Moral injury, moral resilience, and organizational effectiveness among nurse leaders: a descriptive analysis during the COVID-19 pandemic

Abstract

Background

While nurse leaders have a voice in some organizational decisions, their moral resilience and moral injury can be affected by organizational structures and processes during a public health emergency such as the COVID-19 pandemic.

Purpose

The purpose of this exploratory descriptive analysis was to characterize the differences and commonalities between types of nurse leaders and their experiences of perceived organizational effectiveness, moral injury, and moral resilience during the COVID-19 pandemic.

Methods

This was a quantitative study conducted via an online, national, cross-sectional survey. The survey included sociodemographic and professional practice questions, validated instruments measuring organizational effectiveness, moral injury, and moral resilience. Open-ended questions allowed participants to expand on topics of particular interest. Quantitative data were analyzed using ANCOVA models, qualitative data accompanies the quantitative results for descriptive elaboration.

Results

In total, 763 nurse leaders were included in the analysis. Executives scored higher on overall organizational effectiveness than other leaders but not nurse managers. Examining the differences in specific facets of organizational effectiveness revealed that nurse managers rated several aspects of staffing lower than executives. One-third of respondents met the threshold for clinically significant levels of moral injury (score ≥ 36). No significant differences were found between nurse leader roles on moral injury. ANCOVAs indicated that nurse executives had higher total moral resilience than either nurse managers (p = 0.030) or other leaders (p < 0.001). In the open-ended questions, nurse leaders discussed two additional facets of organizational effectiveness that affected moral injury and moral resilience: (1) inequity between healthcare workers in different roles, and (2) an imbalance between organizational finances and patient safety.

Conclusion

Organizations can promote retention and moral resilience among nurse leaders by cultivating trustworthy behaviors. This may be achieved through authentic communication and transparency, and by promoting the values reflected in the nursing code of ethics.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-025-03744-z.

Background

Nurse leaders are essential to the optimal functioning of an institution’s workforce and care provision, and in upholding and maintaining a healthcare organization’s mission and values [1]. While many nurse leaders are trained clinicians who deliver nursing care, to effectively bridge the gap(s) between clinical and administrative/ financial leaders, they must also possess excellent communication and leadership skills, function as advocates for patients and staff, and have an in-depth understanding of organizational policies and finances [2]. Much of the work that nurse leaders do is unseen and uncredited by the public and by interdisciplinary point-of-care clinicians. Nurse leaders are often seen as a monolith, with poor understanding or acknowledgement of the differences between nurse managers (NM), nurse executives, and other types of nurse leaders. As a result, some organizations may assume that nurse leaders have similar professional experiences, perceptions and needs. However, nurse leaders exist at all levels of a healthcare organization, from managers responsible for staffing, human resources, and unit-level outcomes to executives who steer organizational system thinking and work to enhance patients’ experience.

The ecosystem where nurse leaders practice affects their ability to achieve organizational and professional nursing outcomes that may, at times, be at odds. Organizational effectiveness (OE) is a complex construct which includes the efficacy of service delivery, alignment between the institutional mission and its processes, and how well an organization supports personnel to cultivate employee satisfaction and trust [3]. In contrast, poorly effective organizations are characterized by inadequate service delivery, reduced professional autonomy, low perceived value within the organization, and greater exposure to circumstances that violate and eventually erode integrity and moral capability [4].

Nurse leaders play an integral role overseeing service delivery, managing finances, communicating and building relationships, and translating policy into practice [2]. For this reason, nursing leadership style is an important factor in OE, contributing to staff outcomes such as burnout, and intent to stay [5]. A recent systematic review found that OE often dictates structural and psychological empowerment perceived by nurses, and are key factors in nurse outcomes [6]. However, nurse leaders are not the only actors who influence high-level OE. Nurse leaders have varying degrees of influence over institutional factors, factors that may enable or disable professional effectiveness and shape the wellness and resilience of leaders themselves. Despite their distance from the bedside, nurse leaders are not invulnerable to the negative effects of poor OE. Organizational structures and processes that are at odds with individual or professional ethics, or which force nurse leaders to prioritize staffing over patient outcomes or staff wellness can erode trust for nurses and their leaders, contributing to moral injury (MI) in the managerial and executive ranks [7, 8].

MI is the most corrosive type of moral suffering [9]. MI ensues when core moral values have been severely violated, and one’s identity and worthiness are degraded, sometimes permanently. MI commonly manifests as symptoms of shame, guilt, or post-traumatic stress, and can result in burnout, stress, and turnover intention [10–12]. The phenomenon of MI has been widely studied in clinicians, including nurses at the point-of-care [12–14]. Studies indicate that nurses at the point-of-care have experienced feelings of professional betrayal, loss of faith or spirituality, guilt, and difficulty forgiving themselves for foregone or perceived inadequate nursing care provision resulting from the COVID-19 pandemic [15–17]. Many fewer studies have evaluated the impact of the COVID-19 pandemic on nurse leaders’ experiences of MI.

Several studies have found that moral resilience (MR)—“the capacity to preserve or restore integrity in response to moral adversity” [9, 18]—is inversely related to MI [15, 19, 20]. MR potentially mitigates some of the harmful aspects of inefficient or toxic work environments that are characteristic of poor OE [15, 21]. This indicates that MR could be a protective resource for nurses as they navigate ethical challenges—even during crisis situations [9, 13, 15]. A wide variety of studies evaluated the impact of COVID-19 on staff nurses considering moral distress [12, 22, 23], MR [13, 19] and their relationship on outcomes like burnout [24, 25], and intention to leave nursing [26].

In these studies, elements of poor OE such as ineffective communication, lack of empowerment, and poor care continuity were significant correlates of MI [12, 25]. These phenomena (MR, MI) are largely unstudied among nurse leaders; however, their voices, experiences, and perspectives on these issues are vital given their critical roles in leveraging and advocating for organizational change. In our prior work, we heard from nurse leaders who felt betrayed by their colleagues and organizations, and who lacked the tools and autonomy to help their staff and patients during exceptional times [8]. Exploratory research has illuminated a pattern of moral and emotional toll taken by the COVID-19 pandemic despite the administrative nature of nurse leaders’ work [8, 27]. To our knowledge, none considers the constructs of OE, MI and MR by level of nursing leadership.

Therefore, the purpose of this cross-sectional survey was to characterize the differences and commonalities between types of nurse leaders and their experiences of perceived OE, MI, and MR during the COVID-19 pandemic.

Methods

Study design, setting, and participants

A cross-sectional survey was distributed via Qualtrics from August through November of 2022. Recruitment was achieved through snowball sampling. The survey was distributed to nurse leaders across the United States through the American Organization for Nursing Leadership (AONL) via social media, and through the primary investigator’s network of nursing colleagues and collaborators. Participants were eligible to participate if they were nurses working in a leadership role since at least 2019, were 18 years or older, and living in the United States. Characteristics of the full dataset are described in a separate paper [15]. For this sub-analysis, data were limited to nurse leaders in clinically-oriented roles only (N = 763) and were categorized as follows:

• Nurse Managers (NM) (i.e., nurse managers, clinical managers, unit managers).

• Executives (i.e., chief, president/vice president of nursing, executive director or director)

• Other (i.e., clinical nurse specialist, nurse educator/professional development staff, house supervisor, charge nurse).

Throughout the results and discussion, references to managers, executives and other leaders all refer to nursing administrative leaders. Supplemental file 1 details the consort diagram outlining the included participants.

Ethics

This study was designed in compliance with the Declaration of Helsinki. The Johns Hopkins University School of Medicine Institutional Review Board deemed this study to be exempt from full board review because the survey design posed no more than minimal risk to participants (IRB00332536). Individuals who opened the Qualtrics survey were informed of the study purpose and their role as participants. All participants agreed to participate, those who declined to participate were automatically taken to the end of the survey.

Variables

Demographics and work characteristics

Demographic and employment-related variables were predominantly categorical and included: age (0 = 18–35 years old, 1 = 36–45 years old, 2 = 46–55 years old, 3 = 56–65 years old, 4 = over 65 years old; gender (0 = male, 1 = female); LGBTQ status (0 = no, 1 = yes); education (0 = Bachelor’s or less, 1 = Masters, 2 = Doctorate); religion (0 = no religious preference, 1 = Christian/Protestant, 2 = Roman Catholic, 3 = spiritual but not religious, 4 = other); race (0 = white, 1 = Black, 2 = Asian, 3 = other); ethnicity (0 = no, 1 = yes); role (0 = Nurse Manager, 1 = Executive, 2 = other); primary work population (0 = pediatric, 1 = adult, 2 = both); primary work setting (0 = hospital, short-term, acute care, 1 = hospital, long-term, acute care, 2 = post-acute care facility (IRF, SNF, CCRC), 3 = specialty hospital, 4 = health system facility, 5 = health system corporate office, 6 = academic health care setting, 7 = critical access hospital, 8 = behavioral health facility; 9 = outpatient, community-based clinic; 10 = ambulatory surgery, specialty care facility, 11 = free-standing emergency, urgent care facility, 12 = other health care setting); primary work setting location (0 = urban, 1 = suburban, 2 = rural); length of time in current role (0 = Less than 3 years, 1 = about 3–5 years, 2 = about 5–10 years, 3 = about 10–15 years, 4 = about 15–20 years, 5 = greater than 20 years), length of time working in nursing (0 = 1–10 years, 1 = 11–15 years, 2 = 16–20 years, 3 = 21–25 years, 4 = 26–30 years, 5 = more than 30 years).

Organizational effectiveness

We evaluated OE using an 18-item scale, which included some original items [12] and incorporated new items specifically tailored to nurse leaders during the pandemic [21]. The adaptation process involved a comprehensive literature review, input from nurse leaders practicing during the pandemic, and responses from an AONL-sponsored focus group. Participants rated items on the following scale:

▪ 1 (Not at all effective).

▪ 2 (Slightly effective).

▪ 3 (Moderately effective).

▪ 4 (Very effective).

▪ 5 (Extremely effective).

Principal axis factoring in an exploratory factor analysis revealed a single factor explaining 57.2% of the variability in the items. All communalities exceeded or equaled 0.50, and all factor loadings were greater than or equal to 0.70, providing evidence of the scale’s construct validity. Higher total scores indicate greater OE. The Cronbach’s alpha was 0.96, indicating high internal consistency.

Moral injury

MI was assessed using the Moral Injury Symptoms Scale-Healthcare Professionals (MISS-HP), consisting of 10 items rated on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree) [10]. Four items were positively worded, and therefore reverse coded, so higher scores indicated higher MI. The MISS-HP was scored from 10 to 100, with higher scores indicating greater MI. The Cronbach’s alpha reliability of the MISS-HP in this study was 0.71.

Moral resilience

MR was measured using the Rushton Moral Resilience Scale-16 (RMRS-16), a 16-item scale rated on a four-point Likert scale of 1 (Disagree) to 4 (Agree) [23]. There were four subscales: response to moral adversity, personal integrity, relational integrity, and moral efficacy. Each consisted of four items that were averaged to generate subscale scores. Eight items were negatively worded and reverse coded. The total RMRS score was an average of the item responses; higher scores indicated greater MR. Cronbach’s alpha reliabilities for the study by subscale were as follows: response to moral adversity (α = 0.76), personal integrity (α = 0.62), relational integrity (α = 0.77), and moral efficacy (α = 0.66). Reliability for the total scale was 0.85.

Statistical analysis

We analyzed differences by demographic and work characteristics stratified by nurse leader role (managers, executives, other) using Chi-squared tests to determine which covariates to include in the main analyses. We used ANCOVA to assess the differences by leadership role on OE, MI, and MR, including age, education, religion, race, primary work population, and length of time in nursing as covariates. All assumptions for ANCOVA were tested for each model, if the assumptions were not met we used Quade Non-parametric ANCOVAs. If significant differences were found for an ANCOVA (parametric or non-parametric), we conducted pairwise comparison tests to determine which nurse leader roles were significantly different from one another.

Differences were examined at the item- and total score-level for OE and MI. Item-level analysis allowed comparisons of specific experiences between leaders on their perceptions of OE and MI. For MR, differences were examined both by subscale and total score.

Analysis of open-ended questions

We collected free-text data via five open-ended questions embedded within the Qualtrics survey to further inform quantitative responses on nuanced topics. Open ended questions were intended to enhance the quantitative data, and follow up questions were interspersed throughout the survey. Participants were invited to offer comments and clarifications to bring depth and meaning to the quantitative data. Questions were designed to probe deeper into OE, sources of MI, and opportunities for individual and organizational growth. Open ended probes included questions such as, “Please explain why you do or do not feel prepared to address crisis situations in the future” and “Thinking back on the pandemic, in general, what were the ethical issues that kept you up at night?” (A full list of the open-ended questions is available in supplemental file 2). Open-ended responses were sorted by leadership role and copied into Microsoft Excel for management and storage. We used a deductive approach to evaluate theories of OE and Sources of MI. We first grouped the data according to its relationship to OE, MI, MR or a combination, revealing that MR overlapped extensively with OE. Working backwards two study team members sorted the open-ended data and coded to examine how each leader group reflected on each construct. Given the exploratory nature of the research question, descriptive codes helped to highlight characteristics of excellent and poor OE, sources of MI and facilitators of MR among each leader group. Descriptive codes were then built back up into sub-themes and themes to further examine code relationships. Codes and sub-themes were compared across leader groups to consider similarities and differences in perceptions of each concept. Within the domain of OE, quotes were mapped to items of the OE scale. This was not done within the scales for MI or MR because these elements were not identified within the data.

We used open-ended data in an explanatory manner to provide context and depth to our interpretations of the written data. Exemplar quotes and their interpretations are presented directly after related quantitative results to further contextualize the thoughts and experiences of nurse leaders.

Results

Demographics

We included 763 nurse leaders in the final analysis. Significant differences by leadership role were found in age (p < 0.001), education (0 < 0.001), religion (p < 0.001), race (p = 0.025), primary work population (0 < 0.001), and length of time in nursing (p < 0.001) (Table 1). Executives tended to be older, with 54.0% indicating that they were 56 years or older compared to 23.7% of NMs and 36.8% of other leaders. Executives were most likely to have a master’s or doctoral degree (95.1%), followed by other leaders (79.0%), and NMs (65.3%). Much of the sample was White (89.7%); however, NMs were more likely to identify as a race other than White (10.3%) compared to executives (9.3%) and other leaders (8.8%). Executives were more likely to report their primary work population as both adult and pediatric (39.0%) compared to 23.3% of NMs and 22.8% of other leaders. 53% of executives had worked in nursing for more than 30 years compared to 21.6% of NMs and 33.3% of other leaders. No significant differences by level of leadership were found in gender, sexual identity, ethnicity, primary work setting location, or length of time in current role.

Table 1.

Differences in demographic characteristics between nurse leader groups (N = 763)

	Total		Nurse Managers N = 232		Executives N = 464		Other N = 57
Variable	N	%	N	%	N	%	N	%	p
Age (N = 763)									< 0.001
8–35 years old	42	5.5%	26	11.0%	6	1.3%	10	17.5%
36–45 years old	161	21.1%	72	30.5%	75	16.0%	14	24.6%
46–55 years old	229	30.0%	82	34.7%	135	28.7%	12	21.1%
56–65 years old	266	34.9%	52	22.0%	199	42.3%	15	26.3%
Over 65 years old	65	8.5%	4	1.7%	55	11.7%	6	10.5%
Gender (N = 759)									0.612
Male	66	8.7%	22	9.4%	41	8.8%	3	5.3%
Female	693	91.3%	213	90.6%	426	91.2%	54	94.7%
LGBTQ (N = 752)
No	697	92.7%	210	90.5%	432	93.3%	55	96.5%
Yes	55	7.3%	22	9.5%	31	6.7%	2	3.5%
Education (N = 763)									< 0.001
Bachelor’s or less	117	15.3%	82	34.7%	23	4.9%	12	21.1%
Masters	427	56.0%	135	57.2%	256	54.5%	36	63.2%
Doctorate	219	28.7%	19	8.1%	191	40.6%	9	15.8%
Religion (N = 763)									< 0.001
No religious preference	89	11.7%	36	15.3%	42	8.9%	11	19.3%
Christian/Protestant	342	44.8%	119	50.4%	196	41.7%	27	47.4%
Roman Catholic	211	27.7%	46	19.5%	158	33.6%	7	12.3%
Spiritual but not religious	82	10.7%	23	9.7%	53	11.3%	6	10.5%
Other	39	5.1%	12	5.1%	21	4.5%	6	10.5%
Race (N = 754)									0.025
White	676	89.7%	202	87.1%	422	90.8%	52	91.2%
Black	32	4.2%	10	4.3%	22	4.7%	0	0.0%
Asian	21	2.8%	6	2.6%	11	2.4%	4	7.0%
Other	25	3.3%	14	6.0%	10	2.2%	1	1.8%
Are you of Hispanic, Latino, or Spanish origin? (N = 759)									0.155
Yes	33	4.3%	15	6.4%	17	3.6%	1	1.8%
No	726	95.7%	221	93.6%	450	96.4%	55	98.2%
Primary work population (N = 762)									< 0.001
Pediatric	64	8.4%	25	10.6%	37	7.9%	2	3.5%
Adult	447	58.7%	156	66.1%	249	53.1%	42	73.7%
Both	251	32.9%	55	23.3%	183	39.0%	13	22.8%
Primary work setting (N = 756)									N/A
Hospital, short-term  acute care	356	47.1%	121	51.7%	209	44.8%	26	46.4%
Hospital, long-term  acute care	14	1.9%	4	1.7%	10	2.1%	0	0.0%
Post-acute care facility  (IRF, SNF, CCRC)	9	1.2%	2	0.9%	7	1.5%	0	0.0%
Specialty hospital	11	1.5%	5	2.1%	6	1.3%	0	0.0%
Health system facility	107	14.2%	23	9.8%	76	16.3%	8	14.3%
Health system  corporate office	37	4.9%	2	0.9%	33	7.1%	2	3.6%
Academic health care  setting	134	17.7%	40	17.1%	76	16.3%	18	32.1%
Critical access  hospital	22	2.9%	8	3.4%	13	2.8%	1	1.8%
Behavioral health  facility	6	0.8%	3	1.3%	3	0.6%	0	0.0%
Outpatient, community-  based clinic	17	2.2%	5	2.1%	12	2.6%	0	0.0%
Ambulatory surgery,  specialty care facility	8	1.1%	2	0.9%	6	1.3%	0	0.0%
Free-standing  emergency, urgent  care facility	5	0.7%	4	1.7%	1	0.2%	0	0.0%
Other health care  setting	30	4.0%	15	6.4%	14	3.0%	1	1.8%
Primary work setting location (N = 759)									0.577
Urban	406	53.5%	134	57.5%	240	51.2%	32	56.1%
Suburban	243	32.0%	69	29.6%	156	33.3%	18	31.6%
Rural	110	14.5%	30	12.9%	73	15.6%	7	12.3%
Length of time in current role (N = 763)									0.413
Less than 3 years	250	32.8%	84	35.6%	149	31.7%	17	29.8%
About 3–5 years	199	26.1%	61	25.8%	124	26.4%	14	24.6%
About 5–10 years	159	20.8%	46	19.5%	95	20.2%	18	31.6%
About 10–15 years	72	9.4%	23	9.7%	43	9.1%	6	10.5%
About 15–20 years	46	6.0%	10	4.2%	35	7.4%	1	1.8%
Greater than 20 years	37	4.8%	12	5.1%	24	5.1%	1	1.8%
Length of time in nursing (N = 763)									< 0.001
1–10 years	45	5.9%	29	12.3%	8	1.7%	8	14.0%
11–15 years	101	13.2%	53	22.5%	40	8.5%	8	14.0%
16–20 years	93	12.2%	40	16.9%	40	8.5%	13	22.8%
21–25 years	98	12.8%	35	14.8%	59	12.6%	4	7.0%
26–30 years	107	14.0%	28	11.9%	74	15.7%	5	8.8%
More than 30 years	319	41.8%	51	21.6%	249	53.0%	19	33.3%

LGBTQ - Lesbian, gay, bisexual, transgender or queer identity Chi-square analyses were used to test differences between roles on demographics and work characteristics

Levels of organizational effectiveness

The omnibus ANCOVA p-values are presented in (Table 2); in the text we present the p-values for the pairwise comparisons. Table 2 also indicates whether a parametric or non-parametric ANCOVA was used for each variable based on whether the assumptions were met. Executives scored higher on total OE than other leaders (p = 0.007), but not significantly different from NMs. When comparing individual indicators of OE, executives rated “protocols for filling staffing needs when current staff have fulfilled their assignments” more effective than NM (p = 0.009) and other leaders (p < 0.001). Nurse executives (p < 0.040) and NM (p < 0.005) also rated processes for staff to “call-out” without retribution higher than other leaders. Executives also rated the following indicators of OE as more effective than other leaders (but no different than managers):

Table 2.

Comparing OE item and total score by nurse leader role

	Manager N = 232		Executives N = 464		Other N = 57
Item	N	Adjusted M (SE)	N	Adjusted M (SE)	N	Adjusted M (SE)	p
1. Information regarding professional wellness resourcesξ	231	3.56(0.09)	464	3.44(0.06)	57	3.26(0.16)	0.194
2. Policies regarding crisis response (e.g., the role of triage officers/triage teams)	225	3.39(0.09)	458	3.37(0.06)	56	3.05(0.16)	0.151
3. Forums with leaders to whom I report to share concerns	231	3.30(0.10)	456	3.44(0.07)	57	3.09(0.19)	0.194
4. Information regarding hazard supplemental compensationξ	209	2.65(0.11)	412	2.83(0.07)	53	2.23(0.20)	0.097
5. Opportunities for individual or team-based approach to address stress	230	3.08(0.10)	462	3.20(0.07)	57	2.96(0.18)	0.387
6. Pathways for requesting ethics consultation or advice	229	3.28(0.10)	458	3.48(0.07)a	57	2.89(0.19)a	0.012
7. Information regarding confidential reporting mechanisms	228	3.76(0.09)	450	3.78(0.06)	57	3.47(0.17)	0.250
8. An environment that promotes speaking up about concerns without fear of retaliationξ	228	3.51(0.10)	451	3.69(0.07)	55	3.23(0.19)	0.125
9. Communication updates regarding system-based changesξ	227	3.53(0.09)	451	3.78(0.06)b	57	3.32(0.17)b	0.038
10. Psychological and emotional support for leaders	232	2.59(0.10)	461	2.80(0.07)	56	2.66(0.19)	0.306
11. Policies for increasing the number of ICU beds	212	3.15(0.10)	416	3.41(0.07)c	49	2.84(0.19)c	0.010
12. Policies or processes for re-deployment of staffξ	224	3.08(0.09)	450	3.38(0.06)	54	3.02(0.17)	0.060
13. Processes for staff to “call-out” without retributionξ	227	3.21(0.10) d	450	3.42(0.07)e	53	2.82(0.19) d, e	0.015
14. Proactive training of staff to be “cross-trained” to work in multiple areas	227	3.03(0.09)f	456	3.33(0.06)f	56	3.01(0.17)	0.026
15. Protocols for filling staffing needs when current staff have fulfilled their assignmentsξ	227	2.67(0.09)g	461	3.07(0.06)g, h	57	2.33(0.17)h	< 0.001
16. Transparent communication regarding policy or practice changesξ	229	3.27(0.09)	461	3.55(0.06)i	57	3.00(0.17)i	0.010
17. Budget adjustments to increase resources for nursing workforce	230	2.87(0.11)	455	3.14(0.07)j	57	2.54(0.20)j	0.011
18. Equitable compensation for nurses in same role φ	228	2.77(0.11)	453	3.03(0.07)	55	2.53(0.20)	0.038
Total Organizational Effectiveness	232	3.15(0.07)	464	3.35(0.05)k	57	2.91(0.13)k	0.004

M = mean, SE = standard error of the mean

ANCOVAs were used for analyses

Covariates included: age, education, religion, race, primary work population, and length of time in nursing

Means with the same alphabetic superscript (a-k) were statically significantly different based upon post-hoc follow-up test

^φNone of the pairwise comparisons were statistically significant. 

^ξ Indicates that one or more assumption for ANCOVA was not met and therefore the Quade Nonparametric ANCOVA was used

• Pathways for requesting ethics consultation or advice (p = 0.012).

• Policies for increasing the number of ICU beds (p = 0.017).

• Communication updates regarding system-based changes (p = 0.019).

• Transparent communication regarding policy or practice changes (p = 0.005).

• Budget adjustments to increase resources for nursing workforce (p = 0.018).

Differences in perception of ethics support were also seen in the qualitative data. Although NM acknowledged the presence of ethics committees, they felt these resources were not always available or useful. One NM stated that her organization was lacking, “An ethics board that has strong nursing presence, led by nurses, that actually functions and takes action.”

Finally, executives rated proactive training of staff to be “cross-trained” to work in multiple areas (p = 0.014) more effective than managers (but not more than other leaders. NMs reiterated a need for better cross-training to ensure adequate staffing and to meet standards of care. One NM recalled her biggest ethical concern: “floating staff to areas where they were not trained to take on tasks that they were not competent to perform.”

NMs that reported strong OE described having executive presence on site throughout the pandemic, excellent communication, and transparency—even when confronted with challenges such as resource allocation of personal protective equipment (PPE) (gloves, gowns, masks, etc.):

Although it was rapidly changing, we were short on PPE, and there wasan overall feeling of confusion, the organization I work for was extremely transparent in decision making, PPE procurement, and solicited the feedback from frontline leaders on regular bases. Our executive leaders also consistently rounded on the floors including the COVID floors. They were here on the off hours and weekends as well as checking in on staff.

Levels of moral injury

Just over one-third (36.4%) of all respondents met the threshold for clinically significant levels of MI (score ≤ 36) [10]. Table 3 indicates whether a parametric or non-parametric test was used for each variable depending on whether the assumptions were met. No significant differences were found between nurse leader roles on individual MI items or total score, further affirming the high prevalence of MI across all types of leaders. The items of MI that ranked highest across all leaders were as follows:

Table 3.

Comparisons of MI item and total score by nurse leader roles

	Manager N = 232		Executives N = 464		Other N = 57
Item	N	Adjusted M (SE)	N	Adjusted M (SE)	N	Adjusted M (SE)	N
1. I feel betrayed by other health professionals whom I once trusted. ξ	232	5.20(0.23)	464	4.69(0.16)	57	5.38(0.43)	0.250
2. I feel guilt over failing to save someone from being seriously injured or dying. ξ	232	4.02(0.22)	463	3.97(0.15)	57	3.46(0.41)	0.696
3. I feel ashamed about what I’ve done or not done when providing care to my patients. ξ	231	2.70(0.18)	464	2.81(0.12)	57	3.01(0.34)	0.449
4. I am troubled by having acted in ways that violated my own morals or values. ξ	230	2.80(0.18)	462	2.55(0.13)	57	2.79(0.34)	0.248
5. Most people with whom I work as a health professional are trustworthy. (reverse coded)	230	2.96(0.17)	463	3.15(0.12)	57	3.16(0.32)	0.661
6. I have a good sense of what makes my life meaningful as a health professional. (reverse coded) ξ	232	2.15(0.11)	463	2.15(0.08)	57	2.49(0.21)	0.293
7. I have forgiven myself for what’s happened to me or to others whom I have cared for. (reverse coded)	232	3.99(0.17)	462	3.79(0.12)	56	4.04(0.33)	0.607
8. All in all, I am inclined to feel that I’m a failure in my work as a health professional. ξ	232	2.16(0.15)	464	2.21(0.10)	57	2.01(0.28)	0.905
9. I sometimes feel God is punishing me for what I’ve done or not done while caring for patients. ξ	232	1.35(0.10)	464	1.48(0.07)	57	1.44(0.18)	0.986
10. Compared to before I went through these experiences, my religious/spiritual faith has strengthened. (reverse coded) ξ	232	5.70(0.21)	464	5.63(0.14)	57	5.11(0.39)	0.354
Total Score (Range 10–100)	232	32.63(0.92)	464	32.15(0.63)	57	33.62(1.72)	0.680

M = mean, SE = standard error of the mean

ANCOVAs were used for analyses

Covariates included: age, education, religion, race, primary work population, and length of time in nursing. 36.4% of nurse leaders meet the clinical threshold (score > = 36) for moral injury. ^ξ Indicates that one or more assumption for ANCOVA was not met and therefore the Quade Nonparametric ANCOVA was used

• Feelings of betrayal by other healthcare workers.

• Guilt from failing to save someone, and.

• Deriving meaning from healthcare work.

Levels of moral resilience

One or more assumptions were not met for each of the MR variables so Quade non-parametric ANCOVAs were used. The models indicated that executives had higher total MR than either managers (p = 0.023) or other leaders (p < 0.001) (Table 4). When we examined the subscales, executives also reported greater relational integrity than managers (p = 0.045) and other leaders (p < 0.001). Managers also had higher relational integrity than other leaders (p < 0.025). Other leaders had significantly lower scores on both the personal integrity and moral efficacy subscales than executives (personal integrity: p < 0.001, moral efficacy: p < 0.001, respectively) or managers (personal integrity: p = 0.005, moral efficacy: p = 0.005, respectively). No significant difference by nurse leader role was found for response to moral adversity. In the qualitative data, two NMs explicitly mentioned MR, and described a need to enhance MR after experiencing burnout. Though less explicit, the most common theme throughout the NMs’ qualitative responses was a need for mental health resources and time away from work to heal from the impact of burnout. One manager put it succinctly: “[We need] emotional support to leadership—healed people can help people.” Through their responses, nurse leaders made plain the mental, emotional, and ethical wounds they sustained working through the COVID-19 pandemic. In sharp contrast, several executives discussed the skills, training, and experiences that had equipped them to successfully navigate the ethical challenges of a pandemic despite inadequate organizational resources.

Table 4.

Comparisons of MR subscale and total score by nurse leader role

	Manager N = 232		Executives N = 464		Other N = 57
Scale	N	Adjusted M (SE)	N	Adjusted M (SE)	N	Adjusted M (SE)	p
Response to moral adversity ξ	232	2.54(0.05)	464	2.62(0.04)	57	2.56(0.10)	0.706
Personal integrity ξ	232	3.67(0.03)a	464	3.73(0.02)b	57	3.52(0.05)a, b	0.001
Relational integrity ξ	232	3.19(0.04)c, d	464	3.35(0.03)c, e	57	3.00(0.08)d, e	0.001
Moral Efficacy ξ	232	3.47(0.03)f	464	3.54(0.02)g	57	3.29(0.06)f, g	0.001
Total Moral Resilience ξ	232	3.22(0.03)h	464	3.31(0.02)h, i	57	3.09(0.05)i	0.001

M = mean, SE = standard error of the mean

ANCOVAs were used for analyses

Means with the same alphabetic superscript (a-i) were statically significantly different based upon post-hoc follow-up test

Covariates included: age, education, religion, race, primary work population, and length of time in nursing

^ξ Indicates that one or more assumption for ANCOVA was not met and therefore the Quade Nonparametric ANCOVA was used

Descriptive qualitative results

There were two overarching themes identified within the data specific to each group of nurse leaders. These themes were (1) Descriptors of Organizational Effectiveness, (2) Contributors to moral injury. MR was not an independent theme as most reflections of MR were specifically related to aspects of OE. Leaders described Nurse leaders at all levels described common perceptions of OE, and MI in their open-ended responses; however, the manifestation of their experiences differed by role. One experience common to all nurse leaders was their professional commitment to safety and wellness. Threats to safety were a source of MI for all leader groups; however, the scope of care varied between leader groups. NMs comments were most concerned about the safety of their staff and the patients on their units—both from an ethical and operational standpoint. Executives commented about not only patients within their hospitals or practice areas, but also about those living within the wider community in terms of care access and equity.

Regarding OE, nurse leader groups described effectiveness by different standards. NMs evaluated interpersonal interactions and the effectiveness of their supervisors; executives prioritized the efficacy of shared governance. The shortcomings of an ineffective organization operated on a telescoping scale, where a clinical unit is a microcosm of systemic challenges. Table 5 includes quotes relevant to each item of the OE scale, sorted by leadership level. (Supplemental file 3 includes data regarding the themes, subthemes, and codes used to analyze the data).

Table 5.

Open ended comments exemplifying each item of the organizational effectiveness scale by leadership role

Organizational effectiveness scale item	Study team interpretation of item meaning	Executives	Managers	Others
Protocols for filling staffing needs when current staff have fulfilled their assignments	Organizational policies and practices for filling staffing needs	“Financial priorities of the hospital destroying staffing models that took years to recover from.” “Having the authority to have made [decisions about] staffing and equipment needs at the time I requested to have prepared better and prevent staff and resources from being depleted.”	“Begging staff to work while verbally told them to care for themselves.” “Being forced to stretch staff to unsafe ratios and being told that they may be uncomfortable, but it is not unsafe.”	“No support in my position, always had to give in, and provide staffing when we were stretched so thin. Continues on with no end in sight.”
Pathways for requesting ethics consultation or advice	Organizational policies and practices for requesting ethics consultations	No relevant quotes	“Clear escalation pathways for ethical concerns in a crisis, plans for resources during a crisis, nursing leadership in ethics and organization decisions.”	“Routine screening of moral injury symptoms of staff and leaders.”
Policies for increasing the number of ICU beds	Organizational policies and practices for increasing the number of critical care beds	“We had a variety of responses to the covid pandemic - opened new units, repurposed non-patient care areas, implemented team nursing, etc.  I feel like we used a variety of methods that could be applied to future pandemics.”	No relevant quotes	No relevant quotes
Communication updates regarding system-based changes	Organizational policies and practices for communicating changes between supervisors and employees	“Better support of national agencies and government officials. Politics got in the way of connected and coordinated communication and policies. Through a lack of national and state leadership, people became more fearful and very divided.”	“How to make sure staff had the communication they needed about the rapid changes being made while they were redeployed and not in their department.”	“Better information from senior leadership team to middle management, so we can be prepared to speak to changes to front-line staff before it happens.”
Transparent  communication regarding policy/practice changes	Organizational inclusion of employee stakeholders in decision making and disclosure of how leaders arrive at policy changes	“…Simply sharing recommendations from the CDC was not enough to thoughtfully care for patients with severe COVID-19 pneumonia. There were countless times that network leaders would send a document with reformatted CDC recommendations and say “we provided you all the information you need” and several of us would have to get together to discuss how these recommendations would need to be implemented and any process nuances that would need to be considered.”	“Although it was rapidly changing…and there was an overall feeling of confusion, the organization I work for was extremely transparent in decision making, PPE procurement, [etc.] and solicited the feedback from frontline leaders on a regular basis.”	“Using the input of front-line staff in decision making even in crisis. Creating a process that includes a level of shared governance during crisis instead of reverting to autocratic leadership in the C-suite.”
Budget adjustments to increase resources for nursing workforce	Organizational practices and policies to increase spending for nursing workforce (ratios, bonuses, hazard pay etc.)	“We all hear constantly that we need to think of creative new staffing models…after decades of working as a profession to prove that primary nursing effects every aspect of quality and patient experience. It is a moral dilemma to even consider moving to another, less effective nursing model. I haven’t heard anyone talking about that and it breaks my heart.”	“Staffing shortage is so profound yet our census is up 1.5 x the budgeted amount. We are asked to do more with less, constantly. Even if we pooled all staff together, we still don’t have enough to cover patient care. What is missing is higher pay to be offered. We will pay travelers $100/hr. but not willing to give our nurses raises.”	“Nurses were experts at knowing what they needed and how to achieve it. The focus on corporate finances backfired on administrators who later had to pay as much as 5 time more to replace nurses who left.”
Processes for staff to call out without fear of retribution	Organizational practices and policies pertaining to protections for calling out for illness and wellness	“Staff taking full advantage of illness policies to take extended time off.” “Staff calling off/being out sick and unable to cover patients [vs] bringing them back… when was the right time?”	“It was literally becoming an expectation that we were on call 24/7. I needed time with family and time off. Leaders cannot be expected to work all day, all night, and all weekend in staffing in addition to managing nursing input unit operations.”	“I ended up very sick but was forced to go to work because I’m essential staff. Healthcare workers should not have had different guidelines. In fact, we should have had stricter guidelines. We were the ones consistently exposed and fearing for our lives; our families lives. It was so difficult and taxing.”
Items below were not included in the original scale but were important themes in the qualitative data
Perceived value of nursing leadership within the organization	Organizational policies and practices that confer value	“We have disproportionate leadership at the organization I work for. By this I mean the physicians are the voice that is heard and nursing is frequently overlooked.”	“Although it was rapidly changing, we were short on PPE, and there was an overall feeling of confusion the organization I work for was extremely transparent in decision making, PPE procurement and solicited the feedback from frontline leaders on a regular basis.”	“Nursing shared governance structures were shut down when they were most needed. Nurses at the bedside didn’t feel they had a voice and many left to traveler positions for the money, but probably more so as a means of feeling valued.”
Balancing finances with safety	Balancing the institutional budget without compromising patient or staff safety	“[I] Brought [my concerns] to attention of Corporate leadership but the finance leaders stopped any positive initiatives due to cost.”	“Our leaders are unethical and lack integrity. Focus is on finances, not patients or staff.”	“Mostly I am challenged by the inability of upper management to understand the financial impact to them from cutting resources such as education from staff. They don’t come to us knowing everything they NEED to know, and we give them less and less during orientation. We see how it affects outcomes, but they avoid seeing the actual cause. We are using Band-Aids and not fixing the problem.”
Inequity between healthcare worker roles	Sidelining nurses and their expertise over nursing affairs in lieu of other disciplines	“[There is a] growing practice to put top nurse executives in positions to report to MD executives, called Chief Clinical Officers…sends a terrible message to nurses about the value of their profession when there are two professions in Executive practice, but one (nursing) must “report” to the other (medicine). Indicates an age-old bias against Nursing that can be indicative of a lack of respect that will filter into other decisions— including ethical decisions.”	“I found it challenging to integrate the ideas of physician leaders who were able to primarily work remotely when making decisions for staff that were physically present. There was a deep sense of caring for safety but not by example of safe in-person practice.”	“Physician management and communication tips would be nice.  They [physicians] consistently tried to find a loophole to get their way when it clearly wasn’t safe for us.”

Nurse leaders discussed two additional facets of OE that impacted MI and MR and arose as descriptive topics that did not fall within the items in the OE scale. First was the inequity that nurse leaders felt between healthcare workers with different roles. Organizations extended leadership and decision-making privileges to physician colleagues without hesitation—even if it was outside their scope of expertise. Physicians were elevated to leadership roles above nurses and given authority over nursing affairs, which sidelined nurse leaders in important staffing and redeployment decisions. The second issue was the balance between finances and safety. Across nurse leader groups, participants voiced apprehension that financial motives led organizational leaders to sacrifice patient and staff safety. Nurse leaders at all levels expressed concern about the effect of finances on patients but explained these challenges within the context of their roles and responsibilities (Table 5).

Discussion

What fundamentally underpins nursing practice is the nurses’ commitment to caring for patients. Nurse leaders amplify and orient toward this fundamental commitment reflected in the Nursing Code of Ethics [25]. Threats to patient care and safety, which were common during the height of the COVID-19 pandemic, violated nurses’ personal integrity causing moral suffering including MI among staff nurses and their leaders. Unfortunately, many of these threats were caused directly or indirectly by poor OE. This gap between fundamental nursing values and the reality of the clinical practice environment jeopardizes moral well-being and integrity.

Organizational effectiveness

In this study, not all aspects of OE were statistically different between professions, but many were. Executives rated OE higher than NMs and higher than other leaders. It is possible that—compared to NMs or other leaders who may not have been privy to planning and response activities—nurse executives were more familiar with organizational constraints and the steps that the organization was taking to correct ineffective policies. Another potential explanation for this finding is that executives were often involved with decision-making processes regarding organizational priorities, and, therefore, may have had a bias regarding their effectiveness compared to other nurse leaders.

NMs rated the facets of OE dealing with staffing lower than executives. NMs may have been particularly sensitive to aspects of OE that involve staffing. Unlike executives and other leaders removed from the responsibilities of daily scheduling, staffing is one of the primary responsibilities of NMs. NMs are responsible for the wellbeing of the staff and patients on their units; so when staffing is inadequate, they have three options:

• Allow their staff to work with unusually high and potentially unsafe ratios.

• Convince staff to work over and above their required hours or.

• Find additional coverage, if possible, often including provision of direct care themselves.

All three options potentially expose NM to MI as they choose between patient and staff safety, organizational fiscal constraints, or in some cases, their own mental and physical safety. NMs saw the consequences of short staffing and heard the negative feedback from staff and patients directly. Two recent studies identified the moral suffering experienced by NMs as they attempted to balance the needs of their staff against the expectations of their organizations [28, 29]. In each, NMs found they were unable to prioritize staff well-being without effective guidance and communication from their healthcare organizations [28, 29].

The crisis scenario created by COVID-19 paused shared governance in many organizations at a time when it was most needed. This left nurse leaders without clear communication channels or organizational support and resources. Missing clear organizational policies and confronting the pandemic without clear endpoints, leaders had no effective course to realign to. However, some organizations were able to maintain shared governance through remote council meetings, methods for reporting concerns and suggestions online, and in-person leadership rouding [30, 31].This was a testament to strong OE and a commitment to nursing engagement.

The Healthy Work Environment model developed by the American Association of Critical-Care Nurses was designed to evaluate and improve nursing input and safety throughout an institution. The model acknowledges the relationship between the environment and nursing outcomes [32, 33]; this relationship is shaped by an organization’s effectiveness or its dysfunction. The Healthy Work Environment is accompanied by an assessment tool that grades the institutional environment on the following six criteria: communication, collaboration, staffing, decision-making, recognition, and, leadership [32]. This assessment tool has uncovered correlations between the work environment and nurse outcomes such as burnout and intention to leave the profession, although constructs around MI and MR have not been measured [34].

From the survey, it was clear that nurse leaders collectively desired clear pathways and policies for requesting ethics consultations, but perceived the sufficiency of current standards differently. Executives found the current policies more adequate than managers and other leaders. We have developed two possible hypotheses for this finding that warrant future exploration. First is that executives were the least likely to utilize ethics support due to increasing distance from direct patient care where many distressing situations occur. Second, this finding may have been indicative of a generational difference, whereby executives tended to be older, and possibly more established in organizational norms, versus younger leaders who were still developing an ethical consciousness and required clearer guidance [35].

To improve nurse leaders’ perception of limited input and inadequate ethics resources, organizations could integrate nurses as essential and required members of ethics committees. As actors who translate policy into action, carry out care, and witness the outcomes, nurses are important stakeholders in ethical patient decision making. Required representation on ethics committees could create a conduit through which nurses can receive transparent feedback about how and why ethical decisions are made.

Moral injury

There is a gap between what nurses perceive as high-quality care and the care they can provide given organizational and situational constraints [23, 36]. This gap is explained in part by systemic limitations in organizational finances, staffing, and knowledge—all of which were undermined by the COVID-19 pandemic, intensifying the symptoms of MI [36]. More than one-third of this sample (36.4%) met the threshold for clinically significant MI (scores ≥ 36) without differences between leadership roles. Across all groups, the facet of MI that most troubled nurse leaders were feelings of betrayal by other organizational leaders. Public health emergencies like COVID-19 can lead to feelings of betrayal when nurses and their leaders perceive that other leaders do not prioritize care quality in the same way. These data are consistent with other studies of nurse leaders [12, 37] particularly during the pandemic [38, 39], and demonstrate that choosing between patient care and organizational solvency creates symptoms of MI—even for those in positions of ‘power’.

In our sample, NMs also frequently endorsed “guilt from failing to save someone” as a source of MI despite their removal from the bedside. Several interventions and strategies exist to help nurses and other healthcare staff make difficult ethical decisions regarding their patients. For example, nurses in the Netherlands have developed the Cura System (Concentrate–Unrush–Reflect–Act) [40]. The CURA system is designed to address difficult clinical scenarios in real time as clinicians are confronted with ethical challenges [41]. Similarly, Moral Case Deliberation and the Nijmegen method focus on ethical deliberations of individual client scenarios [42, 43]. However, none of these methods target the sources of moral distress for clinical leaders or administrative healthcare personnel and are impractical for intervening on organizational or systemic sources of moral harm.

Within the context of existing literature, these findings present an opportunity to (1) establish proactive mechanisms to recognize and monitor MI symptoms among nurses and nurse leaders, and (2) to design specific strategies for addressing both symptoms and the root causes of MI at an organizational or structural level.

Moral resilience

Our findings also highlight ways that MR can support leaders as a protective resource in response to moral adversity. Executives had higher overall MR than either managers (p = 0.030) or other leaders (p < 0.001). This may be explained, in part, by the years of experience in nursing or their respective leadership roles. During the quantitative analysis, we controlled for length of time in nursing because it was significantly different across nurse leader groups. This was an expected finding since time is an essential factor in professional development and promotion; however, length of time in their current role was not statistically significant. Studies have shown that nurses and other interdisciplinary health professionals with fewer years of experience are significantly more likely to experience MI, and that additional years of experience are associated with greater MR, decreased turnover intention, and lower levels of burnout [19, 21].

When examining the individual subscales within MR, executives were higher in relational integrity than managers or other leaders. Relational integrity refers to the dynamic interplay of peoples’ personal integrity as they engage in the delivery of healthcare [9]. This includes nurses and other healthcare workers, patients and their families, leaders, and the broader community.

Executives may have greater authority to exercise their moral agency around systemic decisions than other nurse leaders, leading to improved relational integrity. It is possible that the other leaders have less leverage to make decisions consistent with their values given their rankings in the organizational decision-making structures. Given this hierarchy, executives have more power to exert their own ethical principles than NMs and other nurse leaders.

The MR scores of nurse executives suggest that MR could be leveraged by other nurse leaders to mitigate MI. It is plausible that MR is a capacity that can be honed over time. A recent study by Faraco et al. suggests that NMs may use personal and organizational strategies to boost MR [44]. Intrapersonal strategies leverage individual and relational approaches such as communication, adapting to changing circumstances and distancing when necessary [44]. Organizational strategies include activities such as ethics education and psychological protections [44]. Additional research is needed to determine if and how MR can be cultivated among nurse leaders, particularly NMs and those who have not reached the highest levels of leadership.

Findings regarding executive MR do not indicate that individual resilience outweighs organizational accountability. Udod and colleagues rightly point out that “resilience is a mutual responsibility between the individual and the organization” [41]. They highlight the importance of the environment and communication structures as important institutional factors in point-of-care nursing. Despite their attention to organizational responsibilities to bedside nurses, Udod’s article promotes individual resilience rather than organizational safety nets for nurse leaders [41] threatening to further absolve organizations for poor OE and subsequent MI. Our data suggests that investments in both MR and OE are necessary to reduce the impact of morally injurious events or organizational structures.

Understaffing – a challenge to organizational effectiveness and a contributor to moral injury

The COVID-19 pandemic exacerbated the preexisting nursing shortage, placing untold strain on nurses and their leaders [45, 46]. Our data identified concerns about how to safely and equitably staff for patient care when point-of-care nurses were mentally and physically exhausted. However, these concerns were not shared equally. Nurse executives rated organizational policies for staffing as significantly more effective than the rating by NMs and other leaders.

To fill staffing shortages, NMs may to return to staff who are already overworked and overwhelmed bringing up issues of relational integrity. There are no federally mandated nurse ratios in the United States, and California is the only state with mandated ratios by nursing specialty. In 2014, Massachusetts adopted statewide ratios for all types of intensive care units [42] and several states have mandates requiring that hospitals disclose average staffing ratios or require hospital-based staffing committees that comprise at least 50% direct care nursing staff. Despite these policies, controversy continues among nurse leaders about the best approach for addressing the staffing crisis nationally. As they return to the same pool of staff to cover care areas, NMs may feel they are violating professional and ethical contracts [44]. While NMs may acknowledge that staff are overwhelmedit, overworked, and less productive at work, they are ultimately responsible for allocating nursing care to meet patient needs. This can lead to an untenable ethical dilemma that requires managers to choose between equally undesirable options.

While redeployment, cross-training, use of student nurses, and temporary nursing assignments are all strategies for managing understaffing, many of these tactics require financial and operational support from executive leaderp [47]. NMs cannot leverage these approaches without the planning and support of an effective organization. Moreover, some research has found that workarounds such as redeployment and temporary nurses can contribute to a lack of professional cohesion and additional burnout due to the burden placed on full-time staff to train, advise, and supervise rotating or temporary nurses [48].

Within healthcare, there is a similar perspective on the interchangeable nature of nurse leaders. As a result, there have been breaches of trust between and across healthcare leadrs [49]. Each leadership role has a unique perspective, serves different populations, and is ultimately responsible for different outcomes. Despite these differences, the qualitative data demonstrate that nurse leaders at all levels feel sidelined by poor OE. Developing robust OE strategies that support strong nursing leadership will require cooperative nursing collaboration along with organizational investments to dismantle ineffective organizational patterns, policies, and practices. Our findings add evidence to focus resources to better equip nurse leaders to address their day-to-day ethical challenges and to create more robust organizational infrastructure such as ethics committees with proportionate nursing representation and new methods of human resource allocation that elevate the value of nursing to achieve organizational and patient outcomes. Future research, focused on interventions to bridge the gaps in expectations and communication among various nursing leadership roles and the broader executive team, is a promising starting point.

Limitations

Despite the many strengths of this analysis, there are limitations. We did not use random sampling because nurse leaders are a harder-to-reach population; therefore, findings may not be fully representative of nursing leaders nationally. Instead, we partnered with the largest professional organization of nursing leaders and successfully recruited a large sample size. It is possible that mean scores of nurse leaders (OE, MI, MR) who are part of a professional organization may differ from the scores of nurse leaders who are not involved in professional organizations; thus, caution should be taken when interpreting the exact means. However, given the sample size, it is likely that differences between nurse leadership groups may be robust to different recruitment strategies. This is also a US sample and thus caution should be taken when generalizing outside of the US, different countries may have different organizational structures and different policies that may impact differences between levels of leadership on OE, MI, and MR.

The study was cross-sectional; therefore, differences between nurse leader roles on OE and MR were confounded by other factors not measured. However, theoretical demographic characteristics that might be confounders were included and controlled for in the analysis.

Survey data was self-reported and thus subjective. MI and MR are subjective personal constructs, and thus self-report is an ideal way to measure these variables. The instruments used in the survey were validated in similar populations with excellent validity and reliability. We were interested in the perceptions of OE from nursing leaders; self-report is an appropriate way to nurse leaders’ subjective assessment of their organization’s effectiveness.

The reliability for one sub-scale of the moral resilience scale, personal integrity was slightly low, however, there were still significant differences by profession indicating that this did not fundamentally attenuate our ability to detect differences between groups on this sub-scale.

Finally, nurse leaders were given the opportunity to respond to open-ended questions, but they were not specific to the OE, MR, or MI scales. As a result, participants’ interpretations of specific scale items were not known. Despite this limitation, we attempted to stay close to the data providing themes and representative quotations that directly represented the participants’ views rather than the team’s latent interpretation of the themes.

Conclusion

Nurse leaders at all levels experienced MI, with one-third experiencing clinically significant MI. ANCOVA modeling indicated, however, that nurse executives experienced significantly greater MR than NMs and other nurse leaders, signaling a capacity for protective growth. Qualitatively, nurse leaders experienced MI beyond OE items related to inequities in privilege between healthcare workers and most significantly when patient safety was compromised for financial gain. Future research should investigate organizational and institutional policy changes and their impact on nursing’s integrity and well-being.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

NM

Nurse managers (i.e nurse managers, clinical managers, unit managers)

ANCOVA

Analysis of covariance

MI

Moral injury

MR

Moral resilience

OE

Organizational effectiveness

RMRS-16

Rushton Moral Resilience Scale-16 item

Author contributions

AB analyzed qualitative data, participated in quantitative data interpretation, drafted the manuscript and provided edits to the manuscript. GH was part of the study conceptualization, supervised quantitative data analysis, data interpretation, and contributed to manuscript generation and edits. CJ participated in qualitative and quantitative data analysis and provided edits to the manuscript. KN participated in data interpretation and provided edits to the manuscript. DB performed initial data cleaning and preliminary analyses and edits to the manuscript. CR conceptualized the study, secured funding for the project, supervised analysis and data interpretation and contributed to manuscript drafting and editing.

Funding

The American Organization for Nursing Leadership Foundation provided funding to support the study implementation. Alanna Bergman’s research and training were supported by the National Institute of Nursing Research (1F31NR020588-01).

Data availability

Researchers interested in accessing the data for purposes of replication, validation, or further analysis may contact the corresponding author at [dhm8ax@virginia.edu] to discuss the terms and conditions for data sharing. Data availability is contingent upon compliance with ethical and privacy considerations and access will be granted in accordance with applicable laws and regulations.

Declarations

Ethics approval and consent to participate

This study was designed in compliance with the Declaration of Helsinki. The Johns Hopkins Institutional Review Board deemed this study to be exempt. By completing the survey, participants gave their implied informed consent to take part in the study. All participants agreed to participate, those who declined to participate were automatically taken to the end of the survey.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.