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Complex ethical issues can be a contributor to nurse burnout, says bioethicist

Moral distress results from managing the complex ethical issues in healthcare practice and patient care, and it can be draining for nurses.

Jeff Lagasse, Associate Editor

Nurse burnout impacts both nurses and patients, and significantly influences the retention of nurses in the healthcare setting, research shows. But it may be a symptom of something larger.

A commentary by Connie M. Ulrich, PhD, RN, the Lillian S. Brunner chair in medical and surgical nursing and professor of bioethics and nursing, explores the effects of ethical issues faced by clinicians in practice and -- how moral distress may play a larger role in the loss of clinicians in the workplace.

This so-called "moral distress," she contends, may in some ways be inevitable. Meeting the healthcare needs of a diverse group of patients can be ethically complicated, and it's this tangled ethical picture that can exacerbate stress.


Moral distress results from managing the complex ethical issues in healthcare practice and patient care. Those morally stressful situations can make clinicians feel unable to provide the care they think is best based on their professional standards of practice and their values.

Such daily decisions may be emotionally laden, and are often made in challenging circumstances. There may be pressure from patients and families, burden from chronic understaffing, complicated organizational structures and hierarchies, system inefficiencies that shift attention away from patients, insurance or institutional policies that limit options, differences of opinion about appropriate care, and breakdowns in communication with interprofessional colleagues and administrators.

For example, moral distress may occur when nurses and clinicians take part in a course of action -- providing or withholding treatment, for example -- with which they may not fully agree, or think is wrong altogether.

While the confidence, moral clarity and self-efficacy that come with moral strength can help clinicians make difficult ethical decisions, moral strength can likewise be eroded in the healthcare environment, said Ulrich.

Support and training efforts to help clinicians develop coping skills, resiliency, and enhanced moral strength are important. It's imperative to also address organizational and systemic factors that contribute to moral distress and ways to support clinicians' capacity to act with moral strength, said Ulrich and co-author Christine Grady, PhD, RN, chief of the Department of Bioethics, Clinical Center, National Institutes of Health.

They warn that having fewer nurses and clinicians in healthcare due to burnout could negatively impact patient care and weaken the health system overall.


Another contributor to burnout is an ongoing nursing shortage, with a 2018 survey from RNnetwork finding almost half of the nation's nurses have considered leaving the profession in the past few years.

The nursing shortage negatively affected workloads for 88% of nurses in 2018, up significantly from 62% in 2016. Forty-six percent feel more overworked than they did two years ago, while 62% of nurses believe the shortage is negatively impacting the quality of care they can provide.

Twitter: @JELagasse

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