Overwhelming hardship wrought by the pandemic created 'moral distress' in frontline nurses

By Carol Davis,

Nurses on the front lines of the COVID-19 pandemic suffered overwhelmingly from "moral distress," says a new study from researchers at DePaul University’s School of Nursing in Chicago.

The study's purpose was to qualitatively describe the emotions experienced by U.S. nurses during the initial pandemic response, so researchers interviewed a diverse group 100 nurses—the first large-scale study of its kind, according to the study.

"Study participants resoundingly articulated a chasm between how they would have liked to have performed according to their professional duty and obligations as nurses versus the reality of providing patient care during the first wave of the pandemic," researchers said.

Within the main theme moral distress, four specific subthemes articulating the emotions felt by nurses experiencing moral distress emerged: fear, frustration, powerlessness, and guilt around letting others down, the study said.


Study participants resoundingly reported "fear of the unknown" in providing patient care during the pandemic's first wave.

Providing nursing care to COVID patients was perceived to be "scary" and "dangerous" by study participants.

"This virus made a lot of older nurses and nurses with preexisting conditions retire," one nurse responded. "It did instill a lot of fear to the point of the nurses quit[ting] their jobs … It just shook everything."


Nurses experienced frustration because of unmet needs and feeling unacknowledged, the study said.

Study participants described various sources of frustration, ranging from dissatisfaction with leadership to irritation during patient interactions.

"It does make me frustrated that there's no medical people in management," one study participant said. "People are making decisions [who] aren't necessarily aware of how it works … why are we not having more power and more say in things?"


Nurses felt an inability to influence an outcome and/or voice their concerns, leading to feelings of powerlessness, according to the study.

Many were dismayed that their institution didn't involve nurses in helping develop safety plans.

"Even when I was there prior to COVID, we were not really involved in … decision making, and it's really unfortunate because the people who govern … nurses are not people who have health backgrounds," one nurse told researchers. "So if we make a suggestion, it sort of falls on deaf ears because they’re not health professionals.


Many nurses expressed regret surrounding care and decision-making as it related to themselves, their colleagues, and the treatment of their patients and family units.

"The hardest part … for me, was the separation of the families [from] the patient and the suffering that [it] caused," one nurse expressed to researchers.

"Their spouses would be sobbing on the phone saying, 'Is there any way you can get me into that room? … I've been at his side for 65 years …. Now at this important time, I can't be with him.' And it broke my heart," the nurse continued. "That, for me, was the hardest thing."

Listening to nurses

Hearing the voices of nurses from this unparalleled moment in history could help inform policies and laws to improve retention and reduce burnout among nurses in the U.S., study researchers said.

"People need to listen to nurses more, and nurses need to feel empowered to share their experiences at every level of leadership," said principal investigator Shannon Simonovich, PhD, RN, assistant professor of nursing.

Simonovich recruited a diverse group of DePaul nurse researchers to conduct the study, which in turn helped recruit a diverse group of nurses to be interviewed, according to assistant professor and coauthor Kashica Webber-Ritchey, PhD, RN.

"We captured the voices of diverse nurses caring for a diverse patient population that was being disproportionately impacted by COVID-19," Webber-Ritchey said.

In the DePaul sample, 65% of the nurses identified as a member of a racial, ethnic, or gender minority group.

Call to action

The narratives in this study should be a call to action, says Kim Amer, PhD, RN, an associate professor with 40 years of nursing experience.

"Nurses need to come together as a profession and make our standards and our demands clear," Amer said. "We are a largely female profession, and we don't complain enough when things are tough. As a faculty member, we teach students that it’s OK to refuse an assignment if it’s not safe. We need to stand by that."

The DePaul research team is calling for clear, safe standards for nurses that will be legally binding and hold hospitals accountable.

“We go into nursing with the intention of saving lives and helping people to be healthy,” Simonovich said. “Ultimately, nurses want to feel good about the work they do for individuals, families, and communities.”

The research is published and available online from the journal SAGE Open Nursing. 

Carol Davis is the Nursing Editor at HealthLeaders, an HCPro brand. This story first appeared on HealthLeaders Media. 

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