Relationships of individual and workplace characteristics With nurses’ moral resilience

Abstract

Background

Moral resilience is the integrity and emotional strength to remain buoyant and achieve moral growth amid distressing situations. Evidence is still emerging on how to best cultivate moral resilience. Few studies have examined the predictive relationship of workplace well-being and of organizational factors with moral resilience.

Research aims

The aims are to examine associations of workplace well-being (i.e., compassion satisfaction, burnout, and secondary traumatic stress) and moral resilience, and to examine associations of workplace factors (i.e., authentic leadership and perceived congruence of organizational mission and behaviors) and moral resilience.

Research design

This study uses a cross-sectional design.

Participants and research context

Nurses practicing in a hospital in the United States were surveyed using validated instruments (N = 147). Individual factors were measured using demographics and the Professional Quality of Life Scale. Organizational factors were measured using the Authentic Leadership Questionnaire and a single item measuring organizational mission/behavior congruence. Moral resilience was measured using the Rushton Moral Resilience Scale.

Ethical considerations

The study was approved by an institutional review board.

Findings

Resilience was noted to have significant small correlations with burnout, secondary traumatic stress, compassion satisfaction, and organizational mission/behavior congruence. Burnout and secondary traumatic stress predicted less resilience, whereas compassion satisfaction and perceived congruence between organizational mission and behaviors predicted higher resilience.

Discussion

Burnout and secondary traumatic stress, increasingly experienced by nurses and other health professionals, have negative effects on moral resilience. Compassion satisfaction can increase resilience, which is especially important in nursing. Organizational practices promoting integrity and confidence can have positive effects on resilience.

Conclusions

Continued work to confront workplace well-being issues, especially burnout, is needed as a way of increasing moral resilience. Studies of organizational and work environment factors to bolster resilience are likewise needed to assist organizational leaders in devising the best strategies.

Keywords

Organizational values moral resilience burnout Rushton Moral Resilience Scale

Introduction

Clinician workplace well-being, conceptualized as the behavioral, attitudinal, and psychological aspects of professional quality of life, is an increasing concern for both healthcare quality and workforce stability.¹ Well-being is a multi-dimensional construct, consisting of positive and negative manifestations and attributes that impact the ability to provide healthcare services.² Workplace well-being, particularly among clinicians includes overall satisfaction of helping through care, and negative ones, including burnout and the traumatic stress of providing care to a person or group during a period of great physical or emotional hardship.³

Well-being can also include aspects of moral health, including moral resilience. Though complex, resilience is largely defined as the ability to retain one’s ethical integrity and professional connections amidst or after an adverse situation or event.⁴ Moral resilience is an aspect of well-being worthy of empirical understanding because it offers a positive, empowering narrative for clinician emotional health.^5–7 As an emerging area of focus in health systems research, resilience strengthening has the potential to counteract the negative outcomes of burnout.⁷ This paper describes the findings of a study to determine what factors might influence moral resilience among nurses.

Background

Moral resilience is a concept in which integrity and buoyancy allow for positive growth even in the midst of difficult, morally challenging situations.⁷ Moral resilience differs slightly from stress resilience, which is conceptually defined as hardiness and endurance of stress.⁸ Though both moral resilience and stress resilience are posited to be personality traits and factors that enhance a person’s ability to remain buoyant in response to a distressing situation, moral resilience differs in that the buoyancy relates to the person’s integrity and ethical growth. The moral dynamic of this type of resilience indicates the person’s integrity, conscious, ethics, and relationships shape their ability to bounce back from adverse situations or experiences.⁷ For caring professions such as nursing, moral resilience is of high importance because of the importance of nursing’s professional responsibility to provide ethical care and because nurses are likely to experience morally distressing situations in patient care or other health service situations.⁹

Evidence is still emerging on the interrelation of moral resilience with workplace well-being. Antonsdottir et al.⁵ studied individual factors, such as workplace demographics and clinician well-being, that relate to moral resilience among interdisciplinary clinicians (e.g., nurses, physicians, social workers, and chaplains). Their findings indicate resilience has associations with well-being aspects, including burnout, turnover intention, and personal achievement. Lin et al.⁴ studied resilience among long term care nurses, using resilience as an outcome variable. Their study identified burnout, compassion satisfaction, and secondary traumatic stress as workplace well-being predictors of resilience. Spilg et al.¹⁰ examined moral resilience among healthcare workers, including nurses; their study found resilience was correlated with lower stress, anxiety, and depression, and that factors associated with higher resilience scores included being male, of older age, and having higher support from employers.

Leadership styles have theoretical links to well-being, including resilience;¹¹ yet, there are limited studies examining associations among these factors. Leadership integrity, transparency, and authenticity are considered important aspects of workplace culture, which can influence the job performance and workplace wellness of employees.¹² Leadership, particularly authentic leadership, is seen as a critical aspect of a healthy work environment for nurses because it provides nurses a feeling of psychological safety to innovate their practices in striving for the best possible care for patients.¹³ Authentic leadership creates a supportive environment for ethical practice, influencing the potential for nurses to feel connected to their systems and leaders and thus feel supported and valued by their workplace.⁷

Another aspect of well-being is that of organizational behavioral integrity, specifically the alignment of organizational mission and values with organizational behavior.¹¹ Behavioral integrity, as defined in organizational behavior research, is the alignment of actions with stated mission and fidelity to stated values.¹⁴ Organizational mission statements are an accepted part of business practice; however, fewer organizations strive to assure their practices and behaviors align with these statements.¹⁵ Organizational behavior integrity is an emerging area of interest in both business and healthcare services research because of its theoretical links to workplace engagement and job performance.¹⁴ Very few studies have examined organizational behavioral integrity in nursing. This is a research gap for both business and nursing ethics research, and increasingly an important topic area considering its influence on moral integrity, psychological contract, and workplace performance.^7,14–16

Despite the growing evidence that resilience is an important issue in health systems workforce and well-being research, a need for studies examining moral resilience remains. Many studies measure resilience, but few use a specific instrument to capture moral resilience.¹⁷ This discrepancy is important because moral resilience connotes the integrity and ethical health of one’s conscious, whereas general resilience refers more to the ability to “bounce back.” Studies examining moral resilience specifically, especially after the COVID-19 pandemic where great moral distress and injury occurred, are needed to best understand help nurses and others heal from their experiences.⁹ Thus, this study seeks to describe individual characteristics of well-being and moral resilience among nurses working in a hospital and determine the workplace factors associated with them. The goal is contribute to the evidence base on moral resilience and to offer evidence to nurse leaders and administrators on the influence of leadership practices on well-being and moral resilience among staff.

Study aims

The goal of this study is to determine factors related to moral resilience among practicing registered nurses. The aims are to examine associations of workplace well-being (i.e., compassion satisfaction, burnout, and secondary traumatic stress) and moral resilience, and to examine associations of workplace factors (i.e., authentic leadership and perceived congruence of organizational mission and behaviors) and moral resilience. The null hypothesis is as follows: H_{0 =} There are no significant associations among variables.

Methods

Research design

This study used a cross-sectional, correlational design with validated instruments and specific questions to measure variables to collect quantitative self-report data.

Conceptual model

The conceptual model for this study is based on Rushton’s 2018 model for moral resilience, which stresses the importance of personal and organizational wholeness and integrity as factors towards moral health.⁷ Within the conceptual model, moral resilience is influenced by personal factors, such as role in the workplace and years of experience, as well as workplace factors, particularly the integrity perceived from one’s leaders and organization. The conceptual definition of well-being includes workplace well-being, that is, workplace quality of life, including satisfaction in the caring aspects of clinical work occurring, stress, and burnout. The conceptual definition of moral resilience is consistent with Rushton’s conceptual definition, in which moral resilience is a buoyancy and stability of one’s moral and ethical self and a positive experience from providing human caring in distressing circumstances.⁷

For the organizational aspects, a focus was placed on workplace factors that relate to integrity, considering the importance of personal and relational integrity in moral resilience. The workplace factors were conceptualized as authentic leadership and organizational behavioral integrity. Authentic leadership is conceptualized as the behaviors and actions which connote connection and commitment on the part of the leader.^11,13 Organizational behavioral integrity is conceptualized as employee’s perceptions of the alignment of organizational behavior with stated mission and values.¹²

Participants

The study used a convenience sample of registered nurses working at a hospital in California. Inclusion criteria are to be a registered nurse employed by the hospital, to have worked a nursing shift in the past 60 days, and to read English fluently. The inclusion criteria were used to assure the nurses had recent exposure to the leadership practices in the workplace and to reduce the possibility of recall bias. The study was conducted by sending a link to the secure survey and recruitment language in an email, sent to approximately 500 registered nurses on staff. The list of nurses was obtained from the hospital’s human resources system by request of the study’s principal investigator, who was employed at the hospital.

Measures

Demographics

Demographic characteristics were selected to best describe the sample and compare with national makeup of the nursing workforce in the U.S. Gender was measured as female, male, or prefer not to answer. Race was measured according to Census track designations—White, Black or African American, Asian, American Indian or Alaskan Native, Multiracial, Prefer not to Answer, and Other. Personal factors related to work were also collected, consistent with the conceptual models used to design the study.¹¹ Workplace was measured according to common titles at the facility—direct care nurse, management, advanced practice nurse, educator, and other. Years of experience was grouped to be consistent with other studies of nurse well-being, and thus allow for comparisons;^10,18 these groupings were less than 2 years, 2–10 years, 10–20 years, and more than 20 years.

Well-being

Workplace well-being was operationalized using demographic questions and the Professional Quality of Life version 5 (ProQOL-5) scale.¹⁹ The ProQOL is a 30-item scale that measures three domains of well-being: burnout, compassion satisfaction, and secondary traumatic stress. Three subscales measure these domains, each subscale containing 10 items measured on a 5-point Likert scale of frequency (0 = never to 5 = very often). Higher scores indicate higher levels of the well-being trait. Scores were used as continuous measures, with subscale scores ranging from 0 to 50. The Cronbach’s alpha for subscales were high and consistent with other published studies (compassion satisfaction = 0.92; burnout = 0.86; secondary traumatic stress = 0.84).

Workplace factors

Extrinsic factors were conceptualized as leadership and organizational integrity inwork environment that could foster resilience. Leadership factors were operationalized using the Authentic Leadership Questionnaire (ALQ) rater survey.²⁰ The ALQ is a 16-item scale which measures four domains of leadership: transparency, moral/ethical behaviors, balanced processing, and self-awareness. Four subscales of the ALQ measure these domains. The ALQ was selected because it Items are measured on a 5-point Likert scale (0 = not at all to 5 = frequently, if not always). Scores range from 0 to 64 on the full scale, with higher scores indicating higher levels of frequency of positive leader behaviors. The scale scores were used as continuous measures. The full scale achieved very high reliability on Cronbach’s alpha (0.97).

Organizational integrity of behaviors was measured using a single question. The question was developed to articulate the conceptual definition of behavioral integrity,¹⁴ and was similar to an item from a four-item scale used in a study by Ete et al.¹² Because the conceptual definition of organizational integrity in this study focused specifically on the alignment of organizational behavior and stated mission/values, the sole item was selected. The item asks the respondent to rate agreement with the statement “this organization’s mission is consistent with its values and behavior.” The item was scored on a 4-point Likert scale (1 = disagree to 4 = agree).

Moral resilience

The Rushton Moral Resilience Scale (RMRS) was used to measure moral resilience and ethical stability.⁶ The RMRS is a 17-item scale which measures four domains of ethical and moral resilience. There are four subscales within the measure—response to moral adversity, personal integrity, relational integrity, and moral efficacy. Items measure agreement with statements using a 4-point Likert scale (1 = disagree to 4 = agree). Higher scores indicate higher levels of resilience. In this study, scores on the full scale were used as dependent variables. Cronbach’s alpha for the full scale was 0.79.

Statistical analysis

ANOVA tests and bivariate correlation were used to examine associations among variables. Multiple regression was used to determine the predictive nature of the variables. Any variables with significant bivariate relationships with the dependent variable (moral resilience) would be considered control variables in the regression models. For missing data, the mean was used on any scale with <10% missing data. Four models were conducted, each controlling for demographic data. Well-being variables (burnout, secondary traumatic stress, and compassion satisfaction) were entered in separate models because inter-item correlation was assumed to be present among variables. The fourth model included organizational factors as independent variables. Assumptions for variables in multiple regression models were tested (normal distribution, heteroscedasticity, multicollinearity). The outcome variable was normally distributed, and the independent variables did not violate assumptions. All data were analyzed in SPSS Version 26. The p value of significance was set at 0.05 for all analyses.

An a priori power analysis was conducted to determine necessary sample size to for multiple regression. To determine likely effect size, the literature was analyzed; however, few studies to date have analyzed moral resilience as a dependent variable in a multiple regression model, offering few indicators of likely effect sizes. Conceptually, moral resilience is influenced by a multitude of internal and external factors, thus this current study supposes a small-medium effect size of 0.10. Three predictors were assumed for the models, including demographics and the three independent variables of interest, entered into separate models. The desired power was set at 0.80, which is standard for most regression models. Using these indicators, the desired sample size was calculated to be 112.

Ethical considerations

Ethical considerations were applied to this study to protect the participants safety and privacy. The study and its methods were approved as exempt under Category 2 by the Glendale Adventist Health Institutional Review Board (IRB) study number 2021–118. The email list was generated by the hospital system after IRB approval was obtained. The email sent to the nurses had a link to the survey; however, clicking the link would have no identifiable connection to the recipient of the email. No identifying information about the participants was collected and the online survey was set to disable IP address data collection. Less than minimal risk was anticipated for participation, though as a precaution, the consent language included general information on resources for coping with distress.

Results

The total sample was 147 nurses, reflecting an approximately 20% response rate. Most were female, direct care nurses, and had more than 10 years of experience. The sample was highly diverse, with 45% White, 25% Asian, 13% other, and 8% reporting more than one race. See Table 1.

Table 1.

Demographics of the sample (N = 147).

Trait		n	%
Gender	Male	24	16.3
	Female	121	82.3
	Prefer not to say	2	1.4
Race	American Indian or Alaska Native	1	0.7
	Asian	37	25.2
	Black or African American	2	1.4
	Native Hawaiian or Pacific Islander	3	2.0
	White	64	43.5
	Multiracial	13	8.8
	Other	20	13.6
	Prefer not to answer	7	4.8
Years of experience	Less than 2	6	4.1
	2–10	51	34.7
	10–20	45	30.6
	More than 20	45	30.6
Role	Direct care nurse	111	75.5
	Management	22	15.0
	Educator	4	2.7
	Advanced practice nurse	1	0.7
	Other	9	6.1

The means and standard deviations for the scales are listed in Table 2. The mean score on the full RMRS was 3.02 (SD = 0.40). For this scale, there was 9% missing data, which upon examination appeared to be at random. The mean was thus substituted for these cases. The subscale means were also examined and are reported in Table 3 to contribute to the literature on the RMRS.

Table 2.

Means and SD for scales used to determine individual and workplace factors.

Scale	Mean (SD)
Compassion Satisfaction	40.41 (7.13)
Burnout	24.06 (6.57)
Secondary Traumatic Stress	23.82 (6.42)
Authentic Leadership Questionnaire	56.81 (18.67)
Perceived Congruence Between Organizational Behaviors and Mission	2.75 (1.10)

Table 3.

Means and SD for Rushton Moral Resilience Scale and subscales.

Scale	Mean (SD)
Rushton Moral Resilience Scale	3.02 (0.40)
Subscales	—
Response to Moral Adversity	2.48 (0.73)
Personal Integrity	3.04 (0.45)
Relational Integrity	3.11 (0.61)
Moral Efficacy	3.34 (0.50)

A series of ANOVA tests were conducted to determine differences in resilience among the demographic and workplace characteristics (gender, race, role in the organization, years of experience). There were no significant differences noted among these groups, indicating the mean score for resilience was consistent among all roles. For age, a Pearson’s correlation was performed and was not significant, indicating no association between age and resilience. None of the demographic variables were used as controls as none had significant relationships with moral resilience.

To determine associations among individual and organizational characteristics and resilience, bivariate correlations were conducted. Resilience was noted to have significant small correlations with compassion satisfaction, burnout, secondary traumatic stress, and congruence of organizational mission and behaviors. See Table 4.

Table 4.

Correlation matrix of scale-measured variables.

	1	2	3	4	5
1. Burnout	-	—	—	—	—
2. Compassion satisfaction	−0.77**	-	—	—	—
3. Secondary traumatic stress	0.65***	−0.42***	—	—	—
4. Authentic leadership	−0.34**	0.23**	−0.26**	—	—
5. Perception of organizational culture	−0.49**	0.34***	−0.23**	—	—
6. Resilience	−0.35***	0.26**	−0.38***	0.13	0.21**

*p < 0.05 **p < 0.01 ***p < 0.001

The three separate multiple regression models showed that all the well-being characteristics significantly predicted resilience. In all models, the data was a good fit based on significant ANOVA tests. In model 1, compassion satisfaction predicted higher levels of resilience (β = 0.29, p < 0.001) and predicted a very small amount of variance (adjusted R² = 0.08). In model 2, burnout predicted lower levels of resilience (β = −0.38, p < 0.001) and accounted for a small amount of variance (adjusted R² = 0.14). In model 3, secondary traumatic stress predicted lower resilience (β = −0.40, p < 0.001) and accounted for a small amount of variance (adjusted R² = 0.16). See Table 5.

Table 5.

Significant predictors of moral resilience among nurses in separate models (N = 147).

	Model 1			Model 2			Model 3			Model 4
Variables	b	t	p	b	t	p	b	t	p	b	t	p
Compassion satisfaction	0.29	3.61	<0.001	—	—	—	—	—	—	—	—	—
Secondary traumatic stress	—	—	—	−0.38	−4.93	<0.001	—	—	—	—	—	—
Burnout	—	—	—	—	—	—	−0.40	−5.24	<0.001	—	—	—
Organizational mission/behavior congruence	—	—	—	—	—	—	—	—	—	0.21	2.59	0.01

*Reference group – manager

**Reference group – 2 years of fewer

Model 1 R² = 0.09; Model 2 R² = 0.14.;Model 3 R² = 0.16. Model 4 R² = 0.05.

An additional model was conducted for age and the organizational mission/behavior congruence variable. Authentic leadership was not included in the model because it was not significant in bivariate testing. Organizational behavior/mission congruence significantly predicted moral resilience (β = 0.21, p = 0.01). This model accounted for a very small (adjusted R² = 0.05) amount of variance. See Table 5.

Discussion

In this study, well-being factors burnout, secondary traumatic stress, and compassion satisfaction have an association with moral resilience. Broadly speaking, this finding is consistent with other studies examining relationships among these variables, though the majority of studies examine resilience as a factor to well-being.^4,5,21,22 The relationships of well-being and resilience makes theoretical sense considering the overall dynamic of resilience as a psycho-social-emotional trait. In this study, burnout and secondary traumatic stress had inverse associations with resilience, whereas compassion satisfaction had directional relationships, again consistent with the theory that resilience is a protective factor in the phenomenon of burnout.

This study presents a new finding as compared with other studies by demonstrating that well-being factors predict moral resilience. This study measures examines well-being factors moral resilience as a dependent variable, demonstrating that issues of well-being, for example, burnout, can detract or enhance resilience. An interesting finding was that secondary traumatic stress had a negative association with resilience among the nurses, indicating that they might not have experienced post-traumatic growth after a distressing event or that the stress from the event inhibited resilience. Theories and studies of resilience posit that moral resilience can buffer the effects of moral distress,^7,17 thus it would seem secondary traumatic stress might not significantly predict lower resilience if post-traumatic growth was occurring. However, sweeping generalizations about the impact of secondary stress on resilience cannot be made considering this study did not measure moral distress, which is considered the major conduit for moral resilience.⁷

A newer finding presented in this study is the associations of individual and workplace factors on moral resilience itself. In most studies to date using resilience as an outcome, general resilience is the common conceptual definition and is measured by the Connor-Davison Resilience Scale.^17,23 This study uses the RMRS, which is a more precise instrument for measuring moral resilience and its associated domains. Analysis of mean scores in this current study with the one other identified study using the RMRS indicate comparable levels of resilience in all the resilience domains, with both studies demonstrating the highest scores on moral efficacy and lowest scores on responses to moral adversity.⁶ Responding to moral adversity is of critical importance in nursing, especially with the reported moral distress in nurses arising among difficult patient care situations.^9,24,25 It is possible that challenges within the work environment (e.g., bullying, low staffing, and reduced autonomy) are creating systems-level barriers to nurses’ ability to respond to moral adversity or even resulting in a feeling of institutional betrayal, compounding the ability to remain resilient.²⁶ Exploration of the barriers to responding to moral adversity should continue to be addressed in future studies, particularly to explore the institutional or workplace culture factors that might inhibit nurse autonomy and efficacy in morally challenging situations. Additional studies measuring moral resilience are also needed to continue building the evidence base of moral resilience and to further refine the operationalization of the concept.

This study also sought to explore workplace characteristics, including leadership and organizational mission/behavior congruence, as factors on nurses’ moral resilience. In this study, authentic leadership style did not share significant associations with moral resilience scores. The lack of significant relationship was surprising considering relational integrity, defined as the stability of relationships with one’s colleagues and coworkers, is a domain of moral resilience.^6,7,27 The findings from this study differed from those in a study in which support from colleagues and employers during COVID-19 pandemic was a found to be a significant predictor of moral resilience.¹⁰ The findings in the current study could indicate resilience’s existence as an innate trait and less likely to change based on the work environment and supervisor interactions. It is also possible leadership style is specific to work environment while the scope and scale of resilience are impacted by work, societal, environmental and life factors. Considering the theoretical importance of a manager’s ethical and moral conduct in making decisions, communicating with staff, and facilitating the workplace culture,⁷ it is plausible that leadership style impacts resilience, but was just not detected in this study. More precise measures of leadership in nursing might better detect these relationships, thus, future studies might consider different operational definitions of leadership style than what was used in this study.

This study did demonstrate significant associations among moral resilience and organizational mission/behavior congruence, although the effect size was very small. This could be an initial indicator that nurses who perceived high levels of organizational behaviors concurrent with the hospital’s mission were more likely to report higher resilience. This is the first identified study to measure the integrity of an organization as a factor in moral resilience. Organizational mission/behavior congruence is likely consistent with the relational integrity domain of moral resilience; it speaks to the virtuosity of a healthcare organization in acting in accord with its mission to preserve and protect human health. This demonstration of wholeness likely inspires nurses and increases their relational connection to the organization. Their resilience, that is, buoyancy in the midst of distress, can be sustained or increased because they perceive their organization as supporting them and their work despite difficult care scenarios. Conversely, organizations who are hypocritical to their mission, perhaps by seemingly valuing profit over humanistic care, can fracture the relationship with the healthcare professionals providing services within that organization.²⁸ This lack of trust likely hampers resilience because the culture in which it exists is dismal and disappointing. However, the very small effect sizes warrant further study with larger samples, especially considering the complexity of organizational culture and organizational relationships.

Limitations

This study has limitations. As a cross-sectional study, findings do not represent causal or temporal relationships. Generalizability to the whole population of nurses is limited due to study design and sample size. The very small effect sizes, while likely due in some part to the high degree of variability of moral resilience as an innate characteristic, reduce generalizability of findings as well. Efforts should continue to encourage participation in nursing research from diverse populations. The study relies on self-report instruments, which represent the potential for recall or response bias. Most other studies measure moral distress along with moral resilience in keeping with the conceptual model that moral distress is a necessary part of moral resilience. This study however did not measure moral distress or distressing circumstances, so it might be difficult to precisely describe the level of moral resilience in a nursing population without knowing the level of morally distressing experiences they encountered. This study uses years of experience as a tangential proxy for moral distress, in which it is assumed that nurses with more years of experience are more likely to have experienced a morally distressing circumstance. A limitation is that this assumption might be flawed. Future studies can measure moral distress and moral resilience to better determine if the conceptual relationship is essential.

Conclusion

The growing interest in moral resilience as an antidote to pervasive nursing workforce issues is a positive step. Encouraging nurses to identify moral resilience as a protective and buoying factor against burnout, negativity, and stress can help them heal from moral suffering. To enable the growth of moral resilience, research is needed to understand the factors contributing to it. This study offers important findings of the impact of professional quality of life on moral resilience and offers unique findings on how the workplace impacts moral resilience. It provides further evidence of the harmful effects of burnout and stress, but also the positive effects of compassion satisfaction. This study offers unique evidence of the importance of workplace integrity and commitment to organizational mission/values as an organizational factor that contributes to moral resilience. Nursing management, administration, and employers can use this evidence to promote individual and systems-level interventions to promote moral resilience.

Footnotes

Declaration of Interest Statement

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare that there is no conflict of interest.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Katherine Brewer

References

Committee on the Future of Nursing 2020–2030 . National Academies of Sciences, Engineering, and Medicine. The Future of Nursing 2020-2030. In, Williams

Menestrel

Flaubert

(eds). National Academies Press, 2021, https://www.nap.edu/catalog/25982. National Academy of Medicine, charting a path to achieve health equity. Washington, D.C.

Trépanier

Fernet

Austin

, et al. Work environment antecedents of bullying: A review and integrative model applied to registered nurses. Int J Nurs Stud 2016; 55: 85–97.

Murthy

Nasca

(eds). Action collaborative on clinician well-being and resilience, national academy of medicine. national plan for health workforce well-being. Washington, DC: National Academies Press, 2022. Available from: https://www.nap.edu/catalog/26744

Lin

Huang

Carter

, et al. Resilience among nurses in long term care and rehabilitation settings. Appl Nurs Res 2021; 62: 151518.

Antonsdottir

Rushton

Nelson

, et al. Burnout and moral resilience in interdisciplinary healthcare professionals. J Clin Nurs 2021; 31(1-2): 196–208.

Heinze

Hanson

Holtz

, et al. Measuring Health Care Interprofessionals’ Moral Resilience: Validation of the Rushton Moral Resilience Scale. J Palliat Med 2021; 24(6): 865–872.

Rushton

. Moral resilience: transforming moral suffering in health care. New York, NY: Oxford University Press, 2018, p. 1.

Connor

Davidson

JRT

. Development of a new resilience scale: The Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety 2003; 18(2): 76–82.

Rushton

Thomas

Antonsdottir

, et al. Moral Injury and Moral Resilience in Health Care Workers during COVID-19 Pandemic. J Palliat Med 2022; 25(5): 712–719.

10.

Spilg

Rushton

Phillips

, et al. The new frontline: exploring the links between moral distress, moral resilience and mental health in healthcare workers during the COVID-19 pandemic. BMC PSYCHIATRY 2022; 22(1): 19.

11.

Brigham

Barden

Dopp

, et al. A journey to construct an all-encompassing conceptual model of factors affecting clinician well-being and resilience. National Academy of Medicine, 2018. [Internet]Available from: https://nam.edu/journey-construct-encompassing-conceptual-model-factors-affecting-clinician-well-resilience/

12.

Ete

Epitropaki

Zhou

, et al. Leader and organizational behavioral integrity and follower behavioral outcomes: the role of identification processes. J Bus Ethics 2022; 176(4): 741–760.

13.

Wei

King

Jiang

, et al. The Impact of Nurse Leadership Styles on Nurse Burnout:. Nurse Lead 2020; 18(5): 439–450.

14.

Simons

Leroy

Collewaert

, et al. How Leader Alignment of Words and Deeds Affects Followers: A Meta-analysis of Behavioral Integrity Research. J Bus Ethics 2015; 132(4): 831–844.

15.

Cady

Wheeler

Brodke

, et al. Mission, vision, and values: What do they say? Organ Dev J 2011; 29: 63–78.

16.

Wei

Sewell

Woody

, et al. The state of the science of nurse work environments in the United States: A systematic review. Int J Nurs Sci 2018; 5(3): 287–300.

17.

Kunzler

Chmitorz

Röthke

, et al. Interventions to foster resilience in nursing staff: A systematic review and meta-analyses of pre-pandemic evidence. Int J Nurs Stud 2022; 134: 104312.

18.

Clark

Crawford

Hulse

, et al. Resilience, Moral Distress, and Workplace Engagement in Emergency Department Nurses. West J Nurs Res 2021; 43(5): 442–451.

19.

Stamm

. The ProQOL concise manual. 2nd ed., 2010. Available from: http://www.proQOL.org/ProQOL_Test_Manuals.html

20.

Avolio

Gardner

Walumbwa

. Authentic Leadership Questionnaire (ALQ). Mind Garden Inc., 2007.

21.

Jeong

Shin

. The relationship between secondary traumatic stress and burnout in critical care nurses: The mediating effect of resilience. Intensive Crit Care Nurs 2023; 74: 103327.

22.

Kelly

Gee

Butler

. Impact of nurse burnout on organizational and position turnover, 2021; 69(1): 96–102. Nurs Outlook https://www.nursingoutlook.org/article/S0029-6554(20)30087-7/abstract

23.

Baskin

Bartlett

. Healthcare worker resilience during the COVID-19 pandemic: An integrative review. J Nurs Manag 2021; 29(8): 2329–2342.

24.

Lake

Narva

Holland

, et al. Hospital nurses’ moral distress and mental health during COVID-19. J Adv Nurs 2021; 78(3): 799–809

25.

Morley

Sese

Rajendram

, et al. Addressing caregiver moral distress during the COVID-19 pandemic, 2020. Cleve Clin J Med. Available from: https://doi.org/10.3949/ccjm.87a.ccc047

26.

Brewer

. Institutional betrayal in nursing: A concept analysis. Nurs Ethics 2021; 28(6): 1081–1089.

27.

Holtz

Heinze

Rushton

. Interprofessionals’ definitions of moral resilience. J Clin Nurs 2018; 27(3–4): e488–e494.

28.

Baron

Berinsky

. Mistrust in science—a threat to the patient–physician relationship. N Engl J Med 2019; 381(2): 182–185.