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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,
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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
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
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
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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
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
Provide care that does not relieve the patient’s suffering because I fear that increasing
the dose of pain medication will cause death
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 family’s wishes to continue life support even though it is not in the
best interest of the patient
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
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 Code status with the family when the patient
becomes non-competent
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.
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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
job
Surgical settings
Nursing experience
job
Intensive settings
Nursing experience
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
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
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.
Implications for nursing management
Gaining further insight into nurses’ experience of
moral distress and the clinical situations that most frequently cause it will facilitate the development of
8
This study received no specific grant from any funding
agency in the public, commercial, or not-for profit sectors.
Ethical approval
Institutional permission was obtained from the appropriate Institutional Review Board. Approval letter:
April 2011, reference detail n. 42120-L29.
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