How ICU Nurses Are Surviving COVID-19-related Moral Distress

Many critical-care nurses have experienced moral distress during the COVID-19 pandemic. Experts at the American Association of Critical-Care Nurses (ACCN) National Teaching Institute & Critical Care Exposition (NTI), which ran from May 24-27, 2021, offered insight into the condition and how to survive it.

“There is so much of the pandemic that impacted our personal and professional ways,” said Maureen McLaughlin, MS, RN, ACNS-BC, CPAN, CAPA, quality nurse at Lahey Hospital and Medical Center in Burlington, Massachusetts.

“If you work in healthcare, you may be exposed to situations that lead to moral distress,” said Lucia Wocial, PhD, RN, FAAN, HEC-C, a nurse ethicist at the Fairbanks Center for Medical Ethics at Indiana University Health during an ACCN NTI session. “The pandemic has taken an enormous toll on people, and we have seen a lot of nurses walk away from nursing.”

A recent study describing the effect of COVID-19 on nurse moral distress and other issues was preliminarily reported at the American Thoracic Society’s 2021 International Conference by Jill Guttormson, PhD, RN, associate dean for academic affairs and associate professor at the College of Nursing, Marquette University in Milwaukee. The study found that 44.6 percent of ICU nurses reported experiencing symptoms of severe depression and 31 percent of respondents said they were suffering from anxiety.

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What is Moral Distress?

Moral distress occurs when a nurse knows the right thing to do but cannot do it, because of institutional, procedural or social constraints, Wocial reported. She emphasized that moral distress is not the same as nurse burnout or compassion fatigue.

Clinical situations, interpersonal issues, or internal, legal or environmental factors may contribute to moral distress. In addition to nurses, other members of the healthcare team can also experience moral distress.

The COVID-19 pandemic has led to a high incidence of moral distress, due to shortages of personal protective equipment and insufficient staff to care for the large numbers of critically-ill patients. Also the standard of care often shifted during the pandemic to crisis standards.

“We were not able to practice in ways we normally would,” Wocial said.

Moral distress is problematic, not only for the clinician but also for patients, who may receive inconsistent and less attentive care from a nurse experiencing the condition, which leads to a lower quality of care, Wocial said.

Nurses Surviving Moral Distress

“The first step is the identification that there is moral injury or moral distress in the individual,” McLaughlin said. “You do not need to suffer in silence.”

McLaughlin encouraged nurses to share their stories and experiences, either with organizational leadership, colleagues or in a journal, and to let go of anger. She recommended focusing on self-care and practicing mindfulness. Also, struggling clinicians may need a rest period, a week or two off, to regroup, which might slow the “massive migration” by nurses weary of the pandemic.

Wocial encouraged nurses to take care of themselves, including healthy eating, exercising, sleeping, taking breaks, seeking out and accepting emotional support, separating from work, and accepting you are doing the best job you can—forgiving yourself when the care given does not feel good enough.

At the AACN NTI meeting, Rebecca Michael, DNP, RN, CCRN-CSC, with UNC Healthcare in Chapel Hill, also suggested nurses try yoga, meditation, mindfulness-based stress reduction, and debriefing and support sessions. She discussed the organization and benefits of nurse-led interdisciplinary sessions implemented at her facility.

Ethics education and discussions of nurses’ ethical challenges can decrease moral distress, said Wocial, who explained how to use facilitated ethics conversations, which create a safe space to open up and talk about one’s emotions. These conversations can lead to decreased moral distress and build community.

“The goal is to increase participants’ abilities and confidence in dealing with ethically challenging situations,” said Wocial’s co-presenter Genina Miller, DNP, RN-BC, also at Indiana University Health.

Moral repair is happening, but it is a journey, McLaughlin said.

“We can embrace what we learned and use it to change the future,” McLaughlin said. “At some point, we need to move forward to who we were before but a little bit different.”

AACN offers complimentary access to a variety of resources for identifying and addressing nurses’ moral distress, on an individual or organizational level.

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