1. Wagner, Cheryl PhD, MSN, MBA, RN


When patient care is compromised, the most committed nurses may feel it most acutely.


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Will we ever resolve the issue of job burnout in nursing? Whenever this topic is discussed, I recall an essay I read over a decade ago in Health Affairs in which an experienced neonatal ICU (NICU) nurse chronicled his struggle to provide life-saving care to premature neonates despite the staffing cuts and unfavorable nurse-to-patient ratios that plagued managed care in the 1990s. The author saw that the care being delivered to these vulnerable patients was compromised, and after many shifts of being forced to spread himself too thin, he left the NICU-and nursing-for good.

Figure. Cheryl Wagne... - Click to enlarge in new windowFigure. Cheryl Wagner, PhD, MSN, MBA, RN

I've never forgotten the chill I felt as this nurse slowly realized that the organization was stacking the deck against him-and against his tiny patients. His anguish is sometimes referred to as "moral distress," an issue that has been getting renewed attention. For example, in 2013 moral distress was identified by Leggett and colleagues as a contributing factor to job burnout among nurses on a burn ICU. The researchers wrote that moral distress "occurs when a person believes he or she knows the ethically ideal or right action to take, but is prevented from doing so because of internal or institutional barriers"-inadequate staffing, patients with care requirements beyond the nurse's capabilities, futile care. The authors recommended the development of interventions that would become part of nursing culture in high-stress environments, such as periodic measurement of the potential for nurse distress, ethics committees, and debriefing.


Owing to staffing issues and other institutional constraints, many dedicated and compassionate nurses are in danger of leaving care areas where they are most needed. But preventing job burnout among nurses is more than just a retention strategy-it's a vital form of patient advocacy. A 2012 study by Cimiotti and colleagues found that patients may suffer in quantifiable ways when nurses are burned out to the extent that they "forget" aseptic technique and other basic principles of care. The researchers found an association between the number of nurses experiencing job burnout and the number of catheter-associated urinary tract infections and surgical site infections.


It's time to reopen the dialogue on nurse burnout. With Medicaid reimbursement rules motivating hospitals to reduce rates of health care-associated infections, this is a perfect time for nurses to make the case that patient safety initiatives should include improvements to the nursing work environment.


It's also time to take a hard look at moral distress, which contributes to burnout and is experienced by nurses in both critical care and acute care. We already know that, at the organizational level, measures like shared governance, nursing representation on ethics committees and process improvement teams, and better collaboration between nurses and physicians can lead to a more empowered nursing workforce. I believe that nurses with a sense of empowerment are less likely to suffer from the ethical conflicts that lead to moral distress.


Since bedside experience contributes to a nurse's confidence, we also need to help younger nurses with less experience avoid the toxic fallout of moral distress. As a nurse educator, I wonder if our ethics courses are too theoretical, creating a disconnect between the ideal nursing experience that we teach and the real world of nursing, where things are not so clear-cut.


Whenever I read a study that attempts to measure moral distress, its prevalence and its resultant harms, it invariably ends with something like this: Strategies to mitigate moral distress should be developed and tested. It's time to make this a priority, as a growing body of evidence confirms that burnout and emotional exhaustion put our patients at risk.