Experiences of Moral Distress in Canadian Intensive Care Unit Professionals During and After the COVID-19 Pandemic: A Qualitative Exploratory Multiple Case Study in Ontario and Alberta, Canada

<b>Background:</b> Since the beginning of the COVID-19 pandemic, moral distress among healthcare workers in the Intensive Care Unit (ICU) has garnered both media and academic attention. Moral distress has been theorized as occurring when individuals are constrained from doing what they perceive as morally right. This study sought to empirically examine the lived experiences of moral distress among clinical and administrative healthcare professionals in a sample of Canadian ICUs during the COVID-19 pandemic. <b>Methods:</b> Qualitative case study methodology was used as the overarching approach, collecting and comparing data from two distinct cases: one ICU in Ontario and one in Alberta. Data collection involved two primary sources: semi-structured interviews with staff and document review of institutional and government directives to provide contextual data. Data analysis commenced concurrently with data collection, and generated within- and across-case themes, as well as allowed descriptive accounts of moral distress. <b>Results:</b> Thirty-six healthcare workers across two sites were interviewed. Participants described three primary categories of constraints leading to moral distress. These were: 1) The rapidity and opaqueness of policy development, specifically pertaining to 2) the implementation of family visitation and treatment triage decisions, and 3) resource shortages, which reduced patient interactions, shifted professional responsibilities. Each of these constraints yielded circumstances and forced decisions that were perceived as morally wrong because they compromised care quality and outcomes. <b>Conclusions:</b> While sharing similarities with the growing literature on moral distress in the context of the COVID-19 pandemic, this study reveals new insights on how provincial and institutional policy has direct bearing on experiences of moral distress. Policies and circumstances forced ICU staff to choose between actions they considered the most right and the least wrong. Understanding these specific policy-driven constraints highlights the need for healthcare systems and processes that mitigate moral distress and sustain our health workforce.