Allison Norful

Background Nurses working through the COVID-19 pandemic experienced moral, ethical, and psychological trauma. Posttraumatic Growth (PTG) is an increasingly recognized recovery phenomena following highly traumatic circumstances. Few qualitative studies explore PTG in nurses during the pandemic. Research aim This study investigated (1) the context and nature of trauma experienced by nurses during the COVID-19 pandemic, (2) nurses’ responses to these traumatic experiences, and (3) whether the core dimensions of posttraumatic growth were present or absent, including how these dimensions manifested in nurses’ experiences. Research design and methods Using a qualitative descriptive design, one-on-one interviews were conducted with participants using an open-ended interview guide informed by the PTG conceptual model. Participants and research context 17 clinical nurses from two campuses within a single academic medical center network in New York City were interviewed. Ethical Considerations This study was conducted with ethical approval (IRB protocol #23-04025921) from the Weill Cornell Medicine IRB, and informed verbal consent was obtained prior to each interview. Findings Following inductive analysis, three emergent themes were identified: (1) Trauma Experienced; (2) Post Trauma Period; and (3) Enduring Adaptations Following Trauma. Following deductive analysis, four of the five PTG model dimensions were endorsed by participants: Appreciation for Life; New Possibilities; Relating to Others; Personal Strength. No participants identified spiritual growth as an outcome of their experience working through the pandemic. Conclusions Nurses that worked through the pandemic experienced high psychological, moral and ethical stress. Despite the highly challenging and traumatic circumstances, nurses demonstrated remarkable capacity for growth through an evolved appreciation for life and professional purpose. Two primary protective factors emerged including the clinical family and active interdisciplinary engagement.

Background Nurses experienced intense ethical and moral challenges during the COVID-19 pandemic. Our 2020 qualitative parent study of frontline nurses’ experiences during the COVID-19 pandemic identified ethics as a cross-cutting theme with six subthemes: moral dilemmas, moral uncertainty, moral distress, moral injury, moral outrage, and moral courage. We re-analyzed ethics-related findings in light of refined definitions of ethics concepts. Research aim To analyze frontline U.S. nurses’ experiences of ethics during the COVID-19 pandemic. Research design Qualitative analysis using a directed content methodology. Participants and research context The study included 43 nurses from three major metropolitan academic medical centers and one community hospital in the northeastern, mid-Atlantic, midwestern, and western United States. Ethical considerations Participant privacy and data confidentiality were addressed. Findings Moral dilemmas arose from many situations, most frequently related to balancing safety and patient care. Moral uncertainty commonly arose from lacking health information or evidence about options. Moral distress occurred when nurses knew the right thing to do, but were prevented from doing so, including with end-of-life issues. Moral injury (accompanied by suffering, shame, or guilt) occurred after doing, seeing, or experiencing wrongdoing, often involving authority figures. Nurses expressed moral outrage at events and people within and outside healthcare. Despite difficult ethical situations, some nurses exemplified moral courage, sometimes by resisting policies they perceived as preventing compassionate care, guided by thinking about what was best for patients. Discussion This content analysis of ethics-related subthemes revealed conceptual characteristics and clarified distinctions with corresponding exemplars. Conceptual clarity may inform responses and interventions to address ethical quandaries in nursing practice. Conclusions Ethics education in nursing must address the moral dilemmas of pandemics, disasters, and other crises. Nurses need time and resources to heal from trying to provide the best care when no ideal option was available.

Background Healthcare worker retention and burnout are confounding issues. Trust among workers and their employer, that is, organization, is an important yet underexplored concept in research. Research aim The aim of this qualitative study is to explore organizational actions and systems that promote or denigrate trust among registered nurses and patient care aides (aides). Research design The study uses the Model of Psychological Contract as a theoretical framework. Focus groups were conducted to explore the concept of organizational trust and the consequences of broken trust. Participants Registered nurses (RNs) (n=6) and aides (n=6) participated in the study. Six focus groups (three RN and three aide) were conducted, with two participants per group. Focus groups were conducted online. Ethical considerations The study's methods were reviewed by the University of Pittsburgh Institutional Review Board. Findings Among RNs and aides, a sense of trust and feeling valued were important to their sense of relationship with their employers. Trust was breached when resources were scarce, employees did not feel validated and listened to, and problems were not addressed. RNs and aides described feeling devalued when compensation practices were unjust or inequitable, they had limited autonomy, and the employer created an organizational climate where business needs superceded human caring. Consequences of trust breach included burnout, dejection, and feelings of non-belonging. Discussion Tangible organizational resources (compensation and staffing) and intangible resources (value, respect, autonomy) are important to RNs and aides alike. Inability to provide these resources diminishes trust and even causes a sense of betrayal. Conclusion Future research can explore the concepts of organizational justice and interventions to restore lost trust and improve healthcare worker well-being. This is one of only a few identified studies to explore organizational factors and well-being among aides and more research among this healthcare worker population is warranted.