Moral Distress, Moral Injury, Secondary Traumatic Stress, and Compassion Fatigue
Moral distress occurs when individuals are constrained in their ability to take ethically appropriate action or are forced to take an action they feel is ethically inappropriate. A perceived lack of power, lack of agency, or structural limitations can result in constraint. Moral distress results from action, inaction, or by witnessing the moral transgressions of others. Moral injury is the result of sustained moral distress and can manifest through shame, self-harm, substance abuse, decreased empathy, and self-condemning thoughts. Common triggers of moral distress in nursing include “end-of-life care, inadequate staffing, value conflicts, challenging team dynamics, and duty conflicting with safety concerns.”
Another phenomenon common among nurses is secondary traumatic stress (STS). STS is the emotional distress clinicians experience indirectly by hearing details of or witnessing the fallout of another’s traumatic experience. Individuals with STS may also develop STS disorder (STSD), which involves symptoms that parallel primary post-traumatic stress disorder, including intrusive thoughts, avoidance behaviors, and hyperarousal.
Compassion fatigue (CF) shares many of the same components as STS, but while the terms are sometimes used interchangeably, differences exist. CF in nurses is defined as a state of “holistic exhaustion that manifests in physical decline in energy and endurance, emotional decline in empathic ability, and spiritual decline as one feels hopelessness or helplessness to recover as a result of chronic exposure to others’ suffering.” The most significant difference between STS and CF is that STS can result from a single experience while CF arises out of caring for multiple suffering individuals over an extended period of time.
Healthcare Heroes or Involuntary Martyrs?
Nursing is regarded as the most trusted profession, having ranked number one on Gallup’s Honesty and Ethics list every year since being added in 1999. The only exception to their otherwise unmarred record occurred in 2001, when they came in at a close second behind firefighters after the September 11 attacks. To honor the 200th anniversary of Florence Nightingale’s birth, 2020 was designated as the International Year of the Nurse and the Midwife by the World Health Assembly in 2019. The Year of the Nurse quickly took on new meaning with the arrival of the pandemic thrusting nurses into the spotlight as they confronted one of their greatest professional challenges to date and resolidifying their status as the most trusted profession. In the first year of the pandemic, over 3,600 healthcare workers died in the U.S.; of these, nurses and support staff died in greater numbers when compared to other groups of healthcare professionals. But experts agree that “even the largest reported numbers almost certainly represent a gross undercounting of the toll on healthcare workers.”
Nurses’ frequent, prolonged exposure to infected patients put them at increased risk of contracting and dying from a severe SARS-CoV-2 infection. That risk was potentiated by widespread shortages of personal protective equipment (PPE), such as N95s, surgical masks, gloves, gowns, and face shields. In response to nurses’ tireless efforts on the front lines of the pandemic, there was an outpouring of adulation for healthcare “heroes” around the world. But the hero discourse became a means of skirting organizational accountability for systemic failures that resulted in nurses becoming involuntary martyrs.
Personal Protective Equipment Shortages and the Normalization of Nurse Exposure to Mortal Risk
The normalization of nurses’ exposure to risk also reinforced existing power dynamics, limiting their ability to improve working conditions. While the nation hailed nurses as heroes, they, and other healthcare professionals, faced gag orders under the threat of losing their jobs for speaking out about personal protective equipment (PPE) shortages. Regardless, nurses continued to speak out and eventually, some hospitals did join in sounding the alarm. Nurses also took to social media to document the dire conditions, such as nurses from New York’s Mount Sinai West hospital, who posted photos of themselves online wearing PPE they fashioned out of large plastic trash bags. The scarcity of once abundant, single-use PPE items necessitated their sharing, reuse, and extended use in combination with strict rationing and safekeeping that rendered replacements inaccessible to staff already provided with their allotted quota.
Although reusing single-use PPE, such as N95 masks and face shields, was known to risk increased exposure to nurses and those around them, a July 2020 survey of more than 21,200 nurses revealed 87% of hospital nurses were reusing at least one type of single-use PPE. In an effort to conserve scarce PPE supplies, nurses were depended on to perform what had once been the duties of others, including physicians, in addition to their regular duties. The reliance on nurses to perform additional duties decreased the number of PPE items consumed by reducing the number of people entering patient rooms and by maximizing the reusing of single-use PPE. The scarcity of PPE raised professional and ethical questions about the extent of nurses’ duty to care for patients and the limits of that duty under working conditions that demanded an inordinate amount of altruism and self-sacrifice. Separate provisions of the ANA Code of Ethics prescribe that a nurse’s primary commitment is to the patient and, separately, that nurses owe the same duty to self as to others. During the pandemic, these competing duties set the stage for moral distress and moral injury as nurses struggled to balance their duty to care for patients while confronting their own mortality. Nurses who continued to provide patient care still feared going to work knowing they could become the next victim, or a vector threatening the health of others, including their own families.
Unprecedented Resource Shortages Necessitated the Use of Crisis Standards of Care
The extreme resource shortages experienced during the pandemic necessitated the widespread implementation of crisis standards of care (CSC). CSC are designed to guide decision-making to achieve the best outcome for the greatest number of people rather than focusing resources on one individual patient, with the goal of extending available resources and reducing the impact shortages have on clinical care. Despite meticulous contingency planning, the need to deny treatment to individuals was not obviated, in part, because not all hospitals can be created equal. Rural access and even some community hospitals deliver many of the same essential services that larger, tertiary care hospitals offer and act as a stopgap for patients requiring specialized, higher levels of care until an appropriate transfer can be arranged. Tertiary care centers, which are equipped to provide highly technical and specialized care, serve rural and community partners by accepting transfers from these hospitals.
The availability of qualified nurses that once precluded patients from reaching their appropriate care destinations was compounded by the lack of physical beds and space during peaks of the pandemic. When hospitals ran out of space, they were forced to provide patients care in their cars and in hospital parking garages. Shortages of staff, space, and physical beds made transfers to higher levels of care or specialty care excruciatingly difficult during this time. Yet desperate pleas for help from facilities and individuals continued to pour into hospitals that could provide coveted services for patients. As a result, patients were often transported hundreds of miles across state lines to secure treatment at a facility with the appropriate level of care, but not before having been turned away repeatedly by countless facilities.
The Delta Surge and Nursing Experiences Under CSCs
When the highly contagious Delta SARS-CoV-2 variant appeared as the dominant strain in the U.S., nurses had seen their numbers depleted by early retirements and career shifts in response to working conditions experienced at the outset of the pandemic. By this time, hospitals were also able to employ real-time pandemic surveillance measures to project what could be coming down the pike in terms of hospital admissions, and in response do their best to prepare. Oregon’s only public academic health center and tertiary care center, OHSU, trained Certified Registered Nurse Anesthetists (CRNAs), many of whom had prior experience as ICU nurses, on critical care workflows and converted the Post Anesthesia Care Unit (PACU) into an ICU within five days to expand ICU capacity in preparation of a 400- to 500-hospital-bed shortage due to the Delta variant in August 2021. Other tertiary care centers in Oregon, such as St. Charles in Bend, increased the number of available beds by 20% using post-operative areas and by putting two COVID-19-positive patients in the same ICU room. The overwhelming desire to help paired with the inability to do so and the knowledge that patients were more likely to die because beds were not available added to nurses’ moral distress and injury at both referring and receiving facilities.
CSC allowed nursing staff to be stretched beyond established nurse-to-patient ratio norms, including in states with legislated ratios like California, to maximize the use of available nursing staff while confronted with a rapidly declining nursing workforce. Nurse-to-patient ratios in many ICUs across the nation were adjusted from the standard one or two patients per critical care nurse to anywhere from three to six patients per critical care nurse. Under these staffing models, nurses often had to prioritize more pressing, advanced critical care interventions over rudimentary care, such as basic hygiene, to ensure the present survivability of patients under their care. Inevitably, the implementation of CSC results in increased morbidity and mortality and further contributed to nurses’ moral distress and injury.
High Levels of Patient Mortality Results in Moral Distress
One of the most challenging aspects of nursing during the peaks of the pandemic has been the overwhelming feeling of impotence expressed by nurses who grappled with their inability to affect a situation. The pandemic saw families torn apart due to stringent infection control policies during their most vulnerable and challenging moments. At the height of the pandemic, patients often died alone, women labored and birthed alone, and newborns were immediately separated from parents who tested positive for COVID-19. Nurses often step in as a source of support in times of transition for those who are without their families, but were stretched so thin they were often unable to provide this small comfort. When time, hospital policies, and internet connectivity allowed, family “visits” were facilitated by nursing staff through the use of video-capable electronic devices or phones. Nurses would hold the device so families could see their loved ones and say their goodbyes, unable to provide them privacy and unable to shield themselves from the cumulative effects of hearing these conversations day after day, further contributing to STS.
Lack of adequate PPE, the expectation to absorb the duties of others, the stretching of nursing staff to the extent that preserving their patients’ dignity by providing basic care was sometimes impossible, watching their patients languish and die while waiting for a bed, seeing families torn apart, seeing patients die alone, watching coworkers die or leave the profession, seeing communities reopen and mask mandates lifted, and watching people unnecessarily suffer and die from a preventable disease due to vaccine hesitancy left many embattled nurses feeling disposable, forgotten, and rife with moral distress, moral injury, STS, and CF. One of the most common complaints echoed by nurses around the nation was that their leaders failed them. Researchers examined whether leadership communication, as a modifiable factor, could reduce nurses’ moral distress during the pandemic. It was determined that effective leadership communication decreased moral distress related to workloads and PPE shortages. Suggested methods to improve nurses’ feeling of support from leaders in times of crisis include timely, transparent communication; acknowledging challenging situations; and providing rationales by leaders. This, combined with education surrounding policies for CSC and a comprehensive ethics education, would provide nurses the tools to address moral distress. These small efforts focused on alleviating mental anguish and improving mental health by nurse leaders could help retain nursing staff and preserve their mental wellness.
Burnout Syndrome or Human Rights Violations?
In 1981, burnout was first identified as a syndrome that afflicted nurses. Burnout syndrome is defined as a state of emotional, mental, and physical exhaustion generated by excessive and prolonged stress. Nurses’ inability to give their best when caring for others because they themselves are not physically and mentally whole translates to diminished quality of patient care, decreased patient satisfaction, a rise in the number of medical errors, increases in healthcare-associated infections (HAI), and higher 30-day mortality rates. Identifying and resolving sources of burnout have historically been framed as an individual responsibility versus a shared responsibility between employers and their employees, in this case, nurses. However, clinician advocates, such as Pamela Wible, MD, argue that the word burnout is victim blaming, a shaming, oppressive term that has served to conceal the rampant abuse of clinicians in a broken and toxic healthcare system. Dr. Wible goes a step further, identifying factors of burnout as human rights violations in disguise, noting that “neither burnout nor moral injury [can] suffice to conceptually encompass the harms done to clinicians.”
It is difficult to imagine that human rights violations happen in professional settings and go unnoticed or worse, ignored, in the U.S. The human rights violations identified by Dr. Wible as commonly occurring in the healthcare setting include food and water deprivation, punishment when ill, sleep deprivation, bullying, harassment, violence, racism, and sexism. While Dr. Wible focuses on how these are common experiences for physicians, other healthcare workers, including nurses, often work under similar conditions. For example, having physical access to food and water are considered basic human rights, yet an argument can be made that nurses are often deprived of physical access to food and water during their working hours.
To better understand this, consider 29 C.F.R. §1910.1030(d)(2)(ix) from the Occupational Safety and Health Administration (OSHA), which prohibits the consumption of food or drink in work areas where there is a potential exposure to blood or other infectious material or where there is a potential for work surfaces to be contaminated. In explaining the meaning of the rule, OSHA indicates that covered beverages at nurses’ workstations have the potential for contamination because a container on a workstation may become contaminated and result in unsuspected hand contamination. On its face, this may not seem like an onerous rule, but when considered in light of the working conditions endured by nurses in a standard twelve-hour shift—the norm for most acute care nurses—abiding by the rule can prove challenging.
Federal law does not require meal or break periods, and less than half of the states have set minimum length meal period requirements. Because nurses are subject to patient abandonment laws, they are required to make reasonable arrangements for the continuation of care for patients with whom they have established a provider-patient relationship. To satisfy this requirement, a nurse must be relieved of their assignment by another nurse or member of the healthcare team with the requisite skill level and competency to accept the assignment or who can make arrangements for the continuation of patient care. With nursing staff already spread thin, this can be a very challenging requirement to meet in a reasonable period of time, or at all. The shortage of staff and absence of employee protections make it all too common for nurses to have to choose between violating state and federal rules or meeting their most basic human needs while working under mentally, physically, and emotionally taxing conditions.
Addressing The Elephant in the Room: Nurse Suicide
Nurse suicide is taking many dedicated nurses away from the profession. On April 3, 2011, Kimberly Hiatt, 50, who worked as a critical care nurse at Seattle Children’s Hospital for 24 years, became a victim of suicide after accidentally administering a fatal overdose of calcium chloride to an infant. Remelinda Tecson, a Nevada ICU nurse, fell victim to suicide on January 19, 2021. Kerry Massoth of Idaho, 45, an ED nurse for over 20 years, died by suicide on June 14, 2021. Neurosurgical ICU travel nurse Michael Odell, 27, told co-workers he was going to retrieve something from his car at approximately 4:30 a.m. while on duty at Stanford Medical Center on January 18, 2022; Michael’s body was found two days later, and all evidence points to suicide. On April 27, 2022, an ED nurse at Kaiser’s Santa Clara Medical Center shot and killed themselves in a supply closet during their shift in front of a coworker; aware of the situation, coworkers continued caring for patients who presented to the ED. These are only a few of the most publicized, recent nurse suicides.
Few studies of suicide among U.S. nurses exist. Despite being the largest profession in healthcare, most of what is known about suicide in nurses stems from physician-focused studies. More recently, data from a longitudinal study that spanned 2005 to 2016 showed female and male nurses alike are at higher risk for suicide and commit suicide at a higher rate than physicians, members of the military, and the public. The silence surrounding nurse suicide may be attributed in part to the stigma related to mental health conditions as well as the culture of stoicism in the face of crisis that is common among healthcare professionals. The stressors and rigors endured by nurses that contribute to burnout are also likely contributors to their high risk for suicide. Because the onslaught of crisis upon crisis can wear down even the best coping strategies, it is important to promote mental health initiatives that focus on nurses’ well-being.
One of the simplest ways to combat mental health conditions in nursing is by fostering individuals’ sense of mattering. Mattering is a feeling of worth, that one adds value or is valued. It is the individual belief that one can make an impact and is thereby significant to the world. Because making a positive impact on the lives of others is fundamental to nursing, a sense of professional mattering may be exceptionally consequential. Mattering is important because it is linked to increased job satisfaction and resilience. In contrast, a sense of not mattering can promote burnout. In addition to fostering individuals’ sense of mattering, an overall increased awareness of mental health conditions that commonly afflict nurses can help bring a greater understanding of what the issues are, their driving factors, and of how nurses can heal.
Nurse Scapegoats: Just Culture and the Criminalization of Nursing Error
Just Culture originated in the aviation industry during the 1980s as a means to reduce catastrophic accidents related to safety errors through systematic review and fostering a non-punitive environment in exchange for open communication. The Just Culture model was first introduced in healthcare as an accountability concept by David Marx in 2001. It was not until 2010 that the ANA provided their first position statement on the concept of Just Culture. The ANA recognized the model as one that acknowledges humans make mistakes and that no system can produce perfect results; therefore, goals for safety in healthcare organizations should focus on error reduction and improved system design.
While working as a critical care nurse at Seattle Children’s Hospital, a mathematical error led Kimberly Hiatt to accidentally administer an overdose of calcium chloride to a critically ill infant who died, in part, from complications of the overdose. Although, this was Kimberly’s only serious mistake during her 24-year career as a nurse at Seattle Children’s Hospital, she was immediately placed on administrative leave, escorted from the premises, and soon after fired. In 2011, seven months after the infant’s death, Kimberly became the second victim of her error when she died by suicide.
A similar scenario played out before the nation in 2022 when former Vanderbilt University Medical Center nurse RaDonda Vaught was criminally prosecuted and convicted of gross neglect of an impaired adult and negligent homicide after a fatal drug error she committed in 2017. The RaDonda Vaught trial was closely followed by scores of nurses and healthcare workers around the world, many of whom expressed their support for Ms. Vaught. Ms. Vaught, who in addition to her normal duties that day was also training a nursing student, administered vecuronium, a paralytic, instead of versed, a sedative, to a patient who later died. It is uncontested that upon realizing her mistake Ms. Vaught immediately disclosed her error, took accountability for her actions, and participated in every step of the process up to her conviction. But despite decades of healthcare systems seemingly embracing “Just Culture,” Ms. Vaught was prosecuted and convicted for her mistake at a time when the nursing workforce was exhausted and overwhelmed from the effects of the pandemic.
The ANA has expressed fear that the criminalization of medical errors will have a chilling effect on the reporting of errors and patient safety. Medical errors are unfortunately common enough to make the list as the third leading cause of death in the U.S. in 2016. Because the healthcare system is dependent on examining errors and near misses for the purpose of identifying areas for improvement, the underreporting of errors can lead to a reduction in patient safety.
Acts of Violence Against Nurses in the Healthcare Setting
A rise in violence against nurses and healthcare workers, like suicide, is also contributing to the tragic, permanent loss of nurses and healthcare professionals. In January 2019, nurse practitioner Carlie Beaudin was found pinned beneath her car, beaten and frozen in the Froedtert hospital parking garage; her brutal attack at the hands of a former valet was captured on unmonitored hospital surveillance video. In April 2019, nurse Lynne Truxillo died after being attacked by a patient at Baton Rouge General – Mid City hospital. In June 2022, a gunman angry over post-surgical pain killed two doctors, a receptionist, and a visitor at Saint Francis Hospital in Tulsa, Oklahoma. Also in June 2022, two days after the Tulsa attacks, a man stabbed a doctor and two nurses at Encino Hospital Medical Center. These are only a few examples of the workplace violence that is commonly experienced by healthcare workers in healthcare facilities.
Workplace violence is defined as an act or threat of violence that occurs in the workplace or while on duty. In 2016, 12.2% of injuries sustained by nurses were a result of violence. The actual number of incidents is believed to be much greater due to underreporting, making healthcare facilities one of the most dangerous places to work in the U.S. The U.S. Bureau of Labor Statistics reported healthcare workers are five times more likely to suffer injury resulting from workplace violence than individuals employed in other industries. There was a significant rise in injuries resulting from workplace violence from 2011 to 2018. The rate of injuries is believed to have surged since the pandemic began, without evidence of abating anytime soon.
Efforts to mitigate violence in healthcare settings thus far have been largely unsuccessful. While facilities focus on mitigation, various healthcare organizations, health systems, clinical partners, and professional membership groups have joined in support of the Safety from Violence for Healthcare Employees (SAVE) Act of 2022. If passed, SAVE would grant federal protections similar to those criminalizing the assault and intimidation of aircraft and airport workers to healthcare workers.
Is There a Shortage of Nurses, or Are Nurses Being Driven Out?
Some nursing organizations, such as National Nurses United (NNU), have questioned whether the U.S. is experiencing a shortage of nurses at all. These organizations assert a nursing shortage does not exist; rather, the only shortage they claim does exist is one of nurses willing to jeopardize their nursing licenses or the safety of patients by working under dangerous conditions created by those who profit from the current system. NNU points to findings in the U.S. Department of Health and Human Services report Supply and Demand Projections of the Nursing Workforce: 2014 to 2030 as direct evidence for their claims. The report indicates there exists an inequitable distribution of the nursing workforce rather than a national shortage. This means a few states are projected to have a shortage of nurses while others are projected to have a surplus, resulting in an inequitable distribution of the nursing workforce across the nation; in other words, the promulgated notion that there is an absence of licensed nurses to meet the nation’s need is misleading and inaccurate.
It is incontestable that systemic issues are driving nurses to leave the profession. The shortage of nurses actively engaged in the practice of nursing is undeniable, and if the nation continues to follow this trend, it threatens to leave Americans vulnerable and without access to care similar to what was experienced during peaks of the pandemic. The ANA recognizes that it is unclear what efforts lead to nurse retention and advocates for strategies similar to ones other countries committed to nursing retention have employed. These strategies require a focus on motivating nurses to return to the workforce, improving workplace conditions, and active investment in nursing education.
Although the number of active nursing licenses reflect that a national shortage of nurses does not exist, it is indisputable that systemic issues are driving nurses to choose employment options outside of the profession. Current efforts to mitigate the effects of the nursing shortage have fallen short and the pandemic only served to exacerbate existing problems by pushing the nursing workforce beyond acceptable limits. To safeguard the nation’s access to healthcare, federal and state government action in combination with employer-directed efforts are necessary to improve nurse retention and to revitalize the nursing workforce.