Moral resilience and moral injury of nurse leaders during crisis situations

This is the authors' abstract. We don't add key points for this paper.

FigureNurse leaders are a heterogeneous group encompassing a variety of roles, settings, and specialties. What ties these diverse professionals together is a common code of ethics. Nurse leaders apply the provisions of their code of ethics not only to patient scenarios, but also to their interactions with nursing colleagues who rely on their leaders as advocates for ethical nursing practice.1 Successful nurse leaders embody principles of professionalism, utilize effective communication and interpersonal skills, have a broad familiarity with the healthcare system and its nuances and complexity, and demonstrate skillful business acumen.2,3 Despite their extensive training, nurse leaders have long been an underappreciated and largely unseen force maintaining the health of the healthcare systems and functioning as a safety net for both patients and nursing staff. However, nurse leaders are under more scrutiny and subject to extraordinary stressors related to the COVID-19 pandemic. Some of these stressors occurred due to the ethical challenges placed on leaders navigating an unprecedented pandemic. Others reflect long-standing patterns within healthcare and nursing that were exacerbated during the pandemic.3 Unresolved ethical issues combined with unrelenting stress can lead to escalating degrees of moral suffering that undermines integrity and well-being.3 Moral injury (MI) occurs when an individual compromises personal or professional values, violating the individual's sense of right and wrong and causing this person to question their ability to navigate ethical concerns with integrity.4,5 Conversely, moral resilience (MR) is the capacity to restore or sustain integrity in response to ethical or moral adversity.6 MR includes six pillars: personal integrity, relational integrity, buoyancy, self-regulation/self-awareness, moral efficacy, and self-stewardship.7,8 This research substudy aimed to explore the experiences and scenarios that exposed nurse leaders to MI during the COVID-19 pandemic and the strategies and solutions that nurse leaders employ to bolster their MR and integrity. This research strives to amplify their stories in the hopes of developing practical solutions to organizational, professional, and individual concerns rooted in their ethical values as nurse leaders. METHODS Design and data collection This is a qualitative analysis of data selected from a larger online survey. A cross-sectional, internet-based survey was distributed via Qualtrics to nurse leaders across the US from August 22, 2022, to November 10, 2022. Participants were recruited through a snowball sampling strategy, including email outreach through the American Organization for Nursing Leadership, a top nurse leader professional organization; direct recruiting to nurse leaders in the primary investigator's (PI) personal network; and social media accounts related to the professional association and the principal investigator's nurse resilience program at Johns Hopkins University. Inclusion criteria included nurse leaders practicing since at least 2019, who were 18 years of age or older and living in the US. Participants completed individual demographic questions and provided information about their practice organization and their organization's handling of the pandemic. Participants also responded to items measuring MI and MR. MI was measured using the Moral Injury Symptoms Scale – Healthcare Professionals (MISS-HP), a validated, 10-item instrument with each item scored on a spectrum from 1 (strongly disagree) to 10 (strongly agree).9 Items in the scale represent the underlying domains of 1) guilt/shame, 2) spiritual troubles, and 3) condemnation.9 In prior literature, a score of 36 or greater has been interpreted as evidence of MI with moderate to severe negative impact on social and professional spheres.9 MR was measured using the revised 16-item Rushton Moral Resilience Scale (RMRS-16), validated in 2023 among interprofessional healthcare workers.10 RMRS uses a 4-point, Likert-type scale to measure four domains of resilience including: 1) responses to moral adversity, 2) personal integrity, 3) relational integrity, and 4) moral efficacy. Qualitative responses were collected from open-ended questions at the end of each section and included prompts such as, “What were the ethical issues that keep you up at night?” and “In your role as a nurse leader, what is missing in your organization that would support you to lead through crisis with integrity?” Responses to open-ended questions were exported to Microsoft Excel for storage and organization. Data analysis Descriptive data were analyzed using SPSS statistical software (version 27.0). Number of responses and percentages were computed to characterize relevant demographics and MI scores. The template organizing style was used to categorize qualitative data, generating a spreadsheet of textual material that was stored in Microsoft Excel.11 Data were organized by open-ended response code and sorted according to whether it pertained to nursing leadership, clinical nursing, patient, or organizational perspective. This subanalysis specifically focuses on data from participants whose responses addressed the experiences, perceptions, and needs of the nurse leader. Open-ended responses addressing the needs of patients, institutions, or frontline clinical nurses will be reported elsewhere. Codes were adopted deductively; the coding team met weekly to discuss code development (adding new codes iteratively) and to ensure consensus across code interpretation. Two authors (AJB, KEN) independently open-coded the data following the general principles of qualitative content analysis.12 Codes were compared using coding discrepancies as opportunities for reflection and discussion. The full research team, inclusing the PI, met weekly to discuss key themes throughout the analysis process. The Johns Hopkins Medicine Institutional Review Board determined this study to be exempt from full review. Organizational model for code analysis After coding was completed, the team selected the Reina Trust & Betrayal Model to contextualize the data for analytic interpretation. The model provided a framework for the team to explore how trust was built and broken among nurse leaders. The model encompasses the Reina Three Dimensions of Trust: Trust of Communication, Trust of Character, and Trust of Capability, each of which offers behaviors exemplifying ideal leadership practices for maintaining a healthy and trusting work environment. The authors collaborated with the cocreator of the Reina Trust Model to confirm its applicability during coding analysis. RESULTS The larger survey included respondents from all levels of nursing leadership, which is reported in a separate publication.13 Of the 1,063 individuals who completed the quantitative survey, 646 answered at least one open-ended question. From these, the investigators derived a sample for this qualitative subanalysis that consisted of 183 nurse leaders who contributed qualitative data regarding their experiences and perceptions. This sample represents a diverse group of nurses that includes executives (16.9%), directors (36.6%), and managers (13.7%), among others. At the time of the survey, most of the sample had been in the nursing profession for at least 20 years (65.9%) and had worked in their role for less than 5 years (61%). The average MI score of the participants who responded to open-ended questions was 36.3 compared with an average score of 32.6 among the entire sample. This suggests that their MI scores were clinically significant.9 See Table 1 for a demographic breakdown of the 183 qualitative participants included in this study. TABLE 1: - Participant characteristics Question Response n % Leadership role Director 67 36.6 Manager 58 13.7 Chief/vice president 31 16.9 Other 21 12 Clinical nurse leader 5 2.7 Practice location Urban 109 59.9 Suburban 51 28 Rural 22 12 Years in the profession 30+ 71 39 21-30 49 26.9 11-20 55 30.2 0-10 7 3.8 Years in your role Less than 3 years 61 33.2 3-5 years 51 27.8 5-10 years 38 20.7 10-15 years 20 10.9 >15 years 14 7.6 Gender identity Female 168 91.3 Male 16 8.7 Racial identity Caucasian/White 164 89.6 African American/Black 9 4.9 Asian American/White 5 2.7 Native American/Native Hawaiian 2 1 Other/prefer not to answer 3 1.6 Level of education Master's 98 53.2 Doctoral 60 32.6 Bachelor's 26 14.1 Spiritual/religious preference Christian/Protestant 81 44.3 Roman Catholic 48 26.2 Spiritual not religious 23 12.6 No religious preference 23 12.6 Buddhist/Muslim 4 2.1 Prefer not to answer 4 2.1 Moral injury score ≥36 86 46.9 <36 97 53 Key themes The initial qualitative findings were organized around five themes: 1) absent nursing voice, 2) I couldn't say no, 3) I was the only one, 4) leadership capacity, and 5) finances over patients. Illustrative quotes to define and represent each theme are included in the results that follow. 1. Absent nursing voice Nurse leaders felt unable to ensure that the voices and perspectives of nurses were heard throughout their organizations. This happened through the systematic exclusion of nursing leadership at the organizational level, by undervaluing nurses' opinions and expressions, so nurse leaders felt that they weren't taken seriously. Inadequate nursing representation was tolerated at the institutional level in part because nurse leaders, unlike their physician counterparts, were no longer considered clinical experts once they moved into administrative roles. When nursing was empowered to bring their concerns forward, the nursing perspective faced skepticism with financial and business leaders questioning the validity and significance of the nurses' viewpoint. “[we deserve] more trust from senior/executive leadership to know the concerns I bring forward with solutions are valid and real.” (Director, urban health system facility) When asked what kind of support was needed for nurses to lead through crisis with integrity, one director answered, “A real voice... I am often listened to and even heard by my direct leader. However, directions come from above that are the polar opposite of what I have voiced, and my teams are feeling. This adds to additional challenges and stress.” (Director, suburban acute care hospital) These issues were particularly concerning when nurses weren't consulted regarding decisions and policies that directly impacted patient and nurse safety, nursing care, and nursing compensation. As a result, there was a strong feeling of disempowerment: that nurse leaders lack autonomy in decision-making for their patients and staff. nurse decisions about clinical not or leaders with and clinical decisions that clinical suburban health system facility) Despite the challenges that they faced to nurse leaders were were and advocates for and patients. Nurse leaders also had solutions to communication and ensure that decision-making was and that as a in the healthcare to and you all you is Nurse leaders not a at the they to and suburban acute care hospital) I couldn't say about time and Nurse leaders felt that their and to patients and were throughout the pandemic. Nurse leaders felt that they were of work over their personal and when they needed to they that they were their colleagues or the larger nursing profession when they were most frontline nurses and for additional nurse leaders weren't for additional and long time nurse leaders were often the only leadership to during the and nurse executives were in a variety of moved into or because they couldn't to work at crisis capacity more than 2 years into the COVID-19 pandemic. nurse leaders their when professional their personal needs time and time is more than in my years of I to the who care for patients. has I am 12 5 and one is not urban healthcare the impact to the nurse leader, a with clinical and administrative the ethical impact on nurse leaders when nursing challenges patient for patients to to the of leadership worked to and with the on top of The on to the impact of this on patient you patients with nurse suburban health In nurses felt that because of their to and to patients, they couldn't say no to these In it with to nurse leaders to more than was or that practices to force managers to on more and more to the suburban acute care hospital) was the ethical that up at nurse leader also that the to lead also used as for nursing or nurse and this that to the issues and the they are on Nursing is not a for your lack of urban care facility) I was the only and missing leadership during the pandemic Nurse leaders felt by leaders who worked from throughout the pandemic but to work in and additional compensation. am a of the ethics at and even I with how to the What was most is that I was on my during a the at a time when needed felt as a leader, I felt urban health system facility) Nurse leaders, particularly to the as and felt that was missing throughout the pandemic. on the clinical to patient suffering and the challenges that nurses as they provided as nurses at all levels faced the pandemic they for healthcare nurse for president and When the worked from for 2 they all acute care hospital) These of by only the nurse leaders and and Leadership for related to leadership, and and the challenges that leaders faced during the nurse leaders support to care of their health and and professional to more effective leaders. development of their leadership skills, a for with nurse leaders and leaders are as as professional and a to and from one I for my direct leaders under but it is for and around as are all because care a but are so in the can no longer to what is (Director, suburban acute care hospital) to during the leaders moved in and of As nursing leaders or nurses with less moved into their roles. These new leaders and faced challenges of the including and a lack of in the survey asked for training, and a to with leaders across and across to and a to experiences and and have on the needs of frontline nurses to to and clinical in nurses in leadership and all are on physician but the leaders are to is one to a leader to and to with to I am to my (Director, urban Some leaders felt for support that from their but they that they have the to through long ethical and of and over financial are at with the of patients Nurse leaders often felt at with administrative leaders within their healthcare organizations. nurses are by a to their patients, leaders on the financial health of the This a when financial decisions impacted patient care, violating the Nursing of and to as a leader is that nursing leadership has financial how nurses are to have to a be the which to a of care of patients with the least of (Director, urban acute care hospital) A clinical nurse leader that leaders no longer in and urban acute care hospital) as by organization's financial decisions and of negative also that financial decisions were solutions and to the challenges nursing and the healthcare support at the level for that to to be to forward of only at the financial impact in the (Director, urban acute care leaders were also by their who they felt their values to on financial because of the pandemic. “In this the has been all about across the to but have and are and that it have and the which is more stress on the nurse urban acute care hospital) coding The theme of broken trust at levels from the The initial themes were to the of the Reina Trust & Betrayal The of Table 2 reflect how the initial themes to these with of this coding are in of trust in the healthcare TABLE - and for trust to Reina Trust Model 3 Qualitative quotes for trust Leadership level of Absent nursing voice Inadequate nursing representation leaders who to leaders in all to to nurse and for to with for when Nurse leaders lack decision-making autonomy decisions and leaders were what to and and not in the nurse leaders to decisions within their and of and for nursing representation in decisions that impact patient care or the decision-making to in nursing representation with for leaders in clinical and the and role of nursing and nursing leadership I couldn't say no work and and support for leaders. to work with to no support or once No to a financial for compensation. for nurse leaders that with for professional nurse leader to Nursing challenges patient care and for patients to to the of leadership worked on top of you patients with strategies to ensure patient care and of the during and crisis crisis of care to for crisis policies for nursing leadership organization and professional nursing to and nurse leader over a to was up at to the profession but feeling to to health and for health and and leadership and for leaders to discuss and nurse leader I was the only one Betrayal by and financial leaders leaders were not the on their and lead from leaders. and policies during that can be and during for nurse in during that to patient and nursing leader or strategies to from the nursing team and nurse leaders. Leadership capacity leadership information organization is professional development for all nurse leaders on and in the an institutional for nurse leaders with time and to institutional and opportunities for nurse leaders. and professional nurse leader organization for with leaders information and is no to discuss concerns or support among nurse nurse leadership to support and of challenges and with and time specifically for and group by a nurse leader for leaders there was more support for leaders, and are and not leaders the and so I it policies for including and of business time for policies for and with all education on and effective communication often addressed in business education but not in nursing a of or to nurse leader and nurse leader over patients Nurse leaders were the only patients and over finances information leaders are and lack integrity. 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These policies patient and safety code of ethics and and needs for and of Trust of on the organization and with to and that nurse leaders were by the ethical of the COVID-19 pandemic on their personal and professional as as on patients, and healthcare organizations. The that the of during the COVID-19 pandemic. 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