The prevalence of moral injury, self-compassion, and self-reflection in advanced practice providers: A secondary cross-sectional analysis

Background: As burnout continues to be prevalent in healthcare providers, moral injury (MI) and moral distress (MD) have become increasingly studied as essential contributors to burnout syndrome. Moral injury results from prolonged moral distress and chronic internal conflict. Advanced Practice Providers (APPs) are often exposed to chronic stressors that can lead to moral distress and moral injury. Objective: This study was conducted as a secondary analysis of a randomized controlled trial conducted in 2023, which sought to explore wellbeing coaching strategies in APPs with a primary outcome of burnout and secondary outcome measures of MI, self-compassion, self-reflection, and insight. This secondary analysis describes the prevalence of MI, self-compassion, and self-reflection in APPs as well as associated work and demographic drivers. Methods: A total of 305 participants were surveyed in September 2023. Three surveys were deployed using Research Electronic Data Capture (REDCap); Self-Reflection and Insight Survey Short Scale (SIRSS), Neff’s Self-Compassion Survey (NSC-S), and The Moral Injury Symptom Scale for Health Professions (MISS-HP). Univariate and multivariate linear regressions were used for data analysis. Results: The cohort demonstrated high levels of moral injury, 47.65 (11.92), moderate levels of self-compassion, 2.81 (0.61), and self-reflection and insight, 59. 04 (11.44). In univariate linear regression analysis, PAs scored 4.4 points higher (95% CI, 1.5,7.3) (p = 0.003) in moral injury compared to APRNs. APPs working with adult patients scored 3 points higher (95% CI: 0.19 to 5.8; p = 0.036) compared to those working with pediatric patients. Variables protective against moral injury included identifying as a caregiver (95% CI: -6.2, -0.4; p = 0.023) and those with more than 11 years of experience (95% CI: -6.0, -0.28; p = 0.031). An adjusted multivariate regression analysis demonstrated that while accounting for all other variables, PAs were still more likely to experience moral injury compared to APRNs (95% CI: 1.4, 7.9; p = 0.008). No significant differences were found in multivariate analysis for either Self-Compassion or Self-Reflection. Conclusions: The findings of this study demonstrate high MI in APPs, and within this group of professionals, PAs experience more MI compared to APRNs. This study did not highlight a cause for MI in APPs or why PAs experience more MI compared to APRNs, and therefore, further research is needed to fully understand the contributors. Healthcare leaders should consider the findings of this study when planning interventions to support well-being in their healthcare workforce.