Moral distress or workplace recognition? Associations with burnout and intention to quit in Swiss nurses and midwives

Research consistently associates moral distress with negative consequences such as burnout and intention to quit. However, methodological shortcomings in prior studies may obscure the factors underlying these associations. In a cross-sectional study with 281 Swiss nurses and midwives, we examined how different statistical approaches influence the estimated associations between moral events and psychological distress, burnout, and intention to quit, while accounting for other workplace factors (workload, staffing adequacy, autonomy, psychological safety, recognition/acknowledgment). The choice of analysis—univariable regression, multivariable regression, or SEM—significantly altered conclusions. Crucially, while moral events predicted negative outcomes in regression analyses, only low recognition and acknowledgment was consistently associated with psychological distress, burnout, and intention to quit across all analytical approaches. Our results demonstrate that estimated effects of moral events depend on the analytical approach employed, suggesting that existing research warrants careful re-examination. Workplace appreciation may be more critical than avoiding morally challenging situations for supporting healthcare professionals.