AACN Position Statement: Moral Distress in Times of Crisis

Mar 01, 2020

Added to Collection


Moral distress is “knowing the right thing to do but being in a situation in which it is nearly impossible to do it.”1

Critical care teams wrestle daily with moral challenges in the context of their normal professional activities.2 During a crisis, such as the COVID-19 pandemic, everyday challenges are compounded. For example, patient surge results in shortages of lifesaving equipment needed to keep patients alive3 and a lack of personal protective equipment necessary to protect nurses, their patients, their families, and their communities.4,5 Team members struggle to maintain their professional, emotional, and moral equilibrium when caught in tragic situations beyond their control.

Nurses, and all members of the healthcare team, must protect their personal integrity and sense of justice to be effective in their work. Too often, nurses are pressured to compartmentalize emotions, and to rapidly and stoically “do your duty.” Sustaining a strong sense of duty maintains order, serves patients, and preserves the respect of coworkers and loved ones. However, discerning one’s duty may not take the linear path of simply following orders and regulations. Those who apply a care-based morality prioritize relationships with others in making moral decisions.1,6 Embracing a care-based perspective recognizes that nurses live in a web of moral duties that includes their duty to protect themselves, their patients, their families, and their communities.

AACN's Position

Moral distress is a complex, challenging problem with damaging repercussions that are often ignored in healthcare work environments. This problem is exacerbated in times of crisis. AACN asserts that every institution must implement readily accessible resources to identify and mitigate the harmful effects of moral distress. In addition, nurses must not hesitate to seek professional ethical support and other types of counseling when experiencing moral distress or feeling a loss of personal integrity. Skilled communication is necessary to ensure that institutional leaders and frontline nurses are allies during times of crisis.7

Recommended Actions for Healthcare Institutions

Every organization must:

  • Provide the vital supplies and equipment that nurses need to protect themselves and others.
  • Establish evidence-based, consistent, procedures for equitably allocating scarce resources and use them in a way that maximizes value without endangering safety.8,9
  • Consider creating an interdisciplinary triage committee composed of respected volunteers to provide unbiased opinions in difficult situations. This preserves each direct caregiver’s ethical duty for beneficence.3
  • Ensure that administrators are accessible to those performing direct patient care, and that they maintain clear communication and transparency regarding institutional challenges.
  • Guarantee that nurses are included as decision makers on all institutional ethics committees.
  • Monitor the clinical and organizational climate to identify situations that could create moral distress.
  • Provide tools to help clinicians recognize the experience of moral distress.
  • Create interdisciplinary forums to discuss patient goals of care and divergent opinions regarding those goals of care in an open, respectful environment.
  • Ensure institutional support systems include easy access to:
    • Ethics committees
    • Critical stress debriefings
    • Protocols for end-of-life care
    • Readily available crisis counseling
    • Employee assistance programs
    • Grief counseling

Recommended Actions for Nurses

Nurses must:

  • Pay attention to your inner voice and recognize when it conflicts with what you are being asked to do or what circumstances demand that you do.
  • Create a moral compass for yourself by expanding your ethical knowledge. Seek out professional and institutional resources that can provide ethical guidance, such as:
    • American Nurses Association Code of Ethics for Nurses10
    • International Council of Nurses Code of Ethics for Nurses11
    • Your hospital’s ethics committee or moral distress consulting team.
  • Learn the signs and symptoms of moral distress. They include:
    • Feelings of frustration, anger, and guilt12
    • Physical manifestations such as heart palpitations, insomnia, and fatigue
    • Psychological consequences such as withdrawal, emotional exhaustion, and depersonalization of patients.13
  • Seek out a trusted mentor.
  • Use employee assistance resources and see a qualified professional counselor or therapist when needed.
  • Lean on coworkers, friends, and loved ones. They are all in the mix as you balance your personal and professional duties, and they need to know when you are experiencing moral distress.

Helpful Resources:

AACN has a webpage on moral distress to provide nurses with articles and other support materials.


  1. Jameton A. What moral distress in nursing history could suggest about the future of health care. AMA J Ethics. 2017;19(6):617-628.
  2. Savel RH, Munro CL. Moral distress, moral courage. Am J Crit Care. 2015;24(4):276-278. doi: 10.4037/ajcc2015738
  3. Truog RD, M.D., Christine Mitchell C, Daley GQ. The toughest triage — Allocating ventilators in a pandemic. NEJM. Published online March 23, 2020. doi: 10.1056/NEJMp2005689 https://www.nejm.org/doi/full/10.1056/NEJMp2005689
  4. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID19) in Healthcare Settings. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html
  5. Interim Guidance: Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19). World Health Organization. Accessed March 25, 2020. https://apps.who.int/iris/bitstream/handle/10665/331215/WHO-2019-nCov-IPCPPE_use-2020.1-eng.pdf
  6. van Nistelrooij I, Leget C. Against dichotomies: On mature care and self-sacrifice in care ethics. Nurs Ethics. 2017;24(6):694-703. doi: 10.1177/0969733015624475
  7. Barden C, Cassidy L, Cardin S, eds. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. 2nd ed. Aliso Viejo, CA: American Association of Critical-Care Nurses; 2016. https://www.aacn.org/nursing-excellence/standards/aacn-standards-for-establishing-and-sustaining-healthy-work-environments. Accessed March 25, 2020.
  8. Emanuel EJ, Persad G, Upshur R, et al. Fair allocation of scarce medical resources in the time of covid-19. N Engl J Med. Published online March 23, 2020. doi: 10.1056/NEJMsb2005114
  9. Daugherty Biddison EL, Faden R, Gwon HS, et al. Too many patients…a framework to guide statewide allocation of scarce mechanical ventilation during disasters. Chest. 2019;155(4):848-854. doi: 10.1016/j.chest.2018.09.025
  10. American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. Silver Spring, MD: Nursesbooks.org Retrieved from https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/
  11. The ICN Code of Ethics. Revised. Geneva Switzerland: International Council of Nurses; 2012.
  12. Epstein EG, Delgado S. “Understanding and Addressing Moral Distress.” Online J Issues Nurs. Published online September 30, 2010. doi: 10.3912/OJIN.Vol15No03Man01.
  13. Rushton CH, Caldwell M, Kurtz M. Moral Distress: A catalyst in building moral resilience. Am J Nurs. 2016;116(7):40-49. doi: 10.1097/01. NAJ.0000484933.40476.5b
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