Structural Racism and Moral Distress: During and Since the Pandemic— Nursing/Healthcare Workforce, Mental Health & Bioethical Implications Restricted; Files Only
Ellis, Rebecca (Spring 2024)
Abstract
Background: Studies conducted to assess factors affecting healthcare workers (HCWs), outcomes, and care during the COVID-19 pandemic signaled a need to assess moral distress as a driver of psychological outcomes. Moral distress—which is the experience of moral conflicts due to structural constraints within the health system—compromises the delivery of care. Co-occurring with the pandemic and its clinical ramifications were traumatic public acts of racism and critical discussion of racism’s structural underpinnings.
Aims: To assess how HCW (1) psychological symptoms; (2) intention to leave; (3) system- and individual- level factors; and (4) a proxy of structural racism, perceived chronic workplace discrimination (CWDH-A)—are associated with moral distress in the healthcare/nursing workforce.
Methods: A sequential mixed methods design (QUANT->QUAL); guided by the theoretical framework of structural racism and moral distress (defined by the author), identified multilevel variables that increase the risk of moral distress (MMD-HP), anxiety (GAD2), depression (PHQ2), and intention to leave. Statistical analysis and preliminary moderation analyses using R software (version 4.3.2). Qualitative analysis used Taguette (version 1.4.1).
Results: The scoping review showed that top individual- and system-level risk factors were being a nurse and/or female, previous health history, and workplace location. Interestingly, prevalence of depression was statistically significant by race/ethnicity, and the relationship to moral distress. Quantitative sample included HCWs [non-Hispanic White (50.8%) and People of Color (49.2%)] who worked during the first year of the pandemic (97.2%); 182 met criteria, and 92 completed all instruments. The simplest predictive multivariable model for moral distress was frontline facility status, identified race/ethnicity (Non-Black vs. Black), and chronic workplace discrimination, which explained 29% of variability. Interviews from 23 nurses characterized the role of managers/management in the workplace as a potential mediator of the upstream effect of structural racism (individual level) and the downstream effect of structural racism (health system level) as factors impacting moral distress for nurses. The theoretical model of structural racism and moral distress evolved, and edits are presented based on study findings.
Implications: Health system administrators and researchers need to address structural racism as factor of moral distress and workforce outcomes to shift the culture of health.
Table of Contents
Introduction .................................................................................................................................. 1
Study Background and Significance ......................................................................................... 2
Conceptual Framework .......................................................................................................... 9
Summary of Papers .......................................................................................................... 13
Chapter 1: Depression and Anxiety: Focusing on Determinants of Health for the Nursing/Healthcare Workforce During the COVID-19 Surge Response—a Scoping Review ………………….…… 16
Introduction .................................................................................................................. 16
Methodology .......................................................................................................................... 19
Results .............................................................................................................................. 20
Discussion ................................................................................................................................ 25
Appendix, Tables, and Figures ................................................................................................... 34
Appendix A ................................................................................................................ 34
Appendix B .................................................................................................................... 38
Chapter 2: Measuring Moral Distress and Structural Racism: Methodology, Associations, and Impact Post COVID-19 Pandemic ..................................................................................................................... 41
Introduction .......................................................................................................................... 41
Background ................................................................................................................................ 42
Methodology .......................................................................................................................... 51
Results ......................................................................................................................................... 58
Discussion ................................................................................................................................ 65
Appendix, Tables, and Figures .................................................................................................... 73
Chapter 3: Structural Racism and Moral Distress: Theoretical Framework, Workplace Structural Hierarchies, and Nursing Ways of Knowing ........................................................................................ 77
Introduction ................................................................................................................................ 77
Background ........................................................................................................................ 78
Theoretical Framework............................................................................................................... 79
Methods .......................................................................................................................... 82
Results ......................................................................................................................................... 88
Discussion ............................................................................................................................... 107
Appendix ………………………................................................................................................. 115
Appendix A ............................................................................................................... 115
Appendix B ................................................................................................................... 118
Conclusion .......................................................................................................................................119
Contributions of Papers to Framework Development ...................................................... 120
Discussion ........................................................................................................................ 121
Figure ......................................................................................................................................... 125
References ......................................................................................................................... 126
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