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Impact of Screening on the Identification and Prevalence of Moral Injury

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Impact of Screening on the Identification and Prevalence of Moral Injury

The complexity and realities associated with delivering quality care and making

challenging medical decisions, especially during the current COVID-19 era, result in challenges

for nurses. Frontline nurses experience daily challenges that result in moral injury, personal

culpability, and emotional burden (Greenberg et al., 2020). The purpose of developing this

document was to identify an evidence-based intervention for mitigating moral injury among

nurses. In essence, the content was discussed in four sections (a) practice problem and clinical

question, (b) evidence synthesis, (c) data-driven decision making, and (d) conclusion.

Practice Problem and Question

The initial action of the evidence-based practice (EBP) initiative involves cultivating a

spirit of inquiry, which is essential because it supports continuously questioning the current

practices (Melnyk & Fineout-Overholt, 2019). Moral injury is a significant and prevalent

problem at the national, state, and local levels, resulting in economic ramifications. Precisely,

moral injury among nurses occurs when a health care provider witnesses, fails to mitigate, or

learns about acts that transgress their moral beliefs, values, or expectations (Greenberg et al.,

2020; Litam & Balkin, 2021). Consequently, moral injury has a chronic psychological,

emotional, social, and spiritual impact on health care professionals (Hossain & Clatty, 2021).

Significance of Moral Injury

Moral injury is a significant problem nationally, particularly among frontline nurses who

experienced significant challenges when responding to the changing protocols, shortage in

resources, triage, and an increasing number of patients that need care in expedited time

constraints during the pandemic (Hossain & Clatty, 2021). In addition to the mentioned

challenges, witnessing patients isolated and dying alone and the fear of contracting COVID-19
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and subsequently infecting their colleagues, friends, and families had an emotional and

psychological impact on the nurses’ well being. Experiencing the trauma can result in moral

injury among the health care providers supporting the need for screening, coping tools, therapy,

and education to enable the clinicians to avoid or overcome the adverse effect’s impact on

wellness (Hossain & Clatty, 2021). In addition to the moral injury’s adverse impact on the

clinician’s wellness, the issue is one of the factors that will cause the anticipated nurse shortage

because the practice problem increases the number of nurses leaving the profession. The

registered nurses’ attrition prevalence within their first five years in the profession is

approximately 8% to 37%, which is in part related to the anticipated shortage of 11 million

nurses in the United States (Haddad et al., 2020; Vaughn, 2020). At Oregon Health and Science

University, 60% (a figure applicable at the state level) of nurses are considering leaving the

profession (Pitawanich, 2021).

Prevalence of Moral Injury

Rushton et al. (2021) collected data from 595 health care providers, which helped

identify that the clinically significant moral injury was 32.4%, the highest percentage being

among nurses. In their study, Litam and Balkin (2021) collected data from a nationally

representative sample size that helped them identify that the mean and standard deviation of

moral injury among the nurses was 20.23 and 12.19, respectively. Amsalem et al. (2021)

assessed the moral injury and clinical symptoms among 350 nationally representative health care

providers and identified that 72% of the participants reported depression, anxiety, and/or post-

traumatic stress disorder. In another study, Stovall et al. (2020) analyzed possible morally

injurious experiences and found that the common moral injury symptoms among nurses included

shame (71%), guilt (67%), loss of trust (52%), and spiritual-existential crisis (9%). Although
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current Oregon’s state-level prevalence of moral injury has not been published, the statistics

above support the extent of the problem.

In the practicum setting in Oregon, an overwhelming number of ill patients because of

the COVID-19 and a scarcity of essential supplies limited the nurses to deliver quality care. The

nurses who believe in the altruistic Hippocratic premise experienced a moral injury because the

mentioned challenges hindered their optimal care delivery and they witnessed patients become ill

and die (Chief Nursing Officer, personal communication, December 17, 2021). It is estimated

that close to 60% of the nurses in the practicum setting are at-risk of moral injury that could

impact them emotionally and psychologically (Chief Nursing Officer, personal communication,

December 17, 2021). Additionally, the moral injury was a problem at the proposed project site

before the COVID-19, which was caused by factors such as (a) continued life support although

not in the patients’ best interest; (b) ineffective communication on end life care among clinicians,

patients, and families; and (c) limited staffing (Chief Nursing Officer, personal communication,

December 17, 2021). Consequently, there is a need for an evidence-based intervention to

mitigate the problem

Economic Ramifications of Moral Injury

Moral injury has economic ramifications because it increases the probability of nurses

resigning (Hines et al., 2021). The expenditure associated with the nurses’ attrition is $40,038

per employee (Institute for Nursing, 2020). Also, moral injury impacts the clinicians’ mental

health, resulting in increased expenditure. Another economic ramification associated with moral

injury is related to increased medical errors and the cost of care (Wang et al., 2021). Medical

errors are a significant problem in the United States health care system because they cost the

nation approximately $20 billion annually (Rodziewicz et al., 2021).

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Evidence-Based Intervention

The different interventions that have been proposed for mitigating moral injury include

moral resilience, self-stewardship, buddy programs, on-demand psychological support, wellness

consults, screening, and the Mindful Ethical Practice and Resilience Academy (MEPRA)

(American Nurses Association, 2017; Greenberg et al., 2020; Hossain & Clatty, 2021; Linzer &

Poplau, 2021; Nelson et al., 2022; Rushton et al., 2021; see Figure 1). The evidence-based

screening was identified as a suitable intervention in the practicum setting since nurses are not

assessed for the moral injury and this prevents timely mitigation of the problem. In addition, in

the practicum setting, there are resources for enhancing the nurses’ moral resilience, but they are

underutilized because nurses do not identify that they are suffering from a moral injury (Chief

Nursing Officer, personal communication, December 17, 2021). Consequently, it is expected that

introducing an evidence-based screening intervention, specifically the Moral Injury Symptom

Scale-Health Professional (MISS-HP), will increase the timely identification of health care

providers with moral injury.

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Figure 1

Evidence-Based Interventions Conceptual Map

Buddy
programs
On-demand
Self-
stewardship psychological
support

Wellness Moral
consults resilience

Mindful Ethical
Screening Practice and
Resilience
Academy
(MEPRA)

PICOT Question

The first step of an EBP is asking a clinical question in the population, intervention,

comparison, outcome, and time format (Melnyk & Fineout-Overholt, 2019). Asking a clinical

question in the PICOT facilitates the evidence search. Accordingly, the following clinical

question will guide the proposed EBP: Among nurses (P), what is the effect of screening (I)

compared with current practice (C) on the timely identification and prevalence of moral injury

(O) within eight weeks (T)?

Evidence Synthesis of the Literature

A literature search was conducted on three electronic databases, specifically EBSCOhost,

PubMed, and Wiley (see Figure 2). Additionally, a search on Google Scholar was conducted to

ensure that the review was comprehensive. The keywords applied included moral injury, moral

distress, mental health, screening, nurses, and MISS-HP. Boolean operators AND/OR were
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applied to the keywords, helping develop search phrases. The developed search phrases were

screening AND moral injury OR mental health, nurses AND moral injury AND screening, and

screening AND MISS-HP AND moral injury AND nurses. Articles were considered appropriate

for inclusion in the literature synthesis if they were (a) published between 2017 and 2022, (b)

written in English, and (c) relevant to the clinical question. Articles that fulfilled the inclusion

criteria were excluded if they were (a) not available in full text, (b) published on predatory

journals, and (c) conducted in developing nations (see Figure 2).

Figure 2

Scope of Evidence Conceptual Map

Screening AND
Keywords moral injury OR
EBSCOhost mental health, nurses
AND moral injury
PubMed Moral injury, moral AND screening, and
Wiley distress, mental health, screening AND
screening, nurses, and MISS-HP AND moral
Google Scholar MISS-HP. injury AND nurses.
Databases and
Search Engine

Search Phrases
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Literature Synthesis

Researchers have supported the efficacy of screening as a proactive strategy for

identifying nurses at-risk or with moral injury, facilitating timely treatment (Hines et al., 2021;

Mantri et al., 2020; Rushton et al.,2020; Zhizhong et al., 2020). Mantri et al. (2020) supported

the efficacy of MISS-HP in identifying the clinically significant moral injury in health care

professionals. Likewise, the researchers supported the tool’s effectiveness in assessing the

nurses’ guilt, betrayal, moral concerns, shame, religious struggle, trust purpose, difficulty

forgiving, and self-condemnation. Ultimately, Mantri et al. (2020) posited that the MISS-HP is a

valid and reliable tool for screening moral injury, underpinning monitoring treatment. In a

different study, Zhizhong et al. (2020) supported the reliability and validity of MISS-HP in

screening for moral injury among health care providers, especially during the COVID-19

pandemic. Although the study was conducted in China, the findings are congruent with those by

the above-discussed researchers who did a United States-based research. Therefore, the findings

are generalizable.

Hines et al. (2021) added to the evidence by assessing health care professionals’

resilience about the workplace and social support. Different from Mantri et al. (2020) and

Zhizhong et al. (2020), Hines et al. (2021) screened the health care providers’ moral injury using

the Moral Injury Events Scale (MIES). The researchers found that improved workplace support

is associated with decreased moral distress. Hence, the implied findings are that identification for

moral distress among health care providers underpins the need to change the work environment

(Hines et al., 2021). Similar to Rushton et al. (2020), Hines et al. (2021) conducted their study

during the COVID-19 pandemic to assess the relationship among the factors for predicting moral

injury. As a result, the researchers provided more evidence on the efficacy of MISS-HP in
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screening for moral injury among health care workers. In addition, the researchers identified the

essence of moral resilience in helping nurses overcome moral injury. Consequently, screening

for moral injury can facilitate the identification of the issue, supporting the referral of the health

care providers to intervention to enhance their moral resilience (Hines et al., 2021).

Objective Rationale

In their systematic review, Hooper et al. (2021) found that psychological, resilience, and

coping interventions for health care providers have been supported as effective interventions for

mitigating moral injury. Conversely, there is limited evidence on the mentioned approaches as

best practices. In contrast, different researchers have supported the effectiveness of screening as

a proactive approach for identifying and managing moral injury (Hines et al., 2021; Mantri et al.,

2020; Rushton et al.,2020; Zhizhong et al., 2020). Additionally, the MISS-HP is a suitable and

valid tool for screening moral injury because it has internal reliability of 0.75 (Mantri et al.,

2020).

Data-Driven Decision Making

The facility’s internal data support the need for change in the practicum setting. In

August, a needs assessment was conducted in the practicum site to assess the hospital’s quality

standards and health care professionals’ wellness. In the need assessment report, the moral injury

was identified as among the issues that adversely affect health care providers, consequently

negatively impacting patient safety. During a personal communication with the Chief of Nursing

in the practicum setting, the Doctor of Nursing Practice (DNP) student became aware that there

are adequate resources to advance the health care professionals’ moral resilience, but they are

underutilized (Chief Nursing Officer, personal communication, December 17, 2021). Hence, to
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mitigate the gap in practice, the DNP student intends to introduce an evidence-based screening

tool, facilitating the identification of nurses with moral injury to underpin timely management.

Information technologies influence the process improvement by supporting the collection

of information on patient satisfaction and medical errors used to determine the quality of health

care delivered at the setting. Moral injury is one factor that influences the nurses’ ability to

provide quality care, meaning that decreased patient satisfaction and prevalent medical errors

signify a gap in practice (Wang et al., 2021). The data collected in the practicum setting using the

electronic health system and Hospital Consumer Assessment of Health care Providers and

Systems are essential in assessing the practicum setting’s core outcomes.

Conclusion

The COVID-19 pandemic has resulted in challenges such as difficulties in allocating

scarce resources, dilemmas for nurses when aligning their duty to patients with those to friends

and family, and issues in providing care to all chronically unwell patients that may have caused

moral injury to health care providers. Moral injury among frontline nurses that has an

occupational and psychological impact on the participants has increased exponentially during the

COVID-19 pandemic. Moral injury is a significant practice problem because the national

prevalence is approximately 32.4%. At the state level, 60% of the health care providers reported

willingness to leave the profession because of moral injury. Additionally, in the practicum

setting, it is estimated that 60% of the professionals are at-peril of moral injury. The economic

ramifications include nurses’ turnover cost and extra expenditure of treating medical errors and

mental health issues among health care professionals. The proposed evidence-based intervention

is screening for moral injury among nurses using MISS-HP, a validated and reliable tool, to

facilitate the timely management of the problem. The DNP scholar anticipates that timely
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identifying moral injury among the nurses will support referral to the resources for enhancing the

nurses’ moral resilience available at the project setting, ultimately decreasing the prevalence of

the problem.
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Appendix: Summary Table of the Evidence

Findings That
Artic Sample, Help Answer Observabl Evidence Level, Quality
le Author and Evidence Sample the EBP e Limitations
Num Date Type Size, Question Measures
ber Setting
1 Hines et al. Level II A sample of The researchers Outcomes The health A - High quality
(2021) 181 health supported the such as guilt, care
care validity and betrayal, professionals
professionals reliability of the moral were
was recruited MISS-HP in concerns, conveniently
from Duke screening for religious sampled from
University moral injury challenges, one setting in
Health among health care purpose, loss the
Systems. professionals of trust, southeastern
underpinning challenges United States.
treatment. forgiving, and The
self- participants
condemnation were 70%
, which are physicians;
moral injury hence
predictor generalizabilit
factors, were y is limited to
assessed. nurses and
other health
care
professionals.
2 Mantri et al. Level III Data were A conducive The The sample A - High quality
(2020) collected workplace researchers size was
from 96 environment assessed the conveniently
participants helps mitigate moral injury, sampled
from a moral injury, which because of the
tertiary care which supports decreased. time
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hospital the need to screen constraint.

for the problem to The specific
identify the contributors of
factors that moral injury
should be were not
improved. assessed.
3 Rushton et al. Level II In the study, Moral resilience The The A - High quality
(2020) 595 health helps participants researchers respondents
care overcome moral assessed the were recruited
professionals injury. Hence, moral injury within Johns
(n = 344, screening for and moral Hopkins
nurses; n = moral injury resilience. It Clinical
70 among nurses can was identified Research
physicians, n support the timely that improved Network,
= 37; introduction of moral limiting the
respiratory intervention to resilience generalizabilit
therapists, n enhance the decreases y.
= 42; nurse health care moral injury.
practitioner/ professionals’
physician moral resilience,
assistant; consequently
others n = decreasing the
99) were prevalence of the
recruited. problem.
4 Zhizhong et Level II The Screening for The MISS- The study was A - High quality
al. (2020) researchers moral injury HP tool was conducted in a
involved 583 using the MISS- identified as nonrandomize
nurses and HP, a valid and an effective d sample of
2,423 reliable tool, can tool for Chinese
physicians. facilitate the screening physicians and
management of moral injury. nurses.
the problem. The cultural
differences
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between the
United States
and China
might have
affected the
findings.