Nurses’ Moral Distress in the Time of Covid-19 Needs to be Further Explored and Addressed

The Concept of Moral Distress

“Moral distress” is a term used to describe a distinct phenomenon that is of great clinical significance. It was first defined by Jameton as “the psychological distress of being in a situation in which one is constrained from acting on what one knows to be right” [1, 2]. This was the original (narrow) definition of the phenomenon which was limited to nurses. In other words, the so-called “constraint distress” was the original definition of the term. Later, the definition of moral distress has been reconceptualized and expanded to include not only nurses but also other health care professionals. The definition of moral distress expanded to include not only the so-called “constraint distress”, but also the so-called “uncertainty distress” that compromises the values and moral integrity of the person who is experiencing it [3]. Fourie put it best in saying that moral distress (broadly understood) “arises from a variety of morally troubling situations related to patient care” that “lead to similar violations of core moral values”, namely, there are “primary moral similarities among these situations” [3]. Over the recent years, moral distress has been conceptualized as a phenomenon that “transcends healthcare professions and affects the entire healthcare team, the family, and most importantly the patient” [4]. For instance, scholars suggested the concept of “parental moral distress” experienced by parents with an infant or a child hospitalized in the NICU or PICU [5, 6]. To this effect, Mooney- Doyle and Ulrich provided an integrated/dimensional definition of moral distress. The authors stated, “Moral distress involves the perception one failed, due to internal and external constraints, to behave in the morally right way or compromised one’s own moral integrity or values (provoking intense self-directed negative emotions)” [6].

It should be highlighted that in the literature there have been offered various and overlapping accounts of moral distress [7]. Among the accounts of moral distress are included various and overlapping accounts of “constraint distress” [7]. At any rate, moral distress is a distinct and generally well-explored concept, which however, is still loosely defined and lacks clear conceptualization. Note that the currently available evidence on the phenomenon of moral distress in the clinical practice is limited. The available studies use various definitions of moral distress and measure it in varying ways. This inconsistency creates incomparable study results, coupled with the fact that longitudinal studies are limited [8, 9]. To this effect, it is to be noted that if the phenomenon of moral distress is too broadly understood, it is made very hard to study and difficult to address.

At any rate however, moral distress in health care professionals remains to be further explored, given that it is of great clinical significance. Ethical dilemmas that arise in clinical practice (often in the context of end-of-life care) can cause moral distress [10, 11]. Nurses providing care for COVID-19 patients are faced with “tremendous dilemmas” [12]. The COVID-19 pandemic has brought many ethical dilemmas to attention [13]. Health care professionals with moral distress are at high risk of experiencing lower levels of mental well-being and work ability, and perhaps burnout syndrome involving quitting or considering quitting their job [9]. Therefore, moral distress may have disastrous consequences not only for nurses (or other healthcare professionals), but also for patients Among other things it can cause poor health care services quality, mistrust and bad relationships between patients and health providers.

Nurses’ Moral Distress

It is well-known that nurses, especially frontline nurses like those working in the ICUs, experience high levels of moral distress [8]. Moral distress is inherent in nursing and has been extensively explored in the context of critical care [14]. Among the common causes of nurses’ moral distress are included paternalistic hierarchical structures at workplaces, ignoring nurses’ professional autonomy or moral integrity, nurses feeling excluded from decision-making processes, nurses who perceive themselves as being left without support, and bad communication between the healthcare team members [13, 15].

Not surprisingly, during the COVID-19 pandemic the risk of moral distress among ICU nurses is high [14]. Importantly, among the common causes of moral distress in nurses working in COVID-19 ICUs are included shortage of ventilators and other healthcare resources, lack of nurses’ personal protective equipment, and restricted family visitations and disconnection between patients dying alone and their loved ones [15].

It is to be noted that there are areas in medicine or nursing, such as caring for elderly people, where moral distress is still greatly unexplored [9]. This is even more the case when frontline nurses are working in COVID-19 wards or ICUs.

Nurses’ Moral Distress in the Time of COVID-19

In the time of the COVID-19 pandemic “the moral distress was different because the clinical conditions differed from prior infectious disease epidemics as well as natural disasters” [16]. This is not surprising, given that moral distress “may manifest in a variety of biopsychosocial ways” [16]. More precisely, Cramer et al. put it best in saying, “The moral distress suffered by nurses during COVID‐19 care differs conceptually and operationally from moral distress experienced by nurses caring for patients in other instances of contagious illness (e.g., HIV/AIDS) or in other clinically intensive settings (e.g., emergency department, intensive care, palliative care, battlefield triage, and natural disaster trauma)” [16].

The understanding of moral distress in nurses caring for COVID-19 patients involves insightful understanding of morally challenging situations associated with the COVID-19

pandemic, and shedding light on nurses’ mental health and well-being as well. Interventions should be planned to mitigate or address the phenomenon of nurses’ moral distress in a sensitive and timely manner [17]. The type of nurse moral distress and the causes of it may differ from individual to individual in the COVID-19 context [17]. The unprecedented and unique pandemic nursing care circumstances revealed a new concept of nurse moral distress that is broader (integrated and dimensional) compared to the concept of nurse moral distress prior to the COVID-19 pandemic. Nurses’ moral distress in the time of the COVID-19 pandemic appears two (at least) dimensions.

First, it appears an intrapersonal dimension. During the COVID-19 pandemic, nurses working in COVID-19 healthcare settings need to provide care for COVID-19 patients while at the same time taking measures to protect themselves (and their loved ones) against COVID-19 patients with a high risk of transmission [18]. Besides, nurses are often committed to providing time-consuming holistic care for two or more patients at the same time. However, this is almost always impossible (and can cause moral distress) due to heavy workload coupled with the severe workforce retention in the context of health care [18;19]. Please, note that there has already been workforce retention in the healthcare systems even before the COVID-19 pandemic [19, 20].

Second, during the COVID-19 pandemic, nurses’ moral distress appears an interpersonal dimension. Most often, nurses strive to achieve optimal and effective communication between the staff members at their workplace, as well as connection between patients hospitalized in isolation and their loved ones [15]. The COVID-19 pandemic has negatively affected the relationships between nurses and their patients, patient family, physicians, and colleagues (including chief nursing officers) [13, 18]. Not surprisingly, chief nursing officers strive to improve these relationships, thus experiencing constraint (moral) distress [13].

Interventions to Mitigate Nurses’ Moral Distress

Given the great clinical significance of moral distress, developing interventions to address or mitigate moral distress in frontline nurses is a matter of priority and high importance to providing high-quality nursing in the COVID-19 context. Various interventions and strategies for mitigating nurses’ moral distress have been proposed in the literature during the COVID-19 pandemic. Furthermore, it is to be noted that these interventions or strategies should focus not only on ICU nurses, but also on reinforcement workers who may have experienced “significant harm in terms of emotional well-being” [14].

In that regard, many studies have argued that creating conditions promoting’ spirituality might serve as a factor promoting resilience and mitigating moral distress in critical care nurses. Note, however, that some studies concluded that the role of spirituality in reducing moral distress is ambivalent: it can “both reduce and increase” it [21]. Surprisingly, an African study concluded that spirituality is a moral distress promoting factor [21, 22].

Furthermore, autobiographic narration of memories and emotions has been proposed as a tool to use in promoting well-being and moral resilience in nurses providing care for COVID-19 patients [23]. To this effect, Lemmo D, et al. [23] state, “by…producing a story, a person refines some details of the event to the advantage of others: some aspects become more significant than others…reconstructing the missing parts and repairing any fragmentations in the story” [23]. Moreover, the authors found that “the main emotional trajectories” that are representative of moral distress in nursing narratives during the COVID-19 pandemic were “powerlessness, worthlessness, anger, anger, sadness, guilt, and helplessness” [23].

In addition, the fact that psychiatric patients are prone to be caught by COVID-19 coupled with a lack of specific facilities in psychiatric hospitals create new factors causing moral distress in nurses working in the mental health context [13, 18]. Addressing such newly appeared institutional shortcomings in mental healthcare settings can substantially contribute to reducing the levels of moral distress in nurses working in these settings.

At any rate, we should bear in mind that nurses should engage in self-reflection to be aware of their own moral distress [13]. Furthermore, the fear of retaliation may act as internal constraint that prevents nurses from expressing their concerns about the quality of the provided care [17, 24]. Finally, training in ethical issues and dilemmas can help mitigate moral distress among ICU nurses in the time of the COVID-19 pandemic [14].

Conclusion

Insightful exploring of the new version of moral distress experienced by nurses working in COVID-19 healthcare settings as well as developing new interventions to mitigate it are needed to sustain the nurses’ role and the quality of care in the COVID-19 context. Starting points for future research emerged from this literature review.