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 Table of Contents  
Year : 2021  |  Volume : 2  |  Issue : 3  |  Page : 272-275

Moral injury and ethical dilemma during COVID-19: Pandemic's fallout for nurses

1 Department of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 School of Nursing, Johns Hopkins University, Maryland, USA

Date of Submission01-Sep-2021
Date of Decision06-Dec-2021
Date of Acceptance07-Dec-2021
Date of Web Publication28-Dec-2021

Correspondence Address:
Dr. Rajesh Kumar
Department of Nursing, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_83_21

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How to cite this article:
Kumar R, Rodney T. Moral injury and ethical dilemma during COVID-19: Pandemic's fallout for nurses. J Med Evid 2021;2:272-5

How to cite this URL:
Kumar R, Rodney T. Moral injury and ethical dilemma during COVID-19: Pandemic's fallout for nurses. J Med Evid [serial online] 2021 [cited 2022 Jan 24];2:272-5. Available from: http://www.journaljme.org/text.asp?2021/2/3/272/333960

  Introduction Top

Nurses are the most significant and integral part of the health-care system. It is well-known that nurses played a pivotal role in fighting pandemics and saved millions of endangered lives. The severity of the disease and global outbreak resulted in an urgent need to screen, diagnose, treat and combat further transmission of the virus.[1] Severe scarcity of resources such as gloves, masks, face shields, respirators and hand hygiene supplies augment acute unmanageable stress and hamper rationalised decision-making.[2] Furthermore, a longer course of pandemic further depleted coping mechanisms resulting in impaired ethical decision making. In light of the ever-increasing risk of contracting the COVID-19 infection, nurses were forced to decide and prioritise the care they could provide while taking care of themselves.[3]

  Moral Injury Top

The acute outburst of the pandemic forced the health-care workers to tough medical decisions making and put them in an ethical dilemma while treating the patients. Inappropriate decision-making and uncounted deaths resulted in emotional burden and moral injury. However, earlier literature describes terms burn out, moral distress and compassion fatigue are frequently used to describe the effects of nursing job stress.[4] Too often, words burn out and compassion fatigue is concerned that we are not strong enough to handle the issue at the workplace. Moral injury is a more suitable term to understand both together in the present scenario. The moral injury was first used to describe the soldier's response in a war in words of failure to respond in war.[5] Moral injury in health-care deals with failure to provide high-quality care and healing.[5] It is considered psychological distress resulting from negligence or ethical and moral codes while involving inpatient care. Further, it is described as a deep soul wound that pierces a person's identity, sense of morality and relationship to society.[5]

  Negative Impact of Moral Injury Top

Moral injury leads to guilt, shame, disgust and negative thinking about self, others and the world.[6] Long duration of the pandemic, extreme working conditions, complex medical decisions and striving to balance between personal and professional life considering the patient, family and friends' emergent need further intensify the moral injury among nurses.[3] In addition, it has been evident that burnout, vicarious trauma and pandemic fatigue are directly related to exaggerated moral injury. Likewise, technology-driven means of communication, i.e., FaceTime and video call with patient and family members, inconsistent care plan, end-of-life decision and amount of care, also found contributed to the moral injury in this COVID-19 pandemic.[7],[8] Leading from the front to decide types of care, breaking bad news, enforcing new protocols and policies every day, holding positions to share the update of a patient with family members left nothing but a scar on the mental health of nurses.[9] Nurses were clinically and morally obligated to serve the best possible care during the pandemic. The never-ending pandemic makes the nurses more vulnerable to emotional and vicarious trauma each passing day.

Nurses look ill-prepared to face long-term emotional burdens and moral injury in the pandemic. Lack of proper education, training and mitigating measures in a pandemic may have a detrimental impact on psychological health, including burnout, impaired physical health and well-being and worse in coming days.[10] This can further exaggerate nurses' moral injury, resulting in impaired job performance and high turnover.

Ignoring or discounting the negative impact on mental health will have short-term or long-term consequences on patient care and delivery system. Nurses are reserved for discussing their feelings with others and are more vulnerable to moral injury by women's nature. Institutional administration must recognise the magnitude and prevalence of moral damage and hold the hands of nurses to encourage them to share their feeling with others. Nurses should be encouraged and appreciated for their success, no matter how big or small. Acknowledgement, instillation of hope and a sense of accomplishment can bring a remarkable change in mental health and work performance.[11] Teaching nurses about self-efficacy and self-control will help them react positively to daily encountered hassles.[12] Mindful breathing will help nurture moral resilience to combat distress, anxiety, fear, helplessness and ethical decision-making in the ongoing pandemic.[9] Self-stewardship is another skill that can help individuals understand and appreciate their actions in the public domain.[9]

  Fixing Moral Injury Top

There are many ways and approaches which can be helpful to enhance organisational culture and moral resilience among nurses. It is equally vital for administration to identify their stage undergoing mental trauma for early intervention and promotion of mental well-being. Changes in working hours, hospital ergonomics and uninterrupted teaching and training will help create a safe work environment and build a culture of resilience with avenues of support. Pandemic is a wake-up call to everyone to examine the psychological health of nurses. Understanding different possible factors (burnout, compassion fatigue, chronic stress and mental trauma) will be helpful to develop evidence-based and tailored interventions to mitigate moral injury and promote post-pandemic mental health. However, there is a lack of literature on moral injury among nurses in developing countries, including India. This suggested an extensive body of literature to put up empirical evidence on moral injury among nurses.

  Ethical Dilemmas Top

Amid pandemics, nurses face a new and daunting challenge to provide equal and optimal treatment, regardless of their gender, age, medical background or personal responsibility. Nurses are forced to work under a dwindling medical supply to manage overwhelmed volume of patients. The shortage of medical and protective resources made ethical decision-making challenging in the pandemic.[10] A situation-driven shift from patient-centred ethics to public-centred ethics also presents new challenges for nurses. With a quick pandemic shift, the nurses must use public health ethics as a guiding principle to care for the patients.[13] However, an overnight transition to using public health was challenging, cumbersome and violated many fundamentals of contemporary nursing care. Furthermore, complex working conditions, adaptation to the new hospital environment and a high volume of deaths left no choice for the nurses to choose public health ethics. Nurses became more directive to leave one patient to treat another vulnerable or critical patient.[9] Interestingly, this situation came in between to counter the implementation of ethical decision-making and left the nurses in a moral dilemma.

During the COVID-19 pandemic, even the developed countries failed to triage the patients in overwhelmed available resources. The concern of priority and failure to abide by ethical principles is jeopardised while meeting the medical need of the patients in the pandemic. During this perplexing situation, nurses became more directive to take immediate decisions to provide care to COVID-19 patients.[9],[14] During the pandemic, a continuous depletion and lack of medical supplies and equipment made the nurses obliged and forced to treat the patient with their best possible medical care. Nurses were confused yet obliged to follow the ethical principles to decide who should be treated first? Whose family needs an update first on the patient's status? How to break the bad news to parents and family members? How to help the parents and family perform the last rights of the departed soul for a dignified death? It looked like confronting to not allow close relatives to pay tribute to the departed soul in the last stage.[15] All these unpredicted and bewildering situations threaten core ethical principles to preserve the life and dignity of an individual patient.[14] However, the problem was highly stressful and unacceptable outside the teaching and nursing training. Exposures to new illnesses, lack of exposure in new situations, i.e., working to handle a massive volume of patients, protecting self from contracting infection, untrained and low nursing manpower and high expectations to provide the best possible care made it more difficult for nurses to abide by ethical principles.[7] Saying that it was challenging to meet the standard of care due to the unprepared infrastructures to handle an enormous number of patients, crunch of trained workforce, lack of time and resources driven situation.[12] Further, it was unethical to force the nurses to choose one over another and decide between community needs and individual needs in low or depleted source-driven countries, including India.[9] This terrifying state strikes nurses to think about their abilities and question whether they provide dignified care to a patient who is cut off from family and stays alone in the hospital area. Further, nurses struggled to adapt to this new normal, such as bar code scanning, using masks, more frequent hand hygiene practices, telenursing services to serve people in remote locations and more non-verbal communication in the workplace.[16] Failure to provide dignified care to all equally causes moral distress and mental health problems such as fear, anxiety, stress, insomnia and irritability to nurses.[10],[17] Likewise, the difficulty of adjusting to excessive pressure resulted in post-traumatic stress as a byproduct of intangible moral and ethical decisions.[18]

Beyond the unethical decision-making, lack of personal protective equipment (PPE) and other mandatory supplies create further confusion and hampered ethical decision-making.[10] In many developed countries, including The United States, nurses were expected to follow the standard of right and responsibility while dealing with the patients. They were ensured to take sufficient measures to protect themselves and their families.[14]

Nurses, by virtue, are never taught to practice medicine in a devastating situation like a coronavirus pandemic. Nurses are never exposed to handle and work in such cases in their training.[9] They have ample resources and supplies at hand while training themselves. However, this pandemic gave a new lesson to prepare our nursing workforce to be ready to deal with every type of awful situation in the future. Nursing training in developing countries like India needs to be revamped using the think tank of nursing leaders to make it more resourceful and safer in the future.

  Ethical Decision-Making Strategies Top

Nurses faced moral injury and ethical dilemmas during the COVID-19 pandemic as different rules were applied to combat pandemics in the early days. However, there is enough evidence from developed countries on these fallouts, which are sufficient to ring the bell to take necessary actions to protect the mental health of the nurses.[4],[5],[9],[19],[20]

The utilitarian model for triage, meeting the shortage of PPE, leadership communication, acknowledgement and appreciation from administration and shared decision-making approach can help mitigate the negative and long-term consequences of moral injury and help the nurses to follow the ethical standard of care.[18],[20] Further, the nurses should be encouraged to take professional psychological counselling to themselves and their professional colleagues before symptoms become clinically significant. The use of Schwartz Rounds (a platform that allows various health professionals to discuss their social and emotional challenges related to patient care) may be another effective strategy to deal with moral distress.[20] Structured feedback opportunities for nurses to open up on challenges to care, emotional burden and psychological experiences may be helpful to reduce the secondary effects of traumatic stress and moral injury. The use of cognitive-behavioural interventions may benefit by validating the experiences and feelings of nurses.[19] Tele-health services may be another tested approach to provide individual counselling irrespective of nurses' odd time and duty hours.[20] Nurses should be prepared to combat moral dilemmas by direct, open and frank conversation with administrative staff and other senior colleagues.

The use of meditation, yoga and puppy therapy was also found beneficial to heal the moral injury.[3] In a nutshell, preparing the nurses for such a situation, managing dwindling medical supplies, ensuring enough PPE, appreciative administrative support and sound feedback from ground-level staff maybe some of the few strategies that can help beat moral injury and ethical dilemmas. Finally, nurses are advised to practice with caution deciding whether or not to participate in patient care. Further, analysis of the situation's pros and cons is highly advisable to nurses to make them accountable for the problem when required.

  Conclusion Top

It is known that nurses faced moral injury and ethical dilemmas considering the crisis of recourses and the sudden surge of COVID-19 cases globally. We should not forget that developing an ideal health-care setup is not a practical solution to prevent moral injury and ethical dilemmas. Some degree of moral distress and ethical dilemmas are inevitable consequences in a mass-casualty situation like coronavirus disease. Just as both individual and systematic measures are needed to control the pandemic and exhaustion of the medical resources in an ongoing pandemic, the use of a proactive approach to providing adequate PPE, rapid access to occupational health, paid quarantine and meeting the physical needs will support the mental health of the nurses.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Mannelli C. Whose life to save? Scarce resources allocation in the COVID-19 outbreak. J Med Ethics 2020;46:364-6.  Back to cited text no. 2
Kathleen D. Moral Injury: Pandemic's Fallout for Health Care Workers; 2021. Available from: https://www.webmd.com/lung/news/20210201/moral-injury-pandemics-fallout-for-health-care-workers. [Last accessed on 2021 Sep 01].  Back to cited text no. 3
Jarrad RA, Hammad S. Oncology nurses' compassion fatigue, burn out and compassion satisfaction. Ann Gen Psychiatry 2020;19:22.  Back to cited text no. 4
Talbot SG, Dean W. Physicians aren't 'Burning Out.' They're Suffering from Moral Injury. STAT. Available from: https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. [Last accessed on 2021 Aug 31].  Back to cited text no. 5
Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during COVID-19 pandemic. BMJ 2020;368:m1211.  Back to cited text no. 6
Morley G, Grady C, McCarthy J, Ulrich CM. COVID-19: Ethical challenges for nurses. Hastings Cent Rep 2020;50:35-9.  Back to cited text no. 7
Henrich NJ, Dodek PM, Alden L, Keenan SP, Reynolds S, Rodney P. Causes of moral distress in the intensive care unit: A qualitative study. J Crit Care 2016;35:57-62.  Back to cited text no. 8
Hossain F, Clatty A. Self-care strategies in response to nurses' moral injury during COVID-19 pandemic. Nurs Ethics 2021;28:23-32.  Back to cited text no. 9
Lake ET, Narva AM, Holland S, Smith JG, Cramer E, Rosenbaum KE, et al. Hospital nurses' moral distress and mental health during COVID-19. J Adv Nurs 2021;00:1-11.  Back to cited text no. 10
Phoenix Australia – Centre for Posttraumatic Mental Health and the Canadian Centre of Excellence-PTSD. Moral Stress amongst Healthcare Workers during COVID-19: A Guide to Moral Injury. Phoenix Australia – Centre for Posttraumatic Mental Health and the Canadian Centre of Excellence – PTSD; 2020. Available from: https://www.acn.edu.au/wp-content/uploads/COVID-19-self-care-moral-stress-amongst-healthcare-workers.pdf. [Last accessed on 2021 Sep 01].  Back to cited text no. 11
Dharra S, Kumar R. Promoting mental health of nurses during the coronavirus pandemic: Will the rapid deployment of nurses' training programs during COVID-19 improve self-efficacy and reduce anxiety? Cureus 2021;13:e15213.  Back to cited text no. 12
Berlinger N, Wynia M, Powell T, Hester DM, Milliken A, Fabi R, et al.. Ethical Framework for Health Care Institutions and Guidelines for Institutional Ethics Services Responding to the Coronavirus Pandemic. The Hastings Center. 2020. Available from:https://asprtracie.hhs.gov/technical-resources/resource/8714/ethical-framework-for-health-care-institutions-and-guidelines-for-institutional-ethics-services-responding-to-the-coronavirus-pandemic. [Last accessed on 2021 Sept 02].  Back to cited text no. 13
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