Abstract

Background & Purpose: In response to the multitude of ethical issues that arise in the delivery of care provided in intensive care units (ICUs), nurses working in this setting frequently experience moral distress. The properties of moral distress have been well defined. However, within the context of the coronavirus-disease 2019 (COVID-19) pandemic, less is known about the properties of moral distress experienced by ICU nurses. This subsequently affects the advancement of our knowledge, specifically of effective mitigative interventions for moral distress. The purpose of this analysis is to describe the key properties of moral distress experienced by ICU nurses during the COVID-19 pandemic.

Methods & Procedures: Guided by interpretive descriptive design, a purposeful sample of 40 Canadian ICU nurses described their experiences of moral distress within the context of their practice during the COVID-19 pandemic. Data generated included the administration of a demographic questionnaire and the Measure of Moral Distress – Healthcare Providers survey, and 1:1 semi-structured virtual (telephone or videoconference) interviews (May – September 2021). Analysis was informed by the tenents of reflexive thematic analysis and rapid qualitative analysis.

Results: Nurses experienced moral distress under the complex interplay of two overarching, broad conditions: (1) when nurses’ voices, driven by efforts to optimize patient care at an exceptionally high standard, were not heard; and (2) when patients received substandard levels of care, that was not patient-centered, pain free, or that did not align with organizational, professional, or personal standards. These two broad conditions were influenced by three sub-conditions: (1) lack of respect for nurses’ expert knowledge; (2) cultures and systems of communication and (3) responses to safety and staffing.

Discussion: Moral distress experienced by Canadian ICU nurses is a complex phenomenon. These findings advance and refine our knowledge of key components of moral distress. We identified the conditions that generate moral distress for nurses, and the properties of the antecedent moral events. Future approaches to mitigate moral distress need to address the broad conditions under which moral distress occurs.

Key words: COVID-19, nursing, intensive care, moral distress, nursing ethics

IMPLICATIONS FOR THE NURSING PROFESSION

• Intensive care unit nurses’ experiences of moral distress, both prior to and amid the pandemic, existed under the interplay of two co-existing conditions: (1) where their voices, motivated by the desire to achieve comprehensive and patient-centered nursing care, were not heard, and (2) circumstances of substandard levels of patient care.
• Conditions of moral distress were cultivated when nurses’ voices were not equally valued or respected, by poor systems and cultures of communication, and inappropriate responses to safety and staffing.
• The key next steps for researchers, educators, and leaders will be to explore strategies that influence the broad conditions of moral distress, in attempts to mitigate the outcomes of moral distress for nurses, patients, and health systems

Background

Given the precarious health status of critically ill patients cared for in intensive care units (ICUs), the clinical work environment is embedded with ethical decision-making. Consequently, healthcare workers in this setting, including registered nurses, are confronted with moral events daily (Ulrich & Grady, 2017). In response to these events, nurses are at high risk for experiencing moral distress. Nurses working in ICUs typically report higher moral distress scores compared to nurses working in other clinical contexts (McAndrew et al., 2016; Sirilla et al., 2017) and to other ICU healthcare professionals (Bruce et al., 2015; Dodek et al., 2016; Henrich et al., 2017; Silverman et al., 2022). In response to moral distress, nurses can experience several negative outcomes that greatly impact their quality of life and health (Arnold, 2020; Atashzadeh-Shoorideh et al., 2021). These outcomes can influence nurses’ professional integrity (Epstein et al., 2020; Forozeiya et al., 2019; Henrich et al., 2017) and rates of attrition from the workplace (Sheppard et al., 2022), affecting both patient care and health system outcomes.

            The study of moral distress has been a long-standing focus of nursing, and consequently, definitions and operationalization of key concepts of moral distress have evolved as researchers have developed theoretical models to explain this phenomenon (Corley, 2002; Jameton, 1984; Morley et al., 2021b; Nathaniel, 2006). Moral distress was first described (Jameton, 1984) as a constraint-based phenomena, in which a nurse is prevented from pursuing a course of action that aligns with what they believe is right (Jameton, 2017). Subsequently, some nursing scholars have argued for an expanded definition to acknowledge the complexity of ethical events beyond constrained-based scenarios (Campbell et al., 2016; Fourie, 2017; Morley, Bradbury-Jones, et al., 2020; Wilson, 2017). For example, in the Moral Distress Model, Morley et al. (2019) defines moral distress as ‘the psychological distress that is causally related to a moral event’ (p 4). Moral events are categories of ethical events that may precede (moral constraint, conflict, tension, dilemma, uncertainty) (Morley et al., 2021a), follow, or have a dynamic relationships moral distress [A1] (moral residue, injury, resilience, disengagement) (Canadian Nurses Association, 2017; Cartolovni et al., 2021; Epstein & Delgado, 2010; Rushton et al., 2016). Definitions of these different types of moral events are summarized in Table 1. Ethical events can be categorized as more than one type of moral event (Morley et al., 2019). [Insert Table 1].

In response to the growing body of knowledge that describes key concepts of moral distress, variation has also emerged in the way in which causes of moral distress are described. Morley et al. (2021b) defines five “compounding factors,” as the avoidable and unavoidable factors that can influence moral events, be moral events, or exacerbate or mitigate moral distress. These compounding factors include: epistemic injustice, the roster lottery, conflict between one’s professional and personal responsibilities, the ability to advocate, and team dynamics (Morley et al., 2021b). However, most often, researchers have categorized the contributing factors and direct situational causes of moral distress as internal (i.e., self-imposed) and external (i.e., others-imposed) (Hamric, 2012; McAndrew et al., 2016). A frequently reported external cause of moral distress experienced by ICU nurses has included participating in end-of-life or invasive care for potentially futile patient outcomes (Browning & Cruz, 2018; Dodek et al., 2016; Henrich et al., 2016; McAndrew et al., 2016). Internal factors that contribute to moral distress are less understood (McAndrew et al., 2016).

Extreme contextual, social or environmental changes such as global pandemics, natural disasters, or events resulting in mass casualties often result in the need for rapid responses and disruptions in critical care environments, and may contribute to moral distress (American Association of Critical Care Nurses, 2020; Dunham et al., 2020; Lapum et al., 2021; Mehta et al., 2021). In response to the coronavirus disease-2019 (COVID-19) pandemic, Canadian critical care services were inundated by the increased demand to care for critically ill patients, under rapidly changing conditions (Gibney et al., 2022; Sharma et al., 2021). Global ICU admissions for individuals with COVID-19 ranged from 5-38%, resulting in high occupancy, mechanical ventilation, and mortality rates (Murthy et al., 2021; Vranas et al., 2021; Wahlster et al., 2021). From 2020-2021, with each wave of the pandemic, Canadian ICUs experienced increased admissions for respiratory illnesses, with a reported 28% mortality rate in 2021 (Gibney et al., 2022). In response to this shift in working conditions, ethical events emerged, related to increased patient-to nurse ratios, shortages of effective personal protective equipment (PPE), and increased anxiety with respect to virus transmission to family and friends and restrictions to visiting policies and practice (Binnie et al., 2021; Morley, Grady, et al., 2020; Simonovich et al., 2022). Despite the documented ethical challenges that occur during global health emergencies (Dunham et al., 2020), less was known about the particular properties and nuances of moral distress experienced by ICU nurses in such contexts, including the COVID-19 pandemic (Morley et al., 2022).

Study Purpose

Conceptual and contextual refinement is required to advance moral distress science (Deschenes et al., 2020), specifically, to inform mitigative interventions to reduce moral distress experienced by ICU nurses and the associated negative outcomes for patients and healthcare organizations. As a part of an overarching qualitative study that aimed to describe ICU nurses’ personal coping strategies and desired interventions to mitigate moral distress during the COVID-19 pandemic, in this paper we present an analysis of the properties of moral distress as described by nurses and the conditions under which they perceived moral distress occurred during the pandemic. Nurses’ responses to moral distress, including their moral distress scores, and their recommendations for mitigative interventions are presented in another paper (Gehrke et al., 2024).

Methods and Procedures

Research Design

In this applied health qualitative study, the principles of interpretive description methodology informed design decisions to answer the overarching research question: How do registered nurses who provided direct patient care in Canadian intensive care units during the COVID-19 pandemic describe their responses to moral distress experienced in their professional practice? Interpretive description, driven by disciplinary inquiry, aims to address the gaps and insufficiencies in existing knowledge of a practice-based issue by generating novel data to be utilized pragmatically in the field. This methodology also aims to highlight the valuable insight of clinicians with expertise in the field or phenomena under investigation (Thorne, 2016). We achieved this by scaffolding the study, which includes a review of the literature and identifying a theoretical fore structure (Thorne, 2016). This was informed by nursing epistemology and modern conceptualizations of moral distress (Epstein et al., 2020; Hamric, 2012; Morley et al., 2019, 2021b; Rushton et al., 2016; Thorne et al., 2018). In efforts to capture the complexity of moral events that contribute to moral distress that go beyond constraint-based scenarios, we chose Morley’s et al. (2019) broadened definition to inform our study. The study scaffolding, as well as the first author’s (PG) disciplinary orientation and experience working as an ICU nurse, informed the formulation of the research question (Thorne, 2016). Study design and analysis were further informed and refined by study co-investigators, who brought insights grounded in their research and clinical experiences in critical care practice (JT), nursing education (RH), and nurse well-being (KC, SJ).

Context (Setting)

Locating participants with firsthand experience and expert knowledge provides rich insights into the topic of interest, strengthens study rigour and trustworthiness, and helps to produce findings that resonate with relevant research consumers (Thorne, 2016). Therefore, the exploration of the phenomenon of interest was investigated in the context of nurses’ work in Canadian ICUs that serve the adult-patient population.

Sampling and Recruitment

To achieve a purposeful sample, nurses were invited to participate in this study if they identified as: 1) an individual with a current registered nursing license from a Canadian province or territory; who 2) worked within an adult ICU in a Canadian hospital; 3) at some point between March 2020 to September 2021; and who 4) self-reported experiencing at least one episode of moral distress in their professional practice during the COVID-19 pandemic. Participants were recruited via a study poster shared on social media platforms, invitations distributed by established ICU professional organizations, and snowball sampling. Participants contacted the first author via email if they were interested in receiving more information about the study.

Initially, a sample size of 20 nurses was estimated to provide an understanding of varied ways in which they experienced moral distress in the context of the COVID-19 pandemic. However, during concurrent data collection and analysis, as diversity in nurses’ experiences of moral distress became evident, the need to expand the sample size was recognized. This process of in situ theoretical sampling allowed us to collect additional data (Gentles et al., 2015; Palinkas et al., 2013). The study sample size was increased to 40 to meet this analytic need, and in response to the significant number of ICU nurses who expressed their interest in sharing their experiences by participating in this study.

Data Collection

Aligning with the pragmatic principles of interpretive description, and to promote data triangulation and rigour, a combination of data generation strategies and sources were employed (Jack et al., 2023; Moisey et al., 2022; Thorne, 2014, 2016). In-depth, semi-structured interviews were completed with all participants, led by one of two authors (SJ, PG), via telephone or videoconference (Table 2). The interview guide was informed by the scaffolding of the study. During interviews with participants, they were asked to reflect on at least one practice episode of moral distress experienced since March 2020, and then to describe the constructs of the moral event that led to moral distress. We also sought to learn about their responses to moral distress, as well as their recommendations for mitigative interventions. If requested prior to the interview, participants were provided with a participant-copy of the interview guide. Field notes were also maintained by the researcher during each interview. [Insert Table 2]

To further contextualize interview data, and to provide a description of the sample, a demographic questionnaire, and the Measure of Moral Distress – Healthcare Professional (MMD-HP) survey were also collected from each participant. At the time of study design, the MMD-HP represented one of the most updated measurement tools of moral distress, which included up-to-date root and system level causes of moral distress (Epstein et al., 2019). The MMD-HP is a validated tool (Cronbach’s 0.93) used to calculate a moral distress score, by having participants rate the frequency (0-4) and level of distress (0-4) for 27 clinical scenarios (Epstein et al., 2019). A frequency score of zero indicates that the scenario never occurs, while a score of four indicates that the scenario occurs very frequently. A distress score of zero indicates that the scenario is not distressing, while a distress score of four indicates that the scenario is very distressing. The frequency and level of distress is multiplied by one another for each item, and then cumulatively added to produce a composite moral distress score (possible score 0-432). There are also two multiple choice questions about attrition, and space for open-ended responses to describe episodes of moral distress that were not captured in the survey (Epstein et al., 2019). Permission to use the scale was obtained (Epstein, E., personal communication, January 7, 2021).

Data Analysis

Multiple methods of analysis were applied to achieve both detailed descriptions and interpretations of the data. Quantitative data, including demographics and MMD-HP scores were analyzed with descriptive statistics using SPSS Version #28.

Contextual practice changes reported by nurses were labeled per the conceptual “4 Ss” framework (Anesi et al., 2020). Anesi et al. (2020) developed an adaptable model for hospital preparedness and surge planning for emerging infectious disease, in response to the COVID-19, and the resultant acute and extreme healthcare demands. This model includes three main components: 1) the conceptualization of and approach to healthcare capacity strain; 2) the 4Ss framework; and 3) domains of focus during a surge. The “4 Ss” framework outlines four factors to be considered when hospital services are expected to be required beyond normal capacity, and include: staff, space, stuff, and system (Anesi et al., 2020). Although our analysis does not use the model in its entirety, the review of this theory and familiarity with these concepts allowed for further refinement and definition of the categories and themes developed for this study.

Reflexive thematic analysis was used as the overarching process to inductively categorize and synthesize the qualitative data from interviews and MMD-HP open-ended responses. This approach to thematic analysis is distinctively situated with Big Q orientation (i.e., interpretivist or constructivist paradigm), aligning with the paradigms of qualitative research methodology and the nature of interpretive description design. Reflexive thematic analysis requires the research to engage in continuous and active reflexive consideration of their positionality, and how it will shape all stages of the study (i.e., study design, data collection, data analysis) (Braun & Clarke, 2023).  The first author engaged in continuous reflexive practice throughout the duration of the project, to acknowledge any personal biases that may influence the research process (Campbell et al., 2021; Thorne, 2016). The following steps of reflexive thematic analysis were followed were followed: 1) data familiarization; 2) code generation; 3) themes construction; 4) a review for potential themes; 5) defining and naming of themes; followed by 6) production of the final reports (Braun & Clarke, 2019; Campbell et al., 2021). To increase familiarity with the data, the first author completed the transcription of the first four transcripts. The remaining audio recordings were securely sent to a professional transcriptionist for verbatim transcription with identifying information removed. To store, manage, and code data, a qualitative data analysis software (https://www.dedoose.com/) was used. Each transcript was then read in its entirety at least twice by the first author before open coding was initiated. From the coding of the initial 10 transcripts, a list of core codes and categories were generated. To facilitate the construction of the overall themes, steps from rapid qualitative analysis, an efficient yet robust qualitative methodology, were utilized (Hamilton, 2020; Hamilton & Finley, 2019; Maietta et al., 2021). A template was created to facilitate a focused summary of data from each transcript. Then, template summaries were entered into a matrix and used to help produce findings (Hamilton & Finley, 2019; Nevedal et al., 2021). In the final stages of analysis, to compare, contrast and find gaps within pre-existing theories, moral events (using the definitions as summarized in Table 1) and concepts from the Moral Distress Model (Morley, et al., 2021b) were used to label, sort, and organize qualitative findings.

Results

Nurses’ experiences of moral distress in the context of the COVID-19 pandemic are shared. We describe the properties of moral distress, which includes two overarching conditions, as well as contributing sub-conditions, under which moral events occurred.

Participant Characteristics and Moral Distress Score

A total of 47 nurses expressed interest in this study. However, seven nurses who signed an informed consent form did not participate (no response to schedule interview n=4; extenuating circumstances n=2; made decision to withdraw n=1). Therefore, a total of 40 ICU nurses completed a survey and an interview for this study (n=32 by videoconference, n=8 by telephone) between May to September 2021. The mean length of interview was 58 minutes (standard deviation [SD]=14.6 minutes; range=33-94 minutes). At the time of the interview, 93% (n=37) of participants continued to work in an ICU, and 7% (n=3) left this clinical setting (between March and July 2021). More information about participant characteristics can be found in Table 3. The mean moral distress score among this sample of nurses was 139.4 (SD=58.2; range=31-252), with half (n=20) of the group falling within the group moderate interval (mean score=131.4, SD= 26.3; range=86-171). Further analysis of nurses’ moral distress scores can be found in (Gehrke et al., 2024). [Insert Table 3]

Moral Events Described by Nurses

Nurses described 182 episodes of moral distress, of which, 125 of these episodes were extracted from interviews and 57 episodes from participants’ responses to the MMD-HP open-ended questions. The 57 episodes of moral distress reported in the open-ended MMD-HP responses were mapped out against the questionnaire scenarios and the definition of moral distress used in this study. Of those responses, 13 did not align with one of the 27 questionnaire scenarios, nor were they considered moral distress based on the definition used in this study, and were excluded (e.g., dissatisfaction with wage or nursing responsibilities). The remaining episodes of moral distress from both data sources (n=169) were then categorized by moral event type. This labeling resulted in a total of 179 moral events (interviews n=135, MMD-HP n=44), as each episode of moral distress could be categorized as more than one type of moral event. Of the 179 moral events, most were categorized as events that precede moral distress, including moral constraint (n=95) and moral dilemma (n=43), followed by moral conflict (n=18) and moral tension (n=13). Other types of moral events described by nurses included stories of moral residue (n=3), moral resilience (n=4), moral disengagement (n=1) and moral uncertainty (n=2).

In their narratives, nurses described the contextual origin during which moral events transpired. These descriptions included reflections on pre-existing and novel moral events, in respect to the context of the COVID-19 pandemic. Consequently, we learned about the factors that contributed to the contextual origin of moral events, including the pre-existing and novel factors that occurred in response to COVID-19 (Table 4). Nurses described how these changes impacted: (1) the physical environment (i.e., space) in which they worked, (2) the number, workload, and well-being of professionals within the unit (i.e., staff), (3) the evolving demands and use of resources (i.e., stuff), and (4) the frequent changes to unit policies (i.e., systems). Many pre-existing factors that contributed to moral events, and pre-existing moral events themselves, were heightened or exacerbated in the context of the COVID-19 pandemic. [Insert Table 4].

Conditions of Moral Distress: Being Heard in the Pursuit of Comprehensive, Patient-Centered Care

Regardless of the type or origin of the moral event, across nurses’ descriptions of moral distress, it became evident that the complex interplay of two overarching and co-existing conditions underpinned all the associated moral events that led to their moral distress: (1) when nurses’ voices were not heard; and (2) when patients’ health, safety, and comfort were perceived to be compromised. Circumstances at each socioecological level of the healthcare system, where nurses’ concerns were not heard, respected, or validated, prevented nurses from engaging in highly valued comprehensive care, resulting in critical conditions in which they experienced moral distress. Likewise, when factors outside of the nurses’ control threatened risks to patients’ welfare, moral distress occurred and further motivated them to seek opportunities to be heard in efforts to promote comprehensive, person-focused care.

Nurses described their fundamental motivations to provide comprehensive care that upheld personal or professional standards, that aligned with patients’ self-reported priority needs, and that reduced patients’ experiences of suffering or “torture.” One nurse with over 21 years of ICU nursing experience stated, “You’ll hear a lot of ICU nurses talk about— they feel like they’re torturing people.” Nurses defined torture as pain and suffering, secondary to (a) prolonged interventions and/or (b) invasive interventions for outcomes that did not align with; (i) patient-centered goals of care (i.e., per their advanced care directive or verbally expressed) or (ii) the nurses’ perception of quality of life. Nurses perceived a poor quality of life, as one riddled with pain, suffering, or significantly less physical, social, or emotional capacity than the patient’s pre-hospital life. Some common examples of “torture” included prolonged intubations, leading to degrading skin integrity and muscle wasting, and providing advanced cardiac life support, which was perceived as painful or “more harm than good.” These events were particularly distressing when the patient had a poor prognosis.

As working conditions rapidly changed during the pandemic, nurses perceived that organizations were acceptive of lower standards of care due to emergency measures and encouraged nurses to “lower your practice expectations.” Regardless of these organizational beliefs, as one nurse explains, it was challenging for nurses to accept that patients might receive a substandard level of care,

…. our workload has doubled and the resources from the hospital have not …. So, we’re having a hard time achieving the same standards that we would achieve before…. they’re not getting ICU level care anymore. They’re getting a big step below that because we just can’t keep up. So, I would say the hospital probably deems that we’re doing an appropriate job, but any ICU nurse worth her salt is not happy with what the current [situation is like].

Moral distress occurred when nurses were not able to adhere to the usual standard of care, as well as their personal expectations for care their patients “deserved,” particularly during end-of-life. These conditions of moral distress were influenced by high nurse-to-patient ratios, which resulted in less time available to dedicate to comprehensive care for each patient. This prevented nurses from developing a holistic understanding of their patients, and when nurses felt unprepared for interdisciplinary rounds, they described moral distress, shame, and guilt. They also reported moral distress when they did not have time to provide interventions at the standard interval (e.g., repositioning, mouth care, perineum care), which led to patient discomfort, suffering, or poor outcomes (e.g., compromised skin integrity, tooth decay). Normally, these regular intervals of care also allowed for nurses to complete thorough assessments. When this could not occur, nurses described that they “missed things,” like new sites of bleeding, bed sores, or subtle changes to respiratory patterns and cardiac rhythms. This further compounded nurses’ moral distress.

Sub-Conditions of Moral Distress

Underpinning these two dominant, co-existing conditions of moral distress, were pre-existing and novel sub-conditions of organizational culture and systemic processes. Pre-existing conditions were those which were present prior to the pandemic, and which may have been exacerbated in response to the new contextual changes to practice. These pre-existing sub-conditions of moral distress included lack of respect for nurses’ expert knowledge, and poor cultures and systems of communication. A novel sub-condition that emerged under the unique contextual circumstances of the pandemic was organizational responses to safety and staffing.

Lack of Respect for Expert Nursing Knowledge

            At the bedside, nurses described feeling like a “puppet” or an “actor,” whereby, despite their expert nursing knowledge, patient concerns expressed by nurses were frequently disregarded by team members, at each level of the healthcare system. At a unit level, moral distress occurred when nurses felt they had to carry out orders against their personal or professional beliefs, that prolonged patient suffering, or resulted in care that was not person-centered. This culture was affected by power hierarchies within the healthcare team that influenced how others valued nursing input, as well as the impact of nurses’ scope of practice. As one nurse described,

I don’t get to make the big decisions, but I am the agent that’s doing those big decisions. And so, it becomes where I don’t have a decision about how the care is being decided upon, sometimes because it’s a physician’s decision or it’s a family decision, but I’m the actor in the actual role of the of the decision…

Many nurses reported that members of the healthcare team “don’t care what nurses think.” They described situations where they perceived that their contributions were dismissed, despite advocating and sharing their expert knowledge on several occasions to multiple different clinicians.

At a systems level, nurses felt excluded from decision-making that directly affected their work, most notably, decisions or policies that impacted their ability to provide high quality patient-centered care or impacted the safety and well-being of themselves and others. Consequently, nurses were left feeling “in the middle,” whereby, they were responsible for upholding organizational policies without knowledge of leadership’s decision-making processes. For example, several nurses described the complexity of the layered moral events associated with enforcing frequently changing patient visitor policies, particularly at end-of-life. Nurses felt morally distressed when enforcing restricted visitation and asking patients’ family and friends to select preferential visitors. They also experienced moral distress when enforcing the visitors to don the required PPE, preventing families from having physical contact at end-of-life or during times of uncertainty, while also recognizing the importance of mitigating viral transmission. Another nurse with more than 21 years of ICU nursing experience, described the difficulty in mandating these policies. She stated,

…they can’t have that physical touch. And when people are dying, that— being able to sit and hold a hand, and being able to hug somebody, and give them that last kiss goodbye. That’s part of the humanity of nursing, and… To have that taken away, and being told that, “No you can’t” …. at what point do we have to say, ‘Let’s take the calculated risk,’ but give them that final little piece of closure that they got to kiss their mom goodbye…. It just feels wrong, is the only way I can put it. It’s that, fundamentally, we’re supposed to be able to be with people.

At a community level, nurses described significant frustration with both public policy and leadership, and community accountability and behaviour in response to public health guidelines. Nurses perceived that their voices and input were excluded from important conversations and decision-making in response to the pandemic, at all levels of government. Moreover, nurses witnessed political actions such as nursing staffing cuts and wage suppression, and the disregard for evidenced-based practice when establishing infection prevention and control policies. Nurses’ emotional reflections of such decision-making at a public policy level demonstrated the downstream effect that created and exacerbated conditions of moral distress.

Culture and Systems of Communication 

Nurses reported several components and ingrained processes of communication that contributed to conditions of moral distress. Commonly, nurses described inconsistent and unclear communication amongst the healthcare team, and between the team, patients, and families. Most nurses described poor communication about goals of care, prognoses, and end-of-life care, including inconsistent approaches to or exclusion of these conversations. Nurses described that many clinicians were not equipped with the knowledge, tools, or confidence in leading these discussions, and therefore, these topics of conversations were delayed, avoided, or ambiguous. Furthermore, within this space of discomfort, clinicians often tried to “spare feelings” by minimizing poor outcomes or prognoses. When these types of responses occurred, nurses perceived that patients and families were left with unclear and dishonest information. Bounded by the limits to the nursing scope of practice, nurses felt conflicted or constrained from openly discussing care plans or prognoses with patients and families, which further contributed to their moral distress. One nurse described the moral distress that occurred in response to this knowledge disparity; “it [pause] makes it worse in the end…. Just not being truthful. This person has so much trust in you, they don’t know any better, and to not be honest with them in such a hard time…” Nurses described that without these conversations, patients and families could not make informed decisions about goals of care, which often delayed decision-making and prolonged invasive, high levels of care.

Nurses reported that these moral events were prevalent prior to the COVID-19 pandemic, associated with high nurse-to-patient ratios that occurred in response to understaffing and staff burnout. However, the emerging staffing crisis, as well as increased burnout and psychological distress of staff, contributed to a higher frequency of these events. Furthermore, in response to increased patient acuity and number of admissions, physicians had less time to spend completing interdisciplinary rounds. Nurses perceived that less formal time to communicate their concerns to the broader team significantly impacted their ability to address the patient needs they had identified. Moreover, challenges with virtual communication (i.e., lack of electronic devices) and restricted visiting policies contributed considerably to poor quality of communication between healthcare teams and families, and further increased nursing workload as they navigated these barriers. The complexity of communication challenges increased further when there was limited family engagement in care planning, differences in languages, or personal care needs that influenced the length and level of care provided. As reported by nurses, moral events occurred when they did not have the time to provide detailed updates, when they had to witness or facilitate difficult conversations over the phone (i.e., end-of-life, goals of care), when virtual communication delayed care-decisions and prolonged suffering, or when the quality of their time connecting with patients’ caregivers was deemed inadequate.

Safety Prioritization of Self, Patients, and Others

Risk to Physical and Psychological Safety. In response to the COVID-19 pandemic, drastic changes to nurses’ day-to-day practice posed risks to their personal safety and well-being. Nurses recalled regularly navigating the risk of transmissible diseases in the context of their pre-pandemic practice, however, we learned that during COVID-19, new moral events related to risk of transmission occurred. To reduce exposure, nurses were asked to bundle care, which was an approach where tasks were grouped together to limit the number entries into the patients’ rooms. They were also asked to don appropriate PPE with each room entry. Nurses recognized that bundled care and PPE were imperative to their own safety but described that it delayed responses to emergent (e.g., cardiac arrest) and non-urgent (e.g., mouth care) patient care needs, which could result in significantly poor outcomes for patients. Moral distress occurred when nurses felt they had to prioritize their safety against the well-being of their patient, making statements like, “Oh, it totally goes against what I’ve… learned as a registered nurse.”  Nurses also described that PPE limited their ability to engage in therapeutic contact and emotional support (i.e., holding hands, hugging) with patients and their caregivers. This affected their ability to establish trusting therapeutic relationships. Nurses perceived that the quantity and restrictiveness of the PPE limited the humanistic aspect of patient care, causing moral distress. As one nurse described:

What makes it [nursing] so unique is, not only the science behind, it but the human connection. Being able to physically touch our patients with our hands, help them…. we’re staring at them through five layers of PPE on; the mask, goggles, face shield on. So, they don’t even really know who their nurses— what their nurses look like. So, I think it really affects that human interaction, and really dehumanizes the whole experience…. So, I think the whole situation is really awful, and it makes us feel terrible.

Across all narratives, pervasive conflicts occurred between values of promoting collective good and reducing the risk of transmission, against the need to provide patient-centered care characterized by dignity and respect.       

Team Staffing Model. In response to high patient acuity, an increased number of patient admissions, and worsened staffing shortages, most organizations initiated a team-nursing model of care. Although this model varied between organizations and across provinces, typically, ICU nurses were assigned as team leaders for a group of healthcare providers recruited from retirement or redeployed from units that care for patients of lower acuity or of a different population (e.g., pediatrics, out-patient services). Therefore, ICU nurses were responsible for overseeing patient care and providing critical care nursing interventions (e.g., titrating and administering high-risk drugs, assessment of cardiac rhythms) for all patients (4-6) assigned to the team.

Most participants described moral distress in response the delivery of care under the new staffing model, perceived as a threat to patient safety and quality of care. Most notably, ICU nurses expressed concerns about the provision of care provided by unqualified staff. The complexity of their moral distress was situated in two main concerns: (1) nurses felt conflicted between respecting their peers’ nursing knowledge, while also recognizing their lack of specialized skills; and (2) nurses had difficulty trusting their peers to adhere to the ICU standards of care, make correct clinical decisions, document appropriately, or catch the subtle clinical changes indicative of significant shifts in a patient’s status. These concerns were particularly prevalent in the context of emergencies, where nurses rely on one another to make quick, critical decisions. Moral distress occurred when unqualified staff, limited by their skills, were not able to meet the needs of the team, and ultimately, the patient.

            Furthermore, to compensate for the lack of orientation and training, ICU nurses were responsible for teaching new staff essential skills, policies, and procedures, and orienting them to unit resources and flow. One nurse reported positive outcomes of teaching, however, most ICU nurses described the moral distress that occurred when having to prioritize between patient care and teaching.

Seeing Colleagues Struggle. In the context of the new staffing model, nurses also described the shift from a collaborative, team-oriented work environment to one characterized more by isolated work. As one nurse described, “you’re in your own zone and you don’t generally leave that zone, ’cause you don’t have time.”Nurses’ stories revealed patterns of moral events grounded in witnessing peers’ difficulties with managing their workload, and consequently, threats to patient safety and standards of care. Moral distress occurred when nurses had to choose between caring for the patients within their own care team and helping their colleagues. Nurses identified that regardless of their chosen action, the standard of care for all patients was at risk.

Similar moral events also occurred for a subset of charge nurses in this study, who were responsible for overseeing the day-to-day activities of the unit, supporting staff, managing conflicts, and facilitating patient flow. All charge nurses in this study reported moral distress in response to making nursing assignments. They described their attempt to balance nurse and patient safety when assigning patients to new or redeployed nurses, when creating team-nursing assignments, or when allocating nurse breaks. One participant, who was a charge nurse for the first time during the pandemic, described:

…the ethical dilemma, for me, in this situation, with being in charge, was trying to make sure that the staff were practicing safely and that the patients were safe and trying to manage all that. And trying to get people for their own breaks because [pause] they need them. We needed them. Especially during the pandemic, everybody was so exhausted.

Similarly, nurses described the moral distress they experienced when they were asked by the organization to pick up over-time or extra shifts. Moral conflict occurred while they considered the outcomes of their peers working understaffed, and their own physical and mental well-being.

Discussion

In this analysis of data from the overarching interpretive descriptive study, we documented the properties of moral distress experienced Canadian adult-ICU nurses working in this setting during the COVID-19 pandemic. This study advances our conceptualization of moral distress by identifying the key concepts of this phenomenon during a global public health emergency. The Moral Distress Model (Morley et al., 2021b) served as a useful framework to explore concepts of moral distress with ICU nurses. While labeling the moral events described by nurses in this study was helpful for understanding the broad range of events that contributed to their moral distress, most importantly, we learned that consistent themes spanned across all types of moral events. These findings provoke questions about the utility of labeling these events, particularly when considering the development of interventions to mitigate moral distress. In a recent study by Morley (2023), in which the authors explored the utilization of resources based on sub-type of moral distress, statistically significant differences were found between resources used (i.e., speaking with senior colleague) and moral event type (i.e., moral dilemma distress). Our study reinforces the authors’ discussion, in which they identify the need for more research to explore how moral event types influences the types of interventions perceived as effect by nurses (Morley et al., 2023).

Confirming Conditions of Moral Distress

Authors have previously described causes of moral distress as both practice level factors (Atashzadeh-Shoorideh et al., 2021; Morley et al., 2021b) or broad conditions (Morley et al., 2021b). Analysis of our data identified that moral distress manifests for ICU nurses in response to the complex interplay of two overarching, broad practice conditions: (1) when nurses’ voices, driven by efforts to optimize patient care at an exceptionally high standard, from both a biomedical and psychosocial perspective, are not heard; and (2) when patients received substandard levels of care, that was not patient-centered, pain free, or misaligned with organizational, professional, or personal standards. Among existing findings of moral distress experienced by ICU nurses, other authors have similarly described the critical influence of nurses’ voices being heard and patient conditions, in both pre-pandemic and pandemic contexts. Caram et al. (2018) explored moral distress through a lens of virtue ethics, with a sample of ICU nurses (n=11) and surgical nurses (n=5). Their findings highlight how in the “real-world” context of practice, nurses deviate from their nursing telos (e.g., goal of practice) and are often left unseen during ethical challenges, which leads to moral distress. Further substantiating our findings, in a qualitative descriptive study of 111 ICU nurses, McAndrew et al. (2020) highlighted that when nurses’ voices are marginalized in response to organizational cultures, practices, and priorities, patients can experience suffering and consequently, nurses can experience moral distress. These findings are reinforced in a scoping review by Riedel et al. (2022), that mapped studies of moral distress, moral stressors, and moral injury experienced by healthcare workers during COVID-19. Among several factors contributing to ethical events, authors underscored the lack of respect for nurses’ autonomy and their exclusion from decision-making, as well as conditions of unsafe or substandard care (Riedel et al., 2022). Moreover, years of work in this field have documented that substandard care, ineffective pain control, or inadequate patient conditions are central to moral distress experienced by nurses (Atashzadeh-Shoorideh et al., 2021; McAndrew et al., 2016). Nurses confirmed this narrative, and corroborated that participating in end-of-life care, or invasive, aggressive care, for potentially futile patient outcomes are one of the most frequent and impactful sources of moral distress (Browning & Cruz, 2018; Dodek et al., 2016; Epstein et al., 2020; McAndrew et al., 2016)

Our findings also highlight the underlying and pre-existing cultures, systems, and processes, at various levels of the healthcare system, that contribute to or compound the broad conditions in which moral events occur. Aligning with the literature, nurses’ feelings of powerlessness, influenced by the culture and beliefs of the nurses’ roles within the healthcare team, and consequently, the disregard of their expert knowledge, prevented nurses from equally contributing to patient care decisions (Caram et al., 2018; McAndrew & Hardin, 2020). Nurses’ accounts also confirmed pre-existing challenges with interdisciplinary collaboration, partial to cultures and systems of poor communication, inconsistent approaches to care, and informal and formal hierarchies, contributed significantly to moral events (Epstein et al., 2020; Hancock et al., 2020; Henrich et al., 2016, 2016; McAndrew et al., 2016; McAndrew & Hardin, 2020).

Capturing Contextual Influences on Moral Distress

In the context of our study during the COVID-19 pandemic, pre-existing moral events were further amplified in both frequency and intensity, and novel moral events also emerged. Consequently, conditions in which nurses’ voices were not heard or validated and situations of compromised patient care, were exacerbated (Moore et al., 2022; Trachtenberg et al., 2022). Nurses in this study emphasized the severe impact of COVID-19 on the quality of care, due to factors like poor staffing levels, increased number of patient admissions, heightened patient acuity, and barriers to communication such as virtual modalities and restrictive visitor policies (Kissel et al., 2023).

With extreme levels of uncertainty, and lack of knowledge and understanding of the novel virus, there was a priority to reduce transmission to staff, their loved ones, as well as patients and their families. Consequently, on a regular basis, nurses evaluated and prioritized their own safety, against the needs of their patient— a significant shift in the guiding culture of nursing practice. Similarly, Trachtenberg et al. (2021) described that amongst ICU healthcare workers (n=18), nurses (n=16) experienced moral distress when they were required to risk the safety of themselves and their loved ones, to meet patient care needs. Although nurses in our study commented on the moral distress they experienced in response to fear of transmission, most were more concerned about limiting their interaction with their patients, and the implications on quality of care. Moreover, nurses experienced moral distress in response to the risk to quality of care and patient safety posed by new models of care (e.g., team nursing), developed and integrated in an effort to address pre-existing staffing shortages exacerbated by the pandemic (Andersson et al., 2022; Romero-García et al., 2022). Implications of these emerging contextual factors that contributed to nurses’ moral distress, that were identified in this study, are important for informing future emergency preparedness (i.e., intervention development, decision-making frameworks). In a separate analysis of study data, we describe nurses’ recommendations for organizational-based mitigative interventions situated in both pandemic and non-pandemic contexts (Gehrke et al., 2024)

Strengths and Limitations

The credibility of this study was maintained and informed by Thorne’s (2016) evaluative criteria. The epistemological integrity and disciplinary relevance of this study were achievedthrough the development of a research question that was congruent with the purpose of interpretive description and was grounded in the nursing epistemology. The application and consistent use of scaffolding, informed by a theoretical fore-structure, maintained representative credibility and analytic logic. Interpretive authority was achieved through the triangulation of data multiple sources (e.g., interview and survey data) and thoughtful clinician test, to provide evidentiary support for truth claims and conclusions. Finally, our findings address and discuss contextual awareness, recognizing the unique influence of the COVID-19 pandemic on nurses’ experiences of moral distress.

A few limitations are noted. First, given the size of the study sample (n=40), findings from this study may not explicitly reflect the experiences of all Canadian critical care nurses. Second, we recognize that those who expressed interest to participate in this study inherently represent nurses who have experienced moral distress in their practice and may have different experiences from those who have not. Third, given the large percentage of female nurses in this study, these findings may not reflect the experiences of those who do not identify as female. Fourth, the demographic survey distributed to nurses in this study was developed at the beginning of 2021, and therefore, novel concepts that emerged in response to the evolving pandemic (e.g., team-nursing) were not captured in the survey. Finally, the authors acknowledge that the MMD-HP aligns with a narrower definition of moral distress, while the broadened definition informed this study. The MMD-HP was selected because of its updated approach to measuring moral distress. However, to further promote rigour, future studies may endeavor to choose a tool and framework that have consistent approaches to defining concepts of moral distress.

Conclusion

This study advances and refines our knowledge of key properties of moral distress. Nurses confirmed existing knowledge about the types of moral events experienced in their professional practice, while also highlighting novel contextual changes that influenced pre-existing and emergent moral events. However, it is most important to focus on the broad conditions in which moral distress occurred, as these were prevalent across pre-pandemic and pandemic contexts. We learned that circumstances in which nurses’ voices are not equally valued in decision-making at each level of the healthcare system and conditions of substandard levels of patient care, were further exacerbated in the context of a global pandemic. Therefore, it is important that in the next steps of research, particularly interventional studies, seek to explore strategies that influence these broad conditions of moral distress.

Ethics Approval

The study protocol was approved by the Hamilton Integrated Research Ethics Board (#13074). Participants completed a signed, informed consent using the online survey platform Lime Survey. A copy was then signed and returned by the research team and was verbally reviewed and confirmed at the beginning of each interview. Participants were advised that the conversation could elicit an emotional response and were given the opportunity to take a break or permanently end the interview at any time. A distress protocol was available to implement if a participant experienced a significant emotional response during or after the interview. All data remained confidential, with identifying information removed from transcripts.

Conflict of Interest

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author Notes

Paige Gehrke, MSc, RN, School of Nursing, McMaster University, Hamilton, ON.

Karen A. Campbell, PhD, RN, School of Nursing, York University, Toronto, ON.

Jennifer L.Y. Tsang, PhD, MD, FRCPC, Department of Medicine, McMaster University, Hamilton, ON.

Ruth A. Hannon, NP-PHC, MHA, MSFNP-BC, DNP, School of Nursing, McMaster University, Hamilton, ON.

Susan M. Jack, PhD, RN, FCAN, School of Nursing and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON

Corresponding Author: Paige Gehrke, MSc, RN, Faculty of Health Science, McMaster University, Hamilton, ON. Email: gehrkep@mcmaster.ca.

Conflict of Interest

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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APPENDICES

Appendix A

Table 1. Categories and Types of Moral Events

Appendix B

Appendix C

Note. n=40.

Hospital status = Classification of hospital in relation to their prioritization and level of engagement in teaching, quality improvement, and research activities. No absolute definitions exist provincially or nationally. Generally, community hospitals are healthcare centers that serve a local community with the principal mandate of providing both acute and non-acute services, and lesser academic or research priorities. Conversely, academic place equivalent priorities towards clinical, academic, and research activities. Categories informed by (Canadian Institute for Health Information, 2020).

ICU level = Categorization of ICU based on local capacity to provide certain measures of intervention and staffing. Categories informed by (Marshall et al., 2017).

Appendix D

Note. Adapted from Anesi, G. L., Lynch, Y., & Evans, L. (2020). A conceptual and adaptable approach to hospital preparedness for acute surge events due to emerging infectious diseases. Critical Care Explorations, 2(4), e0110. https://doi.org/10.1097/CCE.0000000000000

 [A1]Please clarify and or revise.

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