Moral Distress in Nursing Practice – Expert Interview

“We need to offer good healthcare to everyone. Not just the people who have money, not just those who live in the right neighborhood. That’s where it needs to begin because the moral distress comes from the fact that we cannot give [everyone] good care.”

Elda Ramirez, PhD, Clinical Instructor, Acute and Continuing Care Department at the University of Texas Health Science Center at Houston

Being an emergency room nurse practitioner can be an incredibly rewarding and lucrative career. However, it has its challenges. One of the most difficult things ER nurse practitioners can face is moral distress. The American Nurses Association defines moral distress as “when one knows the ethically correct action to take but feels powerless to take that action.” This happens due to external constraints such as policies, insurance, lack of resources or time, or conflicting patient wishes. It’s a heartbreaking situation that can cause emotional pain and feelings of guilt for the nurse. 

To outsiders, it can be easy to assume that moral distress would surface the most when it comes to end-of-life care in an emergency room setting. “No, no, no, no, no,” says Dr. Elda Ramizer emphatically, clinical instructor in the Acute and Continuing Care Department at the University of Texas Health Science Center at Houston. 

“If it’s the end, it is very comforting to me. That’s not where the moral distress is. It’s in all the other places where you feel powerless, like the patient who’s 48 years old and has never been to a doctor because they can’t afford it. And now they have three kids at home and a wife, and you just find out that they have mets in their brain from lung cancer that they didn’t know they had. They had a super long cough but never took care of it. They don’t have life insurance or disability. So what is the treatment plan? Or you have a 35-year-old with head trauma who is homeless, and they are now incapacitated. Who is going to care for them? Or a young woman whose breast mass is now fungating, but she’s never gone in for care because she is scared because she’s undocumented. That’s where you find the moral distress.”

For Dr. Ramirez, these patients that don’t have options, and she can’t help because of how the system is structured, are the most morally distressing: “We are limited in what we can do. And then we just have to send them home and say, ‘Oh, well, we’re gonna get you an appointment to see the doctor.’ But if they don’t have insurance. Then what? 

A recent example was an older woman who came in. She had been trying to get to the pharmacy but had an episode, so they had to take her to the emergency department. She can’t breathe. She’s in real distress. It turns out she had just been discharged from another institution a couple of days ago. She had gone to get her medications refilled and couldn’t afford them, and her paperwork hadn’t gone through to have coverage yet.”

Enduring this persistent level of moral distress and repeated trauma takes its toll. “Every single day that I go to work before I get there, I pray to my higher power, ‘Let me do the next right thing.’ And I try to be as gracious, kind, and respectful as possible when I’m there. Even when the patients and the system make me freaking mad, and it’s hard. Thankfully,  I’m not there every day. If I were there every day, I don’t know if I could do it,” says Dr. Ramirez.

Meet The Expert: Elda G. Ramirez, PhD, RN, FNP-C, FAANP

Dr. Elda Ramirez is a clinical instructor in the Acute and Continuing Care Department at the University of Texas Health Science Center at Houston. She holds a master’s of science in Nursing from the University of Texas Medical Branch at Galveston and a bachelor’s of science in nursing from the University of Texas-Houston Health Science Center. 

In addition to teaching, Dr. Ramirez maintains a clinical practice through a contract with Emergency Consultants, Incorporated providing emergency services. She is one of the founders of the American Academy of Emergency Nurse Practitioners.

Causes of Moral Distress

Here are some of the issues in emergency rooms and healthcare in general that Dr. Ramirez believes contribute to moral distress for nurse practitioners. 

Managed Care

Moral distress occurs when nurse practitioners know what to do but can’t do it. Insurance companies are one of the biggest contributors to this inability to perform job duties. “About 25 years ago, something happened called managed care. And when managed care happened, all of a sudden, insurance companies were the ones that were telling us who to care for. It was so bizarre because the doctors and nurses had no more control. Everything was being run by insurance now. And the truth is, we can’t just take care of people anymore,” says Dr. Ramirez. 

Insurance companies can dictate who patients see and the type of care provided: “Most hospitals now don’t even let you have a bed. We treat you upfront because we don’t have enough beds, and all the metrics say we take too long. We are constantly told we have to make visits shorter. And then we have to discharge you, but you’re in paper scrubs, you don’t have clothes, and you’re homeless. But we’re going to discharge you into the neighborhood just the same because treatment is done,” explains Ramirez. 

Health Disparities

The CDC defines health disparities as “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.” 

These preventable issues can cause high moral distress because they didn’t have to happen in the first place. Often, disparities are directly related to access to care. “I once applied for the Affordable Care Act. I was making $30,000 a year and would still have to pay $5,000 a year in insurance. How can anyone do that? Do you eat and get gas, or do you have insurance?” asks Dr. Ramirez. “Other countries do a lot more preventative medicine than we do. They catch people here before they’re sick, and they don’t have the levels of diabetes and obesity that we do because we don’t have that capacity to provide preventative care.”

Lack of Resources

Staffing shortages, supply chain delays, and overcrowding also contribute to moral distress in emergency room nurse practitioners. The general lack of resources, be it personnel or supplies, means that nurse practitioners cannot always care for their patients how they want to: “It’s almost like PTSD in a sense. When you see somebody in pain, you’re like, ‘Okay, now what?’ Because you don’t have beds, you don’t have enough staffing, so you can’t help that person like you want to because you don’t have the space, the capacity, the time, and the money,” says Dr. Ramirez.  “This is the whole definition of moral distress. I know what is right, but I can’t do that because I don’t have the capacity to do it or the appropriate resources. It’s constant trauma.”

Immigration Policies

Many patients across the US will not seek medical care because they are undocumented and fear what might happen if they visit the emergency room. They worry about deportation, the expense of care, and the lack of access to subsidized insurance. “We ended up using tax dollars to cover undocumented patients because they don’t come in until they’re super sick. They worry about how they will pay the bills and don’t want collectors after them. I tell them I’m going to see them no matter what. There are special programs in our county for repeat patients, but there are just so many patients that are never going to be eligible for that help,” explains Dr. Ramirez.

Solutions and Advice

For Dr. Ramirez, the first and easiest solution to moral distress for emergency room nurse practitioners is to ensure everyone has equal access to care: “We need to offer good healthcare to everyone. Not just the people who have money, not just those who live in the right neighborhood. That’s where it needs to begin because the moral distress comes from the fact that we cannot give [everyone] good care,” she says. 

She continues, “The magic wand would be to offer equitable care to everyone because they’re human, and they deserve it. Period. You must tackle the problem from the inclusive and equitable side of healthcare. How can you say that a person who works two jobs, who has three kids at home, shouldn’t have the same access to care because they didn’t come into this country until later in their lives?” she continues. “And equity doesn’t mean everyone gets the same care, but everyone gets the care they need. For some people, that might be more, and for others, that might be less.”

As an educator, Dr. Ramirez hopes she can help instill resilience in her students: “I teach my students to care. I hope that I give them a little bit of bravado to step back, be strong, and do the right thing. Because that’s really hard—it’s just easy to go along, lose empathy, and get jaded. Never ever give up on what’s right, “ she encourages.

Kimmy Gustafson

Kimmy Gustafson


Among her many diverse writing endeavors, Kimmy Gustafson has also lent her expertise to since 2020, providing insightful and engaging content about the significant role of education in shaping our future generations of nurse practitioners. Many of her pieces include interviewing experts on timely topics such as healthcare workplace violence and moral distress.

Kimmy has been a freelance writer for more than a decade, writing hundreds of articles on a wide variety of topics such as startups, nonprofits, healthcare, kiteboarding, the outdoors, and higher education. She is passionate about seeing the world and has traveled to over 27 countries. She holds a bachelor’s degree in journalism from the University of Oregon. When not working, she can be found outdoors, parenting, kiteboarding, or cooking.