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In response to COVID-19, hospitals in the United States put rigorous risk-reduction measures into place, including strict no-visitor policies. The resulting patient isolation has had negative effects on the mental health and wellbeing of healthcare providers and patients. We argue that COVID-19 risk assessments failed to consider the long-term effects of isolation on the health and wellbeing of patients and healthcare providers. These findings have implications for understanding the ongoing impact of COVID-19 care on healthcare providers, and for thinking about risk mitigation strategies for current and future healthcare provision and pandemic response preparation and planning. The isolation of COVID-19 took a toll on the mental health and wellbeing of both patients and healthcare providers. Restrictive visitor policies were especially harmful for healthcare providers and families. Policy makers – from the CDC to hospitals systems and administrators – must consider the harmful effects of isolation when assessing risk and considering risk reduction measures. A medical anthropologist and emergency medicine physician collaborate on research on the devastating long-term effects of isolation for healthcare providers and patients during COVID-19.

Anecdotal evidence suggests that health care employers have faced increased difficulty recruiting and retaining staff in the wake of the COVID-19 pandemic. Empirical research is needed to understand the magnitude and persistence of these changes, and whether they have disproportionate implications for certain types of workers or regions of the country.To quantify the number of workers exiting from and entering into the health care workforce before and after the pandemic and to examine variations over time and across states and worker demographics.This cohort study used US Census Bureau state unemployment insurance data on job-to-job flows in the continental US to construct state-level quarterly exit and entry rates for the health care industry from January 2018 through December 2021 (Arkansas, Mississippi, and Tennessee were omitted due to missing data). An event study design was used to compute quarterly mean adjusted rates of job exit from and entry into the health care sector as defined by the North American Industry Classification System. Data were examined from January to June 2023.The COVID-19 pandemic.The main outcomes were the mean adjusted health care worker exit and entry rates in each quarter by state and by worker demographics (age, gender, race and ethnicity, and education level).In quarter 1 of 2020, there were approximately 18.8 million people (14.6 million females [77.6%]) working in the health care sector in our sample. The exit rate for health care workers increased at the onset of the pandemic, from a baseline quarterly mean of 5.9 percentage points in 2018 to 8.0 (95% CI, 7.7-8.3) percentage points in quarter 1 of 2020. Exit rates remained higher than baseline levels through quarter 4 of 2021, when the health care exit rate was 7.7 (95% CI, 7.4-7.9) percentage points higher than the 2018 baseline. In quarter 1 of 2020, the increase in health care worker exit rates was dominated by an increase in workers exiting to nonemployment (78% increase compared with baseline); in contrast, by quarter 4 of 2021, the exit rate was dominated by workers exiting to employment in non–health care sectors (38% increase compared with baseline). Entry rates into health care also increased in the postpandemic period, from 6.2 percentage points at baseline to 7.7 percentage points (95% CI, 7.4-7.9 percentage points) in the last quarter of 2021, suggesting increased turnover of health care staff. Compared with prepandemic job flows, the share of workers exiting health care after the pandemic who were female was disproportionately larger, and the shares of workers entering health care who were female or Black was disproportionately smaller.Results of this cohort study suggest a substantial and persistent increase in health care workforce turnover after the pandemic, which may have long-lasting implications for workers’ willingness to remain in health care jobs. Policymakers and health care organizations may need to act to prevent further losses of experienced staff.

This resource is found in our Actionable Strategies for Health Organizations: Establishing Commitment & Shared Governance (Shared Governance).

OBJECTIVES: Evidence has shown significant impacts of the COVID-19 pandemic on physicians. We hypothesized that these effects would impact surgical and non-surgical resident education differently, with non-surgical specialties being more heavily impacted by frontline work and surgical specialties losing elective cases. METHODS: We examined well-being and burnout among resident physicians in surgical and non-surgical specialties during the peak of the COVID-19 pandemic using the Mayo Physician Well-Being Index (WBI). RESULTS: Completed surveys were received from 110 residents, 55% of whom were in a surgical training program. 35% of respondents were identified as ‘at risk’ for burnout. Increased demands from work (adj. OR 3.79, 95% CI 1.50, 9.59, p = 0.005) was associated with an increased likelihood for being ‘at risk’ compared to those without increased demands. Odds of having increased stress level were higher amongst residents with fear/anxiety of the unknown (adj. OR 4.21, 95% CI 1.63, 10.90, p = 0.003) and more demands outside work (adj. OR 10.54, 95% CI 2.63, 42.16, p = 0.001) but lower amongst residents with more time for studying (OR 0.23, 95% CI 0.09, 0.64, p = 0.005). Risk for burnout was not significantly different between surgical and non-surgical specialties when adjusting for increased demands from work (adj. OR 1.43, 95% CI 0.60, 3.37, p = 0.0.418). CONCLUSION: Perceived effects of the COVID-19 pandemic upon residents’ educational experience was mixed: reduced clinical volume had a negative impact, while increased time for study was perceived favorably. These findings suggest potential strategies and targets to mitigate the stress and burnout of a future crisis, whether large or small, among surgical and non-surgical trainees.

The COVID-19 pandemic has shown that all emergencies, major incidents and disease outbreaks can have substantial mental health consequences, and it has demonstrated the proven need for additional care for populations in the wake of disasters. This book brings together practice and recent developments in pre-hospital emergency care, emergency medicine and major trauma care with the wellbeing, psychosocial and mental health aspects of preparing for and responding to emergencies, incidents, terrorism, disasters, epidemics, and pandemics. Practical suggestions are included for future planning to provide better care for people caught up in emergencies. Setting it apart from other books on emergency preparedness is its specific focus on the psychosocial demands imposed on staff of healthcare and responding services. Featuring expert contributions from a wide variety of disciplines, this book appeals to people working within mental healthcare, emergency care, pre-hospital medicine, Blue Light services, public health, humanitarian care, emergency planning, and disaster management.

Background Moral distress (MD) and moral injury (MI) are related constructs describing the negative consequences of morally challenging stressors. Despite growing support for the clinical relevance of these constructs, ongoing challenges regarding measurement quality risk limiting research and clinical advances. This study summarizes the nature, quality, and utility of existing MD and MI scales, and provides recommendations for future use. Method We identified psychometric studies describing the development or validation of MD or MI scales and extracted information on methodological and psychometric qualities. Content analyses identified specific outcomes measured by each scale. Results We reviewed 77 studies representing 42 unique scales. The quality of psychometric approaches varied greatly across studies, and most failed to examine convergent and divergent validity. Content analyses indicated most scales measure exposures to potential moral stressors and outcomes together, with relatively few measuring only exposures (n = 3) or outcomes (n = 7). Scales using the term MD typically assess general distress. Scales using the term MI typically assess several specific outcomes. Conclusions Results show how the terms MD and MI are applied in research. Several scales were identified as appropriate for research and clinical use. Recommendations for the application, development, and validation of MD and MI scales are provided.

[This is an excerpt.] Burnout is associated with depression and attrition in the physician workforce. Recent studies have found that Asian, Black, and Hispanic students and students with disabilities experience increased risks of burnout.1,2 However, little is known about the risk of burnout among racial and ethnic underrepresented students with a disability, or among students who have cooccurring disabilities. Here, we examined the prevalence of burnout among students underrepresented in medicine by race and ethnicity (URiM; American Indian or Alaska Native, Black, Hawaiian Native, Hispanic, Pacific Islanders) with multiple disability types. [To read more, click View Resource.]

[This is an excerpt.] The term “microaggression” was coined by psychiatrist Chester Pierce, MD, in 1970 and was further developed and popularized by psychologist Derald Sue, PhD, in 2007. Microaggressions are “brief, everyday exchanges that send denigrating messages to certain individuals because of their group membership.” There are three types of microaggressions: microassaults, microinsults, and microinvalidations. Microassaults are conscious and deliberate actions or slurs against marginalized groups and most closely resemble blatant discrimination. For example, a senior resident might ask an intern: “Why can't you people ever listen?” In contrast, microinsults and microinvalidations are subtle and thought to be unconscious. Microinsults are verbal and nonverbal communications characterized as being insensitive, rude, and demeaning to a person's identity. A microinsult might include: “Are you a real doctor? You look like a child!” Microinvalidations are communications that exclude, negate, and/or nullify a person's experience as a person of color. One example might be to promote “All Lives Matter” (during the ”Black Lives Matter” movement). Though race/ethnicity is often considered the target of microaggressions, they can also be aimed at a person's gender, sexual orientation, religion, or other marginalized status. All microaggressions are particularly harmful in medicine and can interfere with patient care and the professional interactions and development of resident physicians. [To read more, click View Resource.]

[This is an excerpt.] The multiple challenges facing the current nursing workforce should concern anyone in need of healthcare – in other words, everyone. Nurses play an essential role in helping people live their healthiest lives, addressing the root causes of poor health, and managing teams that bring together clinical care, public health, and social services. They are often the first and most frequent line of contact for patients and families entering the healthcare system. National surveys have revealed nurses as the most trusted professionals. However, as the United States emerges from the prolonged impact of the COVID-19 pandemic [2020-2023], the U.S. healthcare system faces a severe shortage of nurses to meet the health needs of the population, while the stresses of the pandemic have led many nurses to consider changing roles away from patient care or even changing professions. [To read more, click View Resource.]

INTRODUCTION: Healthcare clinicians are often at risk of psychological distress due to the nature of their occupation. Military healthcare providers are at risk for additional psychological suffering related to unique moral and ethical situations encountered in military service. This scoping review identifies key characteristics of moral distress and moral injury and how these concepts relate to the military healthcare clinician who is both a care provider and service member. METHODS: A scoping review of moral distress and moral injury literature as relates to the military healthcare clinician was conducted on the basis of the Joanna Briggs Institute scoping review framework. Databases searched included CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE (Ovid), Embase (Ovid), PsycInfo, 2 U.S. Defense Department sources, conference papers index, and dissertation abstracts. Reference lists of all identified reports and articles were searched for additional studies. RESULTS: A total of 573 articles, published between the years 2009 and 2021, were retrieved to include a portion of the COVID-19 pandemic period. One hundred articles met the inclusion criteria for the final full-text review and analysis. DISCUSSION: This scoping review identified moral distress and moral injury literature to examine similarities, differences, and overlaps in the defining characteristics of the concepts and the associated implications for patients, healthcare clinicians, and organizations. This review included the unfolding influence of the COVID-19 pandemic on moral experiences in health care and the blurring of those lines between civilian and military healthcare clinicians. Future directions of moral injury and moral distress research, practice, and care are discussed.

Moral injury is a serious concern among first responders. Not only does moral injury occur with notable frequency among first response groups such as police, fire safety, and emergency medical personnel, but it also poses considerable mental health challenges. Despite a recent explosion of research on moral injury, the literature would benefit from a systematic investigation of how first responders describe their experiences in their own words. We conducted semistructured interviews with 36 graduates of a first responder trauma healing course. Participants described moral injury as (a) a byproduct of being a first responder, (b) occurring frequently but being difficult to identify, and (c) involving feelings of helplessness and guilt. Effects of moral injury included (a) wide-ranging negative consequences, (b) diminished self-esteem, (c) isolation from and suspicion of others, and (d) spiritual distress. When asked about the advice they would give to other people experiencing moral injury, first responders recommended (a) talking openly about the experience of moral injury, (b) being proactive in seeking help, (c) breaking free from the stigma of needing assistance, and (d) building a network of support. Taken together, these results suggest important guidelines for helping first responders cope with the aftermath of moral injury. (PsycInfo Database Record (c) 2024 APA, all rights reserved)

The COVID-19 pandemic has and continues to impact the world affecting all aspects of life. Healthcare workers have been hit especially hard and, in many cases, experience negative impacts not only on their physical health but also on their mental and emotional well-being. Additionally, the COVID-19 pandemic has not affected populations equally and this is true in the USA, including healthcare workers. However, these workers have also persevered, drawing on moral resilience to push through challenging situations throughout this pandemic. In this scoping review, we analyzed studies to assess the role of race, ethnicity, and/or culture on the moral resilience of healthcare workers throughout the COVID-19 pandemic. Our aim was to understand the research that has assessed these potential connections and determine best practices for building moral resilience in the face of this global catastrophe. Fourteen articles met inclusion criteria and were analyzed in this review. Following a thematic analysis, several themes emerged including (1) moral resilience and the COVID-19 pandemic; (2) race, ethnicity, and culture among healthcare workers; and (3) building moral resilience. In sum, the findings from the literature indicate a paucity of studies that analyze the role played by race, ethnicity, and/or culture in connection to moral resilience during the COVID-19 pandemic.

In response to heightened burnout and moral distress among nurse leaders post-coronavirus disease 2019 pandemic, the Workforce Engagement for Compassionate Advocacy, Resilience, and Empowerment program was initiated at our medical center. One aspect of the program was the implementation of Community Resiliency Model® training. This article explores the impact of a 3-hour Community Resiliency Model session on nurse leaders' resilience, burnout, and moral distress. Results indicate positive changes in resilience, burnout, and moral distress. These findings suggest that Community Resiliency Model training is an effective intervention for enhancing nurse leader well-being and suggests broader implications for organizational well-being initiatives in health care settings.

Artificial intelligence (AI) is a rapidly advancing field that is beginning to enter the practice of medicine. Primary care is a cornerstone of medicine and deals with challenges such as physician shortage and burnout which impact patient care. AI and its application via digital health is increasingly presented as a possible solution. However, there is a scarcity of research focusing on primary care physician (PCP) attitudes toward AI. This study examines PCP views on AI in primary care. We explore its potential impact on topics pertinent to primary care such as the doctor-patient relationship and clinical workflow. By doing so, we aim to inform primary care stakeholders to encourage successful, equitable uptake of future AI tools. Our study is the first to our knowledge to explore PCP attitudes using specific primary care AI use cases rather than discussing AI in medicine in general terms.

BACKGROUND: COVID-19 was devastating for many frontline nurses embroiled in health care's response. Most media outlets reported from several large metropolitan areas in New York, California, and Florida, leaving other regions to wonder about the extent to which their nurses were suffering. OBJECTIVE: The purpose of this article was to understand the specific needs and experiences of Northeast Ohio nurses caring for patients with COVID-19 before designing interventions targeting negative mental outcomes. METHODS: This phenomenological study interviewed 16 Northeast Ohio nurses to understand their experiences of caring for patients with COVID-19. RESULTS: Although not asked about it directly, the participants' stories consistently included details that could be linked to moral distress. Two themes describing their lived experiences included "acquiring moral distress" and "living with moral distress." Additional findings are also reported separately because although they do not represent the lived experience of COVID-19 nursing, they did represent significant concerns that participants had for the future and are reported here to assist other researchers with the intervention design. Furthermore, these participants thought that participation in support groups with other nurses who cared for COVID-19 patients and possibly led by mental health advanced practice nurses offered the best intervention to process their trauma from the pandemic. CONCLUSIONS: The long-term effects of moral distress have been discussed routinely in recent literature and are further complicated by the effects of the COVID-19 pandemic. Threats to the shrinking workforce of nurses must be taken seriously and interventions to improve the mental health and morale of frontline nurses must be prioritized and tested.

BACKGROUND: Improving retention of nurses working in critical care is an urgent priority. Ideas on how to do this abound, but actual data are inconclusive. One common theory is that simply increasing nurse resiliency will minimize turnover. OBJECTIVE: To determine whether knowledge and application of compassionate self-care practices can significantly improve nurses' professional quality of life and thereby promote their retention. METHODS: This pilot study had a mixed-methods design. A training program in self-care techniques was implemented in a level IV trauma care secondary hospital, with data collected before and after the intervention by means of written surveys. Study participants were 40 nursing professionals working in an intensive care unit and a medical/surgical unit. The underlying theory was Jean Watson's framework of human caring. RESULTS: The study results showed that, although the participants evaluated the training program positively and reported improved work-life balance, they did not experience a statistically significant change in professional quality of life from before the intervention to after the intervention. CONCLUSIONS: The study findings are consistent with current literature indicating that prevention of compassion fatigue and burnout cannot be achieved by the efforts of individuals alone but requires collaboration between professionals and their institutions, with special attention to 3 elements: (1) a healthy work environment, (2) organizational support, and (3) nurse resiliency.

[This is an excerpt.] Artificial Intelligence (AI) is a hot topic in health care for its potential to both alleviate and exacerbate the challenges faced by health workers, particularly for clinician burnout and well-being. To discuss how to navigate this rapidly evolving field, the NAM’s Clinician Well-Being Collaborative held a hybrid event on Orienting AI Toward Health Workforce Well-Being: Examining Risks and Opportunities, co-hosted with UC San Diego Health, on December 9, 2024. This free public convening brought together experts, clinicians, and technology innovators to address burnout and other pressures on the health workforce by exploring how AI can enhance clinical practice, streamline workflows, and improve overall job satisfaction. [To read more and view the slides and recording, click View Resource.]

BACKGROUND: Nurse staffing committees offer a means for improving nurse staffing and nursing work environments in hospital settings by giving direct care nurses opportunities to contribute to staffing decision-making. These committees may be mandated by state law, as is the case currently in nine U.S. states, yet little is known about the experiences of staff nurses who have served on them. PURPOSE AND DESIGN: This qualitative descriptive study was conducted to explore the experiences of direct care nurses who have served on nurse staffing committees, and to better understand how such committees operate. METHODS: Participants were recruited by sharing information about the study through online nursing organization platforms, hospital nurse leadership, state chapters of national nursing organizations, social media, and nonconfidential nursing email lists. A total of 14 nurses from five U.S. states that have had nurse staffing committee legislation in place for at least three years were interviewed between April and October 2022. RESULTS: Four themes were identified from the data—a “well-valued” committee versus one with “locked away” potential: committee value; “who benefits”: staffing committee beneficiaries; “not just the numbers”: defining adequate staffing; and “constantly pushing”: committee members' persistence. CONCLUSIONS: The results of this study highlight the importance of actualizing staff nurse autonomy within nurse staffing committees—and invite further exploration into how staff nurses' perspectives can be better valued by nursing and nonnursing hospital leadership. Nurse staffing committees generally recommend staffing-related policies and practices that address the needs of patients and nurses, and work to find areas of compromise between nursing and hospital entities. But to be effective, the state laws that govern nurse staffing committees should be enforceable and evaluable, while committee practices should contribute to positive patient, nurse, and organizational outcomes; otherwise, they're just another form of paying lip service to change.

IMPORTANCE: Dialysis patient care technicians (PCTs) play a critical role in US in-center hemodialysis (HD) care, but little is known about the association of PCT staffing with patient outcomes at US HD facilities.

OBJECTIVE: To estimate the associations of in-center HD patient outcomes with facility-level PCT staffing.

DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study, with data analysis performed from March 2023 to January 2024. Data on US patients with end-stage kidney disease and their treatment facilities were obtained from the US Renal Data System. Participants included patients (aged 18-100 years) initiating in-center HD between January 1, 2016, and December 31, 2018, who continued receiving in-center HD for 90 days or more and had data on PCT staffing at their initial treating HD facility.

EXPOSURE: Facility-level patient-to-PCT ratios (number of HD patients divided by the number of PCTs reported by the treating facility in the prior year), categorized into quartiles (highest quartile denotes the highest PCT burden).

MAIN OUTCOMES AND MEASURES: Patient-level outcomes included 1-year patient mortality, hospitalization, and transplantation. Associations of outcomes with quartile of patient-to-PCT ratio were estimated using incidence rate ratios (IRRs) from mixed-effects Poisson regression, with adjustment for patient demographics and clinical and facility factors.

RESULTS: A total of 236 126 patients (mean [SD] age, 63.1 [14.4] years; 135 952 [57.6%] male; 65 945 [27.9%] Black; 37 777 [16.0%] Hispanic; 153 637 [65.1%] White; 16 544 [7.0%] other race; 146 107 [61.9%] with diabetes) were included. After full adjustment, the highest vs lowest quartile of facility-level patient-to-PCT ratio was associated with a 7% higher rate of patient mortality (IRR, 1.07; 95% CI, 1.02-1.12), a 5% higher rate of hospitalization (IRR, 1.05; 95% CI, 1.02-1.08), an 8% lower rate of waitlisting (IRR, 0.92; 95% CI, 0.85-0.98), and a 20% lower rate of transplant (IRR, 0.80; 95% CI, 0.71-0.91). The highest vs lowest quartile of patient-to-PCT ratio was also associated with an 8% higher rate of sepsis-related hospitalization (IRR, 1.08; 95% CI, 1.03-1.14) and a 15% higher rate of vascular access–related hospitalization (IRR, 1.15; 95% CI, 1.03-1.28).

CONCLUSIONS AND RELEVANCE: These findings suggest that initiation of treatment in facilities with the highest patient-to-PCT ratios may be associated with worse early mortality, hospitalization, and transplantation outcomes. These results support further investigation of the impact of US PCT staffing on patient safety and quality of US in-center HD care.

This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Safe & Appropriate Staffing).

BACKGROUND: Peer support programs have evolved to train physicians to provide outreach and emotional first aid to their colleagues when they experience the inevitable challenge of a serious adverse event, whether or not it is related to a medical error. Most pediatric surgeons have experienced the trauma of a medical error, yet, in a survey of APSA membership, almost half said that no one reached out to them, and few were satisfied with their institution's response to the error. Thus, the APSA Wellness Committee developed an APSA-based peer support program to meet this need. METHODS: Peer supporters were nominated by fellow APSA members, and the group was vetted to ensure diversity in demographics, practice setting, and seniority. Formal virtual training was conducted before the program went live in 2020. Trained supporters were surveyed 6 months after the program launched to evaluate their experiences with providing peer support. RESULTS: 15 referrals were made in the first year, 60 % of which were self-initiated. Most referrals were for distress related to adverse events or toxic work environments (33 % each). While only about 25 % of trained supporters had provided formal support through the APSA program, more than 80 % reported using the skills to support colleagues and trainees within their own institutions. CONCLUSION: Our experience in the first year of the APSA peer support program demonstrates the feasibility of building and maintaining a national program to provide emotional first aid by a professional society to expand the safety net for surgeons who are suffering.