The mediating roles of moral courage and moral resilience between nurses' moral distress and moral injury: An online cross-sectional study

Personal and work-related factors associated with nurse resilience: An updated systematic review using meta-analysis and narrative synthesis

BACKGROUND

Nursing shortages and increased workforce turnover have significantly increased nurses' workloads, thus increasing the risk of burnout and stress, particularly during the COVID-19 pandemic. A systematic review published in 2019 suggested that resilience could act as a buffer to adversity; however, the factors associated with resilience during and after this global pandemic have not been identified.

OBJECTIVES

To identify personal and work-related factors associated with nurse resilience, including the period during and after the COVID-19 pandemic.

DESIGN

Systematic review.

DATA SOURCES

The search was conducted between January and February 2024 in the following databases: CINAHL Plus, MEDLINE (Ovid), PsycINFO, EMBASE, and Scopus, using the key terms 'resilience', 'hardiness', 'work', 'employ', 'occupation', 'job', and 'nursing'.

REVIEW METHODS

Quantitative studies with English full text, published between 2018 and 2024, were selected if they assessed resilience and its associated factors among nurses providing direct patient care. Two authors independently completed the data selection process. Studies with quality assessment grades of 3 or above were included for final analysis. A meta-analysis was utilised for the mean resilience levels from studies using the same measures of resilience, and a narrative synthesis was performed for the demographic and work-related factors.

RESULTS

Fifty-nine cross-sectional studies with a quality assessment score of 3 or above were included. Forty-seven studies were included in a meta-analysis, which reported an estimated mean resilience level of 20.69 using a random-effects model (95 % CI [18.53, 22.85], z = 18.79, p < 0.0001, I2 = 95.1 %). Twenty studies with the Connor Davidson Resilience Scale (CD-RISC)-25 and five with the CD-RISC-10 were meta-analysed for the mean resilience levels of 62.85 (95 % CI: [55.60, 70.10], z = 16.97, p < 0.0001, I2 = 31.70 %) and 26.34 (95 % CI: [20.85, 31.83], p < 0.0001, I2 = 0 %), respectively. A low mean resilience level was identified. Sixteen demographic factors were identified as associated with resilience. Twenty job demand factors negatively associated with resilience were determined and categorised into exhaustion, psychological factors, and work challenges. Thirty-two job resource factors positively related to resilience were identified and classified into the following categories: psychological factors, leadership, work performance, well-being and quality of life, and social and organisational support.

CONCLUSIONS

Understanding the job demand and resource factors can help organisations minimise the risks and develop institutional strategies to protect nurses from the negative impact of COVID-19 or future pandemics on nurses' well-being.

Moral resilience and intention to leave: Mediating effect of moral distress

AimsThis study aims to examine the mediating effect of moral distress on the relationship between moral resilience and the intention to leave.BackgroundMoral distress is a phenomenon that negatively impacts healthcare workers, healthcare institutions, and recipients. To eliminate or minimize the negative effects of moral distress, it is necessary to increase the moral resilience of nurses. Moral resilience is important in protecting against the negative effects of moral distress, such as burnout and turnover intention. In this direction, it is necessary to increase the moral resilience of nurses to reduce negative situations such as turnover intention in nurses.MethodsIt is a descriptive-predictive study. Sociodemographic Information Form, Measure of Moral Distress - Healthcare Professionals, and Rushton Moral Resilience Scale were used to collect data from the nurses. A total of 220 clinical nurses were recruited.Ethical considerationsApproval was obtained from the university's non-interventional ethics committee, and informed consent was obtained from the participants.ResultsThe study found a total moral distress score of 6.39 ± 0.3.12 and moral resilience score of 2.69 ± 0.48. A moderate and weak negative correlation was found between moral distress and moral resilience. Moral distress has a moderating effect on the intention to leave nursing (β = -0.158, p = .010) and the intention to leave the current position (β = -0.174, p = .000). Individual's moral resilience directly affects the intention to leave. The presence of moral distress eliminates the direct effect of moral resilience and affects the intention to leave together with moral resilience.ConclusionsMoral resilience leads to decreased intention to leave, and moral distress mediates this situation. An increase in moral distress decreases moral resilience and increases intention to leave. It can be assumed that if moral distress is not controlled, increasing moral resilience will not affect the intention to leave the job.

Understanding moral injury and its predictors among Chinese physicians

BACKGROUND

Moral injury - the betrayal of one's moral and professional values - is a negative factor affecting physicians' wellbeing. However, few studies have examined moral injury and its predictors in healthcare professionals. Therefore, this study aimed to explore the prevalence, associated factors, and predictors of moral injury in Chinese physicians.

METHODS

This study was a cross-sectional survey conducted from September 14 to October 27, 2023, in mainland China. A total of 549 physicians completed the online self-administered questionnaire through the WeChat app. The 10-item Moral Injury Symptom Scale-Health Professional (MISS-HP) was used to assess the severity of moral injury symptoms, and the Moral Injury Events Scale (MIES) was used to measure exposure to potentially morally injurious events (PMIEs).

RESULTS

The results of the study showed a mean score of 42.07 (SD = 13.67) for the MISS - HP, and the prevalence of moral injury among the physicians was 31.6%. The multiple linear regression identified five main predictors of moral injury: exposure to PMIEs, job satisfaction, lack of organizational support, witnessing patient suffering or death, and mental health needs.

CONCLUSIONS

Chinese physicians reported experiencing different types of PMIEs and suffering from moral injury-related symptoms in their clinical practice. It helped to understand modifiable risk factors for moral injury, highlighting the need for systemic interventions. Healthcare institutions can mitigate moral injury and safeguard the wellbeing of healthcare workers by building peer-support networks, improving communication to address workload issues, and implementing recognition systems for ethics.

Ethical climate, moral resilience, and ethical competence of head nurses

BACKGROUND

The ethical competence of head nurses plays a pivotal role in nursing ethics. Ethical climate is a prerequisite for ethical competence, and moral resilience can positively influence an individual's ethical competence. However, few studies have focused on the relationship between ethical climate, moral resilience, and ethical competence among them.

OBJECTIVES

To investigate the relationship between ethical climate, moral resilience, and ethical competence, and examine the mediating role of moral resilience between ethical climate and ethical competence among head nurses.

DESIGN

A quantitative, cross-sectional study.

METHODS

A total of 309 Chinese head nurses completed an online survey, including ethical climate questionnaire, Rushton moral resilience scale, and ethical competence questionnaire. Inferential statistical analysis includes Pearson's correlation and a structural equation model.

ETHICAL CONSIDERATIONS

This study received ethical approval from the Institutional Review Board of Xiangya Nursing School of Central South University (No. E2023146).

RESULTS

Head nurses' ethical climate score positively impacted ethical competence (r = 0.208, p < .001), and ethical climate could affect ethical competence through the mediating role of moral resilience.

CONCLUSION

This study emphasized the value of ethical climate in moral resilience of head nurses, ultimately leading to an enhancement in their ethical competence.

Investigating the relationship between moral courage and caregiving behaviours among nurses working in COVID-19 wards in Iran

AIM

To examine the correlation between moral courage and caregiving behaviour among nurses who are employed in the COVID-19 ward in Iran.

DESIGN

This study is a descriptive-correlational and cross-sectional research conducted in 2021 in the city of Tehran, Iran.

METHODS

A total of 270 nurses employed in COVID-19 wards, who had been working in these wards for at least 1 month, were recruited from XXX hospitals and XXX Hospital. Data collection was conducted from September to November 2021. The data collection tools included a demographic information form, the Caring Dimension Inventory (CDI-25), and the Professional Moral Courage Scale (PMC). The designed questionnaire links were provided to the participants virtually through the Persian platform 'Pars Line' and via WhatsApp. Descriptive statistics and inferential statistics were used to examine the relationship between moral courage and care behaviour.

RESULTS

There was a significant difference in the mean of caring behaviour between the age groups (<30 and >40 years old), and the work experience groups (<5 years and >15 years) (p < 0.05). Ethical values also varied significantly between certain age and experience groups (p < 0.05), but no significant differences were found in ethical behaviour across most ages (30-40 years) and work experience categories (>10 years) (p > 0.05). The level of moral courage among the nurses was higher than the median score of the instrument (87.31 ± 10.37). Among the dimensions of moral courage, the highest score was related to the dimension of ethical factors (17.64 ± 2.64), and the lowest score was related to the dimension of multiple values (17.26 ± 2.78). The level of caring behaviours among the nurses was lower than the median score of the instrument (46.11 ± 10.84). Among the dimensions of caring behaviours, the highest score was related to physical-technical behaviours (19.22 ± 5.27), and the lowest score was related to professional behaviours (1.35 ± 0.67). Based on the analysis, moral courage had a weak and inverse correlation with caring behaviours among nurses. The higher moral courage does not necessarily result in improved caregiving behaviours, emphasizing the need for further research to explore and address this relationship.

PATIENT

No Patient or Public Contribution.

Moral distress and compassion fatigue among nursing interns: a cross-sectional study on the mediating roles of moral resilience and professional identity

BACKGROUND

Nursing interns often faced moral distress in clinical practice, similar to registered nurses, which can lead to compassion fatigue. The roles of moral resilience and professional identity in influencing the psychological well-being of nursing interns are recognized, but the interrelationships among moral distress, moral resilience, professional identity, and compassion fatigue in this group remain unclear.

OBJECTIVES

This study aimed to investigate the impact of moral distress on compassion fatigue among nursing interns and to explore the mediating role of moral resilience and professional identity.

METHODS

A quantitative cross-sectional study was conducted with 467 nursing interns. Data were collected using Compassion Fatigue Short Scale, Moral Distress Scale-revised, Rushton Moral Resilience Scale, and Professional Identity Scale. Data analyses were performed using SPSS 22.0 and Amos 21.0, adhering to the STROBE statement.

RESULTS

The mean scores for compassion fatigue, moral distress, moral resilience, and professional identity were 35.876, 44.887, 2.578, and 37.610, respectively. Moral distress was positively correlated with compassion fatigue. Structural equation modeling showed that moral resilience and professional identity partially mediated the relationship between moral distress and compassion fatigue (β = 0.448, P < 0.001).

CONCLUSION

The findings suggest that moral distress directly influences compassion fatigue among nursing interns and also exerts an indirect effect through moral resilience and professional identity. Interventions aimed at enhancing moral resilience and fostering a strong professional identity may help mitigate the adverse effects of moral distress on compassion fatigue among nursing interns.

The influence of psychological resilience and nursing practice environment on nurses' moral courage: A cross-sectional study

AIM

To determine the relationship between psychological resilience, nursing practice environment, and moral courage of clinical nurses and also the factors influencing moral courage.

DESIGN

Cross-sectional study.

METHODS

586 nurses from a general hospital were selected by convenience sampling method in January 2023. The general information questionnaire, Nurses' Moral Courage Scale (NMCS), Resilience Scale, and Practice Environment Scale (PES) were measured. Hierarchical linear regression analysis was used to explore the influencing factors of clinical nurses' moral courage.

RESULTS

Nurses' average moral courage score was 79.00 (69.00, 91.00). The nurses' moral courage was positively correlated with psychological resilience and nursing practice environment. Multivariate linear regression analysis showed that psychological resilience and nursing practice environment entered the regression equation, accounting for 23.4% of the total variation. Psychological resilience and nursing practice environment are the main factors affecting the moral courage of clinical nurses. Nursing managers should conduct moral courage training, develop a decent nursing practice environment, pay attention to the psychological emotions of nurses, and actively build a safe, open, and supportive atmosphere for moral behaviour.