U of T researchers investigate 'moral distress' among nurses during COVID-19

Donna Ruffo typically works as a nurse practitioner on the geriatric medicine outreach team at North York General Hospital.

An alumna of the University of Toronto’s Lawrence S. Bloomberg Faculty of Nursing, Ruffo assesses, diagnoses and treats frail seniors – in collaboration with their referring family doctors or nurse practitioner – to help them get the health care they need and prevent unnecessary visits to the emergency room.

But when the COVID-19 pandemic arrived in Canada, Ruffo’s roles and responsibilities began to change as the hospital navigated the rapidly unfolding situation.

“We were no longer allowed to have in-home visits, so I began providing virtual care for patients and their families,” Ruffo says.

As the pandemic ramped up, the hospital reallocated resources in profound ways, closing elective surgeries and reorganizing spaces and teams in order to accommodate incoming COVID-19 patients.

Ruffo says she and other nurses suddenly found themselves innovating and leading in the midst of a crisis.

“Some of my responsibilities involved providing physical assessment for the nurses who were being redeployed, helping them gain confidence in learning new skills to be able to take care of critically ill patients,” says Ruffo.

While nurses have long played a key role in the delivery of health care under difficult conditions –the extraordinary demands placed on nurses  by the1918 Spanish flu pandemic spurred Kathleen Russell, the founding director of U of T Nursing, to call for progressive reforms in nursing education in Canada – many are accustomed to working in a designated specialty area such as the operating room, day surgery or pediatric units.

“Not surprising, there was a lot of fear and doubt,” says Ruffo of nurses who were redeployed to help with COVID-19. “Nurses told me that they didn’t necessarily feel confident to work with acutely ill patients. I reminded them that they are nurses who have exceptional critical thinking skills, effective communication and compassion which are transferable across settings – they’ve got what it takes to do what’s being asked of them.”

Even so, nurses across Canada are struggling with fears surrounding the impact of COVID-19 on themselves, their families, their patients, caregivers and the health-care system at large, which can result in feelings of helplessness and distress.

“Nurses are used to high-demand, fast-paced days,” says Ruffo. “[But] the stress of learning how to support a patient in the absence of their family, and of working in a situation that is rapidly evolving and has so many unknowns, that can cause distress and make nurses feel very helpless.”

Elizabeth Peter, a professor at U of T’s Lawrence S. Bloomberg Faculty of Nursing, which is celebrating its centenary this year, is exploring the emerging moral challenges that nurses are experiencing during the pandemic. Her research is being supported by the University of Toronto COVID-19 Action Fund.

Peter and her team – Shan Mohammed, an assistant professor, teaching stream, Jane MacIver of the Ted Rogers Centre for Heart Research, and PhD student Tieghan Killackey – will recruit and interview 40 nurses who have been caring for patients with COVID-19 to learn about their experiences.

“In nursing, there is significant literature on moral distress, but very little is known on what prevents it or makes people feel better,” Peter says.

The ultimate goal is to develop strategies to help nurses through the moral distress caused by working through the pandemic. Since early support is key for addressing trauma from moral distress, Peter and team plan to disseminate their findings as early as August.

“Once we’ve conducted the interviews, we plan to immediately assemble specific guidelines and recommendations related to alleviating moral distress, and broadly disseminate findings to health-care settings locally and internationally,” she says, adding that the work may help inform the health-care system’s responses to future crises.

As for Ruffo, she spends time each day checking in with nurses throughout the hospital to ask how they’re coping. While some express feelings of stress, worry and fatigue, Ruffo takes comfort in knowing she and her colleagues will band together to get through the crisis.

“In the 21 years I’ve worked at NYGH,” she says, “we’ve always come together in the most critical times to get through.”