Organizational Impact on Healthcare Workers' Moral Injury During COVID-19: A Mixed-Methods Analysis.

OBJECTIVE: The aim of this study was to explore relationships between organizational factors and moral injury among healthcare workers and the impact of perceptions of their leaders and organizations during COVID-19. BACKGROUND: COVID-19 placed healthcare workers at risk for moral injury, which often involves feeling betrayed by people with authority and can impact workplace culture. METHODS: Secondary data from a Web-based survey of mid-Atlantic healthcare workers were analyzed using mixed methods. Data were synthesized using the Reina Trust & Betrayal Model. RESULTS: Fifty-five percent (n = 328/595) of respondents wrote comments. Forty-one percent (n = 134/328) of commenters had moral injury scores of 36 or higher. Three themes emerged: organizational infrastructure, support from leaders, and palliative care involvement. Respondents outlined organizational remedies, which were organized into 5 domains. CONCLUSIONS: Findings suggest healthcare workers feel trust was breached by their organizations' leaders during COVID-19. Further study is needed to understand intersections between organizational factors and moral injury to enhance trust within healthcare organizations.

Application of the Reina Trust and Betrayal Model to the experience of pediatric critical care clinicians.

BACKGROUND: Trust is essential in the workplace, yet no systematic studies of trust among pediatric critical care professionals have been done. OBJECTIVE: To determine the feasibility of measuring trust in a pediatric intensive care unit by using established scales from the corporate world and to determine what behaviors build, break, and rebuild trust. METHODS: The Reina Trust and Betrayal Model was used to explore contractual, competence, and communication trust. Nurses and physicians in a pediatric intensive care unit completed online surveys to measure organizational, team, and patient trust. Quantitative data from 3 standard survey instruments and qualitative responses to 3 open-ended questions were analyzed and compared. RESULTS: Quantitative data from all 3 instruments indicated moderate to high levels of trust; scores for competence and contractual trust were higher than scores for communication trust. Scores indicated agreement on behaviors that build trust, such as pointing out risky situations to each other, actively striving to build supportive and productive relationships, and giving and receiving constructive feedback. Foremost among trust-breaking behaviors was gossip, which was more troublesome to respondents with longer experience in critical care. Responses to the open-ended questions underscored these themes. The most frequently cited items included encouraging mutually serving intentions, sharing information, and involving and seeking the input of others. CONCLUSION: The Reina trust scales and open-ended questions are feasible and applicable to pediatric critical care units, and data collected with these instruments are useful in determining what behaviors build, break, and rebuild trust among staff.

Building trustworthy relationships with critically ill patients and families.

A difficult case study involving repeated health crises and irreversible organ dysfunction illustrates the challenges critical care professionals face in caring for patients and their families. In such cases, trust is especially fragile, and coexists with its counterpart, betrayal. The Reina Trust & Betrayal Model defines 3 types of Transactional Trust. The first, Competence Trust, or the Trust of Capability, requires that clinicians practice humility, engage in inquiry, honor the patient's choices, and express compassion. The second, Contractual Trust, or the Trust of Character, demands that clinicians keep agreements, manage expectations, establish boundaries, and encourage mutually serving expectations. The third, Communication Trust, or the Trust of Disclosure, must be rooted in respect and based on truth-telling. Particularly in life-and-death situations, communication requires honesty and clarity. Each type of trust involves specific behaviors that build trust and can guide critical care professionals as they interact with patients and their families.