The Long Tail of COVID-19: Implications for the Future of Emergency Nursing

Psychological resilience and valued living as mediators in the relation between moral injury and attitudes toward future among Turkish adults

BACKGROUND

Moral injury exacerbates poor outcomes, such as negative attitudes toward the future; however, the potential underlying mechanisms of this association remain unknown. This present study aimed to disentangle the pathways linking moral injury to confidence toward the future through the serial mediation effect of psychological resilience and valued living in a Turkish population.

METHODS

The data analyzed were collected from representative samples of adult aged 18-65 years living in Gaziantep Province, Turkey. A total of 681 participants (77.7% female, mean age = 25.05) were included in this study. Structural equation modeling (SEM) was used to analyze the relationships among the variables.

RESULTS

Indirect effects of moral injury on confidence toward the future were found. The direct effect of moral injury on attitudes toward the future in the presence of mediators was not significant (b = 0.014, p > 0.05). Thus, we concluded that there was a fully serial mediation by psychological resilience and valued living in the relationship between moral injury and attitudes toward the future (b = -0.077, 95% bootstrap CI: -0.115 to -0.048).

LIMITATIONS

The main constraint of this study was its cross-sectional design, which restricted the capacity for causal inference.

CONCLUSIONS

These findings highlight the role of psychological resilience and valued living as serial mediators in the relationship between moral injury and confidence toward the future. Therefore, mental health professionals or clinicians incorporating intervention programs aimed at enhancing psychological resilience and promoting valued living could be beneficial, especially for individuals who have experienced moral injuries. Employing a multifaceted therapeutic approach may be advantageous in addressing these concerns.

From Anxiety to Hopelessness: Examining Influential Psychological Processes Affecting Mental Health Status of Spanish Nurses During the COVID-19 Pandemic

Background and Objective: to test a model aimed at delving into the psychological processes that lead to hopelessness in Spanish nurses two years after a stressful work situation. The model proposed starts with the anxiety experienced at the beginning of the COVID-19 pandemic and includes cognitive fusion and emotional exhaustion, evaluated six months after the end of the confinement, as possible contributing factors to development of hopelessness. Design: prospective study with three data collection periods, May to June 2020 (period 1), January to April 2021 (period 2), April to July 2022 (period 3). Materials and Methods: The sample (n = 131 Spanish nurses) was selected by non-probabilistic convenience sampling. The inclusion criteria were as follows: being female, over 18 years of age, and working as a nurse in direct contact with COVID-19 patients. Results: The model proposed was statistically significant (B = 0.34, SE = 0.07, t = 5.15, p < 0.001, 95% CI = [0.21, 0.47]), contributing to the explanation of 28% of the variance of hopelessness, finding that the direct anxiety-hopelessness effect was equally significant (B = 0.19, SE = 0.08, t = 2.46, p = 0.014, 95% CI = [0.04, 0.34]). An effect of anxiety on cognitive fusion and on emotional exhaustion was observed. In turn, cognitive fusion had a significant effect on emotional exhaustion but not on hopelessness. Finally, emotional exhaustion had a significant effect on hopelessness. In this final model, years of experience had a significant effect (p = 0.004) on hopelessness. Conclusions: Cognitive fusion and emotional exhaustion are shown to be relevant psychological processes upon which to intervene to contribute to the improvement of the mental health of nurses regarding the COVID-19 pandemic.

Bibliometric analysis of nurses' moral distress research

Objective

To identify the research status of nurses' moral distress and predict emerging research hotspots and development trends.

Methods

Articles on nurses' moral distress were retrieved from the Web of Science Core Collection database from the inception of the database to 2024. A bibliometric analysis was conducted using VOSviewer and CiteSpace software to analyze publication distributions by country, institution, journal, author contributions, keyword trends, and reference co-citations.

Results

Our study analyzed 1,781 documents, revealing a notable increase in publications after 2017, with contributions from 88 countries and 2,301 institutions worldwide. The United States and China were prominent contributors, highlighting global interest in this area. Analyses of keywords and cited references reveal emerging research topics such as "COVID-19", "burnout", and "moral resilience".

Conclusion

This bibliometric review sheds light on the growing academic interest in nurses' moral distress, emphasizing key themes and outlining future research directions. By charting the development of this domain, our study provides critical insights, guiding the investigation of complex ethical issues in nursing and enhancing understanding of nurses' moral distress.

Stretching oneself too thin and facing ethical challenges: Healthcare professionals' experiences during the COVID-19 pandemic

BACKGROUNDS

Most countries are facing increased pressure on healthcare resources. A better understanding of how healthcare providers respond to new demands is relevant for future pandemics and other crises.

OBJECTIVES

This study aimed to explore what nurses and doctors in Norway reported as their main ethical challenges during two periods of the COVID-19 pandemic: February 2021 and February 2022.

RESEARCH DESIGN

A longitudinal repeated cross-sectional study was conducted in the Western health region of Norway. The survey included an open-ended question about ethical challenges among doctors and nurses in hospital departments. Free-text comments were analysed using Systematic Text Condensation and also presented in a frequency table.

ETHICAL CONSIDERATIONS

Ethical approval was granted by the Regional Research Ethics Committee in Western Norway (131,421). All participants provided consent when participating in the study.

RESULTS

In 2021, 249 and in 2022, 163 healthcare professionals responded to the open-ended question. Nurses and doctors reported three main categories of ethical challenges related to the COVID-19 pandemic: (1) barriers that hindered them in acting as they ethically would have wanted to do; (2) priority-setting dilemmas linked to overtreatment, transfer of resources and ranking patient needs; and (3) workload expansion threatening work-life balance and employees' health. Category one comprised of resource barriers, regulatory barriers, system barriers, and personal barriers. Regulatory barriers, especially visitor restrictions for next-of-kin, were the most frequently reported in 2021. Resource barriers, related to the increased scarcity of qualified staff, were most frequently reported in 2022. Clinicians stretched themselves thin to avoid compromising on care, diagnostics, or treatment.

CONCLUSIONS

Developing clinicians' ability to handle and cope with limited healthcare resources is necessary. To foster resilience and sustainability, healthcare leaders, in collaboration with their staff, should ensure fair priority-setting and initiate reflections among doctors and nurses on what it implies to provide 'good enough' care.

"I Just Know if I Keep Going, I'll End Up Hating Nursing." Lived Experiences of Emergency Nurses Three Years Into the Global COVID-19 Pandemic

INTRODUCTION

As the coronavirus disease 2019 pandemic continues globally, the personal and professional pressure on health care workers continues to accumulate. Literature suggests that as the pandemic evolves, nurses are experiencing increased levels of anxiety, depression, and post-traumatic stress, ultimately leading them to voice intentions to leave the profession, if they have not done so already.

METHODS

Informed by an interpretive hermeneutic phenomenological approach, this longitudinal study was designed to capture how the lived experiences of 9 emergency nurses evolved over the coronavirus disease 2019 pandemic, highlighting their feelings, attitudes, and perceptions toward working in the emergency department at this time in history. Interviews were undertaken in June 2022 and were analyzed using a thematic analysis approach.

RESULTS

Data analysis resulted in a total of 2 major themes and 8 minor themes. The 2 major themes included "exposed wounds" and "Band-Aid solutions." Levels of burnout increased during the pandemic, with most of the emergency nurse participants dropping their hours, moving roles within the profession, or leaving the profession entirely. Findings elucidate where and how concerns may arise in clinical practice and holistic well-being among emergency nurses, particularly surrounding professional boundaries and protecting work-life balance and professional identity.

DISCUSSION

As the world moves to managing coronavirus disease 2019 as a recognized common respiratory illness, providing time and space for emergency nurses to voice their concerns, design their well-being interventions, set professional boundaries, and reconnect with their professional passion may see lower attrition rates and higher levels of professional satisfaction in emergency nurses globally.

Critical Care Nurses' Moral Resilience, Moral Injury, Institutional Betrayal, and Traumatic Stress After COVID-19

BACKGROUND

Traumatic stress and moral injury may contribute to burnout, but their relationship to institutional betrayal and moral resilience is poorly understood, leaving risk and protective factors understudied.

OBJECTIVES

To examine traumatic stress symptoms, moral injury symptoms, moral resilience, and institutional betrayal experienced by critical care nurses and examine how moral injury and traumatic stress symptoms relate to moral resilience, institutional betrayal, and patient-related burnout.

METHODS

This cross-sectional study included 121 critical care nurses and used an online survey. Validated instruments were used to measure key variables. Descriptive statistics, regression analyses, and group t tests were used to examine relationships among variables.

RESULTS

Of participating nurses, 71.5% reported significant moral injury symptoms and/or traumatic stress. Both moral injury symptoms and traumatic stress were associated with burnout. Regression models showed that institutional betrayal was associated with increased likelihood of traumatic stress and moral injury. Increases in scores on Response to Moral Adversity subscale of moral resilience were associated with a lower likelihood of traumatic stress and moral injury symptoms.

CONCLUSIONS

Moral resilience, especially response to difficult circumstances, may be protective in critical care environments, but system factors (eg, institutional betrayal) must also be addressed systemically rather than relying on individual-level interventions to address nurses' needs.

The Impact of Coronavirus Disease 2019 Visitor Restrictions on the Attitudes of Emergency Department Staff

INTRODUCTION

During the first 2 years of the pandemic, visitors for patients with COVID-19 were prohibited from emergency departments in the United States with few exceptions, leaving patients without their caregivers and advocates. Little is known about emergency nurses and nursing assistive personnel beliefs regarding this issue. Therefore, this study's purpose was to describe and assess relationships among emergency nursing and assistive personnel attitudes and perceptions regarding emergency department "no-visitor policies" for patients with COVID-19.

METHODS

This institutional review board-approved observational study was conducted in a health care system in the Southwestern United States. Nursing personnel (n = 180; 21.74% response rate) working in 11 emergency departments completed the survey during the fall of 2021. Bivariate correlations and multivariable linear regression modeling were performed to explore relationships among survey questions.

RESULTS

Most participants (61%) strongly/very strongly believed that restriction of visitors for patients with COVID-19 was necessary for the protection of staff and patients. In addition, 65% reported strongly/very strongly agreeing that it was unethical and 75% felt upset when these patients died alone. Most (81%) strongly/very strongly agreed that exemptions to the policy should be made in some cases, including imminent death. Respondents' recognition of patients' displeasure with visitor policy, recognition that a lack of visitors affected efficiency, and feeling upset when these patients died alone negatively predicted agreement that restriction was necessary.

CONCLUSION

Although most participants favored visitation restrictions for patients with coronavirus disease 2019, their beliefs were complex. Navigating stringent visitation policies and vulnerable patients' needs can result in moral distress for ED personnel.

Long-Term Trajectory and Risk Factors of Healthcare Workers' Mental Health during COVID-19 Pandemic: A 24 Month Longitudinal Cohort Study

BACKGROUND

Research has shown the substantial impact of the COVID-19 pandemic on healthcare workers' (HCWs) mental health, however, it mostly relies on data collected during the early stages of COVID-19. The aim of this study is to assess the long-term trajectory of HCWs' mental health and the associated risk factors.

METHODS

a longitudinal cohort study was carried out in an Italian hospital. At Time 1 (July 2020-July 2021), 990 HCWs took part in the study and completed the General Health Questionnaire (GHQ-12), the Impact of Event Scale (IES-R), and the General Anxiety Disorder (GAD-7)questionnaire. McNemar's test measured changes in symptoms' trajectories, and random effects models evaluated risk factors associated with scores above the cut-off.

RESULTS

310 HCWs participated to the follow-up evaluation (Time 2; July 2021-July 2022). At Time 2, scores above cut-offs were significantly lower (p < 0.001) than at Time 1 for all scales (23% vs. 48% for GHQ-12; 11% vs. 25% for IES-R; 15% vs. 23% for GAD-7). Risk factors for psychological impairment were being a nurse (IES-R: OR 4.72, 95% CI 1.71-13.0; GAD-7: OR 2.82, 95% CI 1.44-7.17), a health assistant (IES-R: OR 6.76, 95% CI 1.30-35.1), or having had an infected family member (GHQ-12: OR 1.95, 95% CI 1.01-3.83). Compared to Time 1, gender and experience in COVID-19 units lost significance with psychological symptoms.

CONCLUSIONS

data over more than 24 months from the pandemic onset showed improvement of HCWs' mental health; our findings suggested the need to tailor and prioritize preventive actions towards healthcare workforce.