As Patricia Pittman explains here, moral injury is a systemic problem. Individual resilience, increased staffing, and other personal or organizational changes can reduce moral distress, but addressing the root causes—such as the questionable incentives of the fee-for-service payment model—requires a wholesale rethinking of our healthcare industry. (Former Oregon governor John Kitzhaber started the conversation about system transformation in the inaugural issue of AFT Health Care, which you can read here.) Still, many nurses and other frontline healthcare workers are experiencing moral injury now. While we work toward systemic changes, we hope the self-care strategies and organizational supports suggested here offer some relief.
In the midst of the pandemic, nurses are working long, arduous shifts for extended periods; as a result, many are experiencing severe emotional trauma. Many nurses feel overwhelmed by the massive number of patients needing care while being immersed in settings full of contagion and facing high-stakes decision-making challenges that affect both their professional and personal lives.1
Given the severity of the crisis, a significant shift occurred from patient-centered ethics to public health ethics. Whereas patient-centered ethics focuses on duty to care for a particular patient, public health ethics focuses on equity, common good, and the risk and benefit to society as a whole.2 Within a few short weeks, the nursing profession was directed to apply public health as the guiding dictate when caring for patients. This transition is tough and rubs against many basics of nurse training.
Being forced to make clinical decisions in the face of limited resources is a heavy burden for nurses to carry. As a result, many nurses are taken by a sense of helplessness, question their abilities, and are forlorn and frustrated at the bedside of a patient who is cut off from family and friends, dying alone.3 “That’s a tough thing to watch every single day, to watch somebody die without their family there,” said registered nurse Jennifer Mueller. Her statement clearly and succinctly reveals the trauma she and many nurses are going through.4
Moral Distress and Moral Injury
Nurses are critical to the administration of excellent care. They are even more focal during this crisis because they play expanded and multiple roles simultaneously: conducting screening processes, attending to the critically ill, deciding triage protocols, contacting and updating families, and informing the family of the death of a loved one. In many ways, moral distress in this situation might be better seen as moral injury. These moral injuries may be long-lasting due to the intensity of the crisis. Posttraumatic responses are highly likely as a result. During this crisis, many nurses struggle to share with others the effect of seeing someone die, knowing that the reality of the situation did not permit them to provide the care that was needed or necessary. Here is where the seeds of moral injury are sown.5
When moral distress is not addressed, it can lead to burnout, feelings of frustration, and chronic exhaustion. Unattended stressors can lead to secondary traumatic effects, which are identified as negative feelings, vicariously acquired due to indirect exposure of trauma-related events.6 If nurses do not have proper education, training, and tools to mitigate this trauma, they will be ill-prepared to respond to the psychological effects of the pandemic.7
Moral resilience is the courage and confidence to confront distressful and uncertain situations by following and trusting values and beliefs. Being morally resilient allows one to maintain perspective, keep a situation in context, and understand that some conditions are out of one’s control.8 Moral resilience can be built and developed—for instance, by practicing mindfulness. Being mindful helps nurses reduce the cases of distress, anxiety, fear, and helplessness that occur through the trauma of COVID-19 clinical settings. Nurses can also strengthen their parasympathetic nervous systems to combat stress through breathing exercises and mindfulness.
Mindful breathing is also helpful before entering into a patient’s room as a means to calm oneself from the previous encounter.9 There are self-care and breathing apps, such as Calm or Headspace, to help a nurse stay attuned and develop moral resilience.10 Building on moral conscientiousness, moral resilience includes the ability to make important ethical distinctions, to remain open-minded and curious, and to resist the presumption that there is only one way to consider one’s moral obligations or to preserve integrity in any particular situation.11 Moral resilience can help nurses find meaning and respond to ethical issues in a constructive, positive, and healthy way.
Self-stewardship is the skill of tending to and nurturing one’s well-being. Without self-stewardship, it becomes challenging to stay healthy and to serve others well. Self-stewardship—allowing oneself to be seen—helps nurses to contextualize the ethical dilemmas they face between patient-centered care and public health ethics. This helps an individual understand and appreciate that she does nothing “wrong” by providing public health–guided care.12 Psychological interventions and support provide structured forums in which care professionals can talk through and contextualize the ethical and personal challenges and uncertainties they face.13
Discounting or ignoring the mental health of nurses will have some adverse short- and long-term consequences for the healthcare delivery system. Coworkers and institutional leaders must recognize the prevalence and magnitude of moral distress and stand together to view nurses as individuals in need. It is important not to look at nursing in the abstract or as statistics.14 Nurses are typically uncomfortable sharing their feelings with others, but now is the time to make it comfortable for them to open up.
During the crisis, it is important to acknowledge the successes achieved by nurses. Such acknowledgments help bring light into the darkness that seems to cloak the chaos of the crisis. Beyond acknowledgment, hope and a sense of accomplishment must be cultivated by the organization. Instilling hope—and a belief that the crisis will improve and the future will be better—into the fabric of the organizational culture can bring a remarkable change in mood, safety, mental health, and performance.15
Organizations must fully acknowledge the stress and burdens faced by providers. Offering hope is a means to keep the community together, and to keep nurses focused and intent on collectively overcoming the challenges they face. Perfectionism must be cast aside. It is unattainable and only leads to unrealistic expectations. The COVID-19 crisis is a challenge that requires nurses to accept ambiguity and uncertainty while honoring themselves by embracing their humanness.
Nurses also need support and education as they try to work to regain “normalcy.” Cognitive processing therapy is a form of cognitive behavioral treatment to help victims of trauma. There are four main steps, which include education, information, developing skills, and changing beliefs.16 Through this, trauma therapists can help nurses to identify possible symptoms of posttraumatic stress disorder and lead them to understand how receiving treatment can help. The therapist, in turn, can help staff recognize how their thoughts and feelings are related directly to the stress and anxiety they are experiencing. Nurses should be given training and skill-building opportunities that offer coping mechanisms, provided by the institution. This will help nurses question or challenge their beliefs and routines that do not serve them well during the distressing and morally complicated situations they face.17
Another type of therapy that has shown positive results is emotional freedom techniques. This type of therapy combines cognitive behavioral therapy and exposure therapy, and may also involve a type of acupuncture.18
Healthcare institutions are obligated to meet the needs of patients, but also the needs of staff. Healthcare staff will continue to put the needs of their patients before their own and may not recognize that they too need to be cared for. It is the duty of the institution to provide the tools that serve to keep staff safe and protected, including the mental and emotional components of their health.
Fahmida Hossain is a PhD candidate and adjunct professor in the Center for Global Health Ethics at Duquesne University. Her goal is to normalize diversity within healthcare; her research applies ethics and narrative as drivers for individual development and organizational change. Ariel Clatty, PhD, HEC-C, is a medical ethicist at the UPMC Presbyterian and Shadyside hospitals; she recently created a nurse champion program that helps nurses embed ethics in their everyday practice to build a stronger ethics culture.
1. N. Montemurro, “The Emotional Impact of COVID-19: From Medical Staff to Common People,” Brain, Behavior, and Immunity 87 (July 2020): 23–24; and C. Mannelli, “Whose Life to Save? Scarce Resources Allocation in the COVID-19 Outbreak,” Journal of Medical Ethics 46, no. 6 (2020): 364–366.
2. N. Berlinger et al., Ethical Framework for Health Care Institutions Responding to Novel Coronavirus SARS-CoV-2 (COVID-19): Guidelines for Institutional Ethics Services Responding to COVID-19 (Garrison, NY: Hastings Center, 2020).
3. M. Asken, “Now It Is Moral Injury: The COVID-19 Pandemic and Moral Distress,” Medical Economics, April 29, 2020.
4. A. James, “ ‘Unfriend Me’: Nurse Shares Frustrations, Life Experience Months into Pandemic,” ABC15 News, July 24, 2020, wpde.com/news/local/unfriend-me-nurse-shares-frustrations-life-experience-months-into-pandemic.
5. N. Greenberg et al., “Managing Mental Health Challenges Faced by Healthcare Workers During COVID-19 Pandemic,” BMJ 368 (2020): m1211.
6. R. Jarrad and S. Hammad, “Oncology Nurses’ Compassion Fatigue, Burn Out, and Compassion Satisfaction,” Annals of General Psychiatry 19 (2020): 22.
7. J. Moon and J. Kim, “Ethics in the Intensive Care Unit,” Tuberculosis and Respiratory Diseases 78, no. 3 (July 2015): 175–79.
8. C. Rushton, “Moral Resilience: A Capacity for Navigating Moral Distress in Critical Care,” AACN Advanced Critical Care 27, no. 1 (February 2016): 111–19.
9. R. Williams, J. Brundage, and E. Williams, “Moral Injury in Times of COVID-19,” Journal of Health Service Psychology (May 2, 2020): 1–5.
10. M. Abraham and R. Smith, “Beyond Resilience: Addressing Moral Distress During the COVID-19 Pandemic,” Psychotherapy.net, 2020, psychotherapy.net/article/moral-distress-during-COVID-19-pandemic.
11. Rushton, “Moral Resilience.”
12. C. Phillips et al., “Transforming Leaders into Stewards of Teaching Excellence: Building and Sustaining an Academic Culture Through Leadership Immersion,” Contemporary Issues in Education Research 11, no. 1 (2018): 1–10.
13. Williams, Brundage, and Williams, “Moral Injury.”
14. A. Goodman et al., “ETHICS in Disaster Response: The Development of an Ethics Disaster Response Program,” Prehospital and Disaster Medicine 32, no. S1 (2017): S50–S51.
15. Williams, Brundage, and Williams, “Moral Injury.”
16. R. Bianchi, I. Schonfeld, and E. Laurent, “Burnout-Depression Overlap: Review,” Clinical Psychological Review 36 (March 2015): 28–41.
17. D. Church et al., “Emotional Freedom Techniques to Treat Posttraumatic Stress Disorder in Veterans: Review of the Evidence, Survey of Practitioners, and Proposed Clinical Guidelines,” Permanente Journal 21 (2017).
18. Church et al., “Emotional Freedom Techniques.”
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