Nurse work environment, missed nursing care, moral distress, and burnout among ICU nurses

OBJECTIVES: To test whether missed nursing care and moral distress mediate the association between the nurse work environment and burnout among adult ICU nurses. METHODS: This study used data from 4258 direct care nurses in adult ICUs from the 2024 Penn Nurses4All Study. Structural equation modeling with serial multiple mediation examined direct and indirect associations between the work environment and burnout through missed nursing care and moral distress, adjusting for nurse characteristics. RESULTS: Nurses averaged 14.1 years of experience (SD = 11.4); most were female (2429; 79.6%), worked full time (3456; 81.3%), and held a bachelor's degree or higher (2572; 79.2%). A more favorable work environment was significantly associated with lower burnout (total effect: standardized coefficient B = -0.67, p < 0.001). All indirect pathways were significant, including through missed nursing care (B = -0.11, p < 0.001), moral distress (B = -0.05, p < 0.001), and the sequential pathway via both mediators (B = -0.03, p < 0.001). The total indirect effect was significant (B = -0.19, p < 0.001), and the direct effect remained significant (B = -0.48, p < 0.001), indicating partial mediation. CONCLUSIONS: The association between the nurse work environment and ICU nurse burnout is partially explained through a sequential pathway from missed nursing care to moral distress. These findings empirically support a theorized erosion model in which structural deficiencies cascade through care omissions and moral injury to burnout. The remaining direct effect suggests additional unmeasured mechanisms also contribute. Interventions should target the organizational conditions that initiate this chain rather than focusing solely on individual-level resilience. IMPLICATIONS FOR CLINICAL PRACTICE: Nurse leaders should prioritize work environment improvements as upstream strategies to prevent the cascade toward burnout. Reducing missed care through structural investment may attenuate the moral distress that follows from repeated ethical compromise. Unit-level strategies such as structured debriefing and ethics consultation may further interrupt the pathway.