By Rose O. Sherman, EdD, RN, NEA-BC, FAAN
“I can’t do this again.” Over the past 3 weeks, frontline nurse leaders tell me that they hear this from staff as regions quickly move into a fourth COVID surge driven largely by the Delta variant and significant percentages of the population who remain unvaccinated. Some nurses have not recovered from their experiences in the spring and fall of 2020. They worry about re-traumatization, which is a valid concern because that can lead to PTSD.
But there is another emotion that may also be involved here, and that is anger. CDC Director Dr. Rochelle Walensky has said that current vaccinations in the U.S. are so effective that “nearly every death, especially among adults, due to COVID-19, is, at this point, entirely preventable.”
Nurses feel moral distress when they have strong feelings about ethically appropriate actions in a situation that are not acted on. Today, that emotion is sometimes directed to patients and families who have made poor choices that have endangered themselves and others in the eyes of nurses. Nurses report feeling demoralized that the public has not listened to the experts instead accepting disinformation from social media and other sources.
In a recent article in Newsweek magazine. Terrence Coulter, the critical-care medical director at Cox Medical Center in Missouri (a national hotspot), says that he feels conflicted caring for coronavirus patients who could’ve avoided infection by getting vaccinated. “You’re just angry,” Coulter said, “and you feel guilty for getting angry because they’re sick and dying.”
Evidence-based studies have established a relationship between the level of moral distress and intent to stay in a practice setting or even the profession itself. The impact on nursing practice could include any or all of the following:
- Physically withdrawing from bedside care
- Loss of the capacity to care
- Avoiding patient contact
- Failure to give good physical care
- Leaving the profession
Nurse leaders should be attentive to this new kind of moral distress when professionals feel guilty because they are angry about having to provide care to an unvaccinated COVID patient or educate families who oppose the vaccine. The American Association of Critical Care Nurses has a 4-As model that can be helpful in these discussions. The four As include the following.”
Ask – nurse leaders should observe for signs of moral distress on their teams, and if unsure ask whether nurses feel any moral distress in caring for unvaccinated patients.
Affirm – validate staff’s feelings if they are feeling moral distress by acknowledging that they are not alone in these feelings. Discuss the ethical dilemmas in the situation (the moral obligation to provide care versus strong feelings about decisions made by the patient).
Assess – assess the extent of the problem causing staff moral distress. What are the risks and benefits of taking action to reduce moral stress? There may be nurses that feel such a degree of moral distress or concern about re-traumatization that a reassignment to another area may need to be made.
Act – this is where the leader would begin to initiate the change needed to reduce moral distress. There may be a need to bring an ethicist into the unit to support group conversation or a psychologist.
Addressing moral distress when it exists is a moral imperative, especially at this time. Nurse leaders are in an excellent position to provide a sounding board for staff to help them manage these dilemmas and grip their feelings. Helping alleviate or lessen the moral distress that staff feel can improve nurse satisfaction, retention and ultimately improve care.
Read to Lead
American Association of Critical-Care Nurses. (2004). 4As_to_Rise_Above_Moral_Distress
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