Structural moral distress among nurse middle managers in crisis

BackgroundAt a time marked by ongoing global instability and health emergencies, the ethical and operational burdens on healthcare systems derived from the COVID-19 crisis, remain urgently relevant. Positioned between frontline staff and senior management, nurse middle managers (NMMs) were tasked during the pandemic with implementing institutional policies while simultaneously supporting teams facing rapid clinical and emotional challenges. Despite the pivotal role of NMMs, there exists a significant gap in understanding the ethical challenges and the strategies they employed during time of crisis.Research design and populationThis qualitative study used Interpretative Phenomenological Analysis approach to examine the lived ethical experiences and coping strategies of 16 Israeli NMMs from diverse healthcare sectors during COVID-19, and their implications for future crises.Ethical considerationsThe study received ethical approval from the University Research Ethics Committee. All participants gave informed verbal consent after a detailed briefing.FindingsMoral distress emerged as an ongoing, cumulative condition shaped by structural exclusion, constrained moral agency, and institutional inequities Three main themes emerged (1) the dual role of NMMs and its ethical ramifications, (2) ethical tensions and frustration in the relationship with senior leadership, and (3) confronting ethical dilemmas emerging from the unique challenges of the pandemic. Participants reported distress when required to implement policies conflicting with professional values, while being excluded from decision-making yet expected to justify top-down directives. Many served as emotional anchors for their teams without reciprocal support.ConclusionsThe study illuminates the distinctive moral position of NMMs in time of crisis, revealing sustained ethical conflicts rooted in systemic constraints. By reframing moral distress as structurally embedded, it underscores the need for organizational reforms to strengthen ethical preparedness, support NMMs, and enhance healthcare system resilience in future crises.