The moral dilemma pushing so many nurses to quit their jobs

The moral dilemma pushing so many nurses to quit their jobs
Image: Illustration by Ibrahim Rayintakath
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Kiersten Henry’s worst day on the job came in the early months of the pandemic.

She was working as the chief nurse practitioner in an intensive care unit at MedStar Montgomery Medical Center in Olney, Maryland. It was spring 2020, and her team had spent weeks caring for a covid patient in his 50s—a father with a teenage daughter and an 8-year-old son.

Henry got to know the man and his family well as he fought for his life. But eventually it became clear he wasn’t going to recover. “His wife and daughter came in, and his son FaceTimed to say goodbye,” Henry recalls.

“I always think of the day he passed away as our very worst day,” she says. The patient’s brother—also critically ill with covid—died two days later.

Nurses on the front lines of the pandemic have borne witness to staggering losses over the past two years. Now a growing number are hitting their breaking point.

Two-thirds of critical care nurses are considering leaving the field, according to a fall 2021 survey from the American Association of Critical-Care Nurses. Another recent poll of US healthcare workers found that 18% had quit their jobs since February 2020. And a similar pattern is playing out globally: If attrition doesn’t slow, the world could be short 13 million nurses by 2030, according to a report from the International Council of Nurses.

Several factors—including mental health issues, staff shortages, and lack of institutional support—have contributed to the surge in nursing resignations, according to the American Nurses Foundation (pdf). But there’s one factor that deserves particular attention: moral distress.

What is moral distress?

Nurses experience moral distress when they can’t meet their obligations “because of constraints beyond [their] control,” says Beth Epstein, an associate professor of nursing at the University of Virginia whose research focuses on the issue.

For example, nurses know that it’s important for families to visit sick patients, both to comfort loved ones and to participate in their treatment. But many hospitals have restricted or eliminated visitations over the past two years to limit the spread of covid. That puts nurses in the difficult position of enforcing policies even if they’re not in an individual patient’s best interest.

Chronically understaffed ICUs overflowing with patients also create conditions for moral distress. Typically, each nurse in an ICU cares for one or two patients, according to Beth Wathen, a clinical practice specialist in a pediatric ICU in Denver and president of the AACN board. But in the pandemic era, an individual nurse may now be responsible for three, four, or five people—which makes it impossible for them to give each patient the care they deserve.

“As a result, you leave your shift feeling complicit in having done something wrong—‘My patient died alone and scared today,’” says Epstein.

How covid changed nurses’ jobs

Moral distress among nurses isn’t new to the pandemic. But covid has exacerbated healthcare workers’ feeling that they’re culpable for patients’ suffering, or at least powerless to stop it.

Kevin Cho Tipton, a nurse practitioner in Miami, Florida, recalls experiencing this feeling early in the pandemic while working in a makeshift ICU. Multiple patients’ hearts had stopped, and he asked a nurse on his team to decide who she thought they could save. “We didn’t have the staff or the resources at the time to save them all,” he says. “It was distressing for her to realize she had to choose because she knew her patients the best. But when all four of them on a floor at a given time were dying, we had to choose.”

In the months since, he says, the loss of full-time nursing staff has repeatedly put him in situations where there are “people I know I could have saved in other circumstances, but I didn’t have the resources and I didn’t have the time. And it’s something I’ll have to live with for the rest of my life.”

Tipton loves his work. But, he says, “I’ve thought long and hard about what am I doing. Is it something sustainable? And not because I don’t believe in medicine, but because the emotional toll has been really hard.”

This kind of thinking is shared by many nurses, says Epstein. “Who wants a job where they go home knowing they played a role in something unethical?”

Vaccine hesitancy has compounded moral distress for many nurses, says Tipton. With the vast majority of covid deaths now preventable with a course of vaccines, healthcare workers are struck by the unnecessary suffering they continue to see. Some nurses feel responsible, he says, wondering if they’ve failed to communicate the importance of vaccines and save patients’ lives.

Giving healthcare workers the power to solve problems

Moral distress may be entrenched, but it’s not inevitable: Nurses know exactly what practical and systematic changes would allow them to do their jobs well. They just need hospital administrators and policymakers to listen to them.

In that sense, there are clear parallels between the current plight of nurses and the broader rumblings of dissatisfaction and disillusionment among workers across industries. In a post-pandemic era, many people don’t especially want to quit their jobs; they just want to stop feeling like they’re doomed to face the same intractable problems day after day.

With both nurses and doctors, “their powerlessness to do the right thing comes from their lack of voice in the institution,” says Epstein. “This is so demoralizing, especially when they could contribute so much to problem-solving.”

How flexible scheduling can help with staffing and support

Flexible scheduling could go a long way toward improving attrition, which in turn would help alleviate the moral distress, says Rayna Letourneau, an assistant professor of nursing at the University of South Florida. Typically, nurses work 12-hour shifts. And while some nurses like the 12-hour workdays because that allows them to work just a few days a week, others, especially older nurses, may find this too physically demanding as they age. Introducing shorter shift options, Letourneau says, would help retain the more experienced nurses who are opting to retire early because of covid.

Some hospitals are trying to keep more experienced nurses on board with “tele-ICUs,” which use video technology to allow remote healthcare workers to team up with those who are on the hospital floor. “Some people are just done with being at the bedside, they’re so exhausted,” says Wathen. This way you’re not losing the expertise.

Broadly speaking, keeping experienced nurses on board improves hospitals’ overall standard of care, which benefits not just patients but the healthcare workers who desperately want to feel they’re doing right by their patients.

Better pay is another way to stem the tide of resignations. While pay varies by state, US staff nurses earn a median salary of $75,330 per year, prompting some to take more lucrative contract positions that can pay around $5,000 or more per week.

But ultimately, Henry says that the issue goes beyond money. Some hospitals have figured out short-term ways to compensate their existing staff above their normal salary, but “you can tell that fatigue has exceeded any incentive when huge bonuses are being offered for people to pick up an extra shift, and they just don’t have it in them.”

What real support for healthcare workers looks like

Ultimately, addressing the root issue of moral distress calls for much deeper overhauls. As Epstein says, “when the problems arise from the system, the system needs to change.”

One promising model for communicating nurses’ on-the-ground concerns to institutional powers comes in the form of a consultation service offered by the University of Virginia Health System, in which ethics consultants talk with healthcare workers when they’re experiencing moral distress. “We help them figure out where the system’s problems are and what needs to be addressed,” explains Epstein.

For nurses in the US, a lasting solution to moral distress involves fixing our approach to healthcare itself, says Tipton.

In practice, that could mean “making it easier for patients to access care before they’re sick; making it easier for families to access care through a continuum from birth to death,” Tipton says. “I think that there’s an opportunity to return to fighting the things that made the pandemic so grim in America—fighting obesity, fighting poverty, addressing preventable causes of diabetes, and supporting families in a way that changes the risks they face.”

Nurses, after all, spend their days trying to help people who are sick, hurt, or in pain. They know that some suffering is unavoidable. But they also know, more intimately than most, the cost of doing nothing to stave it off.

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