Facing Moral Distress

The COVID-19 crisis creates unprecedented challenges for those healthcare professionals on the front lines of care, including insufficient supplies of personal protective equipment (PPE), shortages of lifesaving equipment, compromised standards of care and professional duty colliding with personal health and safety concerns.

As a result, many nurses and other healthcare providers are now experiencing moral distress, which will only grow as the anticipated surge of patients further exacerbates the barriers to providing safe, effective care.

Moral distress is defined as knowing the right thing to do, but facing constraints that make doing it nearly impossible. This conflict threatens our nursing core values and moral integrity. Many nurses report leaving their jobs or even leaving the nursing profession due to moral distress.

To help you better recognize, understand and manage moral distress, I’ve provided a high-level overview of causes, symptoms and solutions. You can also read more in AACN’s position statement “Moral Distress in Times of Crisis.”

Causes

Situations that may cause moral distress are as varied as the individuals who suffer from it. We each experience distress in different ways and in different situations. In ordinary times, some common sources of moral distress include:

• Performing care perceived as futile
• Implementing unnecessary treatments
• Witnessing needless patient suffering
• Providing end-of-life care
• Inadequate staffing
• Lack of communication

During this COVID-19 pandemic, nurses are facing unique situations that they may not have encountered before, greatly increasing the odds of experiencing moral distress. Examples include:

• Strictly limited hospital visitation policies that prevent nurses from involving families in care decisions
• Isolation measures that may result in patients dying without family physically present
• Dire situations where patients may be denied potentially lifesaving therapies due to shortages and triaged care

Symptoms

Moral distress symptoms vary and may include:

• Emotional ‒ Frustration, anger, anxiety, guilt, sadness, powerlessness and loss of self-worth
• Physical ‒ Diarrhea, headaches, heart palpitations, neck pain, muscle aches and vomiting
• Psychological ‒ Withdrawal, emotional exhaustion and depersonalization of patients

Solutions

The “ANA Code of Ethics for Nurses” states that nurses’ primary commitment is to our patients. However, it also asserts that we have an obligation to care for ourselves. It is important for us to identify moral distress and embrace strategies to lessen its effects. Here are some tips and resources that might help:

• Include a moment of gratitude at the beginning of each shift.
• Remember what went well.
• Consider implementing critical incident stress debriefings as a way to recognize what worked and what could be improved. Explore one team’s use of this strategy.
• Consider enacting The Medical Pause to honor the life of a patient who dies and the efforts of the care team. This short video describes how to take that pause.
• Practice self-care by paying attention to your body’s signals and by taking breaks, eating healthy food, exercising and getting quality sleep. See the National Academy of Medicine’s resources on well-being for more ideas.
• Recognize that resilience is not a trait we have, but a skill we cultivate. Moral resilience can be developed. The first step is acknowledging that you did your best.
• Take advantage of available organizational resources, such as your hospital’s employee assistance program, ethics committee and chaplains.

We are all experiencing profound loss during this COVID-19 pandemic, and many of us will be faced with providing care that does not meet our usual standards. The fact that we show up, especially in unthinkable circumstances, means that we’re making a difference. Every time a patient dies, we must remember that it’s not our failure or that of our teams ‒ the virus won that single battle, but the war is not over.

What actions might you take to help your team recognize and mitigate moral distress?