Depicting occupational trauma concepts impacting nurse well-being during the COVID-19 pandemic

ABSTRACT

Purpose

The purpose of this concept delineation was to differentiate similar concepts impacting nurse well-being during the COVID-19 pandemic, including: compassion fatigue, burnout, moral injury, secondary traumatic stress, and second victim.

Methods

A total of 63 articles were reviewed for concept delineation. Morse’s (1995) approach to concept delineation was utilized to analyse the articles.

Results

Concepts were described interchangeably but were found to present themselves in a sequence. A nurse may experience moral injury, leading to a second victim experience, synonymous with secondary traumatic stress, then compassion fatigue and/or burnout that can be acute or chronic in nature. An Occupational Trauma Conceptual Model was created to depict how these concepts interact based on concept delineation findings.

Conclusion

Nurses are experiencing long-lasting occupational trauma and future intervention research should centre on optimizing nurse well-being to ensure the sustainability of nursing profession.

KEYWORDS:

• Nurse
• well-being
• burnout
• second victim
• compassion fatigue
• moral injury

The COVID-19 pandemic has taken a toll on the well-being of healthcare workers (HCWs). In overburdened healthcare systems worldwide, HCWs have experienced compassion fatigue, burnout, moral injury, and dread of COVID-19 (Bennett et al., 2020; Galehdar et al., 2020; Ruiz-Fernández et al., 2020; Rushton et al., 2022). HCWs who have experienced suffering describe themselves as collateral damage, leading researchers to suggest that HCWs are “second victims” to the COVID-19 pandemic (Moreno-Mulet et al., 2021). The concept of “second victim” was first described by Wu, a physician, in 2000 after he witnessed a lack of support for a physician who made a patient care error. After two decades of research on the phenomenon, Scott (2023), a nurse scientist, has updated the definition of second victim to include HCWs who are personally or professionally traumatized after exposure to challenging patient events. Although these various concepts impacted HCWs during the COVID-19 pandemic, how these concepts may be similar or different is understudied.

Registered nurses (RNs) have been one of the most impacted professions of HCWs during the COVID-19 pandemic. RNs provide more direct patient care than other HCWs, often working 12-hour shifts or longer in understaffed and under resourced settings during the COVID-19 pandemic (Institute of Medicine [IOM], 2011; Maunder et al., 2021). Current literature has focused predominately on burnout and has not addressed other concepts impacting the well-being of nurses. Without addressing the suffering nurses have experienced due to the COVID-19 pandemic, there are potential risks to patient safety and patient outcomes in our healthcare systems, in addition to the nurses’ long-term mental health complications (Schelbred & Nord, 2007; Bodenheimer & Sinsky, 2014; Munn et al., 2021; Rassin et al., 2005). Furthermore, The Future of Nursing Report 2020–2030 (2021) emphasizes that research must focus on understanding the psychological challenges the nursing workforce has faced during the COVID-19 pandemic to aid in developing the most appropriate support programmes, ensure nurse health and well-being, and reduce turnover (National Academies of Sciences, Engineering, and Medicine, 2021).

It is important to analyse similar concepts impacting well-being that are often used interchangeably to describe the experiences of nurses, including compassion fatigue, burnout, moral injury, secondary traumatic stress, and second victim. Although these concepts existed prior to the COVID-19 pandemic, understanding their meaning in the current setting will provide new information regarding the causes, attributes, and consequences that nurses experienced during one of the most distressing times in modern-day nursing. Limited understanding is present in the current literature regarding how concepts impacting well-being are similar or different. For example, Malliarou et al. (2021) assert that secondary traumatic stress (STS) is “closely related to compassion fatigue and burnout,” but no delineations are directly offered between the three concepts. However, Ruiz-Fernández et al. (2020) identify compassion fatigue as synonymous with STS and assert that compassion fatigue is “closely related” to burnout, which leads to the complexity in understanding each concept and how these concepts relate to each other. To our knowledge conceptual analysis and delineation of these concepts is not present in the current literature. Thus, the following broad research question was developed: how are these concepts experienced that have impacted nurses’ well-being during the COVID-19 pandemic?

Through a deeper knowledge of the psychological and emotional concepts impacting nurses, individuals and organizations can better understand the experiences of nurses during the COVID-19 pandemic to promote their well-being and support needs (Galehdar et al., 2020; Munn et al., 2021). The purpose of this concept delineation was to provide a descriptive differentiation of concepts impacting the well-being of nurses during the COVID-19 pandemic, including compassion fatigue, burnout, moral injury, STS, and second victim.

Methods

Morse’s (1995) approach to concept delineation was utilized. Morse (1995) asserts that concept delineation is appropriate for multiple concepts that often appear to be linked together or are part of the same experience. Morse’s (1995) approach began with a review of current literature to analyse the concepts: compassion fatigue, burnout, second victim, STS, and moral injury. For the analysis, nurses were the population of interest, and the setting was the COVID-19 pandemic. Each concept was individually analysed for antecedents, attributes, and consequences (Morse, 1995). Similarities, differences, and connections among concepts were developed to clearly understand seemingly similar concepts and how they overlap (Morse, 1995).

Foli’s Middle Range Theory of Nurses’ Psychological Trauma (NPT) guided the concept delineation. Foli’s Theory of NPT (Foli, 2022) was developed to describe psychological traumas that nurses can experience and how nurses process them. The theory highlights how individual factors, such as psychological or environmental factors, and nursing practice and healthcare organizations can lead to both positive and negative outcomes for nurses (Foli, 2022). Foli (2022) asserts that many traumas that nurses experience result from chronic stress, and includes STS, second victim, burnout, and compassion fatigue in association with the theory.

Articles were collected from three databases in October of 2021: PubMed, CINAHL, and PsychINFO. Keywords used for searching across databases included: nurse, COVID-19 pandemic, burnout, compassion fatigue, moral injury, distress, secondary trauma, traumatic stress, and second victim. For inclusion, articles were included if conceptual definitions, discussions, study aims, or instruments directly related to one or more of the concepts of interest: burnout, compassion fatigue, moral injury, secondary traumatic stress, and second victim. No published concept analysis literature was discovered during the search, leading to included articles being predominantly original research. Included articles had at least 51% of RNs providing patient care. Lastly, articles for inclusion were limited to the COVID-19 pandemic to ensure the time frame was consistent across articles for concept delineation.

Articles were excluded from the concept delineation if they were: 1) not in English, 2) about nurses in advanced practice provider (APRN), licenced practical nurse (LPN), management, and faculty roles to ensure a consistent focus on RNs providing patient care, 3) systematic and scoping reviews 4) not original research, such as media outlet articles and editorials, 5) intervention and solution based research 6) focused on concepts that may require a medical diagnosis including: depression, anxiety, and post-traumatic stress disorder (PTSD), and 7) exclusively focused on opposing positively framed concepts, including: well-being, post-traumatic growth, and resiliency. This concept delineation did not involve human subjects; therefore, no ethics approval was required.

Results

A total of 63 articles met the inclusion criteria for concept analysis and delineation. Figure 1 below, created by the authors, shows the flow diagram. Each concept was assessed individually by definition, antecedents, attributes, and consequences abstracted from the included articles (Morse, 1995). A matrix was developed to abstract data from all included articles during the full-text review. The matrix included the following information: concepts discussed, year, study type, sample, definitions, theory or approach, antecedents, attributes, consequences, delineations, and additional notes.

Figure 1. Flow diagram of reviewed articles for analysis.

Table I identifies the antecedents, attributes, and consequences for each concept drawn from included articles. For each concept, findings have been split into individual and organizational factors. Italicized findings were unique to a concept and not consistent across concepts highlighting potential delineations and differentiations among concepts. Findings for each concept will be described followed by a discussion of concept definitions and delineations.

Table I. Concept antecedents, attributes, and consequences.

Concept	Antecedents	Attributes	Consequences
Burnout	Individual: lack of perceived support, stigma from working in healthcare, distress from caring for severely ill patients	Individual: emotional distress, emotional exhaustion, depersonalization, reduced personal accomplishment, fatigue, insomnia, fear, frustration, anxiety	Individual: risk for long-term mental health conditions (anxiety and depression), risk for physical conditions (heart disease), poor job performance, risk for lower quality of life, risk for medical errors
	Organizational: insufficient staffing, insufficient supplies and resources, increasing workloads, moral or ethical patient dilemmas, lack of support resources		Organizational: risk for increased staff turnover/staffing challenges, risk for increased adverse patient events
Compassion fatigue	Individual: lack of perceived support, stigma from working in healthcare, distress from caring for severely ill patients	Individual: emotional distress, anxiety, intrusive memories, insomnia, fear, frustration, guilt, grief, uncertainty, feeling numb, inability to cope	Individual: burnout, risk for long-term mental health conditions (PTSD), risk for substance abuse (alcohol), risk for medical errors, potential for resiliency and compassion satisfaction
	Organizational: insufficient staffing, insufficient supplies and resources, increasing workloads, moral or ethical patient dilemmas, lack of support resources		Organizational: risk for increased staff turnover/staffing challenges, risk for increased adverse patient events
Moral injury	Individual: witnessing patients die alone, distress from caring for severely ill patients, patients with needs unmet, lack of perceived support	Individual: emotional distress, anxiety, nervousness, anger, frustration, fatigue, fear, insomnia, spiritual conflict, physical symptoms (tachycardia)	Individual: burnout, compassion fatigue, risk for long-term mental health conditions, suicidal ideation, risk for medical errors, intentions to leave the job
	Organizational: insufficient staffing, insufficient supplies and resources, moral and ethical patient dilemmas, increasing workloads, lack of support resources		Organizational: risk for increased staff turnover/staffing challenges, risk for increased adverse patient events
Secondary traumatic stress (STS)	Individual: witnessing patients suffer or die alone, distress from caring for severely ill patients, lack of perceived support, having experienced other traumas	Individual: emotional distress, anxiety, anger, fear, grief, fatigue, insomnia, intrusive memories, easily startled	Individual: burnout, compassion fatigue, risk for long-term mental health conditions, risk for substance abuse (alcohol), risk for cumulative traumas, risk for medical errors, intentions to leave the job, risk for lower quality of life, potential for post-traumatic growth
	Organizational: insufficient staffing, insufficient supplies and resources, moral and ethical patient dilemmas, lack of support resources		Organizational: risk for increased staff turnover/staffing challenges, risk for increased adverse patient events
Second victim	Individual: witnessing patients suffer or die alone, distress from caring for severely ill patients, lack of perceived support, having experienced other traumas	Individual: emotional distress, anxiety, anger, fear, grief, guilt, intrusive memories, fatigue, insomnia	Individual: burnout, compassion fatigue, risk for long-term mental health conditions, risk for cumulative traumas, risk for medical errors, intentions to leave the job, potential for compassion satisfaction and post-traumatic growth
	Organizational: insufficient staffing, insufficient supplies and resources, moral and ethical patient dilemmas, lack of support resources		Organizational: risk for increased staff turnover/staffing challenges, risk for increased adverse patient events

*Findings have been split into two levels for each concept: individual and organizational. Findings that were not found as a commonality among concepts have been italicized to denote variation and potential delineation.

References:

Burnout: Aydin Sayilan et al. (2021); Bellanti et al. (2021); Bisesti et al. (2021); Bruyneel et al. (2021); Butera et al. (2021); Çelmeçe and Menekay (2020); Chen et al. (2021); Clinton and Shehaheh (2021); Cortés-Álvarez and Vuelvas-Olmos (2020); Douglas et al. (2022); Foli et al. (2021); Ferry et al. (2021); Gonçalves et al. (2021); Guttormson et al. (2022); Havaei et al. (2021); Hu et al. (2020); Hu et al. (2021); Huo et al. (2021); Jang et al. (2021); Jose et al. (2020); Kabunga and Okalo (2021); Kakemam et al. (2021); Kameg et al. (2021); Ma et al. (2021); Manzano García and Ayala Calvo (2021); Missouridou et al. (2021); Murat et al. (2021); Naldi et al. (2021); Nishimura et al. (2021); Ohue et al. (2021); Ong et al. (2021); Rivas et al. (2021); Ruiz-Fernández et al. (2020); Sarboozi Hoseinabadi et al. (2020); Seluch et al. (2021); Shah et al. (2021); Shiu et al. (2022); Soto-Rubio et al. (2020); Stocchetti et al. (2021); Vitale and Casolaro (2021); Zare et al. (2021); Zhang, Chai, et al. (2021); Zhang, Jiang, et al. (2021); Zhang, Wang, et al. (2021).

Compassion Fatigue: Akkuş et al. (2021); Carmassi et al. (2021); Foli et al. (2021); Missouridou et al. (2021); Moreno-Mulet et al. (2021); Rossi et al. (2021); Rathnayake et al. (2021); Ruiz-Fernández et al. (2020).

Moral Injury: Donkers et al. (2021); Lake et al. (2022); Malliarou et al. (2021); Moreno-Mulet et al. (2021); Nemati et al. (2021); Petrișor et al. (2021); Piscitello et al. (2021); Rushton et al. (2022); Sheppard et al. (2022); Silverman et al. (2021)

STS: Ariapooran et al. (2022); Erkin et al. (2021); Foli et al. (2021); Lee et al. (2021); Malliarou et al. (2021); Missouridou et al. (2021); Rossi et al. (2021).

Second Victim: Foli et al. (2021); Moreno-Mulet et al. (2021).

Burnout

Burnout is “a psychological syndrome resulting from chronic exposure to emotional or psychological stressors at work and can be illustrated by a model that involves emotional exhaustion, depersonalization, and reduced personal accomplishment” (Bisesti et al., 2021). Forty-three articles focused specifically on burnout, with an additional eight articles discussing burnout with another included concept, such as compassion fatigue or moral injury. With 51 articles discussing burnout, results in Table I became saturated with repetition among antecedents, attributes, and consequences. Thirty articles used the same instrument, the Maslach Burnout Inventory Scale (MBI), a cross-sectional survey with quantitative results. Only one article focused on the concept of burnout alone and used semi-structured interviews (Lee et al., 2021). Many results across burnout articles focused on three burnout attributes. This result is due to the three main survey sections of the MBI: emotional exhaustion, depersonalization, and personal accomplishment (Bellanti et al., 2021; Bisesti et al., 2021).

Individually, nurses experienced a lack of perceived support, stigma from working in healthcare, and distress from caring for severely ill patients leading to burnout (Huo et al., 2021; Rivas et al., 2021). Organizationally, nurses experienced insufficient staffing, supplies, and resources, increasing workloads, moral and ethical patient dilemmas, and a lack of support resources leading to burnout (Huo et al., 2021; Rivas et al., 2021; Tiete et al., 2021). Tiete et al. (2021) found that participants who perceived poor support were seven times more likely to have severe burnout. Individual-level consequences of burnout included risk for long-term mental health conditions, risk for physical conditions (like heart disease), and increased risk for medical errors (Lee et al., 2021; Rivas et al., 2021). Organizational-level consequences of burnout included increased risk for staff turnover and for adverse patient events. The risk for burnout was found to be higher in nurses compared to physicians, in individuals working in an emergency room (ER) or intensive care unit (ICU) setting, and among nurses in ethnic minority groups (Douglas et al., 2022). The higher risk for burnout in nurses is believed to be related to the high level of responsibility for patients’ lives at the bedside (Douglas et al., 2022; Rivas et al., 2021).

Compassion fatigue

Compassion fatigue is “the overall experience of emotional and physical fatigue that social service professionals experience due to the chronic use of empathy when treating patients who are suffering” (Missouridou et al., 2021). Eight articles focused on compassion fatigue. Individually, nurses experienced a lack of perceived support, stigma from working in healthcare, and distress from caring for severely ill patients as antecedents to compassion fatigue (Foli et al., 2021; Rossi et al., 2021; Ruiz-Fernández et al., 2020). Organizationally, nurses experienced insufficient staffing, supplies, and resources, increasing workloads, moral and ethical patient dilemmas, and a lack of support resources leading to compassion fatigue (Foli et al., 2021; Rossi et al., 2021; Ruiz-Fernández et al., 2020). Additionally, nurses experienced compassion fatigue after feeling stigmatized by the public and media perception of nursing, which led to a perceived lack of support (Rossi et al., 2021; Ruiz-Fernández et al., 2020).

Individual-level consequences of compassion fatigue include risk for long-term mental health conditions and increased risk for medical errors (Rossi et al., 2021; Ruiz-Fernández et al., 2020). New substance abuse habits, including alcohol abuse, emerged as consequences (Foli et al., 2021). Compassion satisfaction and resiliency were noted as potential positive consequences (Rossi et al., 2021). Lastly, organizational-level consequences of compassion fatigue included increased risk for staff turnover and adverse patient events.

Moral injury

Moral injury is defined as “suffering characterized by exposure to circumstances that violate one’s moral values and beliefs in a way that erodes integrity, moral capability, perception of basic goodness, and create distress on a psychological, behavioural, social, or spiritual level” (Rushton et al., 2021). Ten articles focused on moral injury, also referred to as moral distress or moral suffering (Rushton et al., 2021). Individually, nurses experienced moral injury from caring for severely ill patients and witnessing patients die alone (Rushton et al., 2021; Silverman et al., 2021). Examples of moral injury antecedents included: providing treatments not believed to be in the patient’s best interest, watching patients die alone due to visitor restrictions during the COVID-19 pandemic, and witnessing constant death and dying (Rushton et al., 2021; Silverman et al., 2021). Silverman et al. (2021) found nurses to be significantly vulnerable to moral injury, as they constantly witness patients suffering at the bedside and the persistent need to provide empathy for patients. Organizationally, nurses experienced insufficient staffing, supplies, and resources, increasing workloads, moral and ethical patient dilemmas, and a lack of support resources leading to moral injury (Rushton et al., 2021; Silverman et al., 2021).

Individual-level consequences of moral injury included risk for long-term mental health conditions, suicidal ideation, increased risk for medical errors, and intentions to leave the job (Lake et al., 2022; Nemati et al., 2021, Rushton et al., 2021; Silverman et al., 2021). Consequences of moral injury included two concepts of interest: burnout and compassion fatigue (Moreno-Mulet et al., 2021). Lastly, organizational-level consequences of moral injury included increased risk for staff turnover and for adverse patient events. Nurses that perceived the patient quality and safety issues at their hospital as “morally distressing” had almost three times the odds of intending to leave their job (Sheppard et al., 2022).

Secondary traumatic stress

Secondary traumatic stress (STS) is defined as “the behavioral consequences and natural emotions arising from knowledge about a stressful event experienced by another person and helping one injured person” (Ariapooran et al., 2022). Seven articles focused on STS. Individually, nurses experienced a lack of perceived support, distress from caring for severely ill patients, and witnessing patients who suffered and died alone, leading to STS (Erkin et al., 2021; Malliarou et al., 2021). Ariapooran et al. (2022) found STS to be higher in females compared to males. STS was also higher in the ER and ICU settings compared to other units (Ariapooran et al., 2022). Organizationally, nurses experienced insufficient staffing and resource shortages, and moral and ethical dilemmas leading to STS (Erkin et al., 2021; Malliarou et al., 2021).

Individual-level consequences of STS include risk for burnout, compassion fatigue, long-term mental health conditions, increased alcohol use, and increased risk for medical errors (Erkin et al., 2021; Malliarou et al., 2021). Although a consequence of STS is the potential for lessened quality of life, a potential for post-traumatic growth exists after STS (Ariapooran et al., 2022; Rossi et al., 2021). Compiling trauma from cumulative exposure to traumatic experiences or events was also a consequence of STS (Lee et al., 2021; Malliarou et al., 2021). Lastly, organizational-level consequences of STS included increased risk for staff turnover and adverse patient events.

Second victim

Second victim has been identified in professionals who “faced a combination of clinical, professional, and personal circumstances” during the COVID-19 pandemic (Moreno-Mulet et al., 2021). Individuals who should be considered as second victims needed to adapt to increased workloads and reduced staffing, as well as increased levels of compassion fatigue and burnout during the COVID-19 pandemic (Moreno-Mulet et al., 2021). Two articles included the second victim. A formal definition was not provided in either article discussing second victim among nurses. Second victim was only discussed with other concepts of interest in the two included articles, such as moral injury and compassion fatigue. The limited articles utilizing second victim language related to the COVID-19 pandemic are believed to be associated with the evolution of the concept, as its origin in 2000 surrounded HCWs who were impacted after involvement in a medical error (Wu, 2000).

Individually, nurses experienced a lack of perceived support, witnessed patients suffering or dying alone, and suffered distress from caring for severely ill patients leading to second victim experiences (Foli et al., 2021; Moreno-Mulet et al., 2021). Organizationally, nurses experienced insufficient staffing, supplies, and resources, increasing workloads, moral and ethical patient dilemmas, and a lack of support resources leading to second victim experiences (Foli et al., 2021; Moreno-Mulet et al., 2021). Individual-level consequences of second victim experiences included burnout, compassion fatigue, the risk of long-term mental health conditions, cumulative trauma, and increased risk of medical errors (Foli et al., 2021; Moreno-Mulet et al., 2021). A potential for compassion satisfaction and post-traumatic growth was seen after experiencing the second victim phenomenon (Foli et al., 2021). Organizational-level consequences of second victim experiences included increased risk for staff turnover and adverse patient events.

Concept delineations

Across all five concepts, many overlapping findings exist. For antecedents, distress from caring for severely ill patients and a lack of perceived support were experienced at the individual-level; insufficient staffing, inadequate supplies and resources, moral and ethical patient dilemmas, and lack of support resources were experienced at the organizational-level. For attributes, individuals experienced the following: emotional distress fatigue, fear, frustration, anxiety, and insomnia. For consequences, risk for long-term mental health conditions and risk for medical errors were experienced at the individual-level; risk for increased staff turnover and risk for increased adverse patient events were experienced at the organizational-level.

A prominent finding delineating the five concepts is the sequential order in which they may be experienced. Across all five concepts, many antecedents included moral and ethical patient dilemmas, witnessing patients die alone, and unmet patient needs. This finding suggests that moral injury specifically is a precursor to experiencing additional concepts, including burnout (Sheppard et al., 2022), compassion fatigue, STS, and second victim. Secondary traumatic stress and second victim both have an extensive overlap in antecedents, attributes, and consequences. Furthermore, their naming convention includes the term “second,” suggesting that traumatic or stressful experiences involving a person or event led to experiencing either STS or second victim experiences. Due to the evolution of the second victim concept to include traumas beyond medical errors alone (Scott, 2023; Scott et al., 2009; Wu, 2000), STS and second victim should be identified as the same type of experience. With the extensive body of research and the evolution of the second victim concept since 2000, it is recommended that this term be utilized for clarity and comprehensiveness.

Lastly, findings across concept consequences suggest that both compassion fatigue and burnout are potentially chronic consequences of moral injury, STS, and second victim (M. S. Lee et al., 2021). This finding is in alignment with Foli’s (2022) Theory of NPT that a traumatic experience likely occurs before burnout or compassion fatigue develops. These findings suggest that a chronological nature, including an acute to chronic pathway, may exist for individuals who experience more than one concept.

Occupational Trauma Conceptual Model

Considering concept overlap and the chronological timing of when these concepts may be experienced, it is crucial to refine definitions and provide a depiction of how these concepts may connect. With extensive commonalities among concepts, an assumption can be made that a larger shared experience exists. A concept name and definition are needed to describe how burnout, compassion fatigue, moral injury, and second victim are all similar, overlapping, and potentially experienced together by an individual nurse or nurses. Table II includes new conceptual definitions after completing the concept delineation. Occupational trauma is a new concept identified to describe a nurse’s overall experience when they either experience or identify with one or many of the following concepts over time related to their job experiences: moral injury, second victim, compassion fatigue, and burnout.

Table II. New conceptual definitions.

Concept	Definition
Occupational trauma	Occupational trauma is the psychological, emotional, and physical experience of an individual who is personally or professionally impacted after enduring distressing events at or related to their occupation
Moral injury	Moral injury occurs when an individual experiences distressing or traumatic events that challenge their moral and ethical beliefs and values in a personal or professional environment
Second victim (same as STS)	Second victims are “individuals working within an environment who are offering/providing care and are professionally/personally traumatized by exposure to an emotionally challenging clinical case/event.” (Scott, 2023)
Compassion fatigue	Compassion fatigue is an experience of emotional and physical fatigue stemming from experiences and events that required compassion and empathy in a personal or professional environment
Burnout	Burnout is an experience of stress, exhaustion, and a lack of motivation stemming from excessive demands or stressors in a personal or professional environment

An Occupational Trauma Conceptual Model, Figure 2, was created to display the concepts delineated while including their relationship to the overall concept of occupational trauma. In Figure 2, the model displays occupational trauma as a storm with darkening clouds showing the acute to chronic nature of potential experiences. The clouds symbolize the contributing and precipitating traumatic experiences leading to moral injury, second victim (same as STS), burnout, and compassion fatigue that may be a part of occupational trauma. Considering the delineations uncovered, the concepts have been displayed in the chronological order that they may occur, starting with moral injury as a potential precursor to second victim experiences; after an individual experiences the second victim phenomenon, they may experience burnout or compassion fatigue. To depict the potential acute to chronic nature of experiencing occupational trauma, the clouds darken from left to right. It is unknown if an individual can experience or identify with one concept, not another, or potentially skip from one concept from the beginning to the end. Furthermore, individual factors and experiencing challenging events at work may predispose an individual to additional consequences, like burnout and compassion fatigue. Cumulative events at work may also leave an individual vulnerable to experiencing additional consequences with a long-lasting impact. As an individual experiences consequences, like burnout and compassion fatigue, a chronic response may be forming compared to an acute reaction. Therefore, the model includes raindrops to represent many of the unknown factors that may impact occupational trauma. The Occupational Trauma Conceptual Model in its initial state only includes concepts delineated. For example, co-occurring personal traumatic events or mental health conditions in an individual’s life may also contribute to occupational trauma. However, acknowledgement of occupational trauma is a crucial starting point to begin identifying how nurses may be traumatized by their occupation.

Figure 2. Occupational Trauma Conceptual Model.

Discussion

This concept analysis delineated five concepts impacting nurse well-being during the COVID-19 pandemic: burnout, compassion fatigue, moral injury, STS, and second victim. All five concepts have similarities across antecedents, attributes, and consequences, suggesting that nurses may easily experience one or more of these concepts in their professional roles during the COVID-19 pandemic. The impact on nurses’ well-being was cited as psychological, emotional, and physical, with potentially long-lasting effects from months to years after the COVID-19 pandemic (Guttormson et al., 2022; Lee et al., 2021; Nemati et al., 2021). Many articles identified high-risk groups, including ER and ICU professionals after constant exposure to critically ill patients and patient deaths (Ariapooran et al., 2022; Moreno-Mulet et al., 2021; Silverman et al., 2021). Through concept delineation, extensive overlap among concepts was uncovered and the Occupational Trauma Concept Model was developed to visualize their relationships.

Findings from this work contribute new knowledge to the literature by understanding contributing factors for each of these concepts that are impacting nurses as a result of the COVID-19 pandemic. Nurses were often impacted by organizational and individual factors (Table I), highlighting two main sources of ongoing challenges. Moreover, a lack of supplies or resources, increased experiences with death and dying, and fear of becoming ill or spreading infection were prominent experiences across concepts and may not have been associated with these concepts prior to the COVID-19 pandemic. Furthermore, by delineating each concept, a better understanding was developed regarding the order they may be experienced by nurses, such as morally distressing events and second victim experiences leading to compassion fatigue or burnout which have been suggested as more chronic experiences (Foli, 2022). Developing knowledge regarding how each concept may be experienced provides an opportunity for preventing specific concepts (i.e., burnout) that may be long-lasting and occur after initial experiences with moral injury or second victim experiences.

These detrimental and ongoing consequences to nurses’ mental health and healthcare organizations may be damaging on an individual, organizational, and global level for the nursing profession. Healthcare organizations and leaders should see these challenges as lessons learned and move towards necessary action aimed at implementing resources and programmes that promote well-being. The National Academy of Medicine (2022) has developed a National Plan for Health Workforce Well-being for organizations including: the creation of a positive work culture, investing in research, supporting mental health and reducing stigma, addressing barriers to daily work, engaging in effective technology, instituting well-being as a long-term solution, and recruiting and retaining a diverse workforce. Healthcare leaders and organizations should understand that the current crisis is multifactorial and feel encouraged by the many approaches available to support nurse well-being. The consequences nurses experience at the individual and organizational-level are notably extensive and concerning for both nursing and healthcare organizations. With the well-being of nurses at risk due to the potential development of mental health conditions, the risk for medical errors, and intentions to leave their jobs, healthcare organizations must also consider downstream impacts, including staff turnover, increased medical errors, and reduction in patient safety and high-quality nursing care (Douglas et al., 2022; Foli et al., 2021; Sheppard et al., 2022). It is critical to note that the aftermath of the COVID-19 pandemic will impact the nursing profession for years to come. Data from the National Council of State Boards of Nursing (NCSBN) in 2023 highlighted that over 100,000 nurses have left the workforce due to the COVID-19 pandemic. Nurses reported feeling emotionally drained due to increasing workloads, burnout, staffing shortages, and lack of resources to foster resiliency (National Council of State Boards of Nursing [NCSBN], 2023). By 2027, almost 900,000 nurses, or one-fifth of the total RNs in the United States, have intentions to leave the workforce (NCSBN, 2023).

The Centers for Disease Control (CDC) has identified “job stress” as a poor mismatch between job demands and the needs of workers (Centers for Disease Control [CDC], 2007), and the newly defined concept of occupational trauma highlights a complex, deep, and potentially long-lasting experience of stress stemming from the COVID-19 pandemic. Opportunities exist to further research occupational trauma and expand beyond the concepts delineated. The model presented only includes concepts from the delineation, suggesting a need to understand additional concepts and contributing factors that may impact occupational trauma, such as co-occurring personal traumas, or diagnosable mental health conditions, like depression and PTSD. The concepts delineated in the Occupational Trauma Model do not yet identify the potential for post-traumatic growth or resiliency that may become more prevalent in a post COVID-19 pandemic area. Articles utilized for concept delineation were mainly from the first two years of the COVID-19 pandemic, which may limit our current understanding of the acute or chronic nature of occupational trauma. Future research using a broader lens to gain knowledge of the various concepts impacting nurse well-being may benefit from historical context (i.e., pre-pandemic) and the evolution of concepts over time that impact the nursing profession. Guidance for concept delineations (Morse, 1995), and for single concept analyses (Walker & Avant, 2005), have not been revisited in the recent years; additional methods for assessing the current literature on concepts impacting nurse well-being may be useful, such as systematic or scoping reviews.

Future research on the concepts impacting well-being from this delineation should focus on gaining the perspective of nurses and additional HCWs to further define each concept’s meaning and implication within healthcare settings. Researching an all-encompassing concept, like occupational psychological trauma, will aid in further understanding related concepts and components to thoroughly explain the phenomenon and develop theoretical guidance. Future research focused on the occupational psychological traumas experienced by nurses and other HCWs can potentially support their individual well-being on a personal and professional level. For example, an opportunity exists to conduct in-depth qualitative research centred on nurses’ experiences after the COVID-19 pandemic to detail the ongoing challenges the profession faces. The well-being of nurses is crucial to the sustainability of the nursing profession, healthcare organizations, and the communities desiring to receive high-quality nursing care.

Conclusion

Through concept delineation, a better understanding was developed regarding how moral injury, second victim, burnout, and compassion fatigue may occur for nurses during the COVID-19 pandemic. Although future research is needed to understand nurse experiences with each concept, in addition to unknown and new contributing factors, the developed Occupational Trauma Conceptual Model offers an initial depiction of the numerous and ongoing challenges nurses endure. Healthcare leaders and organizations must acknowledge the grandiose and long-standing consequences nurses and other HCWs are facing in light of the COVID-19 pandemic to chart a pathway forward that prioritizes creating and developing the necessary support programmes and resources to promote well-being while improving patient care that will inevitability be impacted by future world events.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data supporting the results and analyses is available upon request.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors

Melissa A. Powell

Dr. Powell is a PhD graduate from the Duke University School of Nursing. Dr. Powell’s research focuses on the psychological well-being of nurses and the nursing profession.

AnnMarie L. Walton

Dr. Walton is an Associate Professor in the Duke University School of Nursing. Dr. Walton’s programme of research centres on understanding and minimizing adverse health outcomes for healthcare workers.

Susan D. Scott

Dr. Scott is a Nurse Scientist at the University of Missouri health system and an Adjunct Associate Professor at the University of Missouri School of Nursing. Dr. Scott’s research career has focused on the second victim experience and supportive interventions.