Research indicates that when nurses feel blocked from taking morally justifiable actions or achieving ethical outcomes, it leads to poor mental health, burnout, and a desire to leave their jobs. During the COVID-19 pandemic, surveys revealed that shortages of personal protective equipment (PPE) and lack of support from hospital administrators were linked to higher levels of moral distress among nurses.


Researchers from the University of Pennsylvania School of Nursing and their collaborators hypothesised that nurses working in hospitals predominantly serving Black patients—termed Black-serving hospitals (BSHs)—experience greater moral distress. These hospitals were disproportionately affected by the pandemic and typically had fewer resources. The study is published in Nursing Outlook. 


Study researchers recruited hospitals through the National Database of Nursing Quality Indicators and used data from the 2019 Medicare Provider Analysis and Review to classify hospitals by the percentage of Black patients from low-BSH to high-BSH.


Nurses were asked to rate the frequency and extent of distress for nine moral distress situations. Examples included “caring for patients who die during hospitalisation without family or clergy present” and “witnessing a lack of respect among healthcare team members for patients from vulnerable populations or minority groups”.


Findings show that the percentage of nurses experiencing moral distress was twice as high in hospitals with the largest proportion of Black patients. Poor leadership communication was identified as a contributing factor to this increased distress. Nurses had poorer support from their leaders and less access to PPE, were more frequently caring for COVID patients, and reported greater moral distress. 


The survey data, collected from 3,675 nurses at 90 hospitals in March and April 2021, indicated that BSHs are also likely disproportionately affected in the post-pandemic nurse staffing crisis. Burnout is largely driven by workload and work environment. Post-pandemic burnout is expected to be worse in hospitals serving a higher share of Black patients.


The study found that 4% of nurses in high-BSH hospitals experienced high moral distress compared to 2% in low-BSH hospitals. Nurses in hospitals with better leadership communication showed less moral distress, but those in high-BSH hospitals were more likely to disagree that leadership communication was transparent, effective, or timely. They also reported more frequent care for COVID-19 patients and worse access to PPE.


These findings highlight the need to address inequities in BSHs and find innovative ways to support nurses in their daily care of patients and families to reduce their physical and emotional burdens. While increasing nursing staff may be challenging for resource-constrained hospitals, like many BSHs, fewer resources are needed to implement managerial interventions such as enhancing leadership communication.


Source: University of Pennsylvania
Image Credit: iStock 



Lake ET, Smith JG, Rogowski JA et al. (2024) Nurses' moral distress and leadership communication in hospitals serving Black patients during COVID-19. Nurs Outlook. 72(4):102189. 

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