key: cord-0023201-nu7l8idc
authors: Virani, Salima Bano
title: Moral distress amid COVID-19: A frontline emergency nurse's perspective
date: 2021-11-19
journal: Nursing
DOI: 10.1097/01.nurse.0000800072.35132.c1
sha: b0029e423c4b0a06ac895666e0f4f6e07ef76b49
doc_id: 23201
cord_uid: nu7l8idc

ED nurses are at high risk for developing moral distress during the COVID-19 pandemic. Predisposing factors include limited resources, inadequate staffing, PPE shortages, and caring for vulnerable populations. This article explores personal and organizational strategies to help nurses cope with moral distress.

demands, limited resources such as PPE, the responsibility to implement new no-visitor policies, changing clinical practices, among many others, nurses have been expected to make morally challenging decisions that may result in devaluing patients' wishes and reducing nurse-patient interaction. ED nurses are also coping with working in crowded EDs with limited inpatient beds while observing physical distancing guidelines and having a higher risk of exposure to communicable diseases. [8] [9] [10] This article discusses the predisposing factors for moral distress and discusses effective personal and organizational strategies to support ED nurses.

Having limited critical care resources, particularly mechanical ventilators and ICU beds, forces healthcare professionals to make difficult choices. 1 Seeing patients getting palliative treatment because of lacking resources is not the norm in ED care. This leads to nurses developing feelings of guilt and shame. 11 Unsafe working conditions due to staffing shortages are among the leading factors that contribute to moral distress among ED nurses. 7, 11 At our facility, our ED has required increased staffing during COVID-19 due to strict infection control protocols, greater patient screening prior to entry, higher patient acuity, and ED physical restructuring to accommodate patient needs. We were fortunate to have redeployed nurses in the ED for 6 months during the first wave of the pandemic from March to August 2020. However, the additional staff was removed by September 2020. Since then, we have had a significant staffing shortage, with members calling in sick, resigning, or transferring to other departments.

The availability and quality of PPE have been critical concerns amid this pandemic. 12 To address this, our facility developed strategies for optimizing the PPE supply such as recycling PPE gowns. Initially, all healthcare professionals at our facility were given two surgical masks per day at the entrance, which was a major change from wearing and discarding masks in-between each patient interaction. Having to keep a mask on at all times made it harder to stay hydrated. With the global shortage of PPE particularly at the beginning of the pandemic, healthcare workers were provided with poor quality PPE, which was particularly distressing. 13, 14 Working with unsafe PPE adds to nurses' moral distress.

ED staff have reported perceiving that their health and increased COVID risk are not being properly protected by their employers. 11 In October 2020, our ED had an outbreak with five confirmed positive cases, raising many concerns about protecting patients, the ED staff, and their loved ones. Our ED remained open despite the outbreak, and additional safety strategies were put in place. We were expected to wear full PPE regardless of a patient' s isolation status. We had to be tested for COVID-19 and were expected to wear a surgical mask with a face shield at all times including breaks, except only when eating. These precautions generated feelings of uncertainty; we felt like we couldn't trust our coworkers since we did not know who had tested positive.

While crowding is a common challenge in EDs, it became more evident during the second wave of COVID-19. During the first wave of the pandemic, the number of patients visiting our ED declined by approximately 20%-25%, a decrease similarly seen in EDs in other countries. 10, 15 However, this changed significantly during the second wave, with the rapid influx of patients due to outbreaks in homeless shelters, long-term-care settings, and other hospitals in Ontario. 16 At our facility, all patients being transferred from other hospitals were assessed and stabilized in the ED before they were accepted at inpatient units. Enhanced social distancing requirements also made our ED more congested, which was the case in other EDs as well. 10, 17 Some Ontario hospitals provided "hallway care" in the ED to avoid transmitting infections between patients. 16 To address this issue, our facility converted the anesthesia office space into an overflow reassessment area.

Caring for dying patients amid the COVID-19 pandemic, with scarce resources and no-visitor policies in place, causes significant moral distress in all healthcare professionals. Our ED' s no-visitor policy added another layer of moral distress because we could not allow patients' loved ones to be with them to say their last goodbye. Moral distress increases when nurses witness the dehumanization of patients and families during their care. Experienced nurses working in the ED may put their feelings and emotions aside to prioritize patients' well-being, but this also contributes to moral distress. As such, nurses must have avenues to express their emotions to prevent post-traumatic stress disorder (PTSD). 18, 19 Lack of infrastructure for the homeless population The lack of resources and infrastructure for the homeless population in our area was among the biggest concerns that distress ED nurses in our facility. The homeless population is at high risk for COVID-19 because of their living conditions There is a strong relationship between individual coping mechanisms and moral distress, so nurses need to understand their coping strategies. Some effective coping strategies include positive reframing and growth (e.g., showing appreciation for the staff who helped during critical times instead of complaining about staffing shortage or being grateful for having the ability to care for patients during a pandemic), active coping (e.g., facing problems and seeking solutions like professional help), social support, ventilation of emotion, meditation, humor, and mental and behavioral disengagement to remove the stressor. 23 At our facility, meditation spaces were created to provide the staff with an opportunity to disconnect from morally challenging situations and relax in a quiet place.

Peer support from colleagues or managers could help nurses cope and ventilate their feelings. Groupbased counseling or virtual peer support sessions to feel connected despite social distancing guidelines could reduce moral distress and burnout during COVID-19. Some of our coworkers initiated successful virtual sessions for physical activities like workouts and yoga. Getting recognition from coworkers and the ED leadership even for small achievements also helped improve staff morale.

Healthcare organizations and leaders need to step back and examine systems that may be contributing to a stressful environment and take additional steps to address these challenges and acknowledge the staff' s hard work. The ED leadership should proactively check in with their staff, have open and transparent communication, and offer more flexibility. 25 They should develop a healthy working environment by fostering a sense of safety and empowerment among the staff, offering flexible working schedules, having adequate staffing, and developing initiatives like formal peer support.

Nurse managers can help reduce moral distress by acknowledge the staff' s challenges to prevent moral injury or PTSD, conducting short meetings at the end of shifts to instill hope, and setting up follow-up check-in sessions to help ED nurses feel supported. 8 At our facility, redeployed staff from nonessential units were very helpful in reducing the workload and making the ED nurses feel supported. The leadership team This blog is created to support during difficult times of COVID-19 and to remind us all that we have tools to cope American Psychological Association continues to be available 24/7 to support staff, had ongoing communication with staff through a platform called "Slake board," and daily huddles at the beginning of shifts. These huddles provided a safe space for all healthcare professionals to discuss any clinical or nonclinical concerns, which were forgotten over time with the increasing workload. However, while our department conducted many huddles and simulations to respond to different medical emergencies using infection control practices, psychological debriefing sessions are often forgotten amid the crisis. As such, I recommend having more peer and formal debriefing sessions at the end of shifts or weekly as needed and improving access to mental health care professionals. 26, 27 The Canadian Psychological Association is offering free psychological services for frontline workers impacted by the pandemic. 28 Healthcare institutions need to reduce workplace stress and develop support programs structured for ED nurses. 29 The pandemic has resulted in ED nurses working in conditions that cause moral distress. Nurses need to utilize effective individual and/ or group coping strategies, while managers, employers, and organizations need to provide safe working environments and access to mental health care and other additional support to ensure the well-being of nurses. ■

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Salima Bano Virani is an ED nurse at St. Michaels Hospital in Toronto, Canada, and a sessional faculty member in the School of Community and Health Studies at Centennial College in Ontario