Perceived moral distress and moral injury experienced by nurses during the COVID-19 pandemic

Introduction: This study explores the experiences of direct care nurses with moral distress (MD) and moral injury (MI) during the COVID-19 pandemic. Objective: To understand how nurses experienced ethically challenging events that conflicted with their professional values and led to MD and MI. Method: A phenomenologic design was used to examine lived experiences of direct care nurses in acute care settings. Participants were recruited via social media and professional organizations to complete an online survey. Qualitative content analysis was used to identify themes. Results: Nurses described potentially morally injurious events, including ethical conflicts, clinical decisions beyond their control, inadequate leadership presence, and unsafe staffing. These experiences resulted in MD (feelings of guilt and emotional exhaustion) and MI, including betrayal by leadership, colleagues, and even loved ones. Many nurses described providing suboptimal care, witnessing patients die alone, and being asked to work beyond their expertise. Conclusion: Nurses encountered complex ethical challenges during the pandemic that contributed to MD and MI. These findings underscore the importance of ethical leadership, enhanced preparedness, and further education. Long-term strategies must extend beyond symbolic gestures to provide tangible, visible support and address the moral and psychological burdens that nurses face.