Burnout's hidden driver: The ethics of everyday care

When a patient's wife wanted to stay overnight in the ICU, the nurse explained that hospital policy prohibited overnight visitors and asked her to leave.

Later that night, the patient became agitated, required restraints, and his condition deteriorated.

The nurse had followed protocol. Yet the outcome raised a deeper question: When policies influence patient outcomes, are they operational decisions, ethical decisions, or both?

Most people associate ethics with highly visible dilemmas such as end-of-life decisions, treatment disagreements, or questions of patient autonomy. But healthcare ethicists Aimee Milliken, associate professor of the practice at Boston College Connell School of Nursing, and Aliza Narva, director of ethics at the Hospital of the University of Pennsylvania, argue that ethical decision-making is embedded in the system policies, workflows, and everyday interactions that shape patient care.

"Every decision that affects a patient has an ethical dimension, whether we explicitly name it or not," Narva said.

Organizations often fail to recognize those ethical dimensions, Milliken added.

That perspective is especially relevant as healthcare organizations grapple with burnout, retention challenges, and workforce shortages. According to Milliken and Narva, who presented this spring at the Vizient Nursing Programs Conference, ethical tensions often emerge in the subtle moments—communication breakdowns, discharge disagreements, staffing constraints, rigid policies, assumptions about patients, or missed opportunities to speak up.

"Those moments rarely trigger an ethics consult," Milliken said. "But they add up, and over time unresolved ethical tensions can contribute to moral distress, disengagement, and workforce attrition."

Note: From left, Aimee Milliken, associate professor of the practice at the Boston College Connell School of Nursing, and Aliza Narva, director of ethics at the Hospital of the University of Pennsylvania, during a presentation this spring at the Vizient Nursing Programs Conference.

When ethical tension becomes moral distress

Most clinicians have experienced the tension of knowing what a patient, family member, or team needs and feeling unable to provide it because of circumstances outside their control.

Moral distress emerges when clinicians know what they believe is the right course of action but feel unable to pursue it. Staffing shortages, conflicting policies, limited influence over decisions, and pressure to move patients through the system can all create that tension.

“It’s when clinicians know the right thing to do but feel unable to do so because of internal or external challenges,” Milliken said.

Historically, conversations about moral distress have focused on bedside clinicians. But healthcare organizations are recognizing that nurse leaders experience it as well.

A nurse manager may know a unit needs additional staffing support. A director may recognize clinicians need more resources. A chief nursing officer may identify opportunities to strengthen care delivery. Yet budget pressures, workforce shortages, and competing organizational priorities can limit what is possible.

Repeated exposure to these situations creates what ethicists call moral residue—the lingering effects of unresolved ethical conflict. Those experiences accumulate, shaping how clinicians view their work, their organization, and their ability to practice in alignment with their professional values.

“If those experiences remain unresolved, they contribute directly to burnout,” Narva said. “It’s important to understand that not all stress is moral distress. Healthcare is stressful, but moral distress specifically threatens moral integrity.”

Why resilience isn't enough

For years, healthcare organizations have invested heavily in downstream interventions such as mindfulness programs, wellness initiatives, and individual coping strategies. These efforts can help clinicians recover from stress and emotional strain, but they do little to address the conditions that create distress in the first place.

The distinction is important. Resilience helps clinicians adapt to difficult circumstances. Ethical leadership focuses on improving the circumstances themselves.

That work begins with psychological safety and those organizations that lack it often struggle with silence, blame, and workarounds, Milliken said.

“If nurses don't feel safe speaking up, ethical problems remain hidden until they become crises,” she said. “In psychologically safe environments, problems surface earlier, giving leaders and teams an opportunity to address them before they escalate into larger operational, workforce, or patient safety challenges.”

Building a moral community

If moral distress stems from isolation and unresolved ethical tension, moral communities offer an organizational antidote.

"One of the most important concepts we discuss with leaders is a moral community—creating an environment where people feel supported by doing ethical work together," Milliken said.

A moral community is characterized by trust, mutual support, psychological safety, open dialogue, and shared responsibility for ethical practice. In these environments, ethics becomes part of everyday conversations rather than something reserved for rare or high-profile dilemmas.

Research increasingly demonstrates the value of strong ethical climates. Organizations that foster trust, open communication, and ethical support experience lower levels of burnout and moral distress, stronger workforce engagement, and improved retention.

“When nurses feel safe speaking up, when they trust their leaders and colleagues, and when they have structured spaces to process difficult situations together, it fundamentally changes how teams function,” Milliken said.

Building a moral community does not necessarily require sweeping organizational initiatives.

“Moral communities often develop through small, intentional leadership practices that happen consistently over time,” Narva said. “These could be debriefs after difficult cases, ethics rounds, interdisciplinary dialogue, transparent communication during periods of change, or structured opportunities for teams to discuss concerns openly.”

Individually, none of these practices may seem transformative. Collectively, however, they help create a culture where ethical concerns are acknowledged rather than avoided, where clinicians feel supported rather than isolated, and where difficult experiences become opportunities for learning instead of sources of lasting distress.

“Over time, these environments strengthen trust, resilience, and professional fulfillment,” Narva said. “They help nurses remain connected to the values that brought them into the profession.”

The ethical responsibilities of leadership

For nurse leaders, ethics extends far beyond individual patient situations.

As nurses move into leadership roles, their ethical responsibilities expand from caring for individual patients to shaping the conditions that affect entire teams and care environments.

“Many nurses transition directly from bedside practice into formal leadership roles without much preparation for how dramatically the ethical responsibilities of leadership change,” Milliken said.

According to Narva, the American Nurses Association (ANA) Code of Ethics serves as an important reminder that leadership itself is an ethical responsibility.

“Leadership is not simply about managing operations or supervising people,” Narva said. “It’s about shaping environments where ethical practice can actually happen. The code reinforces leaders’ obligations to create safe practice environments, support professional growth, advocate for patients and staff, and address ethical concerns directly.”

Creating those environments begins with understanding the challenges clinicians face.

“One of the biggest mistakes leaders can make is moving too quickly into problem-solving mode before they fully understand what’s happening,” Narva said. “Questions such as, ‘What have you considered?’ ‘What are you most worried about?’ and ‘How do you think I can help?’ create opportunities for reflection and learning while communicating support rather than judgment.”

Curiosity helps leaders uncover the context behind ethical concerns while perspective-taking helps them understand the people involved.

Milliken noted that healthcare environments can quickly reduce individuals to labels such as difficult patient, noncompliant family member, or problem employee. Those labels often obscure the circumstances driving behavior and decision-making.

“When leaders pause to better understand the circumstances surrounding a situation, the picture often shifts,” Milliken said. “Perspective-taking is not agreement. It’s understanding. That becomes especially important when we think about bias and stigma in clinical care. When clinicians fail to engage in perspective-taking, they are more likely to attribute behavior to character flaws rather than consider trauma, social determinants of health, fear, suffering, or structural barriers.”