By Polo Camacho, PhD, & Tarris Rosell, PhD, D.Min.

September 2022

Bioethics case study on moral distress in healthcare workers.

Angelie is a nurse in the ICU at a research hospital located in the heart of downtown. The hospital has seen a surge in cases at various times since the start of the COVID-19 pandemic. Staff shortages and a general lack of hospital resources has led to high turnover rates and stress among the nursing staff, including Angelie.

She recently graduated from nursing school and comes from a long family tradition of nurses. Her father is a nurse and so was her grandmother. In fact, many of her cousins, aunts and uncles work in the medical field. At a young age, she was taught to value life and human dignity, that working as a nurse is a privilege and is a means of promoting these values. After graduation, Angelie was determined to hold herself and those around her to the highest possible nursing standards.

On this day, Angelie feels like she’s failing. ICU beds are maxed out even though the COVID surge has long since passed. There are numerous active cases always, but it’s more than just COVID. Perhaps some of what is happening now is partly the aftermath of COVID infections. No one knows for sure. What Angelie knows is that the hospital census is consistently pushing the limits of nursing resources, especially for critical care units, and her ICU is short-staffed yet again. Angelie is rushing from room to room and can’t seem to get her head above water.

As she’s monitoring ventilation support for one patient, Angelie notices other hospital staff rushing into the room of another of her patients. Her heart pounds while running down the hallway.

Mr. Randall—an 85- year – old male-identifying patient with a history of chronic lung disease—was admitted into the hospital a couple weeks ago with a severe case of COVID-19. Mr. Randall’s health was on the upswing with hope of transferring out of the ICU. But he now has suddenly suffered a bout of acute respiratory distress, with dangerously low oxygen levels. Alarms in his room went off, but Angelie was so overwhelmed with the care of her other patients that she couldn’t respond immediately. As a consequence, Mr. Randall is crashing and a resident physician called a code blue.

Angelie is devastated. She had promised to provide the best care possible for her patients, including Mr. Randall. But now she had failed him. Her inattention was due not to lack of caring but to an insufficiency of care providers. Her unit is understaffed and maxed out.

Mr. Randall survived. After a long shift and charting for an extra hour, Angelie reflects on how dangerously close her patient came to dying on her watch. It’s hard not to blame herself, even though Angelie knows she was doing her best to provide the best care possible. She had wanted to tell Mr. Randall and his family how very sorry she was for how things had gone today. But what could she say? That doing “her best” had nonetheless placed her patient at death’s door? That her hospital management had failed them both by not staffing adequately? Would there be a lawsuit coming?

Angelie is tired and losing motivation. She feels hopeless and is struggling to find the passion that led her to the nursing profession in the first place. She ponders quitting, doing something else with less stress, whether or not the pay is better. Many of her work colleagues have quit already. Others say they’ll likely do so before the year is over. Angelie hasn’t left nursing in part because it is so much a part of her family tradition. Yet she knows things cannot continue as they are. Mr. Randall’s case is not an isolated incident, and she fears that without proper staffing support, patients like him will suffer needlessly and some will die.

What should be done?