Understanding the disparity in nurses’ moral distress during COVID-19

Research has found that when nurses feel they are prevented from taking a morally justified action or achieving an ethical outcome, it contributes to poor mental health, burnout, and intent to leave the job. Studies in response to the COVID-19 pandemic found that shortages of personal protective equipment (PPE) and a lack of perceived support from hospital administrators were associated with higher levels of this moral distress.

Researchers at the University of Pennsylvania School of Nursing and their collaborators hypothesized that nurses who work in hospitals where Black patients primarily access care — which they call Black-serving hospitals, or BSHs — would suffer more moral distress as these hospitals were disproportionately burdened affected by the pandemic and generally have fewer resources.

In a study published in the magazine Nursing PerspectivesThey found that the percentage of nurses experiencing moral distress was twice as high in hospitals with the highest proportion of black patients, and that poor leadership communication contributed to the greater moral distress.

“The nurses received less support from their leaders and had less access to personal protective equipment, they are more likely to be caring for COVID patients, and they report more moral distress, all of which places an unfair burden on the nurses in those hospitals. ” says lead author Eileen T. Lake, professor of nursing at Penn and deputy director of the Center for Health Outcomes and Policy Research (CHOPR). She says this is a social justice issue for the nurses.

Although the survey data was collected from 3,675 nurses across 90 hospitals in March and April 2021, the paper notes that Black-serving hospitals are also likely to be disproportionately affected by the post-pandemic nurse staffing crisis. Lake says that since burnout is largely driven by workload and work environment, she expected post-pandemic burnout to be worse in hospitals that serve a higher proportion of Black patients.

To study acute care nurses, researchers recruited hospitals through the National Database of Nursing Quality Indicators, and used data from the 2019 Medicare Provider Analysis and Review to rank hospitals based on the percentage of Black patients from low-BSH to high BSH.

The nurses were presented with nine moral emergencies and asked to rate the frequency and extent of the distress. For example, two circumstances under which they were questioned were “caring for patients who die during a hospital stay without family and/or clergy present” and “witnessing a lack of respect among the health care team for patients from vulnerable or minority populations.” .

The researchers found that 4% of nurses in the high BSH category of hospitals experienced high moral distress, compared to 2% in the low BSH category, that nurses showed less moral distress in hospitals with better leadership communication, and that nurses who worked in high BSH category workers showed less moral distress in hospitals with better leadership communication. Hospitals were more likely to disagree that leadership communications were transparent, effective or timely.

Nurses in hospitals with high levels of BSH also reported that they were more likely to care for patients with COVID-19 and had poorer access to personal protective equipment.

“Moral distress remains an ongoing bioethical issue, and as a result we are losing qualified nurses,” said co-author Connie M. Ulrich, the Lillian S. Brunner Chair in Medical and Surgical Nursing at Penn Nursing.

“This study highlights the need to close the inequality gap in BSHs and find innovative ways to support nurses in the daily care of patients and families and reduce the physical and emotional burdens they carry.”

The authors acknowledge that there was a lot of uncertainty during the acute phase of the pandemic and that information changed daily, but they write that distributing email newsletters and organizing staff meetings could strengthen leadership communication. They also floated the idea of ​​a BSH designation through the Centers for Medicare and Medicaid Services so that hospitals with more than a certain percentage of black patients could acquire more resources.

“One of the interesting aspects of this article is that it points to management factors as an important part of the solution to the problem of moral distress among nurses,” said co-author Jeannette A. Rogowski, an economist at Penn State University.

“For hospitals with limited resources, such as many BSH hospitals, increasing nursing staff may be difficult. However, fewer resources are likely needed to implement management interventions such as increasing leadership communication.”

Lake explains that she and Rogowski began working together 20 years ago to investigate why low-birth-weight black babies had worse outcomes than their white counterparts. They found that these results were associated with lower nurse staffing levels and a poorer work environment in the neonatal intensive care units. Over the years, Lake says, they’ve decided to broaden their focus and ask more broadly about outcomes in hospitals with high BSH levels.

About eight years ago, they began working with Jessica G. Smith, a former postdoctoral fellow at CHOPR and now an assistant professor of nursing at the University of Texas at Arlington. Smith is co-author of the new paper along with Ulrich, a bioethicist with experience studying moral distress. Another co-author, Nehemiah Weldeab of the Department of Behavioral Health Sciences at Penn Nursing, is a data analyst.

“The multidisciplinary nature of this team was essential to producing the article and the insights it provided regarding the role of management in reducing moral distress among nurses at BSH hospitals,” says Rogowski.