Barriers and Facilitators to Implementation of Interventions to Mitigate Moral Injury Among Nurses

Cassandra M Godzik^1,2*Jennifer K DiBenedetto^1,2Timothy J Usset^3,4Heather Stiles¹Heather Klein¹Karen Fortuna^1,2Renee L Pepin^1,2Hannah Wright⁵Amy Locke⁶Helen Thomason²Andrew J Smith^1,2

• ¹Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, United States
• ²Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, United States
• ³University of Minnesota Health Sciences, University of Minnesota Medical Center, Minneapolis, Minnesota, United States
• ⁴Minneapolis VA Health Care System, Veterans Health Administration, United States Department of Veterans Affairs, Minneapolis, Minnesota, United States
• ⁵Huntsman Mental Health Institute, University of Utah Health Care, Salt Lake City, Utah, United States
• ⁶The University of Utah, Salt Lake City, Utah, United States

Background: In the post-pandemic recovery era, addressing moral injury is critical due to high prevalence and impact on mental and occupational health. Interventions that address moral injury in hospital settings are limited. Further, engaging HCWs in any mental health interventions has proven challenging for a variety of reasons and exacerbated by factors such as a rural setting. Implementation science aimed at understanding barriers and facilitators to interventions is needed in order to build and offer interventions that are usable, feasible, acceptable, and effective. The current study aimed to understand such barriers and facilitators to building moral injury interventions for nurses on the medical intensive care unit (MICU).Methods: We conducted semi-structured qualitative interviews using the Consolidated Framework for Implementation Science Research (CFIR) and Peer and Academic Model of Community Engagement with 25 participants in a rural hospital system, 19 nurses currently working in the MICU and six nurses who left their MICU employment. Interviews were transcribed and analyzed using a thematic analysis approach.Results: There were five CFIR domains and 14 associated CFIR constructs that impacted intervention implementation in this population. Barriers included resource costs, skepticism regarding the effectiveness of new resources, lack of support from leaders, concerns that emotions affect professional image, inability to take breaks, and a disconnect between nurses' lived experiences and community perceptions. Facilitators included interventions specifically tailored for the MICU, strengths in teaming and social support among fellow nurses, and a desire for change because of factors such as a high turnover rate. Participants also highlighted a strong motivation to provide the best care possible and a desire to build resilience by supporting each other. Conclusions: Analysis of barriers and facilitators suggests value in improving the opportunities for HCWs to process morally injurious experiences with interventions specific to a particular unit and resources such as peer support and chaplains. There is a demonstrated need for high-level organizational change to address the dynamic needs of our nurses.