Reframing Competence and Moral Clarity in Nursing Practice.

This article aims to understand moral distress in carers of people with an intellectual disability during the COVID-19 pandemic. Nine staff carers of seven people with an intellectual disability, who had been participants of the IDS-TILDA study in Ireland, who died during the COVID-19 pandemic participated in in-depth, semi-structured telephone interviews. Template analysis was used to analyze the interviews. Obstructions in performing their duties left carers feeling powerless and experiencing moral conflict distress, moral constraint distress and moral uncertainty distress. Most managed to connect to the moral dimension in their work through peer support, understanding they fulfilled the wishes of the deceased, and/or thinking about how they or others did the best they could for the person they were caring for. This research demonstrates that while restrictions may have been effective in reducing the spread of COVID-19, they were potentially damaging to carer wellbeing.

During the COVID-19 pandemic, many health professionals endured moral distress and moral injury. Whereas many stories about moral distress in hospitals and care facilities were shared, little is known about moral injury among health care personnel and among public health professionals. This workshop wants to offer an opportunity to open a conversation about moral injury in general, in health care personnel and in in public health experts. The public health community should not shy away from openly discussing moral injury and moral distress due to the the Covid-19 pandemic. It is necessary to collect the stories about the situations where members of the public health community were hindered in doing what was the ethically appropriate action due to circumstances beyond their control.Objectives of this workshop are: Clarifying the concept of moral injury and moral distressUnderstanding what ‘ethically appropriate actions' are in times of a pandemicOffering a platform for sharing stories of moral distress Key messages Moral distress and moral injury are potential modifiable mental conditions in times of disaster and stressIdentifying determinants of moral distress and moral injury is necessary to optimize Public health responses to disasters

Introduction: The global COVID-19 pandemic posed challenges to healthcare systems and professionals with the potential moral distress. The purpose of this review was to describe the risk factors associated with the moral distress of nurses in the era of the COVID-19 pandemic. Methods: The search for literature review articles was carried out in three databases (Scopus, Science Direct, and PubMed) with a publication span of 2019-2020. The PRISMA checklist was used to guide this review. Analysis and data tabulation were carried out in the article. Title, abstract, full-text and methodology were assessed to determine study eligibility. Result: A total of eight studies that fit the inclusion criteria were discussed based on internal and external factors of the risk of moral distress by nurses. Internal factors for the risk of nurses' moral distress include experience, decision making, perceptions of job dissatisfaction, patient care, coping with maladaptive strategies, failure to successfully care for patients, and limitations in take action. External factors for the risk of moral distress for nurses include lack of teamwork, unfavorable work environment and situations, conflicts of interest, excessive work demands, lack of resources, and loss of control over work situations. Conclusion: The risk factors for nurses' moral distress can be explained based on internal and external factors. The experience of nurses is important in dealing with the COVID-19 pandemic because this pandemic is a new disease and no treatment has yet been found, so other factors are associated with experience.

The COVID-19 pandemic has devastatingly affected the healthcare system, particularly on nurses. Studies have found that nurses are more likely to experience burnout, mental health, and physical health issues due to the increased stress and workload associated with the pandemic. This paper explores the impacts of the pandemic on nursing burnout and mental health and the correlation between fatigue and burnout. It also discusses the impact of the pandemic on nurses' moral distress and the link between burnout and quality of life of nurses. Finally, it offers useful advice for lowering burnout in nurses and raising their quality of life. The results indicate that identifying measures to lessen nurses' burnout and enhance their quality of life is crucial for ensuring the health and wellbeing of the nursing workforce. Summary: Significant changes have been made to the healthcare system as a result of the COVID-19 epidemic, particularly for the nursing staff. This is because nurses are on the front lines of patient care and are essential in providing direct care to patients and managing their care plans. Unfortunately, there is a global nursing shortage, and the pandemic has further exacerbated this. This shortage has caused great stress for nurses, who are now faced with an increased workload and long hours. Additionally, nurses are at a higher risk of exposure to the virus due to their close contact with patients, leading to increased levels of fear and anxiety. The goal of the paper is to examine how the pandemic has affected nursing burnout, mental health, and the relationship between exhaustion and burnout. Additionally, the pandemic's effects on nurses' moral anguish and the link between burnout and quality of life will be covered. It will end with actionable suggestions for lowering burnout and raising nurses' quality of life.Studies have found that the COVID-19 pandemic has significantly impacted the healthcare system, especially nurses who are more likely to experience burnout and psychological health issues due to the high level of stress and workload associated with the pandemic. There is also a strong correlation between fatigue and burnout in nurses, and the pandemic has increased stress, anxiety, and physical health issues. Additionally, COVID-19 has had an adverse effect on nurses' moral distress, and there is a connection between nurses' life quality and burnout. Therefore, it is essential to lessen burnout to enhance nurses' standard of living.The COVID-19 pandemic has significantly impacted nurses' emotional and psychological health. There is a strong correlation between fatigue and burnout, and the pandemic has increased stress and anxiety levels. Additionally, it has had a harmful effects on nurses' moral distress, and there is a significant relationship between nurses' fatigue and standard of life. To decrease exhaustion and increase quality of life, healthcare organizations should provide flexible work schedules and adequate rest periods. Policymakers should also focus on providing nurses with resources to support their mental health and reduce burnout. Furthermore, they should address ethical dilemmas and ensure access to counseling services. Overall, the findings suggest that exploring ways to reduce nurses' fatigue and improve their life quality is essential.

BackgroundProviding palliative care at the end of life (EOL) in intensive care units (ICUs) seems to be modified during the COVID-19 pandemic with potential burden of moral distress to health care providers (HCPs). We seek to assess the practice of EOL care during the COVID-19 pandemic in ICUs in the Czech Republic focusing on the level of moral distress and its possible modifiable factors.MethodsBetween 16 June 2021 and 16 September 2021, a national, cross-sectional study in intensive care units (ICUs) in Czech Republic was performed. All physicians and nurses working in ICUs during the COVID-19 pandemic were included in the study. For questionnaire development ACADEMY and CHERRIES guide and checklist were used. A multivariate logistic regression model was used to analyse possible modifiable factors of moral distress.ResultsIn total, 313 HCPs (14.5% out of all HCPs who opened the questionnaire) fully completed the survey. Results showed that 51.8% (n = 162) of respondents were exposed to moral distress during the COVID-19 pandemic. 63.1% (n = 113) of nurses and 71.6% of (n = 96) physicians had experience with the perception of inappropriate care. If inappropriate care was perceived, a higher chance for the occurrence of moral distress for HCPs (OR, 1.854; CI, 1.057–3.252; p = 0.0312) was found. When patients died with dignity, the chance for moral distress was lower (OR, 0.235; CI, 0.128–0.430; p < 0.001). The three most often reported differences in palliative care practice during pandemic were health system congestion, personnel factors, and characteristics of COVID-19 infection.ConclusionsHCPs working at ICUs experienced significant moral distress during the COVID-19 pandemic in the Czech Republic. The major sources were perceiving inappropriate care and dying of patients without dignity. Improvement of the decision-making process and communication at the end of life could lead to a better ethical and safety climate.Trial registration: NCT04910243.Graphical abstract

BACKGROUND Staffing and resource shortages, especially during the COVID-19 pandemic, have increased stress levels among health care workers. Many health care workers have reported feeling unable to maintain the quality of care expected within their profession, which, at times, may lead to moral distress and moral injury. Currently, interventions for moral distress and moral injury are limited. OBJECTIVE This study has the following aims: (1) to characterize and reduce stress and moral distress related to decision-making in morally complex situations using a virtual reality (VR) scenario and a didactic intervention; (2) to identify features contributing to mental health outcomes using wearable, physiological, and self-reported questionnaire data; and (3) to create a personal digital phenotype profile that characterizes stress and moral distress at the individual level. METHODS This will be a single cohort, pre- and posttest study of 100 nursing professionals in Ontario, Canada. Participants will undergo a VR simulation that requires them to make morally complex decisions related to patient care, which will be administered before and after an educational video on techniques to mitigate distress. During the VR session, participants will complete questionnaires measuring their distress and moral distress, and physiological data (electrocardiogram, electrodermal activity, plethysmography, and respiration) will be collected to assess their stress response. In a subsequent 12-week follow-up period, participants will complete regular assessments measuring clinical outcomes, including distress, moral distress, anxiety, depression, and loneliness. A wearable device will also be used to collect continuous data for 2 weeks before, throughout, and for 12 weeks after the VR session. A pre-post comparison will be conducted to analyze the effects of the VR intervention, and machine learning will be used to create a personal digital phenotype profile for each participant using the physiological, wearable, and self-reported data. Finally, thematic analysis of post-VR debriefing sessions and exit interviews will examine reoccurring codes and overarching themes expressed across participants’ experiences. RESULTS The study was funded in 2022 and received research ethics board approval in April 2023. The study is ongoing. CONCLUSIONS It is expected that the VR scenario will elicit stress and moral distress. Additionally, the didactic intervention is anticipated to improve understanding of and decrease feelings of stress and moral distress. Models of digital phenotypes developed and integrated with wearables could allow for the prediction of risk and the assessment of treatment responses in individuals experiencing moral distress in real-time and naturalistic contexts. This paradigm could also be used in other populations prone to moral distress and injury, such as military and public safety personnel. CLINICALTRIAL ClinicalTrials.gov NCT05923398; https://clinicaltrials.gov/study/NCT05923398 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/54180

To assess the impact of COVID-19 pandemic on moral distress (MD) among healthcare professionals (HCPs) (physicians and nurses) in Spanish ICUs. Cross-sectional, prospective study. ICUs in Spain. HCPs currently working in Spanish ICUs. Data were collected via electronic survey with the use of a 50-item questionnaire in two different periods: prepandemic (October-December 2019) and during the second wave of COVID-19 (September-November 2020). During the prepandemic and pandemic periods, 1,065 (57.1% nurses) and 1,115 (58.5% nurses) HCPs completed the questionnaire, respectively. Higher MD levels were reported during COVID-19 pandemic, particularly among ICU nurses, when compared with the prepandemic period. Before COVID-19, physicians reported significantly higher levels of MD than ICU nurses (80.0 [interquartile range {IQR}, 40.0-135.0] vs 61.0 [IQR, 35.0-133.0]; p = 0.026). These differences disappeared during the pandemic period (81.0 [IQR, 39.0-138.5] vs 74.0 [IQR, 41.0-143.0]; p = 0.837). During the pandemic, younger and less experienced HCPs working in hospital areas that were converted in ICU or in ICUs with multiple occupancy rooms reported higher MD levels. In addition, HCPs who were off work for psychologic burden reported higher MD levels (108.0 [IQR, 66.0-139.0] vs 76.0 [IQR, 40.0-141.0]; p < 0.05). In the prepandemic period, patient-level root causes were the most morally distressing for nurses, whereas physicians reported higher MD on system-level root causes. During the pandemic, both groups reported higher MD on system-level root causes. During COVID-19, significantly more HCPs considered leaving their job due to MD. MD has increased among ICU HCPs in Spain during COVID-19 pandemic. Physicians reported higher MD levels than nurses in the prepandemic period, whereas both HCPs groups reported similar MD levels in the pandemic period. Strategies are needed and should be implemented to mitigate MD among HCPs.

This bibliometric study examined the evolving research landscape on physician mental health from 2010 to 2023, analyzing key themes, publication trends, and global contributions. A total of 3,360 articles, including 3,137 original research and 223 reviews, were sourced from Web of Science and Scopus. Findings revealed a significant increase in research output, particularly during the COVID-19 pandemic, with burnout, depression, and anxiety emerging as dominant themes. The US accounted for most publications, while research from low- and middle-income countries remains limited, indicating a substantial global disparity. Thematic analysis highlighted variations in burnout assessment methodologies, underscoring the need for standardized evaluation tools. This study also identified systemic challenges, including excessive workload, hierarchical workplace structures, and inadequate institutional support, as major contributors to physician distress. Technological inefficiencies, particularly in electronic health record systems, exacerbated administrative burdens and physician dissatisfaction. Recommendations include developing standardized mental health assessment frameworks, expanding study in underrepresented regions, and implementing organizational policies to enhance physician well-being. This review provides critical insights for policymakers, healthcare institutions, and researchers, offering a foundation for targeted interventions and evidence-based reforms to improve physician mental health globally.

Cardiopulmonary resuscitation (CPR) is one of the most consequential decisions in clinical medicine-a pivotal moment between life and death where science, ethics, and humanity intersect. Although advances in systems of care, technology, and training have refined technique and logistics, outcomes do not consistently result in meaningful, neurologically intact survival. In oncology-where disease trajectories are heterogeneous, treatment burdens substantial, and organ reserve often limited-these tensions are especially pronounced. Methods and approaches: This manuscript examines resuscitation as a medical, ethical, and human process, with explicit focus on patients with cancer. We review contemporary strategies for early recognition of deterioration (MEWS, NEWS, MET activation), team preparedness through Immediate Life Support (ILS), and structured decision-making at the boundaries of resuscitation. We also address communication with patients and families, the legal framework of Do-Not-Resuscitate (DNR) orders, and the distinctions among treatment forgoing, palliative sedation, and euthanasia, emphasising oncology-specific considerations such as metastatic burden, treatment intent (curative vs. palliative), performance status, and organ reserve. The overall effectiveness of resuscitation remains modest (approximately 5-20% survival), highlighting the importance of prevention and early intervention. In cancer care, the limits of resuscitation are both clinical and ethical, requiring proportionality between the likely benefit and the risks of prolonging suffering, careful attention to prognosis and expected neurological outcomes, and rigorous alignment with goals of care. Early and ongoing involvement of palliative services, along with robust long-term care pathways, provides humane, value-concordant alternatives for patients with advanced disease. Psychotherapists and chaplains play integral roles in supporting families and clinical staff. Structured post-event debriefing and system-level safeguards are essential to mitigate burnout and moral distress within oncology teams. Initiating or discontinuing resuscitation in oncology requires expertise, empathy, and moral clarity. Dignity-preserving care depends on aligning interventions with patient values and realistic clinical endpoints. Acceptance of the natural course of dying represents an important component of responsible and patient-centred medical care.

The COVID-19 pandemic produced several ethical challenges for nurses, impacting their mental health and moral distress. In the moral distress model the categories of events related to moral distress are: constraint, dilemma, uncertainty, conflict, and tension, each one related to different emotions. This study explored moral events’ memories and emotions in narratives of a sample of 43 Italian nurses who worked during the COVID-19 pandemic. We constructed an ad-hoc narrative interview asking nurses to narrate the memory, and the associated emotion, of an event in which they felt they could not do the right thing for the patient. We conducted a theory-driven analysis, using the categories proposed by the literature, identifying the main emotion for each category. Results show that 36 memories of events are representative of moral distress; among these, 7 are representative of none of the categories considered, and we categorized them as moral compromise. The main emotional trajectories are powerlessness, worthlessness, anger, sadness, guilt, and helplessness. From a clinical psychological point of view, our findings highlight the narration of the memories of moral events as a tool to use in the ethical sense-making of critical experiences, in order to promote well-being and moral resilience among nurses in emergency situations.

Moral distress and moral injury have become important concepts for understanding the moral experiences of health care professionals in ethically challenging clinical contexts. In this study, a comprehensive bibliometric analysis of research focusing upon the combination of both moral distress and moral injury among health care professionals published between 2006 and 2025 was conducted via the Web of Science Core Collection. The aim was to examine publication trends, collaboration patterns, core journals, disciplinary distributions, and research hotspots in this field. Bibliometric analyses were performed via VOSviewer, CiteSpace, Pajek, and Scimago Graphica. A total of 1,180 publications were included in the analysis. The results revealed a steady increase in research output over time, with rapid growth following the COVID-19 pandemic. Research activity was concentrated in a limited number of countries and institutions, with the USA contributing the greatest number of publications and demonstrating a central position in international collaboration networks. Nursing, clinical medicine, psychology, and ethics were the main disciplinary foundations of this research field. Keyword and co-citation analyses indicated that moral distress has remained the dominant research focus, while moral injury has gained increasing attention in recent years, particularly in relation to high-intensity care settings and psychological outcomes. Overall, this bibliometric analysis provides an overview of the knowledge structure and evolving themes of research on moral distress and moral injury among health care professionals.Several limitations regarding this bibliometric study are acknowledged.

Background: During the COVID-19 pandemic, frontline workers faced a series of challenges balancing family and work responsibilities. These challenges included making decisions about how to reduce COVID-19 exposure to their families while still carrying out their employment duties and caring for their children. We sought to understand how frontline workers made these decisions and how these decisions impacted their experiences. Methods: Between October 2020 and May 2021, we conducted 61 semi-structured interviews in English or Spanish, with individuals who continued to work outside of the home during the pandemic and had children living at home. Interviews were recorded, transcribed verbatim, and analyzed using abductive methods. Results: Frontline workers experienced moral distress, the inability to act in accordance with their values and obligations because of internal or external constraints. Their moral distress was a result of the tensions they felt as workers and parents, which sometimes led them to feel like they had to compromise on either or both responsibilities. Individuals felt morally conflicted because 1) their COVID-19 work exposures presented risk that often jeopardized their family’s health; 2) their work hours often conflicted with their increased childcare responsibilities; and 3) they felt a duty to their colleagues, patients/customers, and communities to continue to show-up to work. Conclusions: Our findings point to a need to expand the concept of moral distress to include the perspectives of frontline workers outside of the healthcare professions and the fraught decisions that workers make outside of work that may impact their moral distress. Expanding the concept of moral distress also allows for a justice-based framing that can focus attention on the disparities inherent in much frontline work and can justify programmatic recommendations, like increasing paid childcare opportunities, to alleviate moral distress.

We investigated the impacts of workload, resources, organizational satisfaction, and psychological safety on changes in physician burnout and moral distress among physicians during the early pandemic. We obtained national administrative and survey data on burnout, moral distress, organizational satisfaction, psychological safety, COVID-19 burden, and state-level restrictions for 11,877-14,246 Veterans Health Administration (VA) physicians from 2019 and 2020. We regressed the changes in burnout and moral distress on the changes in reasonable workload, appropriate job resources, organizational satisfaction, and psychological safety, controlling for COVID-19 burden and restrictions, and individual and medical center characteristics. Burnout and moral distress were not related to COVID-19 cases or restrictions but were reduced by improvements in workload, organizational satisfaction, and psychological safety. Health systems should be conscious of factors that can harm or improve physician well-being, especially in the context of external stressors.

PC-FACS

ObjectiveThe purpose of this study was to explore lived experiences of rehabilitation professionals working in hospitals during the COVID-19 pandemic, including the ethical issues and moral distress that these professionals might have encountered.MethodsAn interpretative phenomenological study was performed. First-person experiences of rehabilitation professionals (dieticians, occupational therapists, physical therapists, and speech-language therapists) were collected with semi-structured interviews and analyzed with interpretative phenomenological analysis.ResultsThe data of 39 hospital-based rehabilitation professionals revealed 4 themes: a disease with great impact, personal health and safety, staying human in chaotic times, and solidarity and changing roles. Participant experiences show that the virus and COVID-19 measures had a significant impact on the in-hospital working environment due to the massive downscaling of regular care, due to infection prevention measures, and due to unknown risks to rehabilitation professionals’ personal health. At the same time, participants experienced a certain freedom, which made room for authentic motives, connection, and solidarity. Participants felt welcomed and appreciated at the COVID-19 wards and intensive care units and were proud that they were able to fulfill their roles. The findings reflect a wide range of situations that were morally complex and led to moral distress.ConclusionTo diminish the long-lasting negative impact of the COVID-19 pandemic and moral distress, employers should empathize with the experiences of hospital-based rehabilitation professionals and create conditions for ethical reflection. Our data show that hospital-based rehabilitation professionals value professional autonomy. Creating room for professional autonomy helps them feel needed, connected, and energized. However, the needs of hospital-based rehabilitation professionals may conflict with organizational rules and structures.ImpactHospital-based rehabilitation professionals were involved in situations they considered morally undesirable, and they inevitably faced moral distress during the COVID-19 crisis. This study offers rationale and guidance to employers regarding how to reduce the long-term negative impact of the COVID-19 pandemic on rehabilitation professionals.