Critical Care Nurses' Moral Resilience, Moral Injury, Institutional Betrayal, and Traumatic Stress After COVID-19.

BACKGROUND: Traumatic stress and moral injury may contribute to burnout, but their relationship to institutional betrayal and moral resilience is poorly understood, leaving risk and protective factors understudied. OBJECTIVES: To examine traumatic stress symptoms, moral injury symptoms, moral resilience, and institutional betrayal experienced by critical care nurses and examine how moral injury and traumatic stress symptoms relate to moral resilience, institutional betrayal, and patient-related burnout. METHODS: This cross-sectional study included 121 critical care nurses and used an online survey. Validated instruments were used to measure key variables. Descriptive statistics, regression analyses, and group t tests were used to examine relationships among variables. RESULTS: Of participating nurses, 71.5% reported significant moral injury symptoms and/or traumatic stress. Both moral injury symptoms and traumatic stress were associated with burnout. Regression models showed that institutional betrayal was associated with increased likelihood of traumatic stress and moral injury. Increases in scores on Response to Moral Adversity subscale of moral resilience were associated with a lower likelihood of traumatic stress and moral injury symptoms. CONCLUSIONS: Moral resilience, especially response to difficult circumstances, may be protective in critical care environments, but system factors (eg, institutional betrayal) must also be addressed systemically rather than relying on individual-level interventions to address nurses' needs.

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 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.

Understanding Type 2 Diabetes Self-Management in Racial/Ethnic Minorities: Application of the Extended Parallel Processing Model and Sensemaking Theory in a Qualitative Study.

PURPOSE: The purpose of the study was to understand the role of perceived disease threat and self-efficacy in type 2 diabetes (T2DM) patients' self-management by using the extended parallel processing model (EPPM) and sensemaking theory. METHODS: Semistructured interviews (n = 25) were conducted with T2DM patients from an urban safety-net hospital. Participants were 50% male/female median age was 55 years and 76% were Black. Participants were categorized by EPPM group based on validated questionnaires (high/low disease threat [HT/LT]; high/low self-efficacy [HE/LE]). Nine were HT/HE, 7 HT/LE, 6 LT/HE, and 3 LT/LE. Interviews were transcribed and analyzed using inductive and deductive coding. Sensemaking theory was applied to contextualize and analyze data. RESULTS: Those with HT indicated threat fluctuated throughout diagnosis but that certain triggers (eg, diabetic complications) drove changes in disease view. Those in the HT/HE group more frequently expressed disease acceptance, whereas the HT/LE group more often expressed anger or denial. HT/HE participants expressed having adequate social support and higher trust in health care providers. HT/LE participants reported limited problem-solving skills. In those with LT, the HE group took more ownership of self-management behaviors. The LT/LE group had heightened positive and negative emotional responses that appeared to limit their ability to perform self-care. They also less frequently described problem-solving skills, instead expressing reliance on medical guidance from their providers. CONCLUSIONS: EPPM and sensemaking theory are effective frameworks for understanding how perceived health threat and self-efficacy may impede T2DM self-care. A greater focus on these constructs is needed to improve care among low-income minority patients, especially those with low threat and self-efficacy.

Moral Injury and Moral Resilience in Health Care Workers during COVID-19 Pandemic.

Background: The 2019 coronavirus (COVID-19) pandemic placed unprecedented strains on the U.S. health care system, putting health care workers (HCWs) at increased risk for experiencing moral injury (MI). Moral resilience (MR), the ability to preserve or restore integrity, has been proposed as a resource to mitigate the detrimental effects of MI among HCWs. Objectives: The objectives of this study were to investigate the prevalence of MI among HCWs, to identify the relationship among factors that predict MI, and to determine whether MR can act as buffer against it. Design: Web-based exploratory survey. Setting/Subjects: HCWs from a research network in the U.S. mid-Atlantic region. Measurements: Survey items included: our outcome, Moral Injury Symptoms Scale-Health Professional (MISS-HP), and predictors including demographics, items derived from the Rushton Moral Resilience Scale (RMRS), and ethical concerns index (ECI). Results: Sixty-five percent of 595 respondents provided COVID-19 care. The overall prevalence of clinically significant MI in HCWs was 32.4%; nurses reporting the highest occurrence. Higher scores on each of the ECI items were significantly positively associated with higher MI symptoms (p < 0.05). MI among HCWs was significantly related to the following: MR score, ECI score, religious affiliation, and having ≥20 years in their profession. MR was a moderator of the effect of years of experience on MI. Conclusions: HCWs are experiencing MI during the pandemic. MR offers a promising individual resource to buffer the detrimental impact of MI. Further research is needed to understand how to cultivate MR, reduce ECI, and understand other systems level factors to prevent MI symptoms in U.S. HCWs.

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.

Primary Care Practice Redesign: Challenges in Improving Behavioral Health Care for a Vulnerable Patient Population.

This study examined a program focused on integrating mental health in a family medicine practice in an economically challenged urban setting. The program included using a behavioral health technology platform, a behavioral health collaborative composed of community mental health agencies, and a community health worker (CHW). Of the 202 patients screened, 196 were used for analysis; 56% were positive for anxiety, 38% had scores consistent with moderate to severe depression, and 34% were positive for post-traumatic stress disorder. There was a statistically significant difference in the diagnosis of depression when comparing the screened group to a control group. Only 27% of patients followed through with behavioral health referrals despite navigational assistance provided by a CHW and assured access to care through a community agency engaged with the Behavioral Health Alliance. Further qualitative analysis revealed that there were complex patient factors that affected patient decision making regarding follow-up with behavioral health care.

Complexities of Addressing Food Insecurity in an Urban Population.

There is an association between food insecurity, poor health outcomes, and increased health care spending. The Temple Food Insecurity Program was initiated to screen patients for food insecurity as part of the post Temple University Hospital discharge process. The community is economically challenged and food insecurity is a significant problem. Food insecure patients were identified and referred to community-based resources, with a 30-day follow-up call. Screening was successful in 3655 patients, 27% (n = 987) of whom reported food insecurity. Of these patients, 66% (n = 647) were already receiving benefits through the Supplemental Nutrition Assistance Program (SNAP), but were still food insecure. All patients with food insecurity were referred to one of 2 resources for help. Despite significant need, less than a quarter of patients connected with these resources. Qualitative data revealed that some patients did not remember the information provided to them, were overwhelmed with poor health or other social determinants of health, had competing priorities, did not perceive the need for food assistance; and experienced system barriers. Health literacy also was an issue. Health care systems addressing food insecurity should consider the high prevalence of food insecurity in impoverished regions, the reality that SNAP benefits may not alleviate food insecurity for many patients, and the need for individualized, custom care plans that address barriers and reflect patient priorities and capabilities. Engaging patients differently may be aided by additional communication from community food resources directly to patients who provide permission for this added service.

Understanding Nonurgent Pediatric Emergency Department Visits: Using Hospital and Family-Centric Data to Inform System Redesign.

We conducted a mixed-method study to analyze the population and financial impact of emergency department use for pediatric nonurgent problems. Findings from this initial study led to our phase 2 case study, in which we interviewed 23 adults accompanying children younger than 4 years with nonemergent fever. The resulting qualitative analysis revealed that participants were unable to distinguish urgent from nonurgent conditions, perceived access limitations to care, and although they preferred the child's primary care physician, went to the emergency department for care.

Implementation and evaluation of a low health literacy and culturally sensitive diabetes education program.

Low health literacy is more prevalent in persons with limited education, members of ethnic minorities, and those who speak English as a second language, and is associated with multiple adverse diabetes-related health outcomes. This study examined the effectiveness of a low health literacy and culturally sensitive diabetes education program for economically and socially disadvantaged adult patients with type 2 diabetes. A pre-post prospective study design was used to examine outcomes over 12 months. Outcome measures included diabetes knowledge, self-efficacy, and self-care, measured using reliable and valid survey tools, and A1C. Over this period of time 277 patients were enrolled in the program, with 106 participants completing survey data. At the completion of the program patients had significant improvements in diabetes knowledge (p < .001), self-efficacy (p < .001), and three domains of self-care including diet (p < .001), foot care (p < .001), and exercise (p < .001). There were no significant improvements in the frequency of blood glucose testing (p = .345). Additionally, A1C values significantly improved 3 months after completing the program (p = .007). In conclusion, a diabetes education program designed to be culturally sensitive and meet the needs of individuals with low health literacy improves short-term outcomes.

Hourly rounding: challenges with implementation of an evidence-based process.

Introduction of an evidence-based practice change, such as hourly rounding, can be difficult in the hospital setting. This study used ethnographic methods to examine problems with the implementation of hourly rounding on 2 similar inpatient units at our hospital. Results indicate that careful planning, communication, implementation, and evaluation are required for successful implementation of a nursing practice change.

Testing the effectiveness of the Amputee Mobility Protocol: a pilot study.

We studied prolonged length of stay (LOS) in the acute care setting on a medical-surgical vascular unit, related to loss of functional mobility status after lower extremity amputation, and implementation of the Amputee Mobility Protocol (AMP) as a standard of care for all patients pre- and post-lower extremity amputation who were admitted to the medical-surgical vascular unit. A comparative pre-post observational study evaluated the effect of AMP on level of functional mobility and LOS after lower extremity amputation in the patient population on the medical-surgical vascular unit. Data was collected retrospectively from patient chart reviews from November of 2004 to March of 2005 for the pre-AMP group and through concurrent patient chart reviews from November of 2005 to March of 2006 for the post-AMP group. Dependent variables included functional mobility and LOS, which were evaluated by a modified Functional Independence Measure (FIM) score and the hospital LOS. Forty-four eligible patients were enrolled in the AMP pilot study during a 5-month period. The sample population consisted of 30 patients pre-AMP and 14 patients post-AMP. LOS for transmetatarsal amputations decreased by 0.7 days, whereas functional mobility increased by a minimum of one level in the modified FIM score. Functional mobility increased for transtibial amputations by one level and transfemoral amputations by 2 levels using the modified FIM score. LOS increased for patients undergoing transtibial (7.1 days) and transfemoral (2.7 days) amputations. This quality improvement project heightened staff awareness regarding ambulation and its impact on functional mobility and early discharge. Vascular nurses were able to affect patients' functional mobility and LOS by implementing a standardized AMP. Data showed that using the standardized AMP increased patients' functional mobility but did not significantly decrease acute care setting LOS. The AMP continues to be used for this patient population because of its impact on functional mobility and independence. This pilot study relates to 3 of the top 20 vascular research priorities: 1) an interdisciplinary strategy to improve the patient's level of functional independence and thereby decrease LOS and cost; 2) the nursing intervention of early, predetermined ambulation schedules will increase the nursing knowledge of strategies that facilitate recovery after vascular surgery in this population; and 3) factors that affect patient outcomes after these three major vascular procedures will be addressed in pilot outcomes. Limitations of the AMP pilot study included the small sample size, staff turnover, and lack of a concurrent control group. The next phase of this project will create and implement a similar activity protocol for patients after abdominal aortic aneurysm repair and various types of lower extremity bypass procedures.

First-year results of a community peripheral vascular screening program at an academic community hospital.

Disease associated with the vascular system, including peripheral arterial disease, poses a serious health problem with incidence growing annually. Recognizing this, several health care organizations across the United States have developed programs for public education and community awareness, and for screening individuals at risk for vascular disease. Lehigh Valley Hospital developed and implemented a screening program that evaluated more than 160 individuals during a 12-month period. Results suggest that screening should be limited to patients at high risk; however, the intrinsic value of patient education and patient peace of mind is worth proceeding with the screening effort because patients reported a positive experience.