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PURPOSE: Moral distress (MD) is the result of barriers or constraints that prevent providers from carrying out what they believe to be ethically appropriate care. This study was initiated to explore associations between MD, burnout, and the organizational climate (OC) for oncology physician assistants (PAs). METHODS: A national survey of oncology PAs was conducted to explore the associations between MD, OC, and burnout. The Nurse Practitioner-Primary Care OC Questionnaire was revised for oncology PAs to assess OC for PA practice. MD and burnout were assessed using the Measure of MD-Healthcare Professionals (MMD-HP) and the Maslach Burnout Inventory. RESULTS: One hundred forty-six oncology PAs are included in the analysis. PAs were mostly female (90%), White/Caucasian (84%), married/partnered (78%), and in medical oncology (73%), with mean age 41.0 years. The mean MMD-HP score for oncology PAs was 71.5 and there was no difference in MD scores on the basis of oncology subspecialty, practice setting, practice type, or hours worked per week. PAs currently considering leaving their position because of MD had significantly higher mean scores on the MMD-HP compared with those not considering leaving their position (108.2 v 64.8; P = .001). PAs with burnout also had significantly higher mean scores for MD compared with PAs without burnout (97.6 v 54.3; P < .001). A negative relationship between OC for PA practice and MD was only found for the PA-administration relations subscale, whereas all subscales were negatively associated with burnout. CONCLUSION: This study demonstrates that the risk of professional burnout increases significantly with increasing levels of MD. Additional research exploring the relationship between MD and burnout is needed.

INTRODUCTION: Ethical issues are pervasive in healthcare, but few specialties rival the moral complexity of transplant medicine. Transplant providers must regularly inform patients that they are no longer eligible to receive a potentially life-saving operation and the stress of these conversations poses a high risk of moral injury. Training in end of life counseling (EOLC) has been shown to significantly reduce provider stress and burnout. We hypothesized that training in EOLC reduces levels of moral injury among transplant providers. METHODS: This was a mixed methods study. A survey was administered to staff in the solid organ transplant department at the University of Kansas health-system. Providers indicated whether they had received training in EOLC and completed the standardized Moral Injury Symptom Scale-Healthcare Professionals version (MISS-HP). A two-sample, one-sided t-test compared levels of moral injury between trained and untrained staff. Subsequently, semi-structured interviews were conducted with transplant providers, and inductive coding followed by thematic network analysis was performed. RESULTS: Thirty-seven percent of respondents reported a moral injury score at or above the threshold for psychosocial dysfunctioning associated with moral injury. Analysis revealed no difference in moral injury scores between the trained and untrained groups (p=0.362, power=0.842). Ten participants were interviewed. Thematic network analysis demonstrated high-level themes of “challenges”, “training” and “stress relief”. CONCLUSIONS: Our study demonstrated a concerning prevalence of moral injury among transplant providers and suggested that EOLC training does not significantly mitigate the threat of moral injury.

[This is an excerpt.] Moral injury has been defined as the combined psychological, social, and spiritual impact of events involving violation of personal moral beliefs and values, especially in high-stress situations. 1 For centuries, this phenomenon has been experienced by military service members who perpetrated, witnessed, or failed to prevent acts that transgressed their own moral values or code of conduct. Examples include causing the deaths of civilians, following illegal or immoral orders, or failing to provide needed medical assistance. General mechanisms of moral injury include acts of commission, acts of omission, and betrayal. [To read more, click View Resource.]

[This is an excerpt.] Physicians make a promise, when joining this profession, to care for ill and injured patients, to the best of their ability, absent self-interest. Throughout training that obligation is ingrained in our every decision. Mentors and colleagues demand that we live up to the same exceptionally high standards they have maintained, or risk rebuke, shunning, and serious sanctions. Our patients believe our oath—that we will put their best interests ahead of personal or professional gain—and, as one author said, they “offer their trust as a gift.”2 In accepting the honor of such freely given vulnerability, most physicians strive, in every encounter, to be worthy of it. However, over the last three decades reimbursement and regulatory pressures have corporatized medicine. Physicians, small business/private practice owners in decades past, are now mostly employed and increasingly torn between their covenant with patients and the allegiance they owe to employers. When that rift is irreconcilable, the result can be moral injury. [To read more, click View Resource.]

BACKGROUND: Potentially morally injurious events (PMIEs) can negatively impact mental-health. The COVID-19 pandemic may have placed healthcare staff at risk of moral injury. AIM: To examine the impact of PMIE on healthcare staff wellbeing. METHODS: Twelve thousand nine hundred and sixty-five healthcare staff (clinical and non-clinical) were recruited from 18 NHS-England trusts into a survey of PMIE exposure and wellbeing. RESULTS: PMIEs were significantly associated with adverse mental health symptoms across healthcare staff. Specific work factors were significantly associated with experiences of moral injury, including being redeployed, lack of PPE, and having a colleague die of COVID-19. Nurses who reported symptoms of mental disorders were more likely to report all forms of PMIEs than those without symptoms (AOR 2.7; 95% CI 2.2, 3.3). Doctors who reported symptoms were only more likely to report betrayal events, such as breach of trust by colleagues (AOR 2.7, 95% CI 1.5, 4.9). CONCLUSION: A considerable proportion of NHS healthcare staff in both clinical and non-clinical roles report exposure to PMIEs during the COVID-19 pandemic. Prospective research is needed to identify the direction of causation between moral injury and mental disorder as well as continuing to monitor the longer term outcomes of exposure to PMIEs.

Moral injury (i.e., perpetrating, witnessing, failing to prevent, or being a victim of acts that transgress one's moral beliefs, values, or ethics) has largely been studied in military-connected populations and is associated with a range of adverse psychological sequelae. Emerging literature suggests that healthcare workers also experience moral injury, particularly in the context of the ongoing COVID-19 pandemic. However, it is not known if moral injury contributes to substance use among healthcare workers or whether these effects might differ by gender, race/ethnicity, or occupational level. In March 2022, we collected self-reported pilot data from a diverse sample of US healthcare workers (N = 200) We examined the cross-sectional relationships between moral injury and several measures of substance use (i.e., current non-medical use of prescription drugs [NMUPD], current cannabis use, current use of other illicit drugs, and hazardous drinking) using separate logistic regression models. Next, we used separate interaction models to examine if any of these relations differed by gender, race/ethnicity, or occupational level. In main effects models, healthcare workers reporting greater moral injury had greater odds of current NMUPD (adjusted odds ratio (aOR) = 1.07; p < 0.001), current use of other illicit drugs (aOR = 1.09; p < 0.01), and hazardous drinking (aOR = 1.07; p < 0.01). These relations did not differ by race/ethnicity or occupational level (ps > 0.05); however, men were more likely to report current NMUPD and hazardous drinking (ps < 0.05) in the presence of high moral injury than women healthcare workers. Our findings suggest that healthcare workers experience substantial distress related to morally injurious events, which may affect their likelihood of NMUPD, cannabis use, use of other illicit drugs, and hazardous drinking, and that men in healthcare may be particularly at risk. Healthcare organizations should address systemic issues driving moral injury (e.g., resource shortages, lack of psychosocial support) to prevent substance-related harms among healthcare workers.

Moral Injury is a concept developing in psychology literature to review the impact of war on veterans and has especially focused on individual symptoms and finding clear diagnosis tools. This paper explores the connection between moral injury and the context in which they occur, a relationship that provides valuable understanding about the experience, but also the systemic factors that increase the vulnerability. The article begins by setting the groundwork for the discussion and introducing moral injury and its associate concepts. Part two explores the institutional dimension of moral injury and how an individual's professions can contribute to the injury. Part three proposes how moral injury insights can be implemented as guiding principles within peace and security, and particularly in peacekeeping missions. The final conclusion points to the context and the institutional system as the frame where personal reaction, values and systemic influences combine to produce moral injury. Therefore, looking for solutions to prevent and treat moral injury must acknowledge the true roots causes of distress that is not part of individualistic pathologizing mental health diagnosis.

The framework of moral injury adds a relational and moral dimension to the discussion of physician distress and burnout, and it aids in the quest for effective interventions.

eHealth applications are considered a technological fix that can potentially address some of the grand challenges in healthcare, including burnout among healthcare professionals, the growing burden of patients with chronic conditions, and retaining and recruiting healthcare professionals. However, as the deployment of eHealth applications in healthcare is relatively novel, there is a lack of research on how they affect the work environment of healthcare professionals. This study explores how work evolves—particularly for nurses—during the utilisation of three eHealth applications.

In modern primary care practice, clinicians face increasing volumes of asynchronous, electronic, non-visit care (NVC). Systems for completing this work, however, remain under-developed and often lack definition around patient and practice expectations for work completion and team member contributions. The resulting reactive, unstructured, and unscheduled NVC workflows cause and exacerbate physicians’ cognitive overload, distraction, and dissatisfaction. Herein, we propose that primary care practices take an intentional, holistic approach to managing systems of NVC and offer a conceptual model for managing NVC work, analogizing the flow of these tasks to the flow of water through a river system: (1) by carefully controlling the inputs into the NVC system (the tributaries entering the river system); (2) by carefully defining the workflows, roles and responsibilities for completion of common tasks (the direction of river flow); (3) by improving the interface of the electronic health record (obstacles encountered in the river); and (4) by optimizing effectiveness of primary care teams (the contours of the river determining rate of flow). This framework for managing NVC, viewed from a broader system perspective, has the potential to improve productivity, quality of care, and clinician work experience.

INTRODUCTION AND OBJECTIVE: Burnout is a pervasive issue in healthcare, with urology trainees reporting burnout rates as high as 63.8%. Resilience training is a proven tool to prevent burnout and improve performance in high stress working environments, with demonstrated efficacy in surgical residency programs. Enhanced Stress Resilience Training (ESRT) is a mindfulness-based cognitive skills training developed and validated by Dr. Carter Lebares and the UCSF Center for Mindfulness in Surgery. ESRT offers tools to reframe thoughts and promote emotional regulation. The primary goal of this study is to assess feasibility and to introduce a curriculum to expand a pre-existing program focused on wellness and individual skill development. METHODS: Through consultation with Dr. Lebares, we customized course structure to include a didactics presentation and five ESRT sessions taught over Zoom by a certified ESRT instructor, a retired surgeon. We conducted the sessions in place of standard departmental conferences to mitigate personal time used for the training. Baseline descriptive pre and post course data was collected using validated surveys, including the Mental Health Continuum Short Form, Physician Wellbeing Index, and the Connor Davidson Resilience Index, with a subsequent focus group to gain qualitative data on overall course perception. Using two-sample t-tests, we compared differences between and pre and post course responses. RESULTS: There were 33 participants in the course, with 20 residents, 7 faculty, and 6 others (student/APP). Surveys were completed by 30 participants pre course and 15 participants post course, with 15 sets of paired data. There were no statistically significant differences in self-reported wellbeing or stress response after course participation; however, participants were significantly more likely to use meditation as a stress coping mechanism after the course (p=0.008). Qualitative descriptive results demonstrated a 15% increase in participants’ understanding of the impact mindfulness practices have on work performance. CONCLUSIONS: Our program successfully implemented ESRT via a novel remote delivery format. Although our analysis was limited by small sample size, our pilot study highlights feasibility in implementation. This curriculum also showed resident skill development in stress regulation through mindfulness practices. Next steps would include repeat delivery within the program to promote durability, and possible expansion beyond our single program.

INTRODUCTION AND OBJECTIVE: Urology residents have reported greater levels of professional burnout compared to other specialties. Recently, increased awareness of risk factors for burnout and interventions to enhance trainee well-being may have contributed to changes in the prevalence of resident burnout. We aimed to measure burnout and career choice regret in a national sample of urology residents. METHODS: We analyzed residents’ responses to the AUA Census in 2019, 2020, and 2021. We compared urology residents’ responses to the 22-item Maslach Burnout Inventory in 2019 vs 2021, including overall professional burnout and the emotional exhaustion and depersonalization subscales. We also assessed responses to questions about career and specialty choice regret in 2019 vs 2020-2021. RESULTS: Among 415 respondents in 2019 and 166 respondents in 2021, the prevalence of professional burnout was 47% and 48%, respectively. 7% and 10% of residents met criteria for emotional exhaustion, while 47% and 48% of residents met criteria for depersonalization. Burnout symptoms were highest among second-year residents in both cohorts (65% and 69%). In 2019, among the 53% of residents who had ever reconsidered career or specialty choice, a majority (54%) experienced this most frequently during the second year of residency. Similarly, in 2020-2021, among the 51% who had reconsidered career or specialty choice, 57% said it was most frequent during the second year. There was no significant difference between the cohorts in terms of the prevalence of burnout, emotional exhaustion, or depersonalization, or in terms of the frequency of career and specialty choice regret (all p>0.05). Finally, there was no significant gender disparity in either cohort regarding the prevalence of career and specialty choice regret: 58% women vs 50% men in 2019, and 56% women vs 49% men in 2020-2021 (all p>0.05). CONCLUSIONS: In a national sample of urology residents, the prevalence of professional burnout has remained unchanged between 2019 and 2021. Second-year residents appear to be at greatest risk for career and specialty choice regret. Interventions targeting early-career residents may reduce the psychosocial burden of residency on trainees.

Healthcare providers (HCPs) experience unprecedented burnout. During the COVID-19 pandemic, the healthcare workforce was pushed beyond its capacity, driving some out of the field, leaving hospitals and healthcare agencies to face unrelenting demand for care. Limited staff and resources challenged organizations to redesign infrastructure and processes to meet COVID-19 safety guidelines while balancing the priorities of finance and people. Two years into the pandemic, the signs of burnout among nurses in an RN-BSN program surfaced, which paralleled the bitter resentment happening across the nursing profession. Nurses working on the front lines reported feelings of abandonment, lack of resources, staffing shortages, exhaustion, fatigue, hopelessness, and a sense that healthcare systems were falling short in caring for the caregivers. Similar to military service members who returned from combat, nurses project the workforce will experience considerable post-traumatic stress disorder after the pandemic.

Nominal research illustrates the lived experience of intensive care unit registered nurses during the COVID pandemic. Palliative care team leaders and nurse researchers designed this cross-sectional study to discover opportunities for palliative care team members to enhance the experience of nurses who cared for critically ill patients during this challenging time. The study aimed to compare the effect of caring for patients in COVID versus non-COVID units. Surveys were distributed after the area's initial COVID patient influx. Questions included general demographics, the Professional Quality of Life survey instrument (measuring compassion satisfaction, burnout, and secondary traumatic stress), and open-ended questions to identify protective factors and unique challenges. Across 5 care settings with 311 nurses eligible for the study in total, 90 completed the survey. The population consisted of COVID-designated unit nurses (n = 48, 53.33%) and non-COVID unit nurses (n = 42, 46.67%). Analysis between COVID-designated and non-COVID units revealed significantly lower mean compassion scores and significantly higher burnout and stress scores among those working within COVID-designated units. Despite higher levels of burnout and stress and lower levels of compassion, nurses identified protective factors that improved coping and described challenges they encountered. Palliative care clinicians used insights to design interventions to mitigate identified challenges and stressors.

Amid the “great resignation” and high rates of stress and burnout among healthcare workers, effective strategies are available for recruiting and retaining physicians.

[This is an excerpt.] Leaders across health care systems in the United States are struggling to ensure an adequate and professionally educated nursing workforce is available to provide quality patient care. Yet, nurses are leaving frontline direct-care roles at healthcare institutions and data show that nurses’ satisfaction with their profession is declining. Appropriate nurse staffing is crucial for optimal patient outcomes in all health care settings, and the focus of this work was acute and critical care. Chronic inappropriate staffing has significant and deleterious effects on care delivery, patient safety, caregiver well-being, and organizational viability. Addressing the nurse staffing crisis requires various stakeholder groups to collaboratively identify and implement immediate actions and long-term solutions. This document represents the work of the Nurse Staffing Task Force. The Partners for Nurse Staffing envisioned the combined work of the Nurse Staffing Think Tank and Task Force to generate progress towards a sustainable nursing workforce. Supporting the health of our nursing workforce requires recognizing their unique contributions to ensure quality care to the communities they serve. [To read more, click View Resource.]

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This resource is found in our Actionable Strategies for Professional Associations: Spotlights: Professional Associations Operational Strategies (Workloads and Workflows).

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[This is an excerpt.] Recognizing the urgent nature of the nurse staffing shortage and the need for collaborative solutions, five professional organizations first came together in 2018 to form the Partners for Nurse Staffing. In January 2022, as the COVID-19 pandemic intensified the nurse staffing shortages, the Partners for Nurse Staffing Think Tank was launched to identify high-priority areas for recommendations that could be implemented within a 12-18 month timeframe. Learn how the five organizations came to work together. [To read more, click View Resource.]

This resource is found in our Actionable Strategies for Health Organizations: Empowering Worker & Learner Voice (Worker & Learner Engagement).

NYC Health + Hospitals implemented a large-scale nurse residency program to reduce turnover, improvetransition to practice and support first-year nurses.

Burnout rates of correctional employees are higher than employees in the general public. The purpose of this study was to identify how occupational factors impact burnout rates among correctional mental health workers. Grounded in the job-demands theoretical model, this study compared burnout rates among mental health staff within county jails and state prisons. Burnout was measured using the Maslach Burnout Inventory and Occupational factors were measured using the Areas of Work life Survey and Pandemic Experience and Perception Survey. Data was analyzed using IBM SSPS software to address multiple a priori directional research questions. Research questions considered how occupational factors impact burnout of this population. Key results indicated no significant difference in burnout rates among mental health providers, though found “workload” and “control” to be significant predictors of emotional exhaustion in both jails and prisons, and “reward” a significant predictor of personal accomplishment in prisons. “Risk perception” and “work life” were predictors of emotional exhaustion during a global pandemic. Future studies should expand the research on the variable “workload” with burnout and consider utilizing the demographic data collected to identify additional correlations. Implications for positive social change include prevention of burnout in correctional settings resulting in lower staff turnover, improved staff quality of life, and increased quality of treatment. Knowing the factors that contribute to burnout in these populations allows for intervention prior to burnout.

BACKGROUND: At the end of life, people experiencing structural vulnerability (e.g. homelessness, poverty, stigmatization) rely on community service workers to fill gaps in access to traditional palliative services. Although high levels of burnout are reported, little is known about these workers' experiences of grief. AIM: To explore community service workers? experiences of grief to identify ways of providing more tailored, meaningful, and equitable supports. DESIGN: A community-based participatory action research methodology, informed by equity perspectives, was employed. SETTING/PARTICIPANTS: In an urban center in western Canada, community service worker (primary) participants (n=18) were engaged as members of an action team. A series of 18 action cycles took place, with secondary participants (n=48) (e.g. palliative, social care, housing support, etc.) being recruited throughout the research process. Focus groups (n=5) and evaluative interviews (n=13) with participants were conducted. Structured observational field notes (n=34) were collected during all team meetings and community interventions. Interpretive thematic analysis ensued through a collaborative and iterative process. RESULTS: During initial meetings, action team participants described experiences of compounding distress, grief, and multiple loss. Analysis showed workers are: (1) grieving as family, not just providers; (2) experiencing complex layers of compounded grief; and (3) are fearful to open the "floodgates" to grief. CONCLUSIONS: Findings contribute to our understanding on the inequitable distribution of grief across society. A collective and material response is needed, including witnessing, acknowledging and valuing the grief process; facilitating community wellness, collective grieving, and advocacy; and providing training and tools in a palliative approach to care.