AACN Position Statement: Moral Distress in Times of Crisis

Apr 15, 2025

Added to Collection

This AACN Position Statement was first published March 1, 2020. It was reviewed and updated on April 10, 2025.

Background

Moral distress is “the inability to do the right thing due to institutional constraints.”1 It is a complex, challenging problem that is exacerbated in times of crisis, often causing damaging repercussions.

Critical care teams wrestle daily with moral challenges in the context of their normal professional activities.2,3 Team members may struggle to maintain their professional, emotional, and moral equilibrium when caught in tragic situations beyond their control. For example, during a crisis such as the COVID-19 pandemic, everyday challenges were compounded when patient surges resulted in shortages of lifesaving equipment and a lack of personal protective equipment necessary to protect nurses, their patients, their families, and their communities.4 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, hospital policies, and regulations. Embracing a care-based perspective recognizes that nurses live in a web of moral duties that includes their responsibility to protect themselves, their patients, their families, and their communities.5

AACN's Position

Healthcare institutions, leaders, and individual healthcare professionals must partner to assess for and minimize situations that can trigger moral distress. 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 peer or professional ethical support 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.6

Recommended Actions for Healthcare Institutions

Every organization must:

  • Provide the vital supplies and equipment that nurses need to protect themselves and others.
  • Consider creating an interdisciplinary triage committee to guide clinicians and ensure equity in the application of rationing under crisis standards of care.7
  • Establish evidence-based, consistent policies and procedures for equitably allocating scarce resources and use them in a way that maximizes value without endangering safety .2,7
  • 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.8
  • Provide tools to help clinicians recognize the experience of moral distress.3,9,10
  • 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:11
    • 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.9
  • Raise concerns about resource allocation and advocate for transparency when decisions about resource allocation are made.2
  • 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 Nurses12
    • International Council of Nurses Code of Ethics for Nurses13
    • Your hospital’s ethics committee or moral distress consulting team
  • Learn the signs and symptoms of moral distress:14,15
    • Physical effects, such as sleep disturbances, poor health status, loss of appetite, headaches, fatigue, and gastric upset
    • Emotional and psychological effects, such as frustration, inadequacy, demoralization, sadness, fear, powerlessness, anger, guile, blunted emotions
  • Seek out a trusted mentor.
  • Use employee assistance resources and see a qualified professional counselor or therapist when needed.16
  • Seek support from 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.

References

  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. https://www.doi.org/10.1001/journalofethics.2017.19.6.mhst1-1706
  2. Kennedy KO, Puccetti DF, Marron JM, Brown SD. Potentially Inappropriate Treatment: Competing Ethical Considerations. AACN Adv Crit Care. 2025;36(1):30-36. https://www.doi.org/10.4037/aacnacc2025898
  3. Booth AT, Robinson KL. System-wide assessment using the Measure of Moral Distress - Healthcare professionals. Nurs Ethics. Published online March 3, 2025. https://doi.org/10.1177/09697330251324296
  4. Rushton CH, Turner K, Brock RN, Braxton JM. Invisible Moral Wounds of the COVID-19 Pandemic: Are We Experiencing Moral Injury? AACN Adv Crit Care. 2025;36(1):37-43. https://www.doi.org/10.4037/aacnacc2025280
  5. van Nistelrooij I, Leget C. Against dichotomies: On mature care and self-sacrifice in care ethics. Nurs Ethics. 2017;24(6):694-703. https://www.doi.org/10.1177/0969733015624475
  6. 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
  7. Supady A, Curtis JR, Abrams D, et al. Allocating scarce intensive care resources during the COVID-19 pandemic: practical challenges to theoretical frameworks. Lancet Respir Med. 2021;9(4):430-434. https://www.doi.org/10.1016/S2213-2600(20)30580-4
  8. Vanderloo MJ, Evans E, Smith A, et al. Exploration of Nurses' Experiences Related to Moral Injury: A Reflexive Thematic Analysis of Nurse Interviews. J Adv Nurs. Published online February 26, 2025. https://doi.org/10.1111/jan.16856
  9. Rushton CH. Transforming Moral Suffering by Cultivating Moral Resilience and Ethical Practice. Am J Crit Care. 2023;32(4):238-248. https://www.doi.org/10.4037/ajcc2023207
  10. Jolaei S, Rodney P, Starzomski R, Dodek P. From Moral Distress to Moral Integrity: Qualitative Evaluation of a New Moral Conflict Assessment Tool. Am J Crit Care. 2025;34(1):52-59. https://www.doi.org/10.4037/ajcc2025500
  11. Salari N, Shohaimi S, Khaledi-Paveh B, Kazeminia M, Bazrafshan MR, Mohammadi M. The severity of moral distress in nurses: a systematic review and meta-analysis. Philos Ethics Humanit Med. 2022;17(1):13. https://www.doi.org/10.1186/s13010-022-00126-0
  12. American Nurses Association. (2025). Code of ethics for nurses. https://codeofethics.ana.org/home
  13. International Council of Nurses. (2021). The ICN Code of Ethics for Nurses. https://www.icn.ch/sites/default/files/2023-06/ICN_Code-of-Ethics_EN_Web.pdf
  14. Aljabery M, Coetzee-Prinsloo I, van der Wath A, Al-Hmaimat N. Characteristics of moral distress from nurses' perspectives: An integrative review. Int J Nurs Sci. 2024;11(5):578-585. https://www.doi.org/10.1016/j.ijnss.2024.10.005
  15. Stephenson P, Warner-Stidham A. Nurse Reports of Moral Distress During the COVID-19 Pandemic. SAGE Open Nurs. 2024;10:23779608231226095. https://www.doi.org/10.1177/23779608231226095
  16. Bergman A, Rushton CH. Overcoming Stigma: Asking for and Receiving Mental Health Support. AACN Adv Crit Care. 2025;36(1):58-62. https://www.doi.org/10.4037/aacnacc2025203

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