Throughout the COVID-19 pandemic, nurses were heralded as health care heroes for their unparalleled commitment to the frontline. They also faced unprecedented challenges providing care—especially in hospitals serving predominantly Black communities. 

A recent study by Senior Fellows Eileen Lake, Connie Ulrich, and colleagues explored the relationship between leadership communication and the moral distress hospital nurses felt during the first peak of the COVID-19 pandemic. Employing a survey of nurses across 90 hospitals nationally, they compared the experiences of nurses in hospitals where Black patients predominantly access their care Black-serving hospitals (BSHs) to those of nurses in other hospitals. They particularly focused on communication trends from managers.

Study findings revealed that most nurses experienced mild to moderate moral distress. The distress of nurses in high BSH was significantly worse. Indeed, 4% of nurses in high BSHs reported significant levels of moral distress compared to 2% of nurses in low BSH, a finding largely attributed to inadequate communication from their managers and insufficient access to necessary personal protective equipment like N95 masks and face shields. The distress was further compounded by the frequency of caring for COVID-19 patients, which was more prominent in BSHs.

We asked the study’s lead investigator Eileen T. Lake PhD, RN and senior investigator Connie M. Ulrich, PhD, RN several questions to learn more.

Why was it important to conduct this research of moral distress among nurses early in the COVID-19 pandemic?

Ulrich: The COVID-19 pandemic highlighted many ethical issues in nursing practice such as end-of-life care, resource allocation including staffing, misinformation, uncertainty in clinical practice, mandatory vaccination, the lack of personal protective equipment, and many others. We saw, and heard, the distress of many nurses during this time. Thus, this research was important to gather firsthand data on what nurses were experiencing and the moral distress that ensued. 

 Lake: Previously we studied nurse burnout, but the pandemic presented unique challenges for nursing care and that prompted us to look at moral distress. 

Our research in the Center for Health Outcomes and Policy Research is designed to inform health care managers and policymakers about how to best support nurses to provide high quality care. So it was urgent to identify ways that nurses could have been more supported during COVID-19, so that we’re better prepared if something like this happens again.

What were your most important findings?

Lake: We found that the clinical circumstances of the nurses in hospitals serving disproportionately higher numbers of Black patients were uniformly poorer than those of nurses in hospitals serving fewer Black patients. That is, they had worse access to personal protective equipment in the first peak month of COVID admissions, they likewise had poorer communication from their leaders and managers, and they suffered greater moral distress.

Did these poor conditions predate the pandemic?

Lake: Yes. For example, we showed in prior work that nurses in high-Black neonatal intensive care units (NICUs) missed more required nursing care than nurses in low-Black serving NICUs due to worse nurse staffing and poorer work environments. 

Ulrich: Staffing is an ongoing problem for nurses across the country that affects quality of care delivery that creates moral distress for nurses because without adequate staffing, they cannot provide the level of care that is required.

Why is moral distress among nurses an important problem to address?

Lake: To have our professional clinicians, who are ethical actors in health care, feel that they cannot act in morally justifiable ways degrades the self and can cause psychological harm. From the system perspective, moral distress negatively affects mental health, including by causing insomnia and anxiety, and increases intentions to leave or quit. These poorer outcomes undermine the workforce and may compromise care quality.

Ulrich: Nurses are the largest professional group in the United States. Yet they often feel powerless to change their situation and may have lingering physical, emotional, and spiritual distress.

Why might poor communication from hospital leaders be associated with higher levels of moral distress?

Ulrich: During the COVID-19 pandemic, information was changing on a daily basis. Communication was not always consistent, and nurses were often unsure of the appropriate institutional policies to support them and their care practices for patients and families. There also was a sense of disconnect between hospital leadership and nurses on the frontlines that led to frustration and moral distress and a perceived lack of value for their knowledge and skill sets. 

Why is it important to quantify dynamics of moral distress among nurses? How can these numbers help us change policy in the future?

 Lake: When we quantify moral distress among nurses or other health professionals, we can learn more about the antecedents to it, particularly modifiable elements like how well leaders and managers communicate with caregivers. Likewise, quantifying the deleterious effects of moral distress can help motivate nurses and managers to minimize it. 

Ulrich: Without solid data and facts, we cannot change health care systems. Data on moral distress can help leadership know that it’s a significant problem and that it may lead to a loss of qualified nurses. We can now ask better questions, design better studies, and try to understand those factors that impact moral distress and aim to intervene so we can retain a qualified and healthy workforce.

What changes could ease the moral distress and poor leadership communication nurses experienced?

Lake: We recommend that nurse managers in Black-serving hospitals be provided additional development and support to improve their communication skills both with frontline nurses but also with administrators. Hiring and employing a nurse ethicist who consults with frontline nurses and nurse managers is a direct way to reduce moral distress and address immediate problems. 

Ulrich: We also recommend creating an in-house ethics committee, if one does not already exist, and suggest that nurses should be part of these committees to share their perspectives on the issues at hand. 

Lake: Ideally, hospital leadership should engage with nurses regularly to share the latest changes in clinical expectations and protocols, and to invite input. Nurses also should share with leaders their most pressing concerns about factors undermining optimal care.

Ulrich: Nurses need to be part of leadership boards and other committees to provide their unique voices to the C-suite. Leadership should make rounds on units to meet with frontline nurses and managers to hear their concerns, and address any unit-based and broader organizational inefficiencies.

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The study, “Nurses’ Moral Distress and Leadership Communication in Hospitals Serving Black Patients During COVID-19,” was published on May 28, 2024, in Nursing Outlook. Authors include Eileen T. Lake, Jessica G. Smith, Jeannette A. Rogowski, Emily Cramer, Vaneh Hovsepian, Hal Chen, Nehemiah Weldeab, and Connie M. Ulrich.

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