A Critical Review: Moral Injury in Nurses in the Aftermath of a Patient Safety Incident

Abstract

Background To date, there has been no published work towards understanding or classifying patient safety incidents (PSIs) or their aftermath as potential morally injurious experiences (pMIEs). A morally injurious experience is one that violates deeply held moral values and beliefs, and can put an individual at risk for burnout, post‐traumatic stress disorder, and other trauma‐related problems. This can also set the stage for moral injury, which can occur when there has been a betrayal of what is right by someone in a position of legitimate authority, or by one’s self, in a high‐stakes situation. Objective The objective of this review of nurse second victim literature is to describe symptoms of moral injury empirically observed in nurses in the aftermath of a PSI. Methods A critical review using a SALSA (search, appraisal, synthesis, analysis) method commenced with a search of electronic data base–indexed original evidence between 1980 and December 2018, focusing on registered nurses involved with a PSI. Results The nurse empirical literature reviewed included qualitative (n = 10), quantitative (n = 7), and mixed‐methods (n = 4) studies (total n = 21). Core moral injury symptoms included guilt (67%), shame (71%), spiritual‐existential crisis (9%), and loss of trust (52%). Secondary symptoms of moral injury included depression (33%), anxiety (57%), anger (71%), self‐harm, (19%), and social problems (48%). Implications Moral injury better describes what historically has been called the nurse second victim phenomenon. Through identification of pMIEs and symptoms of moral injury, nurses and organizations can be empowered to advance training and intervention programs addressing pMIEs that affect nurses’ safety and retention in the aftermath of a PSI. Clinical Relevance By describing the experiences associated with a PSI as potentially morally injurious, we set the stage to describe the potential consequences associated with the aftermath of the PSI. Furthermore, this language avoids victimizing those involved by more accurately reflecting the pMIEs of the aftermath.

Identifying Patterns of Turnover Intention Among Alabama Frontline Nurses in Hospital Settings During the COVID-19 Pandemic

“…10,20,23,57 Ethically, nurses may experience compassion fatigue or moral injury, as they must balance their perceived responsibility to safeguard patient welfare with the fear and anxiety of getting infected and amplifying the spread of the infection. 25,57 These results are consistent with qualitative and empirical research that found many nurses feel they are being pushed beyond their limits. 12,19,21,40 Frontline nurses during this time have limited team support due to the number of professionals allowed in the room with the patient, as well as time constraints related to the suggested time nurses can be in the rooms with patients.…”

“…4,5,8,[12][13][14]24 Due to their professional obligations to provide patients with the best treatment possible, many nurses may feel the emotional and mental stress of watching their patient's health quickly deteriorate due to worsening symptoms. 9,14,25 As one nurse from the initial design phase stated:…”

“…[1][2][3][4] Ethically, nurses may experience moral injury, as they must balance their responsibility to safeguard patient welfare and provide patient satisfaction with their fear, anxiety, and emotional fatigue surrounding the pandemic. 9,14,25 Psychological anxiety resulting from job demands during the COVID-19 may help to explain the ethical component to patient services that appear to exacerbate nurse stress. 9,14,25 In this case, a frontline nurse's inability to provide patient services, particularly in cases where the nurse perceives gaps in their training and the patient's treatment complexity, is expected to lead to high turnover intention.…”

“…9,14,25 Psychological anxiety resulting from job demands during the COVID-19 may help to explain the ethical component to patient services that appear to exacerbate nurse stress. 9,14,25 In this case, a frontline nurse's inability to provide patient services, particularly in cases where the nurse perceives gaps in their training and the patient's treatment complexity, is expected to lead to high turnover intention. 4,5,8,[12][13][14]24 Their perceived access to organizational support also influences frontline nurse stress.…”

Moral Injury: An Increasingly Recognized and Widespread Syndrome

“…Furthermore, MI has been associated with increased medical errors among HCPs during the COVID-19 pandemic (Mantri et al, 2021a;Wang et al, 2021). It may be difficult, however, to determine whether such medical errors are the result of MI or its cause (Curlin 2005;Stovall et al, 2020).…”