Nurse moral distress: A survey identifying predictors and potential interventions.

BACKGROUND: Ethical dilemmas and conflicts are inherent in today's health care organizations and may lead to moral distress, which is often associated with physical and psychological symptoms. Although the existence of moral distress has been observed by scholars for decades, most of the research has been descriptive and has examined what types of health care conflicts lead to distress.

OBJECTIVE: This study tested a comprehensive model, underpinned by Social Cognitive Theory, that examined work environment and intrapersonal variables that may influence moral distress.

DESIGN/SETTING/PARTICIPANTS: We surveyed nursing staff employed in a U.S. acute care hospital (response rate=45%; n=290).

RESULTS: More than half of the respondents reported they experience ethical dilemmas and conflicts from several times a month to daily, and nearly half reported they experience moral distress at least several times a month. Structural equation modeling analysis simultaneously examined the effects of five independent variables on moral distress and moral voice: (a) frequency of ethical dilemmas and conflicts; (b) moral efficacy; (c) ethics communication; (d) ethical environment; and (e) organizational ethics support. Results revealed significant independent effects of the frequency of ethics issues and organizational ethics support on moral distress. Bootstrapping analysis indicated that voice fully mediated the relationship between moral efficacy and moral distress, and partially mediated the relationship between organizational ethics support and distress. Supplemental analysis revealed that organizational ethics support moderated the moral efficacy-voice-moral distress relationship such that when organizational support was low, moral efficacy was negatively related to moral distress via voice.

CONCLUSIONS: Although it may be impossible to eliminate all ethical dilemmas and conflicts, leaders and organizations may wish to help improve nurses' moral efficacy, which appears to give rise to voice, and reduced moral distress. Increasing organizational ethics support may be a key approach.