By Melinda Young

Case management and nursing were stressful jobs before the pandemic. Now, hospital nurses are facing unimagined stressors, all setting the stage for possible emotional crises and moral distress.

Moral distress can develop when nurses feel as though they are prolonging a patient’s dying and can only provide interventions that might be inappropriate, said Alexander Wolf, DNP, RN, APRN, palliative care nurse practitioner with TriHealth in Cincinnati.

Wolf studied moral distress among critical care nurses, finding that many do not feel prepared to provide palliative care to patients. While palliative care is needed in situations in which patients are ill, it sometimes is inadequate because clinicians have not received palliative information or training.1

“I’ve been very impressed with our ICU [intensive care unit] doctors and nurses; they get us [palliative care] involved early, and that’s when palliative care specialists do their best work,” Wolf explained. “We are there to be a support to all types of patients with serious illnesses, even if they’re getting better and want aggressive treatment.”

Case managers in some hospitals have seen their jobs change to include working in critical care units (CCUs) and ICUs. Their concerns about handling new responsibilities and duties could contribute to stress.

Nursing and case management leaders also are experiencing new forms of stress as their roles evolve when hospitals gear up for a surge of COVID-19 cases.

“This is an unprecedented and challenging time for leaders in nursing and all healthcare professions,” says Michelle Sanchez, MSN, RN, Beacon Program manager with the American Association of Critical-Care Nurses (AACN).

With COVID-19 patients, there are no recommended treatments to cure the disease. Providers can provide only symptom relief, experimental treatment, and/or palliative care. Also, hospital staff deal with the stress of conserving personal protective equipment (PPE) because of nationwide shortages and supply chain obstacles.

“Despite their years of experience and education, most nurse leaders are facing a new landscape when it comes to navigating the evolving COVID-19 crisis,” Sanchez says. “What we know about staffing, PPE, and practice challenges is continuously changing, making it difficult for nurse leaders to answer questions and share information that is vital to their staff’s work.”

This situation can cause leaders, nurses, and case managers to experience moral distress and helplessness.

“We’re also seeing an increase in moral distress among healthcare leaders and providers,” Sanchez says. “Leaders are asking their staff to not only provide care to critically ill and infectious patients, but to be the sole source of support for those patients, whose family members are not permitted at their bedside. These leaders also are seeing their co-workers and peers contract the virus and, in some cases, losing their life to it.”

Information about the pandemic changes daily — even hourly. This contributes to stress.

“One of the hardest things, and this gets back to the moral distress issue, is what healthcare workers, nationally, are facing with PPE — guidelines which change by the day,” Wolf explained.

Resource allocation and staffing challenges during the crisis require innovation to provide safe and effective care, Sanchez says. “Nurse leaders can help themselves and their staff through the pandemic by including a moment of gratitude in daily shift huddles, and by employing critical incident stress debriefings, when needed,” she adds.

Leaders also should keep in mind that their staff’s stress and concerns include personal concerns about their own health and the health of their families. “There are a number of things that are morally distressing to staff for different reasons, and one is that everyone is scared of bringing the viruses back to their families, and getting sick and dying and not being there for their families,” Wolf said.

Healthcare leaders can help nurses, case managers, and others reduce stress and prevent burnout by following various methods for building resilience. For example, leaders can maintain awareness and help staff keep aware of stress. (For more information, visit:

“As nurse managers and leaders, we are going through the stress of this pandemic just like our employees,” says Caryl Goodyear, PhD, RN, NEA-BC, CCRN-K, FAAN, practice excellence programs manager with the AACN. “Acknowledging that we are all sharing this same experience can help glue us together, now more than ever, as we navigate the highs and lows of caring for patients with COVID-19. This support is vitally important, particularly in crisis situations, where there is minimal time to debrief and renew.”

Peer support helps with destressing. Case managers and nurses can share their experiences, and a shared hope can help staff find a new meaning in the midst of chaos, she adds.

Personally, healthcare workers can write down or acknowledge the things they did well in a day’s work. It is one way to build resilience, Goodyear says.

“This idea of recognizing the good things we have accomplished comes from J. Bryan Sexton, PhD, associate professor in psychiatry and behavioral sciences at Duke University School of Medicine, and a well-known expert in personal and professional resilience,” Goodyear says. “He states that we are conditioned to remember the bad things that happen to us, but if we consciously make ourselves remember the good, we can retrain the brain toward positive thinking, thus helping us to become more resilient.”

For nurses and case managers on the front lines of the pandemic, it is important to take time to reflect, grieve, and remember.

“Many critical care units are so busy, staff is unable to pause and perform their usual ritual of remembering the life of a patient or loved one. This can add to the emotional and mental toll on care providers,” Sanchez says. “One way that leaders can help is to make time for ‘moments.’ For example, after losing a critical care nursing peer, one New York City nursing team met in the middle of the unit to pause for a moment of remembrance and grace.”

These types of moments are important, Sanchez notes. “Most importantly, leaders need to take care of themselves in order to effectively lead their staff.”


  1. Wolf AT, White KR, Epstein EG, et al. Palliative care and moral distress: An institutional survey of critical care nurses. Crit Care Nurse 2019;39:38-49.