Ohio Nurse - March 2021

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Page 8 Ohio Nurse March 2021 Moral Injury in the Nursing Workforce Cynthia Hammond, PhD, MS, RN, and Shirna Gullo, DNP, MSN, BSN, RN Kettering College Division of Nursing Marquis and Houston (2017) emphasized the prevalence of key terms identified to “describe the moral indifference, moral uncertainty, moral conflict, moral distress, moral outrage, and ethical dilemmas” faced by nurses (p. 85). However, this list of terms did not include moral injury. Moral injury was coined by the psychiatrist, Dr. Jonathan Shay. Dr. Shay studied military veterans that suffered from Post-Traumatic Stress Syndrome (PTSD). He defined moral injury as a “betrayal of what is right by someone who holds legitimate authority in a high stakes situation” (Delima-Tokarz, 2017, p.1). As a result of this research, Dr. Shay discovered that while soldiers were in active duty, they could reconcile their own moral values with military duty but when they returned to civilian life, the same moral conflicts, caused the soldiers internal distress or moral injury (Delima-Tokarz, 2017). The purpose of this article is to discuss and explore the following questions: Can the same moral injury seen in military veterans be seen in nurses that fight the battle of COVID-19 and the regular day-to-day challenges in healthcare? Are nurses at all levels of the healthcare organization, at the bedside and in administration having to face internal and external demands that compromise quality care, or patient and individual safety that could lead to moral injury? What recommendations can be integrated to help identify and intervene early in actual or potential moral injury dilemmas? According to the Ohio Nurses Association (2020), moral injury can be defined as “the feeling that occurs when we are prevented from doing what we believe is right. We feel compromised in our ability to practice as moral agents according to our Code of Ethics.” The Code of Ethics for Nurses is the profession’s public expression of those central ethical values, duties, and commitments (ANA, 2015). Finally, Dictionary.com (2020) defined moral injury as concerning itself with right and wrong principles of behavior. Exactly who or what becomes the compass of assessing moral principles to determine what is acceptable behavior by an individual or society? (Delima-Tokarz, 2017). Perhaps, it is an internal moral guide that directs how we live our daily lives and actions? On the other hand, Beard (2019) found moral principles represent treating others the way the individual wants to be treated (being treated fairly), speaking truth and avoid telling a lie (building trust), avoiding spending what you do not have (living a personable affordable life), and avoiding taking what does not belong to you (building honesty). The moral code is comprised of building blocks that construct society’s culture (Beard, 2019). If our individual moral code is damaged, a moral injury has occurred (Delima- Tokarz, 2017). Therefore, each nurse and nursing leader can turn to the nursing process which is the framework at the heart of the provision of nursing practice to help identify and rectify situations causing actual or potential moral injury. Utilization of the nursing process allows the nurse to promptly assess, diagnose, plan, implement, and evaluate issues directed at themselves, the patient, co-workers or the organization. Nurse Burnout Versus Moral Injury Dean, Talbot, and Dean, (2019) posited that the difference between burnout and moral injury must be identified because a better understanding will reframe the problem and the solutions. The term burnout indicates that an individual cannot withstand something in the work environment. “Over the last 10 years, burnout has become a significant psychosocial problem that is caused by unsuccessfully managed chronic stress in the workplace. It is a psychological syndrome characterized by energy depletion, increased mental distance from one’s work (i.e. cynicism or negativism), and reduced professional efficacy” (WHO; ICD-11; 2013; 2018 as cited in Raudenska et al. (2020). Because burnout is an internal and individual problem, then a solution to burnout is to fix the internal deficiency. Alharbi et al. (2019) identified anxiety, depression, decrease in satisfaction, diminished quality of care, PTSD, and an increase in suicide rates as prevalent in healthcare professionals experiencing burnout. This is contrasted with moral injury, which is a description of knowing what care is needed for patients and being unable to offer the care or treatment, due to barriers beyond the control of the nurse (Dean et al., 2019). The moral injury debacle of the COVID-19 pandemic has placed extreme pressure on the nursing workforce daily with morally challenging dilemmas (Duhig, 2020). According to Duhig, the morally challenging dilemmas are being described as: fear of not being able to protect the patient or self because insufficient supplies of personal protective equipment (PPE). Nurses are not able to provide quality care to patients. Nurses are taking on roles that they are inadequately trained to implement. Moral injury can be caused by severe understaffing, poor team communication, conflict with physicians about patient care, physician-only input into clinical decisions, and clashes between physicians and nurses regarding inappropriate use of resources (Duhig, 2020). Moral injury is present among nurses when nurses feel that high standards of patient care are not being met, personal values cannot be lived up to, personal negative feeling of being devalued and voiceless which can lead to shame or guilt of and mistrust of colleagues and organizational administrators. The long-term effects of moral injury can lead to mental health threats (National Center for PTSD, n.d.). Marquis and Houston (2017) echoed this point by saying that “nurses are often placed in situations where they are expected to be agents for patients, physicians, and the organization simultaneously, all of which may have conflicting needs, wants, and goals” (p. 84). Nurse leaders and nurses need to implement strategies to reduce the incidence of moral injury. Nursing Solutions for Moral Injury Nurse leaders can support nursing teams by presenting moral injury as a lens to talk about personal experiences. This informal peer group can be referred to as “soul repair” (Duhig, 2020, p.1) The overarching goal of supporting nurses is to move from an analysis of the problem to a vision of a positive outcome (Duhig, 2020). This change in perspective and shared vision can lead the nursing organization through the following recommendations by Duhig (2020) and Dean et al., (2019): • The nurse leader should focus on what small or large steps can be taken to obtain a sense of fulfillment. • The nurse leaders can also reevaluate workflow, revise team communication, strive to identify and eliminate episodes of poor time management, eliminate inefficient use of resources, and curtail ineffective processes in daily practice and operations of the departments (Duhig, 2020). The healthcare team and nursing administrators must work together to identify the problems that prevent clinicians and other healthcare team members from building trust and providing optimal care. The quality and safety of patient care must be changed to put the patient first instead of letting business practices drive treatment options (Dean et al., 2019). In a recent article by Dean et al., (2019), recommendations given to address moral injury are summarized below: • Invite and expose administrators to the innerworkings of the clinical environment. The administrators and the clinician’s make-up the interprofessional healthcare team. These two parties must engage each other on a common ground. If administrators would work a shift with a clinician in various areas such as a clinic or the emergency room, they would be exposed to the challenges experienced by the nurses. These encounters would expose administrators to the depth of the challenges that occur in the system. Clinicians need to be open-minded to see the challenges from the overall administrative perspective. Having an understanding from both perspectives is where commonality and happy mediums are found, and shared visions are explored. Garden Healthcare strives to provide excellent care for our residents. We are hiring nurses to join our talented team in our facilities located in and around the Columbus area. Send your resume to careers@gardenhc.com to be connected with our Recruiters. Bella Terrace Capital City Gardens Wesleyan Village Pinnacle Rehabilitation Prestige Gardens Buckeye Terrace Country Meadows Country Lane Gardens Whispering Hills The Pavilion Rehabilitation Crestline Nursing Center Rolling Hills Legends Care OUR FACILITIES: Columbus, OH Columbus, OH Elyria, OH Tallmadge, OH Marysville, OH Westerville, OH Belleville, OH Thornville, OH Mt Vernon, OH N. Royalton, OH Crestline, OH Bridgeport, OH Massillon, OH
March 2021 Ohio Nurse Page 9 • Change the paradigm that links patient satisfaction with clinician compensation to clinician satisfaction with executive compensation. • Clinicians must have the ability to impact lobbying efforts. Clinicians, like physician leaders, chief wellness officers, department chairpersons, and nurse leaders must open lines of communication with those who can impact healthcare change. • Establish and maintain a sense of community and collaboration among clinicians. This can be implemented by offering and fostering a more supportive, mentoring, and team building environment/culture instead of one where there is increased competition. Conclusion The year 2020 has taken nursing by a vast storm, namely COVID-19. The year 2020 can even be described as a landlock tsunami. The sweep of devastation that the wrath of previous tsunami’s has echoed is a reflection of death and destruction. The familiar memories of death and destruction are reflections of how nurses have carried the banners of care, treatment, loss, and success stories. Ignatavicius, Workman, and Rebar (2018) validated that “patient and staff safety is a major priority for professional nurses. Best safety practices reduce error and harm through established protocols, memory checklists, and systems such as bar-code medication administration” (p. 4). Even though the year 2020 has taken nursing by an unprecedented, unexpected, unrelenting surprise with this pandemic, the healthcare team, especially nurses, has exhibited a matchless resiliency and perseverance for this cause. Nurses have been at the front lines, the first responders, and the supporters of health care throughout this ordeal. Nurses have worked their scheduled shifts and overtime which have now become a way of life. The tragedy of loss has been overwhelming but recovery cases have encouraged nurses, with a sense of duty to an internal calling. This internal calling is the nursing oath (Dean et al., 2019) which promotes us to a higher standard even in the midst of a pandemic. One helpful tool to keep in mind in helping to educate nursing leadership and nursing staff about the prompt identification of a potential or actual moral injury is “RACK:” Recognize what is happening, Act promptly, Consult with the nursing leader by following the chain of command (chief nursing officer, nursing director, nurse manager, supervisor, charge nurse, etc.), Keep alert to signs and symptoms of moral injury and avoid and mitigate situations within your control from occurring that can lead to ethical dilemmas (S. Gullo, personal communication, December 6, 2020). Research is needed on the identification, response, overall impact and effective resolution of moral injury in the nursing workforce to specifically assess, diagnose, plan, implement and evaluate prompt and intentional efforts to mitigate any and all episodes of moral injury. Healthcare organizations, nursing administrators, nursing regulatory agencies, and nurses themselves must take a stand to prevent and protect themselves and their patients, from moral injury. Nurses must act now! References Alharbi J., Jackson, D.,& Usher, K.(2019). Compassion fatigue in critical care nurses. An integrative review of the literature. Saudi Med J. 40(11):1087–1097. doi:10.15537/smj.2019.11.24569. American Nurses Association (2015). Code of ethics for nurses with interpretive statements, https://www. nursingworld.org/practice-policy/nursing-excellence/ ethics/code-of-ethics-for-nurses/coe-view-only/ Beard, S. ( 2019). Deep ethics: The long-term quest to decide right from wrong. Future. Retrieved from: https:// www.bbc.com/future/article/20190617-deep-ethics-thelong-term-quest-to-decide-right-from-wrong Dean, W., Talbot, S., & Dean, A. (2019). Reframing clinician distress: Moral injury not burnout. Federal Practitioner: For the Health Care Professionals of the VA, DoD, and PHS, 36(9), 400–402. Delima-Tokarz, T. (2017). The psychiatric ramifications of moral injury among veterans. The American Journal of Psychiatry. https://doi.org/10.1176/appi.ajprj.2016.110505 Dictionary.com (2020). Retrieved from https://www. dictionary.com/browse/moral?s=t Duhig, S. (2020). Relias Institute. Retrieved from: https://www. relias.com/blog/are-your-nurses-experiencing-moral-injury Ignatavicius, D., Workman, M. & Rebar, C. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care (9thed.). Elsevier. Marquis, B. L. & Houston, C. J. (2017). Leadership roles and management functions in nursing: Theory and application. (9th ed.). Wolters Kluwer. National Center for PTSD (Posttraumatic Stress Disorder). (n.d.). Advancing science and promoting understanding of traumatic stress: Moral injury in healthcare workers on the frontlines of the Coronavirus (COVID -19) outbreak. U.S. Department of Veterans Affairs. Retrieved from: https://www.theschwartzcenter.org/ media/Moral-Injury-Covid-19-Fact-Sheet-040420_ JH.pdf Ohio Nurses Association (2020). Moral Injury Research Application. Retrieved from https://onaapply.smapply.io/ prog/moral_injury_research_application_/ Raudenská, J., Steinerová, V., Javůrková, A., Urits, I., Kaye, A. D., Viswanath, O., & Varrassi, G. (2020). Occupational burnout syndrome and post-traumatic stress among healthcare professionals during the novel coronavirus disease 2019 (COVID-19) pandemic. Best practice & research. Clinical anaesthesiology, 34(3), 553–560. https://doi.org/10.1016/j.bpa.2 020.07.008 Join live virtually for ambulatory care clinical, management, leadership, CCTM, and telehealth knowledge you need now! Attend for as low as $219. Register Today! conference.aaacn.org
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Ohio Nurse - March 2021

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