A recent study reveals how the COVID-19 pandemic intensified moral suffering among nurse leaders, highlighting the urgent need for organisational reform, ethical support, and resilience-building to safeguard nurse wellbeing and care quality.
Nursing practice is fundamentally grounded in the commitment of nurses to care for patients, a principle deeply embedded in the Nursing Code of Ethics. However, the COVID-19 pandemic exposed and intensified significant challenges within healthcare organizations, revealing critical gaps between these nursing values and the practical realities of clinical environments. These gaps have led to moral suffering and moral injury (MI) among nurses and nurse leaders, primarily stemming from organizational ineffectiveness (OE).
A recent comprehensive study exploring nurse leaders’ experiences during the pandemic highlights that nurse executives perceive their organizations as more effective than nurse managers (NMs) or other nurse leaders do. This discrepancy may arise because executives are more involved in decision-making processes and thus have greater insight into organizational constraints and corrective measures, creating potential bias. Conversely, NMs rated OE lower, especially concerning staffing issues, which are central to their daily responsibilities. These managers face profound ethical dilemmas when staffing is inadequate—balancing patient and staff safety, budget limitations, and their own wellbeing—often leading to moral injury. The strain becomes particularly acute when they must decide between allowing unsafe staff-to-patient ratios, asking staff to work excessive hours, or personally providing direct care under overwhelming conditions.
During the pandemic, many healthcare organizations paused shared governance structures critical to nurse leadership engagement and clear communication. Those that maintained mechanisms such as remote meetings, online reporting systems, and in-person rounding demonstrated robust OE and a commitment to nursing inclusion. Models like the Healthy Work Environment, developed by the American Association of Critical-Care Nurses, which assess institutional communication, collaboration, staffing, decision-making, recognition, and leadership, have shown that positive work environments correlate with reduced burnout and turnover intentions among nurses, though the link with moral injury specifically requires further research.
Moral injury became a pervasive issue, with more than one-third of nurse leaders in the study reaching clinically significant levels. Feelings of betrayal by organizational leadership were the most troubling, especially during the public health emergency when care quality sometimes seemed subordinated to financial or operational concerns. Nurse managers, despite being removed from bedside care, also reported guilt relating to patient outcomes, illustrating the breadth of MI’s impact. While certain ethical support tools exist for bedside nurses, like the Cura System or Moral Case Deliberation, these do not adequately address the systemic sources of moral harm faced by nurse leaders, highlighting a gap that needs attention.
Moral resilience (MR), the capacity to sustain or restore integrity in response to moral adversity, emerged as a potential buffer against moral injury. Executives exhibited higher MR than managers or other leaders, possibly related to their greater years of experience and decision-making power, which afford them more agency to align organizational actions with their ethical values. Nonetheless, the study emphasises that resilience should not shift responsibility away from organizations; rather, MR and OE are mutually reinforcing. Investment in both personal resilience-building and organizational reform is necessary to mitigate moral suffering effectively.
A significant contributor to the moral injury and organizational ineffectiveness nurses experience is chronic understaffing—exacerbated by the pandemic and the broader nursing shortage crisis. Nurse managers face the ethical burden of staffing decisions without adequate support and with limited avenues to implement solutions like redeployment or cross-training. Such measures often require executive leadership and financial backing. Furthermore, strategies to manage staffing shortages can unintentionally lead to burnout among full-time staff who must train temporary or redeployed nurses, undermining team cohesion.
Organizational breakdowns and ineffective policies have caused breaches of trust across healthcare leadership levels, despite the distinct perspectives and responsibilities inherent at each level. Robust OE requires cooperative collaboration among all tiers of nursing leadership, alongside investments in ethical frameworks, transparent communication channels, and equitable human resource allocation. The study suggests that integrating nurses more fully into ethics committees could create vital feedback loops and ethical guidance, fostering shared governance and mutual support.
While the study’s focus was on a US sample and recruitment was via professional organisations—potentially limiting generalizability—its findings resonate with broader research on the importance of organizational accountability, ethical support, and resilience in nursing. The implications call for healthcare entities to proactively monitor moral injury, enhance moral resilience among nurse leaders, and bridge communication gaps within leadership hierarchies to support ethical practice and care quality.
In the wake of these findings, healthcare organizations are urged to cultivate trustworthy behaviours, authentic communication, and transparency, embodying the nursing code of ethics to promote nurse leader retention and wellbeing. Clear policies, ethical resources, and meaningful leadership involvement in ethics decision-making stand as crucial pillars to address the pandemic’s legacy and prepare for future crises, safeguarding both nurse leaders and patient care integrity.
Source: Noah Wire Services
