling betrayed by institutional leaders, and/or people outside healthcare. Clinical staff were more likely to report feelings of betrayal than non-clinical staff. For all respondents, 49.5% reported mental distress and 38.2% reported PTSD symptoms. Having any feelings of betrayal increased the odds of mental distress and PTSD symptoms by 2.9 and 3.3 times, respectively. These associations were not significantly different between clinical and non-clinical staff. As health systems seek to enhance support of HHWs, they need to carefully examine institutional structures, accountability, communication, and decision-making patterns that can result in staff feelings of betrayal. Building trust and repairing ruptures with HHWs could prevent potential mental health problems, increase retention, and reduce burnout, while likely improving patient care.

Palliative Care Early in the Care Continuum among Patients with Serious Respiratory Illness: An Official ATS/AAHPM/HPNA/SWHPN Policy Statement.

Background: Patients with serious respiratory illness and their caregivers suffer considerable burdens, and palliative care is a fundamental right for anyone who needs it. However, the overwhelming majority of patients do not receive timely palliative care before the end of life, despite robust evidence for improved outcomes. Goals: This policy statement by the American Thoracic Society (ATS) and partnering societies advocates for improved integration of high-quality palliative care early in the care continuum for patients with serious respiratory illness and their caregivers and provides clinicians and policymakers with a framework to accomplish this. Methods: An international and interprofessional expert committee, including patients and caregivers, achieved consensus across a diverse working group representing pulmonary-critical care, palliative care, bioethics, health law and policy, geriatrics, nursing, physiotherapy, social work, pharmacy, patient advocacy, psychology, and sociology. Results: The committee developed fundamental values, principles, and policy recommendations for integrating palliative care in serious respiratory illness care across seven domains: 1) delivery models, 2) comprehensive symptom assessment and management, 3) advance care planning and goals of care discussions, 4) caregiver support, 5) health disparities, 6) mass casualty events and emergency preparedness, and 7) research priorities. The recommendations encourage timely integration of palliative care, promote innovative primary and secondary or specialist palliative care delivery models, and advocate for research and policy initiatives to improve the availability and quality of palliative care for patients and their caregivers. Conclusions: This multisociety policy statement establishes a framework for early palliative care in serious respiratory illness and provides guidance for pulmonary-critical care clinicians and policymakers for its proactive integration.

Emerging Experiences with Virtual Clinical Ethics Consultation: Case Studies from the United States and Malaysia.

AbstractThe COVID-19 pandemic has inspired numerous opportunities for telehealth implementation to meet diverse healthcare needs, including the use of virtual communication platforms to facilitate the growth of and access to clinical ethics consultation (CEC) services across the globe. Here we discuss the conceptualization and implementation of two different virtual CEC services that arose during the COVID-19 pandemic: the Clinical Ethics Malaysia COVID-19 Consultation Service and the Johns Hopkins Hospital Ethics Committee and Consultation Service. A common strength experienced by both platforms during virtual delivery included improved ability for local practitioners to address consultation needs for patient populations otherwise unable to access CEC services in their respective locations. Additionally, virtual platforms allowed for enhanced collaboration and sharing of expertise among ethics consultants. Both contexts encountered numerous challenges related to patient care delivery during the pandemic. The use of virtual technologies resulted in decreased personalization of patient-provider communication. We discuss these challenges with respect to contextual differences specific to each service and setting, including differences in CEC needs, sociocultural norms, resource availability, populations served, consultation service visibility, healthcare infrastructure, and funding disparities. Through lessons learned from a health system in the United States and a national service in Malaysia, we provide key recommendations for health practitioners and clinical ethics consultants to leverage virtual communication platforms to mitigate existing inequities in patient care delivery and increase capacity for CEC globally.

The Long Tail of COVID-19: Implications for the Future of Emergency Nursing.

INTRODUCTION: COVID-19 has led to exacerbated levels of traumatic stress and moral distress experienced by emergency nurses. This study contributes to understanding the perspectives of emergency nurses' perception of psychological trauma during COVID-19 and protective mechanisms used to build resilience. METHOD: The primary method was qualitative analysis of semistructured interviews, with survey data on general resilience, moral resilience, and traumatic stress used to triangulate and understand qualitative findings. Analyses and theme development were guided by social identity theory and informed by the middle range theory of nurses' psychological trauma. RESULTS: A total of 14 emergency nurses were interviewed, 11 from one site and 3 from the other. Almost all nurses described working in an emergency department throughout the pandemic as extraordinarily stressful, morally injurious, and exhausting at multiple levels. Although the source of stressors changed throughout the pandemic, the culmination of continued stress, moral injury, and emotional and physical exhaustion almost always exceeded their ability to adapt to the ever-changing landscape in health care created by the pandemic. Two primary themes were identified: losing identity as a nurse and hopelessness and self-preservation. DISCUSSION: The consequences of the pandemic on nurses are likely to be long lasting. Nurses need to mend and rebuild their identity as a nurse. The solutions are not quick fixes but rather will require fundamental changes in the profession, health care organizations, and the society. These changes will require a strategic vision, sustained commitment, and leadership to accomplish.

The new frontline: exploring the links between moral distress, moral resilience and mental health in healthcare workers during the COVID-19 pandemic.

BACKGROUND: Global health crises, such as the COVID-19 pandemic, confront healthcare workers (HCW) with increased exposure to potentially morally distressing events. The pandemic has provided an opportunity to explore the links between moral distress, moral resilience, and emergence of mental health symptoms in HCWs. METHODS: A total of 962 Canadian healthcare workers (88.4% female, 44.6 + 12.8 years old) completed an online survey during the first COVID-19 wave in Canada (between April 3rd and September 3rd, 2020). Respondents completed a series of validated scales assessing moral distress, perceived stress, anxiety, and depression symptoms, and moral resilience. Respondents were grouped based on exposure to patients who tested positive for COVID-19. In addition to descriptive statistics and analyses of covariance, multiple linear regression was used to evaluate if moral resilience moderates the association between exposure to morally distressing events and moral distress. Factors associated with moral resilience were also assessed. FINDINGS: Respondents working with patients with COVID-19 showed significantly more severe moral distress, anxiety, and depression symptoms (F > 5.5, p < .020), and a higher proportion screened positive for mental disorders (Chi-squared > 9.1, p = .002), compared to healthcare workers who were not. Moral resilience moderated the relationship between exposure to potentially morally distressing events and moral distress (p < .001); compared to those with higher moral resilience, the subgroup with the lowest moral resilience had a steeper cross-sectional worsening in moral distress as the frequency of potentially morally distressing events increased. Moral resilience also correlated with lower stress, anxiety, and depression symptoms (r > .27, p < .001). Factors independently associated with stronger moral resilience included: being male, older age, no mental disorder diagnosis, sleeping more, and higher support from employers and colleagues (B [0.02, |-0.26|]. INTERPRETATION: Elevated moral distress and mental health symptoms in healthcare workers facing a global crisis such as the COVID-19 pandemic call for the development of interventions promoting moral resilience as a protective measure against moral adversities.

The Impact of Traumatic Stress, Resilience, and Threats to Core Values on Nurses During a Pandemic.

OBJECTIVE: The aim of this study was to understand the traumatic stress and resilience of nurses who cared for patients with COVID-19. BACKGROUND: Studies have shown a high proportion of healthcare workers are at risk for developing posttraumatic stress disorder after a pandemic. Resilience factors are believed to play an important role in the well-being of healthcare professionals. METHODS: This was a triangulated mixed methods study; a phenomenological qualitative approach with survey data was used to triangulate the findings, and sensemaking was used as the theoretical framework. RESULTS: Four themes emerged from the study: 1) phases of traumatic stress response to perceived threats; 2) honoring their sacrifice; 3) professional self-identity; and 4) sustaining resilience in a stressful work environment. Quantitative results on traumatic stress, general resilience, and moral resilience supported the themes. CONCLUSIONS: The findings will help leaders understand the potential for postpandemic mental health problems and the role of resilience in maintaining well-being.

Organizational Impact on Healthcare Workers' Moral Injury During COVID-19: A Mixed-Methods Analysis.

OBJECTIVE: The aim of this study was to explore relationships between organizational factors and moral injury among healthcare workers and the impact of perceptions of their leaders and organizations during COVID-19. BACKGROUND: COVID-19 placed healthcare workers at risk for moral injury, which often involves feeling betrayed by people with authority and can impact workplace culture. METHODS: Secondary data from a Web-based survey of mid-Atlantic healthcare workers were analyzed using mixed methods. Data were synthesized using the Reina Trust & Betrayal Model. RESULTS: Fifty-five percent (n = 328/595) of respondents wrote comments. Forty-one percent (n = 134/328) of commenters had moral injury scores of 36 or higher. Three themes emerged: organizational infrastructure, support from leaders, and palliative care involvement. Respondents outlined organizational remedies, which were organized into 5 domains. CONCLUSIONS: Findings suggest healthcare workers feel trust was breached by their organizations' leaders during COVID-19. Further study is needed to understand intersections between organizational factors and moral injury to enhance trust within healthcare organizations.

Burnout and moral resilience in interdisciplinary healthcare professionals.

AIMS AND OBJECTIVES: To examine demographic and work characteristics of interdisciplinary healthcare professionals associated with higher burnout and to examine whether the four domains of moral resilience contribute to burnout over and above work and demographic variables. BACKGROUND: Healthcare professionals experience complex ethical challenges on a daily basis leading to burnout and moral distress. Measurement of moral resilience is a new and vital step in creating tailored interventions that will foster moral resilience at the bedside. DESIGN: Cross-sectional descriptive design. METHODS: Healthcare professionals in the eastern USA were recruited weekly via email for 3 weeks in this cross-sectional study. Online questionnaires were used to conduct the study. The STROBE checklist was used to report the results. RESULTS: Work and demographic factors, such as religious preference, years worked in a healthcare profession, practice location, race, patient age, profession and education level, have unique relationships with burnout subscales and turnover intention, with the four subscales of moral resilience demonstrating a protective relationship with outcomes above and beyond the variance explained by work and demographic characteristics. CONCLUSIONS: Higher moral resilience is related to lower burnout and turnover intentions, with multiple work demographic correlates allowing for potential areas of intervention to deal with an increase in morally distressing situations occurring at the bedside. Additionally, patterns of significant and non-significant relationships between the moral resilience subscales and burnout subscales indicate that these subscales represent unique constructs. RELEVANCE TO CLINICAL PRACTICE: Understanding the everyday, pre-pandemic correlations of moral resilience and burnout among interdisciplinary clinicians allows us to see changes that may exist. Measuring and understanding moral resilience in healthcare professionals is vital for creating ways to build healthier, more sustainable clinical work environments and enhanced patient care delivery.

Ethics in nursing: Progress on national nursing ethics summit.

BACKGROUND: In 2014 a National Nursing Ethics Summit was undertaken to chart a future for nursing ethics in the United States. PURPOSE: The purpose of this study was to understand changes in the field over a 5-year period as a measure of longitudinal impact and identify recommendations for education, practice, research and scholarship, and policy. METHODS: This cross-sectional study used a mixed method design. FINDINGS: Nineteen participants from 15 institutions participated in the survey. The majority of respondents agreed or strongly agreed on their effort in promoting education (84%), contributing to scholarship (74%), creating a sustained environment for ethical practice (63%) and developing new initiatives (58%) in nursing ethics. DISCUSSION: Further investment is needed to establish a more broadly funded research agenda for ethical issues in nursing, improvement in evidence-based practice, and development of policy initiatives to promote ethical practice and infrastructure for sustainability and responsiveness to contemporary challenges.

International consensus-based policy recommendations to advance universal palliative care access from the American Academy of Nursing Expert Panels.

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. On behalf of the Academy, these evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. Through improved palliative nursing education, nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative care nurses worldwide, nurses can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations. Part II herein provides a summary of international responses and policy options that have sought to enhance universal palliative care and palliative nursing access to date. Additionally, we provide ten policy, education, research, and clinical practice recommendations based on the rationale and background information found in Part I. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter.

Mapping the Terrain of Moral Suffering.

This essay explores what to make of the various kinds of moral distress and moral injury increasingly discussed in multiple disciplines and fields of work. It argues for transdisciplinary cooperation and inquiry and proposes a common name "moral suffering" to embrace the diversity of morally fracturing experiences that negatively impact those in health care and other helping professions. The authors offer important insights into the phenomenological relationship between moral conscience and traumatic experience, presenting questions and offering a possible hypothesis for those who want to pursue this discussion further. The essay reviews the diversity of theories regarding moral distress and moral injury advanced by health-care researchers, military clinicians, and educators. It names questions that transdisciplinary engagement can help address, such as what do the disciplines of health humanities, psychology, and education have to teach each other about prevention of moral harm and the healing of invisible wounds?

Ethical Dilemmas for Nursing Students and Faculty: In Their Own Voices.

AIM: The aim of this national study was to explore student and faculty personal experiences of ethical dilemmas in nursing education and clinical practice. BACKGROUND: Nurses encounter complex ethical dilemmas in practice that can lead to moral distress when they cannot "do the right thing" because of external constraints. METHOD: A mixed-methods study via online survey was conducted on senior nursing student members and faculty advisors of the National Student Nurses Association. Over 1,600 students and 600 faculty answered a "two-minute survey" with the question: "Please describe an ethical dilemma you have experienced." RESULTS: Descriptive statistics demonstrated a difference in student and faculty reports about the ethics content they received. The qualitative results from constant comparison of open-ended questions also supported differences in themes from student and faculty perspectives. CONCLUSION: This study supports that students and faculty voice their concerns with different ethical dilemmas in their nursing education experiences.

American Academy of Nursing Expert Panel consensus statement on nursing's roles in ensuring universal palliative care access.

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. Part I of this consensus paper herein provides the rationale and background to support the policy, education, research, and clinical practice recommendations put forward in Part II. On behalf of the Academy, the evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter. The authors recommend greater investments in palliative nursing education and nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative nurses worldwide. By enacting these recommendations, nurses working in all settings can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations.

Nurses confronting the coronavirus: Challenges met and lessons learned to date.

Registered nurses are an essential workforce group across the globe. They use their expertise and skill sets every day in clinical practice to protect, promote, and advocate on behalf of patients and families under their care. In this article we discuss the physical, emotional, and moral stresses that nurses are experiencing in their day-to-day practice settings created by the novel coronavirus. We consider the demands placed on nurses by unexpected patient surges within hospital environments and inadequate personal protective equipment and other critical resources, challenging nurses' ability to meet their professional and ethical obligations. We also share our thoughts on supporting nurses and others now, and ideas for needed healing for both individuals and organizations as we move forward. Finally, we argue for the need for substantive reform of institutional processes and systems that can deliver quality care in the future when faced with another devastating humanitarian and public health crises.

Interprofessionals' definitions of moral resilience.

AIMS AND OBJECTIVES: To describe common characteristics and themes of the concept of moral resilience as reported by interprofessional clinicians in health care. BACKGROUND: Research has provided an abundance of data on moral distress with limited research to resolve and help negate the detrimental effects of moral distress. This reveals a critical need for research on how to mitigate the negative consequences of moral distress that plague nurses and other healthcare providers. One promising direction is to build resilience as an individual strategy concurrently with interventions to build a culture of ethical practice. DESIGN/METHODS: Qualitative descriptive methods were used to analyse descriptive definitions provided by 184 interprofessional clinicians in health care attending educational programmes in various locations as well as a small group of 23 professionals with backgrounds such as chaplaincy and nonhealthcare providers. RESULTS: Three primary themes and three subthemes emerged from the data. The primary themes are integrity-personal and relational, and buoyancy. The subthemes are self-regulation, self-stewardship and moral efficacy. CONCLUSIONS: Individual healthcare providers and healthcare systems can use this research to help negate the detrimental effects of moral distress by finding ways to develop interventions to cultivate moral resilience. RELEVANCE TO CLINICAL PRACTICE: Moral resilience involves not only building and fostering the individual's capacity to navigate moral adversity but also developing systems that support a culture of ethical practice for healthcare providers.

A social-ecological framework: A model for addressing ethical practice in nursing.

AIMS AND OBJECTIVES: To develop a framework to enable discussion, debate and the formulation of interventions to address ethical issues in nursing practice. BACKGROUND: Social, cultural, political and economic drivers are rapidly changing the landscape of health care in our local environments but also in a global context. Increasingly, nurses are faced with a range of ethical dilemmas in their work. This requires investigation into the culture of healthcare systems and organisations to identify the root causes and address the barriers and enablers of ethical practice. The increased medicalisation of health care; pressures for systemisation; efficiency and cost reduction; and an ageing population contribute to this complexity. Often, ethical issues in nursing are considered within the abstract and philosophical realm until a dilemma is encountered. Such an approach limits the capacity to tangibly embrace ethical values and frameworks as pathways to equitable, accessible, safe and quality health care and as a foundation for strengthening a supportive and enabling workplace for nurses and other healthcare workers. DESIGN: Conceptual framework development. METHODS: A comprehensive literature review was undertaken using the social-ecological framework as an organising construct. RESULTS: This framework views ethical practice as the outcome of interaction among a range of factors at eight levels: individual factors (patients and families); individual factors (nurses); relationships between healthcare professionals; relationships between patients and nurses; organisational healthcare context; professional and education regulation and standards; community; and social, political and economic. CONCLUSIONS: Considering these elements as discrete, yet interactive and intertwined forces can be useful in developing interventions to promote ethical practice. We consider this framework to have utility in policy, practice, education and research. RELEVANCE TO CLINICAL PRACTICE: Nurses face ethical challenges on a daily basis, considering these within a social-ecological framework can assist in developing strategies and resolutions.

Harnessing the Promise of Moral Distress: A Call for Re-Orientation.

Despite over three decades of research into the sources and costs of what has become an "epidemic" of moral distress among healthcare professionals, spanning many clinical disciplines and roles, there has been little significant progress in effectively addressing moral distress. We believe the persistent sense of frustration, helplessness, and despair still dominating the clinical moral distress narrative signals a need for re-orientation in the way moral distress is understood and worked with. Most fundamentally, moral distress reveals moral investment and energy. It is the troubled call of conscience, an expression of fidelity to moral commitments seen as imperiled or compromised. It is crucial that we find ways to empower clinicians in heeding this call-to support clinicians' moral agency and voice, foster their moral resilience, and facilitate their ability to contribute to needed reform within the organizations and systems in which they work. These objectives must inform creative expansion in the design of strategies for addressing moral distress in the day-to-day of clinical practice. We include suggestions about promising directions such strategies might take in the hope of spurring further innovation within clinical environments.

A concept analysis of moral resilience.

BACKGROUND: Nurses experience moral distress, which has led to emotional distress, frustration, anger, and nurse attrition. Overcoming moral distress has become a significant focus in nursing research. PURPOSE: The continued focus on moral distress has not produced sustainable solutions within the nursing profession. Since positive language may alter the outcomes of morally distressing situations, we look to better understand one such positive phrase, moral resilience. METHODS: We explored moral resilience through a literature search using 11 databases to identify instances of the phrase. Occurrences of moral resilience were then divided into three distinct categories: antecedents, attributes, and consequences, and following this, major themes within each category were identified. DISCUSSION: There is a dearth of scholarship on moral resilience, and additionally, there is currently no unifying definition. Despite this, our analysis offers promising direction in refining the concept. CONCLUSION: This concept analysis reveals differences in how moral resilience is understood. More conceptual work is needed to refine the definition of moral resilience and understand how the concept is useful in mitigating the negative consequences of moral distress and other types of moral adversity.