Clinicians experience a high level of moral distress when they know they are not providing optimal care to patients. However, investigators have found leaders can mitigate the effects of moral distress. Such information could not arrive at a better time as hospitals in many regions cope with surging COVID-19 case volumes amid a shortage of skilled nurses.

Researchers surveyed registered nurses in two academic medical centers using the COVID-19 Moral Distress Scale for nurses.1 While the survey took place in September 2020, the nurses were specifically asked about their experiences during the first full peak month of COVID-19 (April 2020).

A key question researchers asked these nurses concerned how many patients with COVID-19 were under their care. “Nurses who cared for the most patients with COVID-19 had the highest extent of moral distress,” says Eileen Lake, PhD, MSN, MA, BSN, FAAN, associate director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania.

Managers can mitigate some distress by paying careful attention to how many patients with COVID-19 are assigned to a nurse and over what period. “Those decisions about nurse assignments are in management’s purview,” Lake says. “Managers can reduce the quantity of patients with COVID-19 that nurses are caring for over the course of many days in sequence.”

Another important question concerned shortages of personal protective equipment (PPE). “We found that about half the nurses in the group we surveyed had shortages of PPE,” Lake reports. “A variety of workarounds would be used to get masks, shields, gloves, and even cleaning supplies.” The need to pursue these workarounds, what the investigators termed PPE inadequacy, was a critical determinant of moral distress.

Communication was a big issue, too. Participating nurses were asked about the timeliness, transparency, and effectiveness of their managers’ communication. “One of our messages to management is that communication should be a two-way street because the nurses are the ones who have the most knowledge about the care reality and the care environment. They should be informing the protocols that are changing,” Lake says. “Having that dialog with nurses rather than just information-sharing is an important way to not only come up with the best informed protocols and procedures, but also to have nurses’ distress reduced. Their insights are being incorporated into decisions that are affecting care.”

Managers must acknowledge nurses work from a unique vantage point, and then capitalize on that to produce the best policies. “This will give nurses an opportunity to contribute in a very meaningful way during circumstances that are dire, and that could lead to multiple gains,” Lake offers.

It is equally important for managers to acknowledge the suffering that goes along with moral distress and give nurses the resources to address it. For example, in the studied medical centers, an ethicist was available to consult with nurses, which happened frequently. “That is a very important resource,” Lake says. “But managers need to be open with nurses about the moral distress that crisis standards of care lead to. It is, to some degree, inescapable, but if nurses know what it is, and have resources to help deal with it, then it can be reduced.”

Lake and colleagues asked nurses how often they felt anxious and withdrawn or struggled to sleep. The results surprised researchers, considering that at the time of the survey, hospitalization levels were fairly low and stable in the region regarding patients with COVID-19. “This was before the fall and winter surges ... and yet the nurses experienced those psychological symptoms two or three days in the last week for each symptom,” Lake says. “There was really no day that went by when they didn’t either feel withdrawn, have difficulty sleeping, or experience anxiety.”

While moral distress has been linked to several negative outcomes, such as anxiety and depression, one unique sign of moral distress is “moral residue,” which lingers because of moral distress. “It is one of those things that has been linked to burnout and intent to leave [the profession],” Lake says. “It is an aspect of nurses’ work that has these ripple effects on their mental health and their future as a nurse.”


  1. Lake ET, Narva AM, Holland S, et al. Hospital nurses’ moral distress and mental health during COVID-19. J Adv Nurs 2021 Aug 17;10.1111/jan.15013. doi: 10.1111/jan.15013. [Online ahead of print].