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ACADEMIA Letters COVID-19 and Work climate impact on Health Care Workforce Wellbeing: Moral Resilience and Mental health among nurses for Quality Health Outcomes in Indian Health care settings Varalakshmi Manchana, University of Hyderabad Abstract Background: Resilience is the ability to sustain with and recover from the challenging situations effectively. Moral resilience is the ability to manage ethically conflicting and challenging situations with least distress or moral trauma. Moral distress, a pervasive and growing challenge prevalently experienced but mostly left unaddressed in nurses. Health care system is exposed with unprecedented and varied challenges and the outbreak of COVID 19 has aggravated the burden on health care system and health workforce and other frontline health care personnel. Nurses being the vital partners of health care delivery experience aggravated stress and challenges in their practice. There is limited research to understand the moral distress and work place climate affecting the health and wellbeing of nurses and in turn their impacts on patient care. The present research attempts identify the extent of the problem with a scope to develop strategies to address this gap. Methods: Registered Nurses (n=100), who were registered in their professional council and working in the selected public based health care setting not less than one year were included to participate in the study. The frequency of moral distress and common causes and the coping skills adopted by the health care workforce were measured. Results: The mean scores of Moral distress found were 78.06(±35.27) among Nurses majority (58%)of nurses agreed for feeling powerless and passive in patient care deciAcademia Letters, December 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Varalakshmi Manchana, drmvlakshmy@gmail.com Citation: Manchana, V. (2021). COVID-19 and Work climate impact on Health Care Workforce Wellbeing: Moral Resilience and Mental health among nurses for Quality Health Outcomes in Indian Health care settings. Academia Letters, Article 4353. https://doi.org/10.20935/AL4353. 1 sion making. About 62 % nurses shows depression and 79% often felt anxious prevalence of stress among nurses was 31.9%. Factors identified for stress, anxiety and depression included; lack of conducive working conditions (57%), work load related pressure (67%), frequent ethically challenging situations and lack of ethical work climate (36.3%) and lack of professional support system (73.2%) and not being recognized as valued profession among other health professions irrespective of their major role and contribution. Conclusion: Frequency of moral distress experienced by nurses is an alarming indicator for the need for addressing the work place challenges and adopting measures for promoting moral resilience in nurses for quality health care outcomes and for health and wellbeing of nurses. Keywords: Moral resilience, Mental health, Wellbeing, Ethical climate, Registered Nurses, and Quality Health care outcomes. Introduction Globally, moral distress in nurses is recognized as a pervasive problem (Oh &Gastmans, 2015). However, studies on moral distress seldom draw any measures to build moral resilience and promote ethical work climate in health care settings across the globe in general and in Indian health care in particular. Nurses play a vital role in the health care system; however, the Indian health care system frequently provides complex working situations with scarce resources and overburdened patient care. Nurses are exposed to various kinds of challenges in everyday practice. When they practice in disharmony and experience frequent ethical dilemmas, it may result in poor coping and job dissatisfaction. Nurses were recognized for having the utmost honesty and ethical integrity among all professions (Gallup, 2015). They are educated to believe primarily accountable to the patients and act as patient advocates; however, the healthcare environment challenges them with toughest and conflicting situations to caregiver loyalty. Nursing in India is especially feminized, where they cannot voice their rights for them as well for the patients. Nurses are accountable to families, their colleagues, team, working organizations and professional bodies and society (Corley, 2002). Though nurses experience ethical conflicts frequently, managing them in a professionally satisfied manner, for the welfare of the patients is very difficult. Ethical concerns of nurses’ in delivering health care on regular as well in special situations like COVID-19 such as conflict about care goals and treatment decisions between patient/ families and healthcare providers, inadequate resources, uncertainty, work load, work bias and dilemmas may directly or indirectly influence the quality of patient care. Moral distress may arise wedged between the patient’s welfare to the hospital policies, and/or team decisions. Academia Letters, December 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Varalakshmi Manchana, drmvlakshmy@gmail.com Citation: Manchana, V. (2021). COVID-19 and Work climate impact on Health Care Workforce Wellbeing: Moral Resilience and Mental health among nurses for Quality Health Outcomes in Indian Health care settings. Academia Letters, Article 4353. https://doi.org/10.20935/AL4353. 2 Challenging work and work overload, inability to voice their decisions for the benefit of patients and their families aggravate the work stress. Distress at the workplace negatively affects the physical, mental health, and the efficiency of providing quality patient care. Ethical challenges at the workplace are the situations where even knowing the right action and nurses are not able to take the right step for the benefit of patients. Recurrent ethical challenges give rise to a sense of dissatisfaction, unhappiness and make them feel powerless, which in the course of time, turns to moral distress, which may in turn impact nursing-sensitive outcomes. Resilience as a nursing sensitive indicator helps to cope and manage ethical challenges they encounter during their practice effectively. Moral resilience is the capacity of an individual to sustain or restore their integrity in response to moral complexity, confusion, distress, or setbacks” (Rushton, 2016a). Subjective wellbeing (SWB) is a comprehensive psychological satisfaction and happiness about people own overall life (Diener E, 2009). Evidence suggests that high level of well-being will yield positive performance outcomes, emotions and distressing working conditions leads to job dissatisfaction, low subjective wellbeing and may also affect the quality of care. Health Professionals, especially nurses are at high risk for moral distress and low well-being, Moral distress as an example of a nursing-sensitive indicator in turn, have been link to an array of nursing-sensitive outcomes, including individual, personal-level outcomes (e.g., loss of self-esteem, guilt, emotional detachment, burnout; personal health and well-being; moral resilience); inter-personal and relational process level outcomes (e.g., powerless over treatment decisions; frustration; interpersonal conflict; poor work relationships) and the system/organizational-level outcomes (reduce patient satisfaction; job dissatisfaction; high staff turnover, staff shortages; poor quality of care and patient safety; increase medical errors, and increase health care costs) (McAndrew, Leske&Schroeter, 2018). Evidence (Manchana.V.2017) supports that moral distress was experienced by both nurses and doctors but comparatively nurses show higher levels than doctors due to various factors. Moral distress may give rise to psychological imbalance and loss of control over the work-related decision making, and feel unable to act for the patient safety due to various institutional and workrelated constraints (Andrew Jameton, 1984). Achieving a quality practice environment that sustain ethical practice and in which nurses can provide safe, compassionate and competent care in ethical manner (Canadian Nurses Association, 2017, p. 3) remains a challenge globally. An ethical environment (Murray, 2007a) is the working culture in which the nurse is comfortable identifying the ethical work culture, address ethical concerns for a healthy work environment. Health professionals may experience a healthy work environment when they can have an open and fair discussion for positive health care outcomes. Unfavorable ethical climate in the workplace results in moral distress to health professionals. The ethical climate Academia Letters, December 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Varalakshmi Manchana, drmvlakshmy@gmail.com Citation: Manchana, V. (2021). COVID-19 and Work climate impact on Health Care Workforce Wellbeing: Moral Resilience and Mental health among nurses for Quality Health Outcomes in Indian Health care settings. Academia Letters, Article 4353. https://doi.org/10.20935/AL4353. 3 of the hospitals directly associates with the self-esteem, coping skills, and job satisfaction in nurses. When a hospital environment is safe and enables nurses to engage in moral decision making, facilitates to work in team approach is crucial for her to feel a controlled and engaged member of the health care team. A cross sectional study among Registered Nurses (RN) to explore the prevalence of moral distress, stress and common causes for work pressure and distress. The study includes RN (n=100), who were registered in their professional council and working in the selected public based health care setting not less than one year were included to participate in the study. The frequency of moral distress and common causes and the coping skills adopted by the health care workforce were measured. Data was collected both offline and online after securing informed consent from the participants. Findings of the Research identify the mean scores of Moral distress found were 78.06(±35.27) among Nurses majority (58%) of nurses agreed for feeling powerless and passive in patient care decision making, 56% agreed for experience of professional distress often. About 62 % nurses’ shows depression and 79% often felt anxious prevalence of stress among nurses was 31.9%. Factors identified for stress, anxiety and depression included; lack of conducive working conditions ( 57%), work load related pressure (67%), frequent ethically challenging situations and lack of ethical work climate ( 36.3%) and lack of professional support system (73.2%) and not being recognized as valued profession among other health professions irrespective of their major role and contribution. Professional support, interdisciplinary and team approach among health professionals is an essential component in the safe and quality patient care, however which is seen lacking in the health care team. Nurses often are overloaded with work but access inadequate resources to deliver quality health care resulting to frequent experience of professional distress and reduced job morale. Lack of professional support is another trigger to work pressure, anxiety and stress among nurses. Among the participants, 34% felt the need for psycho-social support at work place and 49% felt it as essential during COVID-19 patient care to cope with the fear and stress. Fear associated with care of patients with COVID 19 among nurses was due to fear of getting infected (30%), losing family relations due to isolation and staying away from family during their postings in the units of COVID-19 care and 40% were afraid of spreading the infection to their family. Health care system experiences unpredicted challenges and COVID 19 has increased the health care burden and multi-folded the stress and professional distress among nurses, which needs immediate attention. Academia Letters, December 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Varalakshmi Manchana, drmvlakshmy@gmail.com Citation: Manchana, V. (2021). COVID-19 and Work climate impact on Health Care Workforce Wellbeing: Moral Resilience and Mental health among nurses for Quality Health Outcomes in Indian Health care settings. Academia Letters, Article 4353. https://doi.org/10.20935/AL4353. 4 Conclusion Resilience is the ability to bounce back to normalcy after exposure to stressful situations. The study findings suggest the intensity of the problem and the immediate need for programs to build moral resilience in health professionals for positive health outcomes. Moral resilience programs to identify and address ethical challenges in health care to empower the resilient work culture and ethical environment for professional integrity and quality health care outcomes. Academia Letters, December 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Varalakshmi Manchana, drmvlakshmy@gmail.com Citation: Manchana, V. (2021). COVID-19 and Work climate impact on Health Care Workforce Wellbeing: Moral Resilience and Mental health among nurses for Quality Health Outcomes in Indian Health care settings. Academia Letters, Article 4353. https://doi.org/10.20935/AL4353. 5 References 1. Oh, Y. &Gastmans, C. (2015). Moral distress experienced by nurses: A quantitative literature review. Nursing Ethics, 22(1), 15-31. doi: 10.1177/0969733013502803 2. Gallup. (2015). Honesty/ethics in professions. Retrieved from http://www.gallup.com/ poll/1654/Honesty-Ethics-Professions.aspx 3. Corley, M. C. (2002). Nurse moral distress: A proposed theory and research agenda. Nursing Ethics, 9(6), 636-650. 4. Diener E. Subjective well-being. Psychol Bull 2009;95(3):542e75. 5. McAndrew, N.S., Leske, J. &Schroeter, K. (2018). Moral distress in critical care nursing: The state of the science. Nursing Ethics, 25(5), 552-570. doi: 10.1177/0969733016664975 6. Manchana. V. (2017). Moral competence and perceived Moral distress among Health care Professionals in an Urban Health care setting; Facility based study. IJSR, (6)4; 919-923. 7. Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice Hall. 8. Canadian Nurses Association. (2017). Code of ethics for registered nurses (2017th ed.). Ottawa. 9. Murray, J.S. (2007a). Creating ethical environments in nursing. American Nurse Today, 2(10), 48 – 49. 10. Rushton, C. H. (2016a). Moral resilience: a capacity for navigating moral distress in critical care. AACN Advanced Critical Care, 27(1), 111-119. Academia Letters, December 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Varalakshmi Manchana, drmvlakshmy@gmail.com Citation: Manchana, V. (2021). COVID-19 and Work climate impact on Health Care Workforce Wellbeing: Moral Resilience and Mental health among nurses for Quality Health Outcomes in Indian Health care settings. Academia Letters, Article 4353. https://doi.org/10.20935/AL4353. 6