The Professional Dissonance: When Highly Educated Nurses Work in Basic Staff Roles

Abstract

Highly educated nurses, such as those holding a Doctor of Nursing Practice (DNP) degree or licensed as Psychiatric–Mental Health Nurse Practitioners (PMHNPs), often face serious challenges when practicing in environments designed for basic staff Registered Nurses (RNs). These challenges include conflicts related to limited autonomy, rigid management structures, ethically questionable clinical practices, and harmful turnover patterns. This paper explores these conflicts using current research on moral distress, trauma-informed care, patient safety, and nursing autonomy. A real-world, anonymized case example is integrated to demonstrate how poorly structured environments can place advanced-practice nurses at risk of professional harm and ethical conflict. The paper argues that advanced-practice nurses must be supported with proper clinical autonomy, safe policies, and transparent management to practice both ethically and legally.

Introduction: Why Advanced Education Changes the Professional Landscape

Nurses who pursue advanced education, including the DNP and PMHNP credentials, do so with the intention of practicing at a higher level of clinical responsibility. Their training includes advanced assessment skills, diagnostic reasoning, complex ethical decision-making, leadership preparation, and deep knowledge of evidence-based practice (Peacock & Hernandez, 2020). They are prepared to think critically, make independent decisions, and take accountability for high-level clinical outcomes.

However, when these clinicians accept roles as staff RNs—often through temporary or agency assignments—a major mismatch occurs. The job description may say “RN,” but their ethical, educational, and regulatory responsibilities remain aligned with their advanced scope of practice. This creates professional dissonance, a conflict between what the nurse is trained and obligated to do versus what the environment expects or allows.

This dissonance is not merely uncomfortable; research shows it can lead to moral distress, decreased job satisfaction, burnout, and threats to professional licensure (Choupani et al., 2024). Advanced-practice nurses are expected to practice with meaningful autonomy, yet many low-level roles restrict even basic nursing judgment. This mismatch is not sustainable and may place the advanced nurse at risk of ethical conflict, harm to reputation, or legal vulnerability.

Autonomy Conflicts in Low-Level Environments

Autonomy is a foundational expectation for advanced-practice nurses. APNs are trained to think independently, make rapid decisions, and apply high-level clinical judgment. However, many low-level RN environments restrict autonomy through rigid rules, scripted interactions, and punitive oversight practices (Lockwood & Schober, 2024).

Restricted Clinical Judgment

In some facilities, basic nursing tasks require approval, documentation becomes excessive, or staff are discouraged from exercising professional judgment without supervisory permission. Research shows that when nurse autonomy is restricted, the ability to provide high-quality care is compromised, and job dissatisfaction increases sharply (You et al., 2023). Advanced-practice nurses find these restrictions especially challenging because they contradict the standards of their training.

For example, an APN trained in psychiatric crisis intervention may be told they cannot speak privately with a patient, cannot intervene without a supervisor present, or cannot adjust simple care strategies without formal approval. While policies may be designed for consistency, they can unintentionally remove the very skills that advanced nurses must use to protect patients from harm.

Punitive Oversight and Surveillance

A second autonomy conflict involves excessive monitoring. Some facilities use hundreds of cameras, frequent supervisor check-ins, or policies that encourage reporting even minor concerns. While safety monitoring can be necessary, excessive surveillance often reflects distrust rather than support. Research links surveillance-heavy environments to heightened anxiety, defensive practice, and moral distress (Rosalind de Lisser et al., 2024).

In such environments, nurses may fear making independent decisions—even when independent decisions are medically appropriate—due to fear of disciplinary action. This undermines the advanced nurse’s ability to use their expertise and may force them into passivity rather than active clinical engagement.

Autonomy and Legal Responsibility

Advanced-practice nurses carry a higher level of accountability than basic staff RNs, even when employed in an RN role. Regulations expect them to notice and respond to clinical and ethical concerns at a higher level. If an APN follows a restrictive policy that contradicts their training and a patient is harmed, the APN may face serious professional consequences. This is why autonomy is not only a professional preference—it is a legal and ethical necessity.

Ethical Conflicts: When Facility Policies Contradict Nursing Values

Ethical conflict is often the most serious challenge advanced nurses face in low-level environments. Nursing ethics are not optional; they are mandatory, and advanced-practice nurses are held to the highest standards.

Violations of Beneficence and Nonmaleficence

The ethical principle of beneficence requires nurses to act in the patient’s best interest. Nonmaleficence requires preventing harm. When a facility discourages intervention during active self-harm or minimizes the severity of dangerous behaviors, it conflicts directly with these principles.

Research shows that failing to protect a patient during active self-injury exposes nurses to potential legal complaints and severe moral distress (Salari et al., 2022). Trauma-informed care should never be misapplied to justify allowing a patient to suffer physical harm. Proper trauma-informed care focuses on safety, collaboration, and empowerment—not non-intervention during emergencies (Isobel & Edwards, 2017).

Moral Distress in Conflicted Environments

Moral distress occurs when a nurse knows the right action but is prevented from doing it. Studies reveal that moral distress is especially common in environments with poor leadership, unclear policies, or ethically conflicting expectations (Kim et al., 2023). Prolonged moral distress can lead to anxiety, depression, burnout, resignation, or self-doubt. For advanced-practice nurses, moral distress may also include fear for their license and career stability.

Expanded Case Example: When Management Practices Create Unsafe Conditions

The author recently worked in a facility that exemplified several of these systemic issues. Without naming any organization or individual, this example demonstrates how advanced nurses can become vulnerable in certain environments.

Orientation Dominated by Punitive Examples

During orientation, the leadership provided numerous examples of staff being terminated for minor communication issues, such as “speaking softly” or “whispering.” Instead of focusing on clinical excellence, safety standards, or high-level training, the orientation emphasized surveillance, disciplinary action, and dismissals.

This approach created an impression that the facility prioritized staff fear over staff competence. Research shows that fear-based management undermines team cohesion and leads to poor outcomes (Lucas et al., 2025).

Problematic Language Practices

The facility required staff to avoid the word “patient” and instead use alternative labels. While trauma-informed language can be beneficial, replacing medically established terminology without explanation introduces legal ambiguity. Documentation is a legal record. Using unofficial terms can blur clinical accountability and confuse the nurse’s duty of care.

Ethically Concerning Statements on Non-Intervention During Self-Harm

One of the most alarming statements made during orientation was the idea that staff should not intervene during active self-harm. The justification was that physical restraint may traumatize the individual. While trauma prevention is important, allowing intentional injury contradicts every accepted nursing standard.

Nursing ethics, psychiatric emergency guidelines, and crisis intervention protocols all require immediate action to prevent significant harm (Choupani et al., 2024). An advanced-practice nurse cannot ethically work under a policy that discourages intervention in a medical emergency.

Oversight Without Transparency

The facility reportedly used more than 200 cameras but did not provide clear procedures for how recordings were used or protected. Staff were encouraged to report anything that “felt wrong” without guidance on objective standards. This creates a climate where supervisors may feel pressured to find fault, not to support staff.

Lack of Community Transparency

Staff stated that the community surrounding the facility was unaware of its purpose. While confidentiality laws protect patient privacy, lack of institutional transparency can raise safety concerns. Community members should not be unclear whether a facility is a school, a treatment center, or a correctional program. Transparency supports public trust and emergency preparedness.

Leaving as a Professional Obligation

Given these ethical conflicts, safety concerns, and professional risks, the author made the responsible decision to withdraw from the assignment. Withdrawal under such circumstances is an act of professionalism, not abandonment. It reflects adherence to the highest standards of nursing ethics, patient safety, and licensure protection.

The Role of Turnover: A Warning Sign of Systemic Dysfunction

High turnover rates among nurses are strongly linked to deeper structural problems. Research consistently shows that turnover increases when workplace environments are unsafe, punitive, or ethically conflicting (Lucas et al., 2025).

In the case example, the facility’s repeated focus on dismissals during orientation reflected a high-turnover culture. A cycle of frequent firings or departures destabilizes the care environment, increases the burden on remaining staff, and creates inconsistent patient care. Advanced-practice nurses must be especially cautious in such environments, as instability increases the likelihood of miscommunication, inappropriate reporting, and ethical violations.

Conclusion

Advanced-practice nurses must be placed in environments that honor their expertise, uphold evidence-based practice, and respect their legal and ethical responsibilities. When facilities fail to provide adequate autonomy, present conflicting ethical expectations, create punitive surveillance systems, or maintain opaque and unstable working conditions, advanced-practice nurses must evaluate whether staying endangers their professional license.

The author remains committed to practicing ethically and safely and welcomes opportunities within organizations that value transparency, professionalism, and respect for clinical judgment. Organizations that foster stable, supportive, evidence-based environments will attract and retain the highly skilled clinicians they need.

Legal and Academic Disclaimer

This paper presents an anonymized academic case reflection for educational purposes only.No organization, individual, or entity is named, identified, or accused.The case example reflects subjective professional impressions and does not assert wrongdoing.This paper should not be interpreted as a legal complaint or factual allegation.

References

Choupani, S. S. H., Ghaffari, S., Jafari, H., Bazarafshan, M., & Gholampour, M. H. (2024). Professional Ethics and Ethical Challenges Related to Nurses and patients: a Narrative Review. Journal of Nursing Reports in Clinical Practice, 3(4), 1–7. https://doi.org/10.32598/JNRCP.2403.1055

Isobel, S., & Edwards, C. (2017). Using trauma informed care as a nursing model of care in an acute inpatient mental health unit: A practice development process. International Journal of Mental Health Nursing, 26(1), 88–94. https://doi.org/10.1111/inm.12236

Kim, M. S., Oh, Y., Joo Yun Lee, & Lee, E.-H. (2023). Job satisfaction and moral distress of nurses working as physician assistants: focusing on moderating role of moral distress in effects of professional identity and work environment on job satisfaction. BMC Nursing, 22(1). https://doi.org/10.1186/s12912-023-01427-1

Lockwood, E. B., & Schober, M. (2024). Factors Influencing the Impact of Nurse Practitioners’ Clinical autonomy: a Self Determining Perspective. International Nursing Review, 71(2). https://doi.org/10.1111/inr.12948

Lucas, P., Jesus, É., Almeida, S., Costa, P., Cruchinho, P., Teixeira, G., & Araújo, B. (2025). The Nursing Practice Environment and Job Satisfaction, Intention to Leave, and Burnout Among Primary Healthcare Nurses: A Cross-Sectional Study. Nursing Reports, 15(7), 224. https://doi.org/10.3390/nursrep15070224

Peacock, M., & Hernandez, S. (2020). A concept analysis of nurse practitioner autonomy. Journal of the American Association of Nurse Practitioners, 32(2), 113–119. https://doi.org/10.1097/jxx.0000000000000374

Rosalind de Lisser, Rosalind de Lisser, Rosalind de Lisser, Rosalind de Lisser, & Rosalind de Lisser. (2024). The Social Ecology of Burnout: A framework for research on nurse practitioner burnout. Nursing Outlook, 72(4), 102188–102188. https://doi.org/10.1016/j.outlook.2024.102188

Salari, N., Shohaimi, S., Khaledi-Paveh, B., Kazeminia, M., Bazrafshan, M.-R., & Mohammadi, M. (2022). The severity of moral distress in nurses: a systematic review and meta-analysis. Philosophy, Ethics, and Humanities in Medicine, 17(1). https://doi.org/10.1186/s13010-022-00126-0

You, W., Cusack, L., & Donnelly, F. (2023). A lack of nurse autonomy impacts population health when compared to physician care: an ecological study. Scientific Reports, 13(1), 12047. https://doi.org/10.1038/s41598-023-38945-6