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Poor leadership communication may lead nurses to feel unsupported amid a crisis. Good leadership communication acknowledges the difficulty of the situation, its rapidly changing status and provides rationales for changing policies.

The association of PPE workarounds to moral distress is not surprising given the transmission risks that nurses faced. Circumstances of severe workarounds to obtain PPE is likely to correlate with concurring broader chaos in the healthcare setting, which fuels morally distressing situations even if they are not about transmission risk. Research shows that in the early pandemic months, HCWs experienced high rates of anxiety, depression and sleep problems Muller et al.

This unfortunate finding may be due to the psychological trauma of moral distress. As noted by Spalluto et al.

Our study reveals a similar circumstance, indicating that we have not learned from 2 decades of prior outbreaks. We are overdue to create resilient structures to meet future challenges.

Our findings have implications for managers. To mitigate moral distress, nurse managers should provide clearly communicated policies and guidelines. Consistent with our study, others have found that clear and timely communication about frequent policy changes, solicitation of questions and concerns from clinical nurses, and timely responses to those concerns enable nurses to practice with certainty and support, knowing their care is based on the best available information Rosa et al.

Forthwith, managers should develop unit policies for a crisis standard of care and educate staff about them. Nurses should be invited to leverage their unique vantage point to collaboratively create policies and protocols as well as solutions to mitigate moral distress.

Accordingly, managers should direct resources to these nurses. Morley et al. The ANA has held numerous webinars for clinicians and managers and also provides a wellness website with links to apps, podcasts and hotlines ANA, b.

Direct care nurses may benefit if a designated staff member, e. Our findings have implications for nursing education. Comprehensive ethics education should be mandated for all nurses but is not currently universally required. This education would give nurses tools to identify ethical implications and challenges of a crisis standard of care. This education should include the nature of moral distress and resources to address it.

Our findings have research implications. The potential for a better nurse work environment to mitigate moral distress during a crisis is worthy of investigation given that transparent communication is one element of a favourable work environment. Interventions about communication timing and methods i. Our study had several limitations. Our sample was a convenience sample from two urban academic medical centres in the Northeastern U.

Results may not generalize to nurses working in other hospital types and regions. These responses may have differed from those of nurses who chose not to participate. There was potential recall bias of nurses recalling events and distress from 5 months earlier. Those events and distress, however, were likely to have made a distinct impression. A more detailed measure of communication in future studies may provide additional insights for managers.

The data supported Epstein's framework by revealing that the three levels of moral distress contributed significantly to moral distress. Unique features of pandemic patient care generated the most moral distress. Given the lingering negative effects on nurses of suffering moral distress during a crisis, our findings should motivate and provide guidance for leaders in future crises.

The authors wish to thank the staff nurses who completed the survey and Morgan Peele for her analytic support. Lake, E. Journal of Advanced Nursing , 00 , 1— Funding information Dr. Clark's postdoctoral fellowship and Ms. French's and Ms. National Center for Biotechnology Information , U. J Adv Nurs. Eileen T. Lake , 1 Aliza M. Narva , 2 Sara Holland , 2 Jessica G.

Smith , 3 Emily Cramer , 4 Kathleen E. Clark , 1 and Jeannette A. Rogowski 5. Aliza M. Jessica G. Kathleen E. Fitzpatrick Rosenbaum. Rebecca R. Jeannette A. Author information Article notes Copyright and License information Disclaimer. Lake, Email: ude. Corresponding author. Email: ude. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

This article has been cited by other articles in PMC. Associated Data Data Availability Statement The data that support the findings of this study are available on request from the corresponding author. Results Many respondents had difficulty accessing personal protective equipment. Conclusion Pandemic patient care situations are the greatest sources of nurses' moral distress.

Leadership communication may reduce moral distress While moral distress during pandemic nursing care is inevitable, effective manager communication with staff during a crisis may mitigate moral distress.

Participants Participants were registered nurses RNs who provided direct patient care. Data collection Data were collected via an online survey administered through RedCap for 1 week, the last week of September Ethical considerations We considered whether it was ethical to ask nurses about sensitive moral distress and mental health without providing services. Measures The measures are described in the order they were presented in the survey.

Data analysis Sample characteristics and key variables were described with descriptive statistics. Open in a separate window. Note Table data reflect subsample of nurses who reported difficulty accessing PPE or cleaning supplies. Frequency of workarounds for personal protective equipment and cleaning supplies.

Note n varies from to due to missing data.