Research Packet - Moral Injury Among Nurses

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MORAL INJURY AMONG NURSES: Stories of Fractured Hearts & Wounded Souls

The Problem A central dilemma in the nursing profession's history has been searching for an identity independent of the dominant medical model. That alternative centers on the idea of compassionate care for the whole patient, not just as individuals but as members of families and communities. It speaks to a professional pathway that requires practicing at the intersection of medicine and society and involves a close partnership with other professions inside the health system and professions outside the health sector. 1 Significant drivers of the dominant model of professionalism, as described by Elliot Friedson and others, include control over the education, regulation, and practice of its members. 2 Yet, at different times in history, nursing has been more or less beholden to the interests of dominant economic forces, such as physicians, hospitals, and health insurance companies. The struggle, therefore, is to build sufficient power that, in practice, nurses are not forced to be complicit in situations that are in conflict with their ethical standards. Most work to date on nurses' workplace distress has focused on the concept of burnout. The research conducted by Linda Aiken and Eileen Lake on the cost of burnout has been of particular interest to hospital leaders related to the high costs of nurse turn-over. 3,4 However, the ethical

1 Pittman, P. (2019). Rising to the Challenge: Re-Embracing the Wald Model of Nursing. The American Journal of Nursing, 119 (7):46-52. doi: 10.1097/01.NAJ.0000569444.12412.89 2 Friedson E. Professional Dominance: the Social Structure of Medical Care . 1970. New York: Atherton Press. 3 Vahey, D. C., Aiken, L. H., Sloane, D. M., Clarke, S. P., & Vargas, D. (2004). Nurse burnout and patient satisfaction. Medical Care, 42 (2 Suppl), II57–II66. doi:10.1097/01.mlr.0000109126.50398.5a 4 Aiken, L.H., Clarke, S.P., Sloane, D.M., Lake, E.T., & Cheney, T. (2008). Effects of hospital care environment on patient mortality and nurse outcomes. Journal of Nursing Administration, 38 (5):223–229. doi:10.1097/01.NNA.0000312773.42352.d7

conflicts that occur in nurses' work and the resulting moral injury are a less studied cause of burnout. Moreover, the concept of burnout has recently been challenged, some going so far as to call it "victim shaming." Dr. Zubin Damania argues that the idea implies, "You're not resourceful enough, you're not strong enough to adapt to a system". 5 Damania believes that our current health care system prevents caring relationships by limiting time with patients and focusing health workers' attention on EHRs and insurance company records instead. The result is that nurses feel guilty and conflicted about their work. Simon Talbot and Wendy Dean called this "moral injury" and focus on situations in which health care workers, who are committed to compassionate care, confront a system that cares only about profit. 6 For the purposes of this project, moral injury relates to a conflict between professional identity and the reality encountered in many workplace settings. In an extraordinarily ambitious document, the American Nurses Association (ANA) updated its Code of Ethics in 2015. How this guiding document infuses nurses' actions, however, is a far more challenging question. ANA has recognized this and has launched an educational project around moral distress. Most of this work focuses on defining moral distress and generally identifying the prevalence of the problem. Important work is also been done on the concept of moral resiliency by the team at the Johns Hopkins Institute of Bioethics. They argue that moral resiliency is one type of resiliency, and that it is a necessary prerequisite to broader action to address system level problems. Our project is focused on a slightly different angle. The focus is on situations in which nurses are forced (because they perceive themselves to be powerless) to be complicit in a practice that they know is unethical. In other towards, the project will analyze system-level forces that constrain nursing practice. This focus is distinct from a broader definition of moral injury that includes all ethical decision- making by nurses, and includes those over which they have full control. It is also different from

5 Damania, Z. [ZDoggMD]. (2019, March 8). It's not burnout, it's moral injury | Dr. Zubin Damania on physician "Burnout" [Video]. YouTube. 6 Moral Injury of Healthcare . (n.d.). Fix Moral Injury. Retrieved August 12, 2020, from

a more general focus on moral distress that could also be called human suffering derived from the important topic of empathy and compassion. Some define these domains as moral distress, but that is not the focus of our study. Project Objective The project’s aim is to give voice to nurses' experiences of moral injury in different settings and to link these systemic conflicts to specific policy and regulatory debates. The analysis will connect personal narratives to specific structural and system level problems. A key point of reference is nurses' professional identity, as expressed in documents such as its Code of Ethics. Our premise is that until the breadth and depth of these ethical conflicts surface through systematic analysis, it is difficult for the profession to "see the forest for the trees". Thus, these stories will also explore what it would take to empower nurses to act upon their professional code of ethics in their everyday lives, and what these actions could mean for policy and regulatory reforms. Methodology Recruitment of nurses willing to share their stories of moral injury will include disseminating the opportunity via partnerships with nurse organizations, social media, virtual meetings and conferences, and snowballing of contacts Additionally, nurses have the option to submit their stories or request a research interview through our website at Participants privacy will be protected by not identifying their name or place of employment. We will select narrative cases for inclusion based on the narrow definition of moral injury described above, and we will select a purposefully diverse sample of cases. Analysis will include a typology of system-level causes that are leading to moral injury, and a policy analysis of those emerging problems. The project will result in a report with each chapter featuring a nurse's story and the final chapters, a cross-case analysis. The report will be an essential tool for nursing educators to stimulate discussion with students about the nursing profession's ethics and professional future

and interest the general public. We plan to also use the materials to develop a podcast or video series. Advisory Committee The project will include an advisory committee made up of partner organizations and select individuals that may represent sectors of the country not otherwise present. The Advisory Committee will help identify informants, suggest and respond to ideas for topic areas, and review all deliverables. Some may also be co-authors if they conduct interviews or participate in the analysis.

Date : November 21, 2019 To:

Pittman, Patricia M, Ph.D.


The George Washington University Committee on Human Research, Institutional Review Board (IRB), FWA00005945 IRB# NCR191772 ,“The Social Conscious of Nurses in the Context of U.S. Health Care Education, Regulation, and Practice”


Exempt Determination Date: November 21, 2019

The request for an exemption determination for the above-referenced study has been completed. The study was determined to be research that is exempt from IRB review under DHHS regulatory category 2 . The project as described in the application may proceed without further oversight by the OHR. The exemption determination applies only to the project described in your IRB Application. Any changes that may alter in any way the risks to participants, type of information to be accessed, addition of new populations, or change in PI may not be instituted without submission of a Modification within the iRIS system and further review by the OHR prior to implementation of the changes. Questions or concerns regarding the exemption determination made for the study should be directed to the OHR staff at

MORAL INJURY AMONG NURSES: Stories of Fractured Hearts & Wounded Souls Informed Consent and Agreement to Participate This study is directed by Dr. Patricia Pittman of the Department of Health Policy & Management and the Fitzhugh Mullan Institute for Health Workforce Equity, at George Washington University. Please review this important information about your rights and protections to decide if you wish to participate in the study. Participation is Voluntary. Taking part in this study is entirely voluntary and you may choose not to participate or to stop participating in the study at any time. Your employment status will not be affected in any way should you choose not to take part or to withdraw. Study Purpose. The project objective is to focus on nurses in a variety of settings, and through the narratives of individual nurses that have experienced, or are currently experiencing “moral injury”, identify the major themes that constrain nurses and are weakening the social conscience of the profession. Time Required. Your participation in this study will vary. If you participate in a semi-structured interview, your time commitment will be approximately 1 hour. If you send in your story via email, your time commitment will be however long it takes you to write your story. You may decline to answer any questions during an interview and you may stop your participation in this study at any time, including withdrawing your story. Potential Risks of Participation. Privacy and confidentiality are usually participants’ most important concerns. They are discussed in detail below. Privacy and Confidentiality Protections. Interviews will be audio-recorded and transcribed. Information you provide will be used for research purposes only. The GW Department of Health Policy and Management will have access to notes and recordings to monitor research compliance. Every effort will be made to keep your information confidential, including coding interviews by number rather than listing names. If results of this research study are reported in journals or at scientific meetings, the people who participated in the study will not be named or identified, unless you provide consent to associate your name with your response. However, confidentiality can not be ever be guaranteed. IN addition, participants who choose to be identified may encounter possible risks to their reputation or employability. Benefits of Participation. Your participation will provide important information that will be used to expand knowledge of the everyday stresses and difficult decisions nurses must make. If your case is selected for inclusion, it could be part of a manuscript or book. The publication will be an essential tool for nursing educators to stimulate discussion with students about the nursing profession’s ethics and professional future, and will also be of interest to the general public.

Study Approval and Further Information. This study has been reviewed and approved by the George Washington University Office of Human Research. Please contact Patricia Pittman, Principal Investigator (202-994-4295) or the Office of Human Research of George Washington University (202-994-2715) for further information about your rights as a research participant. INFORMED CONSENT: Your signature is not required in this document unless you prefer to sign it. Your willingness to participate in this research study is implied if you proceed to participate in an interview.

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