Decisions made during the pandemic could have a lasting impact on nursing staff. Many arrive to work and find a sign on the entrance of the nursing facility stating that, for the protection of staff and residents, visitors are prohibited due to COVID-19.

Rationally, it is easy to explain that these restrictions, and other similar decisions, are intended to protect staff and residents. But it also puts staff in new situations, ones that can challenge their values, ethics, and morals.

As a result, staff may be experiencing moral distress: an emotional state that occurs when a person knows the morally right thing to do but is prevented from doing so by some constraining factor.

Uncommon Circumstances

While moral distress isn’t a new phenomenon, it may have gone unnoticed and occurred less frequently before the pandemic. In contrast, during COVID-19, staff may find themselves prevented from “doing the right thing” because of limitations placed on health care providers.

For example, a nurse caring for a terminally ill resident who died without family due to visitation restrictions may be emotionally affected, particularly if, due to staffing constraints, the nurse was unable to sit at the bedside to be with the resident. Low or unsafe staffing levels intensify high levels of moral distress as nurses struggle to provide appropriate care.

Unfortunately, the pandemic makes these circumstances all too common. These situations go against nurses’ core values and are likely to have a negative emotional impact on them, especially when there are several instances of this type of challenge. As the pandemic unfolds, and there are more situations in which circumstances beyond their control render nurses unable to do what they know is right, more will experience moral distress.

While immersed in the crisis, moral distress might not be obvious—even to the staff themselves; they are too busy dealing with what is in front of them. As it continues, how can facility leaders support staff? And, for both the pandemic and other crisis situations, how can one mitigate the impact of moral distress?

Consequences and Strategies

Moral distress leads to decreased quality of life and burnout. Staff struggling with moral distress can present with both physical and psychological symptoms. They may be anxious, depressed, exhausted, discouraged, and feeling a sense of helplessness. Others report feeling regret, remorse, and guilt.

Physical symptoms include insomnia, headaches, or gastrointestinal issues. Staff may call off from work, or, when they are at work, they may appear disconnected. If left unaddressed, high levels of moral distress lead to staff turnover. Some staff may not only leave an organization, but the profession as well.

Facility leaders should begin to build a plan to address moral distress to help build resiliency. To aid in coping, consider implementing:

• Quick debriefings following stressful events. When an event occurs that is out of the normal, take a pause to acknowledge what happened and why it feels bad. For example, the sudden death of a fellow staff member may shake colleagues. Remember to give all staff that were impacted by the event an opportunity to confer. Talking about a situation immediately lessens moral distress.
  
• Regular team meetings to discuss difficult emotions. Staff who have suffered from moral distress indicate that having a peer with whom to examine their emotions and to discuss how they felt helped them cope. This forum allows staff to share how they feel about crisis care delivery and how it differs from conventional care.
  
• Promoting gratitude. Start each shift with all staff sharing one to three things they are thankful for. Expressing gratitude has been linked to positive physical and psychological health and lower levels of aggression. Expressing gratitude helps start the shift on a positive note and brings optimism into the workplace.
  
• Checking on new nurses. The degree of moral distress experienced by nurses may vary depending on age and experience. For newer nurses, the decisions made during a crisis may have a greater impact. These individuals may require daily check-ins and greater information on why certain crisis decisions are necessary.
  
• Special check-ins with nurse assistants. Nurse assistants are often affected by moral distress in a slightly different manner, which may include feeling powerless. They are responsible for carrying out functions that nurses or management staff have asked of them. As such, nurse assistants are often excluded from decision making. During a crisis, it is imperative to include them in discussions and share why care practices have changed or will change.
  

• Starting a wellness campaign. It can seem impossible to begin anything new with so many competing priorities. However, a wellness campaign today may mitigate staff turnover tomorrow. The campaign can start small, such as encouraging all employees to take breaks. Encourage self-care, such as getting enough sleep, eating healthy, and exercising. Or, as a thank you, provide staff with access to a meditation app on their phone that they can use to relax after a stressful day.
  

• Referrals to an employee assistance program (EAP). Staff may be severely impacted by recent events and need to talk with a professional. Remind staff that the EAP is there to assist them confidentially.
  

• Post-crisis management education. Education related to ethics or ethical decision making can help staff process their experiences and put them in context. Providing ethical education correlates positively with a reduction of moral distress. This is especially needed for nurse assistants who may not otherwise receive ethics education.
  

Support Critical

Situations that arise during the pandemic are bound to impact staff. Already difficult care decisions are made more difficult due to constraints related to COVID-19. Nursing staff are especially susceptible to moral distress. Not only are they on the frontline of the response, but the impossible choices that the constraints they are experiencing impose undermine the core values of a caring profession.

Moral distress has serious implications for frontline staff and threatens the nursing workforce if not addressed. Caregivers cannot care for others if they don’t take care of themselves. The more that leaders can assist in building moral resiliency, the more they can help improve staff emotional well-being and quality of life.

Amy Stewart, MSN, RN, DNS-MT, is vice president of curriculum development for the American Association of Nurse Assessment Coordination. She can be reached at astewart@AAPACN.org.​