Table 2.

Integrated Quantitative and Qualitative Findings

Subthemes	Link to Reina Three Dimensions of Trust	Qualitative Exemplar Quotes	No. Comments	Corresponding Survey Item	Quantitative Results
Major theme 1: organizational infrastructure
Availability of resources	Trust of Character  • Manage expectations  • Keep agreements	“Appropriate nursing staffing on COVID units. Ratios currently are extremely unsafe, cannot monitor or respond to patients. Stop treating COVID unit like a normal Med-Surg unit-acuity is so much higher. High nurse attrition is making it worse.” “The pandemic is not over so stop pulling resources to save your budget.” “Administration actually paying attention to what is actually happening and how dangerous short staffing is.”	67	Qll: Given the pandemic crisis right now, to what extent are you experiencing moral distress related to the following situations? Working with limited resources (ie, PPE, COVID testing, staff, ventilators).	55%, a lot/a great deal
Clear communication (includes available resources)	Trust of Communication  • Share information  • Speak with good purpose	“More streamline communication on specific actions leadership is taking to serve us as staff, and the community.” “Reasoning behind decisions to be explained.”	31	Q8: Please consider how effective your organization is in providing the following: communication updates regarding system-based changes.	35%, not effective at all/slightly effective
Hazard pay and other incentives	Trust of Character  • Manage expectations  • Keep agreements	“Better Pay. When you are struggling to provide the best patient care in the midst of a pandemic but aren’t paid well, this creates poor morale.”	21	Q8: Please consider how effective your organization is in providing the following: information on hazard supplemental compensation.	75%, not effective at all/slightly effective
Consistent enforcement of policies, practices, and rules	Trust of Character  • Manage expectations  • Be consistent  • Keep agreements	“We need CONSISENT, well thought out and logical policies for protecting staff and patients, and we need consistent enforcement of these policies.” “Clear straight forward rules that are update and notified to each and every nursing staff. It is stressful coming into work with a new policy on how to handle COVID-19 every shift.”	17	Q8: Please consider how effective your organization is in providing the following: policies regarding crisis response. Qll: Given the pandemic crisis right now, to what extent are you experiencing moral distress related to the following situations? Communication of new policies/practice that may forego interventions with patients/ families.	46%, not effective at all/slightly effective 32%, a lot/a great deal
Major theme 2: support from leaders
Being heard and having concerns addressed	Trust of Communication  • Speak with good purpose  Trust of Character  • Mutually serving intensions  Trust of Capability  • Involve others and seek their input	“I need to feel that I have a voice and that my concerns will be addressed and dealt with, not tucked away. Saying the words does not make me feel better. I want the problem fixed.” “To be able to voice concerns and questions without being treated as if I am a problem.” “...understanding that when I have a concern it is heard and not immediately dismissed or that everyone is so overwhelmed it will get dealt with at some point.”	42	Q8: Please consider how effective your organization is in providing the following: Having forums with leaders to share concerns An environment that promotes speaking up without fear of retaliation	49%, not effective at all/slightly effective 49%, not effective at all/slightly effective
Trustworthiness	Trust of Communication  • Share information  • Tell the truth  • Speak with good purpose	“I would appreciate hearing the truth from hospital administrators—we are told that PPE is short, but we are fine. We are not fine. We also know that PPE supplies are limited. Please do not insult me by telling me that we are safe as we should be right now. Instead, please tell me what you are doing to get us the equipment we need. It does no good to try to convince me of something untrue instead of acknowledging the problem and explaining how we are trying to fix it.” “...transparency of administration by sharing why decisions are being made.” “...trust in coworkers and health care across the nation to provide us with actual facts instead of releasing info on ‘studies’ that have not been proven to the fullest extent possible.” “Leadership that believes in and respects science. I will only feel better about the ethical challenges in the pandemic if I know that there is not an entity that is constantly spouting misinformation that directly goes against everything that I’m trying to do to help my patients. Furthermore, it would be nice if our patients had less skepticism regarding their care during the pandemic due to what they have heard from our leadership.” “Scientific proof and knowledge of what is taking place.”	27	Q8: Please consider how effective your organization is in providing the following: An environment that promotes speaking up about concerns without fear of retaliation Communication updates regarding system-based changes	49%, not effective at all/slightly effective 35%, not effective at all/slightly effective
Empathy, appreciated, and being valued	Trust of Capability  • Acknowledge people’s skills and abilities  Trust of Character  • Encourage mutually serving intentions	“...understanding what we are going through and that we are scared.” “Feel appreciated and valued, but not through words of thank you but instead by helping them solve problems.” “Nurses feel abandoned, we are taking care of these patients with limited resources, rotating staff and limited compensation. We feel under-appreciated and under compensated.”	27	Not applicable	Not applicable
Being present and visible	Trust of Character  • Manage expectations  • Encourage mutually serving intentions  Trust of Capability  • Involve others and seek their input	“For my workplace to actually put in work to help support us rather than give blanket statements and call us ‘heroes.’” “Executive leaders to be visible during the crisis. Executive leaders to involve the leaders and bedside staff in decision making because we are the ones actually doing the work and know what works in current practice.” “Support from administration letting us know they know what we are up against/see them on the front line.”	14	Q8: Please consider how effective your organization is in providing the following: Having forums with leaders to share concerns	49%, not effective/ slightly effective
Major theme 3: palliative care involvement
Advocating for dying patients	Trust of Capability  • Allow people to make decisions  • Involve others and seek their input	“Palliative support for those that are dying, they deserve a peaceful death, and many did not receive that.” “Advocating for ethically dying for my patients, not prolonging COVID illness.” “Do not keep people alive that should not be kept alive. Make sure family visits bedside when they want to in the event of end of life.”	15	Qll: Given the pandemic crisis right now, to what extent are you experiencing moral distress related to the following situations? Not being able to advocate for patient needs due to resource constraints.	36%, a lot/a great deal
Dying alone	Trust of Capability  • Involve others and seek their input  Trust of Communication  • Share information  • Maintain confidentiality	“...need better communication with critically ill/ possible end of life with family—this is very distressing that patients do not get better when they are left alone in a room without family; staff are strained and have little time to call families to update on condition—make it hard to make good decisions especially when they cannot see their loved ones.”	6	Qll: Given the pandemic crisis right now, to what extent are you experiencing moral distress related to the following situations? Not having access to loved ones.	64%, a lot/a great deal