Resource Library

OBJECTIVE: There is currently little consensus as to how burnout is best defined and measured, and whether the syndrome should be afforded clinical status. The latter issue would be advanced by determining whether burnout is a singular dimensional construct varying only by severity (and with some level of severity perhaps indicating clinical status), or whether a categorical model is superior, presumably reflecting differing ‘sub-clinical’ versus ‘clinical’ or ‘burning out’ vs ‘burnt out’ sub-groups. This study sought to determine whether self-diagnosed burnout was best modelled dimensionally or categorically. METHODS: We recently developed a new measure of burnout which includes symptoms of exhaustion, cognitive impairment, social withdrawal, insularity, and other psychological symptoms. Mixture modelling was utilised to determine if scores from 622 participants on the measure were best modelled dimensionally or categorically. RESULTS: A categorical model was supported, with the suggestion of a sub-syndromal class and, after excluding such putative members of that class, two other classes. Analyses indicated that the latter bimodal pattern was not likely related to current working status or differences in depression symptomatology between participants, but reflected subsets of participants with and without a previous diagnosis of a mental health condition. CONCLUSION: Findings indicated that sub-categories of self-identified burnout experienced by the lay population may exist. A previous diagnosis of a mental illness from a mental health professional, and therefore potentially a psychological vulnerability factor, was the most likely determinant of the bimodal data, a finding which has theoretical implications relating to how best to model burnout.

OBJECTIVE: To explore the causes and levels of moral distress experienced by clinicians caring for the low-i­ncome patients of safety net practices in the USA during the COVID-1­ 9 pandemic. DESIGN: Cross-­sectional survey in late 2020, employing quantitative and qualitative analyses. SETTING: Safety net practices in 20 US states. Participants: 2073 survey respondents (45.8% response rate) in primary care, dental and behavioural health disciplines working in safety net practices and participating in state and national education loan repayment programmes. MEASURES: Ordinally scaled degree of moral distress experienced during the pandemic, and open-e­ nded response descriptions of issues that caused most moral distress. RESULTS: Weighted to reflect all surveyed clinicians, 28.4% reported no moral distress related to work during the pandemic, 44.8% reported ‘mild’ or ‘uncomfortable’ levels and 26.8% characterised their moral distress as ‘distressing’, ‘intense’ or ‘worst possible’. The most frequently described types of morally distressing issues encountered were patients not being able to receive the best or needed care, and patients and staff risking infection in the office. Abuse of clinic staff, suffering of patients, suffering of staff and inequities for patients were also morally distressing, as were politics, inequities and injustices within the community. Clinicians who reported instances of inequities for patients and communities and the abuse of staff were more likely to report higher levels of moral distress. CONCLUSIONS: During the pandemic’s first 9 months, moral distress was common among these clinicians working in US safety net practices. But for only one-­quarter was this significantly distressing. As reported for hospital-­based clinicians during the pandemic, this study’s clinicians in safety net practices were often morally distressed by being unable to provide optimal care to patients. New to the literature is clinicians’ moral distress from witnessing inequities and other injustices for their patients and communities.

Moral distress has been well reviewed in the literature with established deleterious side effects for all healthcare professionals, including nurses, physicians, and others. Yet, little is known about the quality and effectiveness of interventions directed to address moral distress. The aim of this integrative review is to analyze published intervention studies to determine their efficacy and applicability across hospital settings. Of the initial 1373 articles discovered in October 2020, 18 were appraised as relevant, with 1 study added by hand search and 2 after a repeated search was completed in January and then in May of 2021, for a total of 22 reviewed articles. This review revealed data mostly from nurses, with some studies making efforts to include other healthcare professions who have experienced moral distress. Education-based interventions showed the most success, though many reported limited power and few revealed statistically lowered moral distress post intervention. This may point to the difficulty in adequately addressing moral distress in real time without adequate support systems. Ultimately, these studies suggest potential frameworks which, when bolstered by organization-wide support, may aid in moral distress interventions making a measurable impact.

Moral challenges have clear impacts on physician well-being. The concept of moral injury emerged from work with combat veterans. Existing diagnostic categories did not adequately capture the psychological challenges and distress seen in soldiers returning from war. The concept of moral injury was later applied to augment the understanding of physician distress, with the aim of considering varying etiologies of the symptoms of distress seen in healthcare workers. Healthcare worker moral injury occurs when physicians are repeatedly asked to participate in or witness acts which are not in accordance with their personal moral compass. System changes which acknowledge these distinct drivers of physician distress will be needed to improve physician well-being and enhance individual self-resilience.

BACKGROUND: "Moral distress" describes the psychological strain a provider faces when unable to uphold professional values because of external constraints. Recurrent or intense moral distress risks moral injury, burnout, and physician attrition but has not been systematically studied among neurosurgeons. OBJECTIVE: To develop a unique instrument to test moral distress among neurosurgeons, evaluate the frequency and intensity of scenarios that may elicit moral distress and injury, and determine their impact on neurosurgical burnout and turnover. METHODS: An online survey investigating moral distress, burnout, and practice patterns was emailed to attending neurosurgeon members of the Congress of Neurological Surgeons. Moral distress was evaluated through a novel survey designed for neurosurgical practice. RESULTS: A total of 173 neurosurgeons completed the survey. Half of neurosurgeons (47.7%) reported significant moral distress within the past year. The most common cause was managing critical patients lacking a clear treatment plan; the most intense distress was pressure from patient families to perform futile surgery. Multivariable analysis identified burnout and performing ≥2 futile surgeries per year as predictors of distress (P < .001). Moral distress led 9.8% of neurosurgeons to leave a position and 26.6% to contemplate leaving. The novel moral distress survey demonstrated excellent internal consistency (Cronbach alpha = 0.89). CONCLUSION: We developed a reliable survey assessing neurosurgical moral distress. Nearly, half of neurosurgeons suffered moral distress within the past year, most intensely from external pressure to perform futile surgery. Moral distress correlated with burnout risk caused 10% of neurosurgeons to leave a position and a quarter to consider leaving.

A specific kind of trauma results when a person’s core principles are violated during wartime or a 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 af?liation, 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.

Police and law enforcement agents in their professional work can, at times, face and experience situations which put them at risk of suffering from moral distress and moral injury. Moral distress and moral injury result from the discrepancy of one’s moral norms and values, on the one hand, and the organisational policy that a police and law enforcement agent has to implement, or the actual professional conduct she is performing, on the other hand. For example, a police officer using force to protect herself (or others), or being unable to help arriving at an accident, crime scene, or in a conflict situation. In this chapter, we first explore moral distress and moral injury from an ethical perspective. Then, since the concepts of moral conflict and moral dilemma are key to understanding moral injury, they are explained from a normative point of view. A brief exploration of the (philosophical) concept of the conscience follows. The second focus of this chapter is on the role of ethics, and particularly ethics education, in police conflict management and use of force training. One approach of how ethical theories, traditions and insights can help to frame moral conflicts and dilemmas is presented. The potential role of ethics in the prevention and healing of moral suffering is sketched. It is argued that – even basic – knowledge of ethical theories and recognising the underlying dimensions of moral conflicts and dilemmas can help one to better understand professional conduct and to deal with different layers of responsibility for the outcome of (in)actions. This understanding is important for reflecting on individual professional conduct – but also for police organisations to better deal with the challenges of moral stress and injury and support for their officers and agents.

[This is an excerpt.] Moral injury can occur when someone engages in, fails to prevent, or witnesses acts that conflict with their values or beliefs. Examples of events that may lead to moral injury include: Having to make decisions that affect the survival of others or where all options will lead to a negative outcome; Doing something that goes against your beliefs (referred to as an act of commission); Failing to do something in line with your beliefs (referred to as an act of omission); Witnessing or learning about such an act; Experiencing betrayal by trusted others. Such potentially morally injurious experiences may lead to feelings of moral distress such as guilt, shame, and anger. Moral injury is the lasting psychological, spiritual, behavioral or social impact that may result from these experiences. [To read more, click View Resource.]

Frontline health-care workers experienced moral injury long before COVID-19, but the pandemic highlighted how pervasive and damaging this psychological harm can be. Moral injury occurs when individuals violate or witness violations of deeply held values and beliefs. We argue that a continuum exists between moral distress, moral injury, and burnout. Distinguishing these experiences highlights opportunities for intervention and moral repair, and may thwart progression to burnout.

This paper presents the presence and impact of different models of occupational distress and their relationship with functioning. Evidence suggests that whilst multiple pathology frameworks contribute to overall distress, moral injury plays a unique role, with significant impacts on functioning

In recognition that existing theoretical paradigms may not offer a comprehensive account of the range of occupational stressors and responses experienced by healthcare professionals, interest in moral injury has grown. The Moral Injury Events Scale (MIES) remains the dominant assessment tool used to measure poten­ tially morally injurious experiences (PMIEs) across different occupational groups, including healthcare professionals. Given the proliferation of research using the MIES in healthcare, in the context of ongoing debates about its structure and utility, an exploration of the psychometric properties of the MIES with this population is timely. Using the data (N = 235) from a study exploring the prevalence of exposure to PMIEs, the current study reports on the factor structure of the MIES in healthcare professionals working within a secure mental health setting. The results yielded a two-factor model representing transgressions and betrayals by ‘others’, and transgressions committed by the ‘self’. Exploration of the internal consistency of the scale yielded a McDonald’s ω of .93. Multi-group confirmatory factor analysis highlighted the model was an adequate fit for White females, tentatively suggesting that experiences of moral injury may vary by gender, intersected by ethnicity. Accordingly, future frameworks, measures and interventions to remediate the impact of moral injury may require an intersectional approach.

Healthcare workers in secure psychiatric settings operate within highly restrictive legal frameworks and are often exposed to ethically complex scenarios. They also have an increased risk of experiencing a constellation of occupational traumas, resulting from exposure to violence and self-harm, which cumulatively can affect wellbeing and violate deeply held moral codes. Moral injury, which results from perpetrating, failing to prevent, witnessing, or learning about acts that transgress deeply held moral beliefs and expectations, has been posited as a construct that can account for a range of deleterious psychological outcomes. The current study sought to explore whether moral injury was endorsed, and related to wellbeing, within a secure psychiatric setting. The cross-sectional survey data (N = 237) showed that exposure to potentially morally injurious events and distress resulting from such events, were prevalent in healthcare professionals. Furthermore, moral injury was predictive of higher secondary trauma and burnout, and lower compassion satisfaction. The perceived impact of COVID-19 was also predictive of secondary trauma and burnout, though held no relationship with moral injury nor compassion satisfaction. The findings indicate that models of occupational distress would benefit from including consideration of the morally challenging nature of working in secure settings.

OBJECTIVE: The aim of this study was to determine relationships between moral injury (MI), well-being, and resilience among staff nurses and nurse leaders practicing during the COVID-19 (coronavirus disease 2019) pandemic. BACKGROUND: Attention to MI among health professionals, including nurses, increased in 2021, particularly related to the pandemic. Few studies examined MI, well-being, and resilience; even fewer provided implications for leadership/management. METHODS: The sample included 676 RNs practicing in Ohio. The electronic survey included assessments of MI, well-being, and resilience distributed via the Ohio Nurses Association and the schools of nursing alumni Listservs. RESULTS: There was a significant association between MI and negative well-being and negative association between MI and resilience. Differences were observed between staff nurses and leaders. CONCLUSIONS: This is the first study relating MI, resilience, and well-bring among nurses and nurse leaders during the pandemic. There is a need for additional research to further our understanding about nurses' health and well-being during the pandemic and beyond.

The construct of moral injury is relatively new, primarily studied in trauma-exposed military personnel, and measurement scales recently available to screen symptoms of moral injury. However, no scale exists for firefighters; consequently, resulting in limited data for the risk and protective factors of moral injury in firefighters. Firefighters are considered one of the most stressful occupations, responding to critical incidents involving personal threat or harm to self, a violation of core beliefs about the world, and witnessing pain and suffering of others. Exposures to a single traumatic event or cumulative traumatic events can result in posttraumatic stress disorder (PTSD), depression, suicide ideation and possibly risk for moral injury. The objective of this study aims to address the gap in available instruments by developing a moral injury scale for firefighters and assess the potential risk and protective factors of moral injury in firefighters.

OBJECTIVE: Volunteerism represents an important mechanism to promote resilience, empathy, and general well-being in medical students, a group that stands to benefit. Medical students report feelings of fatigue, burnout, exhaustion, and stress that correlates with poor academic performance, and significant decline in empathy over the ­3rd year of both MD and DO programs. Volunteer motivations have been shown to mediate participant well-being. The relationship between medical student volunteer motivations and specific outcomes during the COVID-19 pandemic has not been addressed. METHODS: We characterized features of medical student volunteers during the COVID-19 pandemic in 2020, including volunteering motivation using the Volunteer Functions Inventory, the types of activities in which they participated, and the physical, psychosocial, and emotional outcomes they experienced following volunteering. RESULTS: Altruistic and humanitarian values–centric motivation predicts positive volunteering outcomes including increased resilience, ability to deal with disappointment and loss, and ability to cope with the COVID-19 pandemic. Values-centric motivation also increases volunteer empathy independent of educational stage. Values-centric participants were more likely to select volunteering activities with patient contact, which promotes student empathy and resilience. Conversely, careercentric motivation does not predict positive outcomes. These students are more likely to engage in research-oriented activities. CONCLUSIONS: The efficacy of integrating volunteerism into medical school curricula may be limited by professional pressure that manifests as career-oriented motivation. We propose that practical integration should promote altruistic and humanitarian values–centric participant orientation to the volunteering process, which is associated with enhanced recruitment, preservation of empathy, and additional positive volunteering outcomes of interest.

According to Kirk & Rhodes (2011), Nooijen et al. (2018), and Saridi et al. (2019), the motivators and barriers to exercise are influenced by one’s occupation, especially among those in the healthcare field. We sought to examine the barriers and motivators to physical activity that are distinctive to clinicians. Community hospital clinicians were surveyed regarding motivators and barriers to exercise that they experience, their burnout levels as described by an adaptation of the Mini-Z single item burnout scale, and average weekly exercise habits. The top barriers and motivators were then correlated to burnout levels, levels of physical activity, and demographics. We received 64 total responses from clinicians. The overall average level of burnout was 2.37 and the median level was 2. Approximately 38% of clinicians reported adhering to American Heart Association (AHA) guidelines of 150 minutes of exercise per week, while 33% of clinicians exercise <75 minutes per week. The top general motivator was for one’s own well-being and the top clinician-related motivator was reducing stress. The top two barriers to exercise were COVID-19 concerns at an indoor exercise facility and a lack of time. Higher average levels of burnout were experienced by those who marked being too stressed or too burnt out as barriers to exercise. Because of clinicians’ roles in propagating healthy practices in their patients from their own habits, wellness programs should be aimed at capitalizing motivators to combat barriers that this group distinctively experiences. Efforts to improve physical and mental wellness among clinicians will translate into better provider and patient health outcomes.

OBJECTIVE: To quantify the prevalence of burnout in our surgical residency program and to assess the impact of a weekly wellness program for surgical residents through validated tools measuring mindfulness, self-compassion, flourishing, and burnout. Our hypothesis was that participants with more frequent attendance would: (1) be more mindful and self-compassionate and (2) experience less burnout and more flourishing. DESIGN: An optional one-hour weekly breakfast conference was facilitated by a senior surgical faculty member with the time protected from all clinical duties. Following a guided meditation, participants were given time for reflection and dialogue about their training experiences or led in a wellness exercise. TRANCE (tolerance, respect, anonymity, nonretaliation, compassion, egalitarianism) principles were utilized to create a safe and open environment. Residents were surveyed at the end of the study period, which was from March 2017 through June 2018. SETTING: The conference and data analysis was conducted at Denver Health Medical Center, affiliated with the University of Colorado School of Medicine. PARTICIPANTS: This study analyzed survey responses from 85 surgical residents. RESULTS: Following the wellness program, when answering the 2-question Maslach Burnout Inventory, 35.7% of residents reported feeling burned out by their work once a week or more, and 29.7% reported feeling more callous toward people once a week or more. After multivariate analysis, the only independent predictors of increased burnout were “not being married or in a committed relationship,” lower positive affect, and higher negative affect. Written feedback was overwhelmingly positive, and residents expressed gratitude for the conference, the opportunity for self-reflection, and open dialogue with attendings and colleagues. CONCLUSIONS: The prevalence of burnout is high among surgical residents. Allowing time to practice a mindfulness meditation while providing space for residents to share their experiences may be protective, and efforts should be made to reduce barriers to participation.

Although empirical evidence has shown that socially responsible human resource management (SRHRM) practices positively influence employees’ outcomes, knowledge on the social impact of SRHRM practices on employee well-being has been limited. Drawing upon the social information processing theory and attribution theory, we investigate whether, how, and when SRHRM practices increase the well-being of employees. Using multiphase and multilevel data from 474 employees in 50 companies, we find that SRHRM practices positively predict employee well-being and that the relationship is mediated by employees’ perspective-taking. Furthermore, substantive attributions strengthen the positive relationship between SRHRM practices and perspective-taking of employees, whereas symbolic attributions weaken this relationship. We also find that substantive attributions positively moderate the indirect effect of SRHRM practices on employee well-being through perspective-taking, whereas symbolic attributions negatively moderate this indirect effect. Our study contributes to the understanding of the complex effect that SRHRM has on employee well-being.

OBJECTIVE: Violence is a major preventable problem in emergency departments (EDs), and validated screening tools are needed to identify potentially violent patients. We aimed to test the utility of the Aggressive Behavior Risk Assessment Tool (ABRAT) for screening patients in the ED. METHODS: A prospective cohort study was conducted among adult and pediatric patients aged ≥10 years visiting 3 emergency departments in Michigan between May 1, 2021, and June 30, 2021. Triage nurses completed the 16‐item checklist using electronic health records (EHRs), and the occurrence of violent incidents were collected before ED disposition. A multivariate logistic regression model was applied to select a parsimonious set of items. RESULTS: Among 10,554 patients, 127 had ≥1 violent incidents (1.2%). The regression model resulted in a 7‐item ABRAT for EDs, including history of aggression and mental illness and reason for visit, as well as 4 violent behavior indicators. Receiver operating characteristics analysis showed that the area under the curve was 0.91 (95% confidence interval [CI], 0.87–0.95), with a sensitivity of 84.3% (95% CI, 76.5%–89.9%) and specificity of 95.3% (95% CI, 94.8%–95.7%) at the optimal cutoff score of 1. An alternative cutoff score of 4 for identifying patients at high risk for violence had a sensitivity and specificity of 70.1% and 98.9%, respectively. CONCLUSION: The ABRAT for EDs appears to be a simple yet comprehensive checklist with a high sensitivity and specificity for identifying potentially violent patients in EDs. The availability of such a screening checklist in the EHR may allow rapid identification of high‐risk patients and implementation of focused mitigation measures to protect emergency staff and patients.