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Journal of Nursing Management, 2016 Moral distress among nurses in medical, surgical and intensive-care units MAURA LUSIGNANI M S N , R N 1, MARIA LORELLA GIANNI M D 2, LUCA GIUSEPPE RE MARIA LUISA BUFFON M S N , R N 4,5 MSN, RN 3 and 1 Associate Professor, Coordinator Course Session, Bachelor in Nursing, Department of Biomedical Sciences for Health, University of Milan, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, 2Assistant Professor, Department of Clinical Sciences and Community Health, University of Milan, NICU, Fondazione IRCCS C a Granda Ospedale Maggiore Policlinico, Milan, 3Tutor, Course Session Bachelor in Nursing, Fondazione IRCCS C a Granda Ospedale Maggiore Policlinico, Milan, 4Nurse, Ospedale Ca Foncello, Azienda 5 ULSS 9 and Vice President, Provincial College of Nurses, Treviso, Italy Correspondence Maura Lusignani Department of Biomedical Sciences for Health University of Milan Via Pascal 36 20133 Milan Italy E-mail: [email protected] LUSIGNANI M., GIANNI M. L., RE L. G. & BUFFON M. L. (2016) Journal of Nursing Management Moral distress among nurses in medical, surgical and intensive-care units Aim To assess the frequency, intensity and level of moral distress perceived by nurses working in medical, surgical and intensive care units. Background Moral distress among nurses compromises their ability to provide optimal patient care and may cause them to leave their job. Methods A cross-sectional questionnaire survey of 283 registered nurses was conducted to evaluate the frequency, intensity and levels of moral distress. A revised version of the Moral Distress Scale (MDS-R) was used. Results The highest level of moral distress was associated with the provision of treatments and aggressive care that were not expected to benefit the patients and the competency of the health-care providers. Multivariate regression showed that nurses working in medical settings, nurses with lower levels of experience working in medical, surgical or intensive care settings, and nurses who intend to leave their job experienced the highest levels of moral distress. Conclusions The present study indicates that nurses experience an overall moderate level of moral distress. Implications for nursing management Gaining further insight into the issue of moral distress among nurses and the clinical situations that most frequently cause this distress will enable development of strategies to reduce moral distress and to improve nurse satisfaction and, consequently, patient care. Keywords: burnout, ethics, medical care, moral distress, registered nurse, surgical and intensive care Accepted for publication: 14 August 2016 Introduction Scientific and technological advances, the decreased availability of health-care resources, and the increasing numbers of elderly patients admitted to acute care wards (Ministry of Health, Italy 2010, World Health Organisation 2015) and diagnosed with multimorbidity, DOI: 10.1111/jonm.12431 ª 2016 John Wiley & Sons Ltd disability, terminal illness or cognitive impairment that render them care-dependent have led to a need to review approaches to patient care. The care provided to patients on an acute ward is often different from that needed by many elderly patients. The turbulence and complexity of aged care environments (Burston & Tuckett 2012), especially those in which elderly patients require critical care, 1 M. Lusignani et al. can lead to value conflicts in clinical practices (Sørlie et al. 2005). Some of the key issues concerning elderly patients, associated with aspects such as dignity, informed consent, the capacity to make decisions and the intervention of families in decision-making (LeinoKilpi et al. 2003, Suhonen et al. 2010, Edwards et al. 2013), exacerbate this complex situation. As a result of ethical issues regarding patient management, health-care professionals who treat patients in acute-care hospitals are frequently challenged by clinical situations that are morally complex. Moral distress was defined by Corley, as quoted by Jameton (1984), as a ‘painful psychological disequilibrium’ caused by situations in which the ethically appropriate action is recognised but cannot be taken because of institutional barriers (Corley et al. 2001). Moral distress compromises the ability of nurses to provide optimal patient care and achieve quality outcomes for patients. Furthermore, nurses who experience moral distress may reach a state of burnout and eventually leave their job (Epstein & Hamric 2009, Huffman & Rittenmeyer 2012, Varcoe et al. 2012). The perception of moral distress is exacerbated by a lack of organisational policies and support, inter-professional conflicts and legal obligations (Pauly et al. 2009, Brazil et al. 2010, Papathanassoglou et al. 2012). Furthermore, the effects of models of nursing care delivery that are not patient centred and team oriented might compromise patient outcomes and nursing outcome, leading to job dissatisfaction (Fernandez et al. 2012). Individual characteristics such as age, gender, and professional experience affect the experience of moral distress (Corley et al. 2001, 2005, Elpern et al. 2005, Hamric et al. 2006, K€ alvemark Sporrong et al. 2006, Rice et al. 2008, Pauly et al. 2010). In addition, specific health-care settings are associated with higher levels of moral distress (Gutierrez 2005, McCaffree 2006, Mobley et al. 2007, Fernandez-Parsons et al. 2013, St Ledger et al. 2013). To our knowledge, data concerning the experience of moral distress in medical and surgical settings are scarce because previous studies have addressed the topic mainly in intensive-care settings and have reported conflicting results. Moderate frequency and intensity levels of moral distress were reported by Negrisolo and Brugnaro (2012) in oncology treatment settings, home assistance and intensive care. Lovato and Cunico (2012) investigated nursing situations that led to moral distress in medical settings and reported that clinical decisions, nursing competence, nurse– physician collaboration, organisation of care and safe care were the areas that were most often associated 2 with experience of moral distress. With regard to paediatric and neonatal intensive care, Lazzarin et al. (2012) reported high levels of moral distress in the former setting, whereas Sannino et al. (2015) found relatively low levels in the latter. The purpose of the present study was to investigate the level, frequency and intensity of moral distress perceived by nurses working in medical, surgical, and intensive-care units. Moreover, we aimed to determine whether nurses caring for patients admitted for urgent care and aged ≥65 years perceived a higher level of moral distress than nurses caring for non-urgently admitted patients aged ≤65 years. Methods Design A cross-sectional survey was conducted from November 2011 to February 2012 and included forty-six medical, surgical, and intensive-care units at C a Foncello Hospital in Treviso, Italy. The institutional review board approved the study. Sample Nurses were recruited using convenience sampling. The inclusion criterion was practice in a medical, surgical or intensive-care unit. The exclusion criteria were practice in accident and emergency departments, operating theatres, ambulatory units or day hospitals, and having <1 year of professional working experience. Data collection procedures The survey was initiated via e-mail. Several meetings were held with the participating nurses to explain the purpose of the survey and describe the questionnaire. Participation in the survey was voluntary and anonymity was ensured. Approximately 15–20 minutes were required to complete the questionnaire. The questionnaires were delivered and then collected by the investigator in charge of the study. Consent from each nurse was implied with the return of the completed questionnaire. Data analysis The descriptive characteristics of the study participants are presented as a mean (range) or percentage. To identify the independent variables (gender, age, setting, working experience, educational level and intention to ª 2016 John Wiley & Sons Ltd Journal of Nursing Management Moral distress among nurses in acute care units leave the job) that best predicted the ranked score of moral distress (dependent variable), a multivariate stepwise regression analysis was performed. All relations with P < 0.05 were included in this analysis. An odds ratio (OR) above 1 indicates that as the variable increases, nurses are more likely to be distressed. In order to evaluate the independent variables (percentage of patients admitted for urgent or non-urgent care and age) that were significantly associated with medical, surgical or intensive care setting, a chi-square test was performed with two degrees of freedom. A P-value <0.05 indicates a significant association between the care setting and the modality of admission and age. Windows Excel 2008 (Microsoft, Redmond, WA, USA) and the statistical software R (version 2.13.1, R Foundation for Statistical Computing, Vienna, Austria) were used to develop a database for data processing and perform the statistical analyses, respectively. Instrument: the Moral Distress Scale The frequency (F), intensity (I) and level of moral distress (F 9 I) were assessed using a revised version of the Moral Distress Scale (MDS-R) (Hamric et al. 2012). The MDS-R is composed of three main categories of root causes: clinical situations (e.g. continuing to provide aggressive care in situations of futility, providing care not in the patient’s best interest and working with incompetent care providers); internal constraints (e.g. perceived powerlessness, lack of assertiveness); and external constraints (e.g. power hierarchies or institutional policies) (Hamric et al. 2012). Written permission to use the MDS-R was obtained from Corley and Hamric, who developed this tool and gave us permission to use the scale before their paper was published (written permissions received by e-mail in August and November 2010). The back-translation method was adopted to translate the scale into Italian. Three situations (e.g. euthanasia) were removed because they are not legally permitted in Italy; thus the Italian version of the MDS-R comprised 18 items. Before the start of the study, the content validity of the Italian version of the MDS-R was submitted to a group of expert nurses and university lecturers to ensure comprehension of the text. A pilot study was conducted on a sample of 60 nurses to further validate the revised MDS. The Cronbach’s alpha coefficient of 0.83 showed that the remaining 18 items maintained the internal consistency of the scale. The participants were asked to assess each situation according to its frequency (i.e. how often a specific situation occurred) and intensity (i.e. how much distress the ª 2016 John Wiley & Sons Ltd Journal of Nursing Management situation caused) on a Likert scale ranging from 0 to 4 where 0 = never and 4 = very frequently, and 0 = no intensity and 4 = to a great extent, respectively (Hamric et al. 2012, Sannino et al. 2015). The total score for frequency and intensity for the 18 clinical situations ranges from 0 to 72. The level of moral distress was determined by multiplying the frequency score by the intensity score to yield a combined score ranging from 0 (low) to 16 (high) (Hamric et al. 2012, (Sannino et al. 2015). The total score for level of moral distress for the 18 clinical situations ranges from 0 to 288. A mean score for frequency, intensity and level of moral distress was obtained by calculating the scores of each participants for each of the 18 clinical situations investigated and dividing by 283 (the number of participants who completed the questionnaire) or by the number of participants for each setting investigated. Owing to the lack of reference values in the literature the frequency, intensity and level of moral distress were calculated by a mean sum score for each participants for the 18 clinical situations investigated and were subsequently categorised. The frequency and intensity were ranked based on a Likert scale (0–4) as low (from 0 to 1.33), moderate (from 1.34 to 2.67) and high (from 2.68 to 4). The level of moral distress was ranked (0–16) as low (from 0 to 1.77), moderate (from 1.78 to 7.13) and high (from 7.14 to 16).The mean sum score for the level of moral distress was calculated and then ranked as high (≥83) or low (<83) for multivariate statistical analyses. The dichotomized level of moral distress highlighted more clearly the impact of every independent variables (individual characteristics) on the moral distress level obtained. The most appropriate cut-off value was calculated using the Kolmogorov–Smirnov test on a single sample. The participants reported age, gender, educational level, postgraduate level and professional work experience, which were recorded on a demographic datasheet. The participants were also instructed to indicate whether they intended to leave their current position or whether they had already left a position because of moral distress. The data concerning the number of admissions to the medical, surgical and intensive care units according to modality (urgent or not urgent) were also provided by the authors’ institution hospital. Results Sample characteristics A total of 559 nurses were invited to take part in the study, and 283 completed the questionnaires. Eighty 3 M. Lusignani et al. per cent of the participants were female, with an average age of 40 (22.6–57.5) years. Their mean nursing experience was 16 (1–38) years, with an average of 6.1 (0.1–37.1) years in the current clinical position. Most of the individuals had attained a 3-year state nursing diploma outside the university, whereas only Table 1 Individual characteristics of the study participants (n = 283) Nursing experience, mean years (range) 16 (1–38) Experience in current position as a 6.1 (0.1–37.1) nurse, mean years (range) Age, mean years (range) 40.2 (22.6–57.5) Gender, n (%) Female 227 (80) Male 56 (20) Familiar with the term ‘moral distress’, n (%) Yes 103 (36) No 180 (64) Educational level, n (%) RN (equipollent qualification pursuant to Law 163 (58) 42/1999) RN (3-year nursing degree) 109 (38) Postdiploma training (master’s degree first and 11 (4) second level) Left previous or present job because of moral distress, n (%) No 154 (54) Considered but did not leave 121 (43) Yes 8 (3) RN, registered nurse. 4% of the respondents had received postdiploma training. With regard to the latter finding, it must be noted that in Italy, the 3-year university nursing degree programme was implemented in 2001, and the nurses who completed this programme are younger than nurses with 3-year state diplomas and nurses with postdiploma training. Among the nurses who answered the questionnaire, 64% were unaware of the concept of moral distress before the study. Of the participant registered nurses, 43% claimed to have considered leaving their job because of moral distress, and 3% had actually changed jobs because of moral distress (Table 1). Individual characteristics were similar among nurses working in medical, surgical and intensive care settings. Frequency, intensity and level of moral distress The 18 clinical situations for the mean frequency, intensity and level of moral distress were ranked in decreasing order for each situation (Tables 2–4).The mean moral distress score for frequency was 1.51 (0.92–2.1), indicating that the situations associated with moral distress generally occurred with moderate frequency. Performing tests and treatments, providing Table 2 Eighteen clinical situations for frequency of moral distress (mean scores) Clinical setting Rank 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 4 Clinical situations Sample Medical Surgical Intensive Carry out the physician’s orders for what I consider to be unnecessary tests and treatments for terminally ill patients Follow the family’s wishes to continue life support even though it is not in the best interest of the patient Follow orders for pain medication even when the medications prescribed do not control the pain Provide care that does not relieve the patient’s suffering because I fear that increasing the dose of pain medication will cause death Assist a physician who in my opinion is providing incompetent care Provide less than optimal care owing to pressures to reduce costs Follow that family’s request not to discuss death with a dying patient who asks about dying Initiate extensive life-saving actions when I think it only prolongs death Work with physicians/nurses who are not as competent as the patient care requires Follow the physician’s order not to tell the patient the truth when he/she asks for it Ignore situations in which patients have not been given adequate information to ensure informed consent Increase the dose of intravenous morphine for an unconscious patient that I believe will hasten the patient’s death Prepare an elderly person for surgery to have a gastrostomy tube put in who is severely demented Follow the physician’s request not to discuss death with a dying patient who asks about dying Follow the physician’s request not to discuss Code status with the patient Follow the physician’s request not to discuss Code status with the family when the patient becomes non-competent Ignore situations of suspected patient abuse by caregivers Ask the patient’s family about donating organs when the patient’s death is inevitable 2.50 2.84 2.14 2.37 2.25 2.59 1.67 2.49 2.12 1.99 2.40 2.37 2.02 1.67 1.59 1.69 1.90 1.79 1.79 1.75 1.70 1.67 1.61 1.68 1.97 2.05 1.86 1.60 1.81 1.53 2.20 1.82 1.59 1.24 1.88 1.57 1.80 1.84 1.27 1.53 2.47 1.59 1.55 1.45 1.34 1.43 0.97 1.86 1.05 1.44 0.70 0.78 1.04 0.80 0.79 1.17 0.82 0.90 0.91 0.67 0.62 0.98 1.02 0.84 0.67 0.45 0.71 0.33 0.64 0.30 0.84 1.06 ª 2016 John Wiley & Sons Ltd Journal of Nursing Management Moral distress among nurses in acute care units Table 3 Eighteen clinical situations for intensity of moral distress (mean scores) Clinical setting Rank 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Clinical situations Sample Medical Surgical Intensive Follow orders for pain medication even when the medications prescribed do not control the pain Work with physicians/nurses who are not as competent as the patient care requires Provide care that does not relieve the patient’s suffering because I fear that increasing the dose of pain medication will cause death Ignore situations of suspected patient abuse by caregivers Assist a physician who in my opinion is providing incompetent care Carry out the physician’s orders for what I consider to be unnecessary tests and treatments for terminally ill patients Ignore situations in which patients have not been given adequate information to ensure informed consent Follow the physician’s request not to discuss death with a dying patient who asks about dying Provide less than optimal care owing to pressures to reduce costs Follow the family’s wishes to continue life support even though it is not in the best interest of the patient Initiate extensive life-saving actions when I think it only prolongs death Ask the patient’s family about donating organs when the patient’s death is inevitable Follow the physician’s request not to discuss Code status with the patient Follow that family’s request not to discuss death with a dying patient who asks about dying Follow the physician’s order not to tell the patient the truth when he/she asks for it Follow the physician’s request not to discuss Code status with the family when the patient becomes non-competent Increase the dose of intravenous morphine for an unconscious patient that I believe will hasten the patient’s death Prepare an elderly person for surgery to have a gastrostomy tube put in who is severely demented 3.19 3.18 3.10 3.29 3.09 3.29 3.13 3.36 2.94 3.04 3.06 2.92 3.08 3.05 2.94 3.06 2.84 3.09 3.23 3.29 2.83 2.84 3.08 2.80 2.93 2.77 3.14 2.92 2.92 2.88 2.84 2.97 3.01 2.89 2.93 2.86 2.76 2.75 2.59 2.90 2.84 2.79 2.76 2.68 2.60 2.43 2.97 2.64 2.74 2.78 2.59 2.40 2.60 2.98 2.81 1.59 2.62 2.50 2.98 2.76 2.73 2.29 2.57 2.37 2.39 2.33 2.57 2.18 2.36 2.56 2.32 1.94 Table 4 Eighteen clinical situations for level of moral distress (F 9 I; mean scores) Clinical care setting Rank 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Clinical situations Sample Medical Surgical Intensive Carry out the physician’s orders for what I consider to be unnecessary tests and treatments for terminally ill patients Follow orders for pain medication even when the medications prescribed do not control the pain Provide care that does not relieve the patient’s suffering because I fear that increasing the dose of pain medication will cause death Follow the family’s wishes to continue life support even though it is not in the best interest of the patient Assist a physician who in my opinion is providing incompetent care Work with physicians/nurses who are not as competent as the patient care requires Provide less than optimal care owing to pressures to reduce costs Initiate extensive life-saving actions when I think it only prolongs death Ignore situations in which patients have not been given adequate information to ensure informed consent Follow that family’s request not to discuss death with a dying patient who asks about dying Follow the physician’s order not to tell the patient the truth when he/she asks for it Follow the physician’s request not to discuss death with a dying patient who asks about dying Increase the dose of intravenous morphine for an unconscious patient that I believe will hasten the patient’s death Prepare an elderly person for surgery to have a gastrostomy tube put in who is severely demented Follow the physician’s request not to discuss Code status with the patient Ignore situations of suspected patient abuse by caregivers Follow the physician’s request not to discuss Code status with the family when the patient becomes non-competent Ask the patient’s family about donating organs when the patient’s death is inevitable 7.89 9.29 6.45 7.25 7.10 8.42 6.53 4.94 6.80 8.47 5.46 5.25 6.60 7.77 4.73 7.39 6.34 5.72 5.49 5.39 5.13 5.33 5.32 6.38 5.91 4.72 7.75 6.50 5.47 3.47 5.88 6.06 5.18 3.31 7.92 4.65 5.06 4.61 3.25 3.25 5.90 4.94 3.62 3.15 4.61 4.42 2.96 2.36 3.86 4.16 2.88 4.16 2.67 3.88 1.55 1.90 2.32 2.23 2.02 2.49 2.29 2.37 1.78 2.26 1.57 2.98 1.98 2.04 1.28 0.91 0.81 3.16 F and I are frequency and intensity of moral distress, respectively. ª 2016 John Wiley & Sons Ltd Journal of Nursing Management 5 M. Lusignani et al. pain medication for terminally ill patients, maintaining life support even against the best interests of the patient, and assisting a physician who, in the opinion of the nurse, provided incompetent care were the survey items that showed the highest values (mean values from 1.90 to 2.50). Other distressing situations (mean values from 1.67 to 1.79) included conflicting perceptions between the wishes of the patient and the family and a lack of resources, professional competence and willingness to provide the patient with optimal care and truthful information about their care and condition. The remaining eight clinical situations had lower values, ranging from 0.45 to 1.61 The highest scores were observed in the medical setting (Table 2). The mean score for the intensity of moral distress was 2.83 (2.57–3.09), indicating an overall high intensity of moral distress. Administering pain medication, low team care competence and suspected patient abuse were among the primary clinical situations that showed the highest intensity values (mean values from 3.05 to 3.19) (Table 3). Performing tests and treatments that nurses deemed unnecessary, not giving adequate information to the patient, following the family’s wishes even when not in the best interest of the patient and the lack of resources to provide optimal care were additional distressing situations with high intensity values (from 2.84 to 2.94). The other eight clinical situations scored lower, (from 2.36 to 2.84). The scores for intensity were high in both the medical and surgical settings. The items that scored highest in terms of frequency and intensity were related to administration of pain medication. The mean score for the level of moral distress was 4.27 (2.41–7.89), indicating an overall moderate level of moral distress. The highest score (7.89) was attributed to observing or administering unnecessary tests and treatments administered to terminally ill patients (Table 4). Nurses who worked in medical settings reported higher values than nurses who worked in surgical and intensive-care settings for all but two items – perception of incompetent care by doctors and nurses (scored 6.50 and 7.75, respectively) and inappropriate information given to a patient for the purpose of obtaining consent (scored 5.88) – in surgical settings. Interventions in life support and extensive life-saving actions that were not in the best interest of the patient were, together, the most relevant cause of moral distress in the intensive-care setting (scored 7.92). Multivariate stepwise regression analysis performed on the overall sample (n = 283) indicated that three variables explained the variance of the moral distress 6 scores (Table 5). Nurses who worked in medical settings, nurses with lower levels of experience working in medical, surgical or intensive-care settings and nurses that intended leaving their job experienced the highest levels of moral distress. No significant correlation between age, gender, education level and level of moral distress was identified. Nurses who worked in medical settings provided care to urgently admitted patients aged ≥65 years at a significantly higher frequency compared with nurses working in surgical and intensive-care settings (Table 6). Further analyses of these correlations were performed considering the medical, surgical and intensive settings separately (Table 5). Nurses who worked in medical settings with the intention of leaving their job experienced more moral distress compared with those who did not express this intention. Nurses who worked in surgical settings with higher levels of nursing experience experienced less moral distress compared with those who had less nursing experience. Table 5 Characteristics related to level of moral distress: stepwise multiple regression analysis Characteristics Overall sample Medical settings Nursing experience Intention to leave the job Medical settings Nursing experience Intention to leave the job Surgical settings Nursing experience Intention to leave the job Intensive settings Nursing experience Intention to leave the job Odds ratio 95% Confidence interval P-value 2.002 0.421 1.539 0.170–3.452 0.197–0.891 0.949–2.509 0.012 0.025 0.081 1.043 2.285 0.076–14.077 1.131–4.691 0.975 0.022 0.251 1.890 0.065–0.914 0.795–4.690 0.039 0.157 1.743 0.522 0.031–107.420 0.153–1.696 0.786 0.285 Table 6 Patients admission characteristics Settings Medical Modality of admission (%) Urgent 86.7 Not urgent 13.3 Age in years (%) <65 34.3 ≥65 65.7 P-value (v2 test) Surgical Intensive 48.1 51.9 11.3 88.7 <0.0001 56 44 95.8 4.2 <0.0001 ª 2016 John Wiley & Sons Ltd Journal of Nursing Management Moral distress among nurses in acute care units Age, gender and education level did not correlate with the level of moral distress in both medical and surgical care settings. When considering the intensive care setting, no significant correlation was found between any of the independent variables and the level of moral distress. Discussion The findings of the present study indicate a moderate level of moral distress among nurses working in medical, surgical and intensive-care settings, with the highest level of moral distress found in medical settings. Specifically, as shown by the multivariate regression analysis performed on the overall sample, higher moral distress scores were experienced by nurses who worked in medical setting who had less professional experience and intended to leave their job. Overall, these findings suggest that nurses with higher levels of nursing experience working in surgical and intensive care settings and nurses who had not expressed an intention to leave their job may be less susceptible to moral distress. When considering the medical care setting, nurses that intended to leave their job experienced higher moral distress scores compared with those who had not expressed this intention, but no other significant relationship was detected. With regard to the surgical care setting, nurses with more nursing experience experienced lower moral distress scores than nurses with less nursing experience. These results show that nursing experience may be a protective factor against moral distress. When the intensive-care setting was considered, none of the variables correlated with the level of moral distress. Although not consistent with the data previously reported in the literature, this latter finding might be explained by the fact that few of the respondents worked in the intensive-care setting. Finally, these findings showed that the intention to leave the job was associated with a moderate level of moral distress both in the overall sample and in the medical setting. These results have several implications for nursing management. When considering the impact of working with urgently admitted patients aged ≥65 years, nurses who worked in medical settings seemed to be exposed to moral distress at a significantly higher frequency than those who worked in surgical and intensive-care settings (Table 6). This finding may have partly resulted from the fact that nurses who care for elderly patients, who are perceived as being more frail and vulnerable than other adult patients, encounter a higher rate of ª 2016 John Wiley & Sons Ltd Journal of Nursing Management morally complex conditions and are therefore more likely to experience high levels of moral distress. The levels of moral distress found in the present study were similar to those reported in other studies (Corley et al. 2001, 2005, Rice et al. 2008, Papathanassoglou et al. 2012, Fernandez-Parsons et al. 2013, de Veer et al. 2013). According to our results, the moral distress experience appears to be mainly related to the inability of nurses to influence medical decisions related to the patients’ levels of pain and suffering, pressure from the patient’s family to maintain life support even when it is not in the patient’s best interest and the provision of truthful information to the patient. In agreement with previous studies conducted in specific settings, other clinical situations associated with the experience of moral distress were those related to collaboration within the team caring for the patient (Lazzarin et al. 2012, Papathanassoglou et al. 2012 Kleinknecht-Dolf et al. 2015). This finding may be partly explained by the different frameworks related to patient care, the perception of an unequal hierarchical authority and the lack of communication, evaluation and discussion of cases between doctors and nurses on both clinical and ethical bases. Although several nursing models of care have been implemented over the past 10 years, the most commonly applied model has been the functional (task) model. This traditional model remains contentious in terms of the improvement of patient-centred care and multidisciplinary team-oriented care. Another situation that scored a high level of moral distress was the perception of the inadequate competence of nurses and doctors in relation to the care needed by the patient. This finding highlights the need to provide management support within the working environment to improve professional performance. The high level of moral distress observed in the medical care setting may be caused by the presence of many elderly patients who are urgently admitted and are consequently in critical condition or at the end of their life. In contrast, the surgical setting was characterized by a lower level of moral distress, with the exception of two clinical situations: when a nurse reported having to ‘Assist a physician who in my opinion is providing incompetent care’ and ‘Work with physicians and nurses who are not as competent as the patient’s care requires’ (Hamric et al. 2012). With regard to the intensive care setting, the highest scores for the moral distress level (Elpern et al. 2005, Hamric & Blackhall 2007, Mobley et al. 2007, Zuzelo 2007, Fernandez-Parsons et al. 2013, de Veer 7 M. Lusignani et al. et al. 2013) concerned two situations: ‘Initiate extensive life-saving actions when I believe that they only prolong death’ and ‘Follow the family’s wishes to continue life support even though it is not in the best interest of the patient’ (Hamric et al. 2012). Although the results of this survey indicate that there was no difference in the percentage of nurses who experienced either a low or a high moral distress score and expressed the intention of leaving their job, a relatively high percentage of nurses (43%) had considered leaving their job because of their experience of moral distress. However, only 3% had actually left a previous job because of moral distress. Contrary to the present findings, Corley et al. (2001) reported a higher percentage (23%) of nurses who experienced moral distress and had left their current position within 1 year. These results can be partly explained by the fact that the majority of the nurses interviewed in the present survey were not aware of the concept of moral distress, resulting in an underestimation of the number of nurses deciding to leave their job because they experienced moral distress. strategies to reduce moral distress and improve patient care and nurse satisfaction. Continuing ethical education and nursing management support to improve ethical and clinical evaluations and discussion of cases between doctors and nurses would contribute to addressing the value conflicts in patient care and reduce moral distress. Physician and nurse responsibilities and ethical obligations must be interpreted and balanced in light of the patient’s values in order to find the best possible decision that serves the patient. Multidisciplinary discussions involving physicians and nurses may be an extremely complex ethical challenge and, at the same time, a vital resource to reach consensus among the care team and the patient regarding the most appropriate action in clinical care. Acknowledgements The authors gratefully acknowledge Prof. Mary C Corley and Prof. Ann B. Hamrich for their encouragement in the conducting of this study. Source of funding Limitations Although the present study provides interesting clinical data, it has some limitations. First, the results apply to nurses who work at a single institution and may not be representative of the nationwide population of nurses. Moreover, the percentage of participant registered nurses in the study represented only 50.6% of the nurses screened for eligibility. Finally, the modified questionnaire adopted for the study (three situations were removed from the original version) may reflect only the Italian nursing practice. Conclusions This survey provides data regarding the moral distress perceived by nurses and suggests that medical settings, limited nursing experience and an intention to leave the job are the factors that are associated primarily with the highest levels of moral distress. Further studies are needed to confirm these findings and identify strategies for alleviating moral distress, especially among the most vulnerable groups of nurses. 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