Sub-categories of moral distress among nurses: A descriptive longitudinal study

Abstract

Background

There is ongoing debate regarding how moral distress should be defined. Some scholars argue that the standard “narrow” definition overlooks morally relevant causes of distress, while others argue that broadening the definition of moral distress risks making measurement impractical. However, without measurement, the true extent of moral distress remains unknown.

Research aims

To explore the frequency and intensity of five sub-categorizations of moral distress, resources used, intention to leave, and turnover of nurses using a new survey instrument.

Research design

A mixed methods embedded design included a longitudinal, descriptive investigator-developed electronic survey with open-ended questions sent twice a week for 6 weeks. Analysis included descriptive and comparative statistics and content analysis of narrative data.

Participants

Registered nurses from four hospitals within one large healthcare system in Midwest United States.

Ethical considerations

IRB approval was obtained.

Results

246 participants completed the baseline survey, 80 participants provided data longitudinally for a minimum of 3 data points. At baseline, moral-conflict distress occurred with the highest frequency, followed by moral-constraint distress and moral-tension distress. By intensity, the most distressing sub-category was moral-tension distress, followed by “other” distress and moral-constraint distress. Longitudinally, when ranked by frequency, nurses experienced moral-conflict distress, moral-constraint distress, and moral-tension distress; by intensity, scores were highest for moral-tension distress, moral-uncertainty distress, and moral-constraint distress. Of available resources, participants spoke with colleagues and senior colleagues more frequently than using consultative services such as ethics consultation.

Conclusions

Nurses experienced distress related to a number of moral issues extending beyond the traditional understanding of moral distress (as occurring due to a constraint) suggesting that our understanding and measurement of moral distress should be broadened. Nurses frequently used peer support as their primary resource but it was only moderately helpful. Effective peer support for moral distress could be impactful. Future research on moral distress sub-categories is needed.

Keywords

moral distress clinical ethics nursing nursing ethics survey

Introduction

Moral distress has been defined in a number of different ways and there is ongoing debate about how it should be conceptualized.^1,2 Originally described by Jameton³ in the nursing literature, it was defined as occurring when one knows the right thing to do but is prevented from carrying out that action due to an institutional constraint. Some scholars have argued that there are significant political, social and economic reasons to maintain Jameton’s³ standard narrow definition of moral distress.⁴ Others have argued that broader definitions of moral distress capture the breadth of morally distressing experiences which should not be disregarded.⁵ Though broadening the definition creates challenges to measuring the concept,^4,6 without measurement, the true extent of the problem remains unknown. Failing to broaden our understanding of moral distress systematically overlooks other morally relevant causes of distress that nurses and other healthcare professionals’ experience.^1,7,8 In her theoretical work, Fourie^5,7 suggested sub-categorizing moral distress based on causes of distress; for example, moral-constraint distress, moral-conflict distress, and moral-uncertainty distress. Qualitative data supported these three sub-categories of moral distress^8–10 and the addition of two other sub-categories: moral-tension distress and moral-dilemma distress (see Table 1).⁸ Finally, Morley, Bradbury-Jones, and Ives² argued that broadening the definition of moral distress could have positive benefits. First, embracing the possibility that moral distress occurs because of moral uncertainty and moral dilemmas could increase the ability to nurture moral communities in healthcare.² Second, as argued by April and April: 11, acknowledging that moral uncertainty is associated with moral distress could diminish the belief that there is a “moral white knight” working against all others to carry out the right actions.¹¹ The standard narrow view of moral distress creates a risk of undermining moral discussion and deliberation among healthcare professionals who work together to advocate for patients and families.¹² Importantly, failing to capture the prevalence or severity of other sub-categories of moral distress means that interventions will not be developed or tailored to address the other specific sub-categories of moral distress. By sub-categorizing moral distress by cause, targeted interventions can be developed and tested.

Table 1.

Description of sub-categories of moral distress.

Sub-category of moral distress	Description
Moral-constraint distress	The moral agent is experiencing psychological distress because they are constrained from doing what they think is the most ethically supportable action
Moral-conflict distress	The moral agent is experiencing psychological distress because they are engaged in conflict with another moral agent about what they think is the most ethically supportable action
Moral-uncertainty distress	The moral agent is experiencing psychological distress because they are uncertain about the most ethically supportable action
Moral-dilemma distress	The moral agent is experiencing psychological distress because they are unable to choose between two or more moral requirements
Moral-tension distress	The moral agent is experiencing psychological distress because they feel unable to share their beliefs with others

Research aims and objectives

The aims of this research were to examine hospital-based registered nurses (1) perceptions of frequency and intensity of sub-categories of moral distress; (2) personal and work characteristics and their association with each sub-category of moral distress; (3) resources used and their usefulness when addressing moral distress; and (4) associations between moral distress, resource utilization, intention to leave, and turnover.

Methodology

Research design

A mixed methods embedded design included longitudinal, descriptive electronic surveys, and free-text (open ended) responses to explore sub-categories of moral distress, resources used during morally distressing experiences, intention to leave, and turnover. Participants were also invited to participate in interviews and these data will be reported elsewhere.

Sample size calculations were performed based on the ability to detect moderate correlations between frequencies of different moral distress sub-categories, and to detect associations between categorized groups of moral distress frequency with other factors that included hospital site, intention to leave, and actual turnover. Since actual participation was unknown for this novel project, calculations assumed that 100 nurses would be willing to participate. With a sample size of 100, there would be 80% power to detect small to moderate correlations of at least 0.28 between frequencies of moral distress and similar power to detect absolute percentage differences of at least 28% in intention to leave and turnover between groups defined by moral distress response frequency. With our observed sample size of 80 participants with 3 or more surveys, there was similar power to detect correlations of at least 0.31 and absolute percentage differences of 31% or more for similarly defined groups. Power calculations were performed using G*Power14, and assumed use of two sided tests with significance level of 0.05.

Data collection

Registered nurses were recruited from a large, academic quaternary care medical center and three small to mid-size regional acute-care hospitals within the health system. Nursing units within each hospital were designated as sites (purposive sampling) based on nurse manager support of the research project. Registered nurses were recruited from within the designated nursing units. Potential participants received an email with an IRB approved research information sheet and information about the research at nursing unit huddles. Potential participants could ignore email requests and once recruited, could drop out of the study at any time by ignoring email requests to complete surveys or requesting to no longer receive email reminders. There were no exclusion criteria; all clinical nurses in direct patient care were included if their unit was selected for inclusion in the study. Non-clinical nurses were excluded.

Ethical considerations

This study was approved by the healthcare system institutional review board (IRB number 19-1025). Completion of surveys signified consent to participate.

Survey development

Moral distress sub-categorizations were examined using the Moral Distress Sub-Categorization Survey (MD-SCS), an investigator-developed survey. The instrument was designed with the aim of capturing the different sub-categories of moral distress longitudinally so the goal was to keep the survey as brief as possible to decrease nurses’ response burden. Each of the moral distress questions were developed to reflect the five different sub-categories that were identified in empirical research conducted by Morley et al.^8,13 in the United Kingdom which followed an in-depth review of the literature.¹⁴ For example, to capture the sub-category of moral-conflict distress, participants could choose the option “I am engaged in conflict with the team or family because of disagreement about what is right.”

Content validity was evaluated using the Lynn method.¹⁵ Eight content experts were given information about the aim of the survey and the different sub-categories of moral distress. Content experts consisted of one professor of nursing ethics, two professors of nursing, one clinical nurse with ethics expertise and four bioethicists. They individually rated each item based on relevance, clarity and importance. The original survey contained 23 items. Following feedback on clarity and importance, the survey was reduced to 11 items. The same eight content experts provided feedback on the 11-item version. The content validity index was 0.969 which exceeded the acceptable content relevance threshold of 0.78. To assure all eleven items were clear and understandable, cognitive interviewing was completed with a clinical nurse specialist with ethics and moral distress knowledge to ensure that the questions were clear and understandable.¹⁶ The MD-SCS was not compared to previous moral distress instruments such as the Moral Distress Scale-Revised and the Moral Distress Measure for Healthcare Professionals because the aim was to capture the different sub-categories of moral distress over time rather than the various constraints that cause distress.

Moral distress sub-categorization-survey

The final MD-SCS consisted of 11 items designed to understand themes of interest (8 items related to moral distress sub-categories and resources, and 3 items related to intention to leave and turnover). Depending on how participants responded, the survey could have been as short as 1 item or it could have encompassed the full 11 items. Questions were tiered with participants first asked to reflect upon the most recent 72 hours of work (the last 1–3 shifts of work) and state whether they experienced distress using a dichotomous yes/no checkbox. Participants were asked to recall the last 72 hours or 1–3 shifts to minimize recall bias of the phenomenon.¹⁷ If participants selected yes, they were asked if the distress was due to clinical work using a yes/no checkbox. If participants selected no, they would be presented with demographic questions and the survey ended. If yes, participants were asked to describe the cause of moral distress. They were presented with 5 options that represented the sub-categorizations or “other.” Participants were able to choose all that applied to capture the possibility that different sub-categories of moral distress occurred simultaneously. A free text option allowed for individualization of the cause of distress. The fourth item requested that participants provide the intensity of each sub-category of moral distress on a scale from 0 (no distress at all) to 100 (most distress imaginable). A 0–100 scale was utilized to capture breadth in responses. Two items of the survey captured healthcare system resources that participants might seek to use when experiencing different sub-categories of moral distress. Participants were provided with a checklist of resouces (for example, speaking with colleagues, using an employee assistance program, consulting the ethics consultation service (ECS) or palliative medicine) that could be used to address each cause of moral distress they selected. A free text option was provided to allow for resources that were not prepopulated. After participants selected a resource or support service, they rated it based on how helpful it was in mitigating moral distress, on a scale of 0 (not helpful at all) to 100 (extremely helpful). The final two items on resources and support services were free text that asked participants to explain why they didn’t access support services (when applicable) and if another service could have helped.

Intention to leave and turnover

Three items were developed by investigators to address intention to leave and also the influence of moral distress on turnover. Participants used fill-in-the-blank to show how long they saw themselves working on their current unit, hospital and in the nursing profession. Then, participants were asked about whether they were considering leaving the unit because of moral distress (dichotomous yes/no checkbox) and they used free text, as desired, to describe their reasons for intending to leave.

Turnover was captured in follow-up surveys. Participants completed a 2-item survey at 3, 6, and 12 months that asked if they worked on the same or a different unit and they were able to explain why via a fill-in-the-blank box. If a participant’s email was no longer active, the participant was no longer an active employee, as email addresses are removed immediately after service departure.

Participant demographics

Six nurse characteristics were collected at baseline, midpoint, and in the final survey using fill-in-the-blank or a drop down option list: highest nursing degree; length of time as a nurse (overall), on the current unit and within the healthcare system; gender; work shift; and if the ethics team rounded on the unit.

Data collection

Data were collected and stored using the REDCap database system, a secure, HIPAA compliant web-based program designed for building and managing web-based projects that is password protected. A research information sheet was emailed electronically to nurses who met the inclusion criteria. The information sheet contained a direct link to the electronic survey. At the end of the initial survey, participants were asked to provide their email address to receive surveys longitudinally, twice a week for six weeks. When nurses supplied their email via REDCap, longitudinal surveys were automatically emailed at the scheduled time point. Participants had the option to ignore requests or complete one or more surveys during the 6 weeks follow-up period. Participants could opt-out by sending an email request to the principal investigator. Survey responses were connected to each email address; and emails were visible to the principal investigator but not to other investigators; thus, participants’ identities were confidential. Data were collected from November 2019–January 2020.

Data analysis

Categorical variables were described using frequencies and percentages, and continuous variables were described using means, standard deviations, medians, minimum and maximum values. In analysis, data were grouped based on the causes of moral distress and resources used, and frequencies and percentages were calculated. Comparisons between groups were assessed using Kruskal–Wallis tests for ordered variables, or Fisher’s exact tests. When overall comparisons were significant, pairwise comparisons were run. Analyses of non-free text responses were completed using SAS® Software (version 9.4; Cary, NC).

Free text responses were analyzed using content analysis, guided by Vaismoradi et al.¹⁸ This approach provided a process for legitimately quantifying qualitative data without requiring close attention to context to build understanding, since context for responses is not available in short free text survey responses.¹⁸ This approach required reading and re-reading the data, creating groupings and categories and identifying themes.¹⁸

Results

In total, 246 nurses completed the baseline survey and 176 (71.0%) participants provided demographic data. Of baseline responders, 86.3% were female and the majority worked at the quaternary care hospital (77.3%); 38.6% worked in medical-surgical or neurosurgical ICU. Other characteristics of baseline survey responders were that most had a bachelor’s degree (90.3%) and around one-half had 3 years’ experience as a nurse on their current unit and in the health system. Most nurses rotated shifts and one-half reported that the ethics team rounded on their unit.

As anticipated, responses decreased in longitudinal follow-up. Eighty nurses completed at least 3 surveys over time, with 26 participants completing 3–4 surveys, 25 participants completing 5–7 surveys and 29 participants completing 8–13 surveys. At midpoint (3 weeks) and final surveys (6 weeks), participants continued to be more likely to work at the quaternary care hospital (80.0% and 72.7%, respectively). At midpoint, the majority of participants worked with cardiac patients, from either the ICU or intermediate (stepdown) units (40.0%), and in the final survey 36.4% of participants worked on medical-surgical units, emergency services or other areas. Over time, nurse participants who continued completing surveys indicated lower rates of ethics team rounding on their units. Demographic and work characteristics are reported in Table 2.

Table 2.

Participant characteristics (of those who completed demographic information); N, 176.

Characteristic	Baseline, n (%)
Work setting
Main campus	136 (77.3)
Regional hospitals (3 sites)	40 (22.7)
Clinical setting
Medical-surgical units/emergency service/other	49 (27.8)
Medical-surgical/neurological intensive care	68 (38.6)
Cardiac intensive care/cardiac step down units	59 (33.5)
Ethics team rounds in clinical setting
Yes	88 (50.3)
No/not sure	87 (49.7)
Highest qualification
Associate’s/bachelor’s degree/diploma	159 (90.3)
Graduate (masters or doctorate)/other	17 (9.7)
Years in profession
<3 years	90 (51.7)
4-5 years	12 (6.9)
6–10 years	21 (12.1)
11–15 years	17 (9.8)
16–20 years	6 (3.4)
>20 years	28 (16.1)
Years in current clinical setting
<3 years	103 (58.5)
4–10 years	38 (21.6)
11–20 years	19 (10.8)
>20 years	16 (9.1)
Years in current healthcare system
<3 years	85 (48.3)
4–10 years	45 (25.6)
11–20 years	25 (14.2)
>20 years	21 (11.9)
Gender
Female	151 (86.3)
Male	20 (11.4)
Prefer not to say/other	4 (2.3)
Shift pattern
Days	69 (39.2)
Nights	40 (22.7)
Alternating	67 (38.1)

Moral distress frequency and intensity by sub-categories

Of nurse participants at baseline, 203 (82.5%) indicated that they had recently (within 72 hours) experienced “distress” and 176 (71.5% of those with distress) reported that it was related to their clinical work. The frequency and intensity of distress varied depending on the cause. The most frequent sub-category of moral distress experienced was moral-conflict distress (48.9%), followed by moral-constraint distress (43.8%), moral-tension distress (39.2%), moral-dilemma distress (35.2%), and moral-uncertainty distress (33.0%). Overall, 21% of nurses who experienced recent moral distress related to clinical work categorized it as caused by “other.” At baseline, the intensity of distress of sub-categories of moral distress varied, with moral-tension distress occurring with the highest intensity (see Table 3 for all sub-category results).

Table 3.

Sub-categories of moral distress, distress frequency, and intensity at baseline and 3 of more surveys completed^*.

Moral distress sub-category	DescriptionPsychological distress due to being…	Baseline; N, 176		3 of more surveys completed; ^*N, 80
Moral distress sub-category	DescriptionPsychological distress due to being…	Frequencyn (%)	IntensityMean (SD)	Frequencyn (%)	IntensityMean (SD)
Moral-conflict distress	Engaged in conflict about the most ethically supportable option	86 (48.9)	59.5 (28.5)	41 (51.3)	7.9 (14.2)
Moral-constraint distress	Constrained from doing what they think is the ethically appropriate action	77 (43.8)	59.7 (29.2)	34 (42.5)	12.2 (16.6)
Moral-tension distress	Unable to share beliefs with others	69 (39.2)	64.6 (30.5)	29 (36.3)	15.8 (15.8)
Moral-dilemma distress	Unable to choose between two or more moral requirements	62 (35.2)	52.5 (31.6)	25 (31.3)	8.0 (18.3)
Moral-uncertainty distress	Uncertain about the ethically supportable option	58 (33.0)	47.5 (27.4)	25 (31.3)	13.9 (19.4)
Other	Other cause of work-related distress	37 (21.0)	60.9 (28.8)	21 (26.3)	8.1 (12.1)

^*Intensity was measured on a 0–100 scale.

In total, 80 participants completed 3+ surveys over the 6 weeks data collection period. By frequency, moral-conflict distress occurred the most often (51.3%), followed by moral-constraint distress (42.5%), and moral-tension distress (36.3%). Moral-uncertainty distress (15.2%) and moral-dilemma distress were experienced with the same frequency (31.3%). By intensity, moral-tension distress and moral-uncertainty distress ranked highest (see Table 3).

Resources used when experiencing moral distress

Of the overall sample of participants, 12 resources including an “other” free-text response were utilized to different degrees by participants. Of resources selected, speaking with a colleague or a senior colleague occurred most often. Services that involved communicating with non-collegial personnel such as the employee assistance program were used less often (see Figure 1). Of resources selected, ratings of helpfulness varied (see Figure 2). For example, although the employee assistance program was rarely used, participants rated it as highly helpful. Among nurse participants who experienced moral-uncertainty distress, the most frequent resource was speaking to family and friends (14%), followed by plan of care visits (7%). Nurse participants who experienced moral-constraint distress and moral-tension distress most frequently reported not using any resource (8.7%; 16.9%). Half of the sample indicated that ethics rounded on their units, and half stated no/not sure with free text responses stating that they worked predominantly night shift. Given that all of these rounds occur during day shift, this suggests that many participants were aware of ethics round.

Figure 1.

Frequency of Resources Used at Baseline (N, 176).

Figure 2.

Helpfulness of Resources Used at Baseline (N,176).

Moral distress sub-categories and resources used based on nurse and unit characteristics

There were three statistically significant findings when conducting stratified analysis of moral distress sub-categories, resources used, and nurse and unit characteristics. During moral distress episodes, participants who spoke with a colleague or senior colleague were less likely to work at the hospital system’s main campus (p = 0.048), in the surgical ICU (p = 0.013) and night shifts (p = 0.014). Within the moral distress sub-category, those who spoke with a colleague or senior colleague when experiencing moral-dilemma distress were more likely to identify as female (p = 0.019). After adjusting for multiple responses per subject, female gender continued to be associated with using colleagues or senior colleagues when experiencing moral-dilemma distress (p = 0.019).

Intention to leave and actual turnover based on moral distress sub-categories, resources used, and support services

Of the overall sample of participants who completed at least one survey, 19% (at 3 months) and 22% (at 12 months) completed intent to leave surveys. Among those with three or more surveys, the percentage of responses ranged from 53% (at 3 months) to 58% (at 12 months) (Table 4). Among participants who responded, over 90% were still working on the same unit over time. Intention to leave ranged from 10.9%–14.8% but actual turnover was low (3.8%) at 12 months. Of 80 participants who completed longitudinal surveys, turnover at 12 months was 2.6%. Responses were compared between those who left the healthcare system within 12 months and those who stayed. By participant demographics, moral distress sub-categories, and resources used, there were no differences in turnover, except that those who left the unit were more likely to report moral-dilemma distress and “other” distress, and seek out palliative medicine as a supportive resource.

Table 4.

Intention to leave and actual turnover.

Variables^*	Nurses who completed 1+ survey (N, 246)						Nurses who completed 3+ surveys (N, 80)
Variables^*	3 months, n (%)		6 months, n (%)		12 months, n (%)		3 months, n (%)		6 months, n (%)		12 months, n (%)
Working on the same unit	46	44 (95.7)	54	52 (96.3)	56	51 (91.1)	42	40 (95.2)	44	42 (95.5)	46	43 (93.5)
Intention to leave within 3 months	46	5 (10.9)	54	8 (14.8)	55	8 (14.5)	42	4 (9.5)	44	6 (13.6)	45	4 (8.9)
Actual turnover	246	4 (1.6)	242	4 (1.6)	238	9 (3.8)	80	0 (0.0)	80	2 (2.5)	78	2 (2.6)

^*Numbers to the left of the n (%) in each column reflect the number of participants at each survey time point.

Free text responses

Participants provided free-text responses across data collection time points to describe other causes of their work-related distress (47 responses); other supportive resources that were not available but would have been helpful (130 responses) and reasons for considering leaving the workplace, if indicated (135 responses). Themes and illustrative quotations are displayed in Table 5. Categories of other causes of work-related distress were the emotional impact of work and an inability to provide sufficient quality of care to patients due to perceived insufficient staffing. Categories of supportive resources that were not available were responsive management, impartial support, protected time to access resources, better inter-professional communication, and increased staffing. In addition to comments, 22 participants commented that there was nothing that could be done to support them. Of those who reporting an intention to leave and provided a free-text response to explain the reason, the majority indicated workload stress (n = 32) specifically, insufficient staffing (n = 12), and high acuity (n = 14). This was followed by career advancement (n = 35) with many participants reporting an intention to pursue different nursing career paths through further education.

Table 5.

Themes from free-text responses.

Question	Theme and sub-themes	Illustrative verbatim quotations
If none of these items apply then please provide a brief description about the source or cause of your distress at work	Emotional impact of work i. Sadness and grief (n = 6) ii. Lack of respect from patients (n = 7), families (n = 4) and physicians (n = 2) iii. Stressed due to workload (n = 19)	- Sad about withdrawing care on a patient. It was completely appropriate and ultimately the patient’s decision and I am proud that we are allowing her to pass with dignity. However, I am sad that we can’t ‘fix’ her. She is incredibly nice and well loved by her family and friends and it just doesn’t seem fair that her time is being cut short. (T2.P6)^* - Sadness of the loss of a patient (T1. P10) - I feel as I am not respected by patients, and am constantly trying to meet outrageous demands from the patient, and under pressure to keep these unreasonable patients happy (T1.P2) - The families not following rules or being respectful to nurses and other patients (T2.P8) - Physicians questioning our nursing practice and talking with us in a demeaning way… very stressful to be told that nursing is ‘at fault’ for patient’s decline or that we are providing inappropriate care (T2.P2) - I feel stressed by the amount of work and the pace of my work (T1, P19) - We work in a VERY stressful environment. There is a lot going on and we are responsible for basically everything in regards to our patients. (T1, P18) - Stressful environment/work load (T2, P13)
	Unable to provide sufficient quality of care to patients i. Insufficient staffing (n = 14)	- Not enough staff to nurse ratio too high to give the best care possible (T1.P9) - The cause of moral distress results from the stress and frustration that is inherently present in an ICU environment. However, more appropriate staffing (adequate nursing support staff, HUCs, etc.) would lessen the stress of the amount of tasks placed upon nursing. (T1.P12) - Not enough staff to give the care these critically ill people need (T1.P19) - High volume; acute patients, unable to provide the care I would have liked to (T2.P16)
Is there a different type of support service or resource that would have been helpful? why?	It’s a lost cause (n = 22)	- I feel that no matter who I share these concerns with, nothing will be done to change certain physician practices (T1.P5) - Maybe being able to talk with Attending’s superiors? but really feel that nothing will change despite nursing’s efforts to make other’s aware of the causes of our distress. And that helplessness is distressing in itself!! (T2.P8) - My colleagues feel powerless to change things we feel aren’t right (like a physician who does not appear to do things that are in the best interest of the patient.) we don’t feel that we can go to his superior to express our concerns. (T2.P9) - No (T1, P4, P12, P19, P29, P36, P47; T2, P10, P17, P24, P25, P28, P30, P44, P50; T3 P2, P3)
	Responsive management (n = 15)	- I do not feel as though I can go directly to my manager when I feel she has done or said something to upset myself or another coworker. This is based upon previous experiences I have had with her. When I have gone up the chain of command, my concerns have been acknowledged, but not followed up on. (T1.P7) - Our nurse manager is a very sweet and caring person, but not strong as a manager, and any concerns about anything in the unit aren’t dealt with--she DOES listen to us, but doesn’t take any action. (T2.P9) - Having management stay beyond 5pm and not question why you are asking for help. (T2.P34)
	Impartial support (n = 7)	- A nurse representative that helps support nurses without judgment. Nurse managers are for the [healthcare institution] and are unable to see the nurses’ views. HR pretends to care but is also for the [healthcare institution] and not for the employees. (T1.P9) - It would be nice to be able to speak with an uninvolved peer or member of management and be able to speak freely without fear or retribution (T2.P55)
	Protected time to access resources (n = 17)	- Nurses are ostracized for the use of code lavender. It also unrealistic because on the ICU because when a code lavender would be useful it is not possible for the nurse to step away from the bedside. (T1.P11) - Too busy with assignments, need to care for the patients .I don’t feel like there is any time to attend a code lavender (T1.P44) - Most services [code lavender, ethics committee, human resources] would require us to either come in on a day off, or stay over in the morning. (T2.P7) - Employee assistance program needs to be more available and have walk in appointments and even evening appointments. Having limited hours and limited appointments demonstrates lack of concern for us (T1.P2) - More available spiritual resources for us, and maybe more ethics discussions (T1.P37)
	Better inter-professional communication (n = 16)	- Having the LIP/ACNP open to discussion about the issue. The NP just brushed off/avoided the conversation (T2.P36) - Physician colleagues who actually LISTENED, rather than just trying to promote their personal ethical agenda. (T2.P38) - Rapid nurses listening to concerns and understanding that on [the medical-surgical floors] there aren’t providers down the hall to call for help. Rapid nurses not belittling floor nurses for choosing to escalate care (T3.P7)
	Increased staffing (n = 22)	- [Healthcare Institution] does surgery on people who other hospitals won’t touch due to acuity therefore we need more staff to care for them appropriately (T1.P52) - Most of it is staffing related stress: I know we cannot provide the level of care we desire due to staffing. More staff. (T1.P21) - Had a free charge who was helpful closer to the end of the shift and helped with a few tasks (T2.P66) - Having more help on the floor to assist patients who need help using the bathroom and etc. I had one patient who was yelling out and another patient who needed nursing help that needed to be escalated to the team. There wasn’t enough CTs on the floor to assist with simple tasks and I was extremely busy trying to handle both patients. (T3. P8)
If you are considering leaving, why?	Workload i. Insufficient staffing (n = 12) ii. High acuity (n = 14) iii. Stress (n = 32)	- Understaffed, workload, mandatory on call shifts, rotating day/night shifts, acuity, lack of charge nurse help (T1.P1) - Being short staffed, having several very sick patients to take care of and feeling I am not providing the best possible care for my patients because there are 6 of them and one of me. (T1.P40) - Patient acuity keeps rising but staffing is not adjusting based on need. We are receiving patients that are inappropriate for the floor…physicians look at the numbers during rapids, not the actual patient. The amount of time we are able to spend with less critical patients decreases if there is an issue with one. (T1.P68) - The stress is extremely high and often go disregarded. We go through periods of stress depending on the patient population. We get a ‘I am sorry that you have had a rough week’, but our responsibilities as a bedside nurse are endless. (T2.P64) - The stress of the ICU is extremely high for caregivers. I don’t feel like we have any support to handle this stress other than leaning on each other but sometimes even that is not enough. (T1.P41) - I am currently enrolled in a masters program. I am totally burnt out from bedside nursing care. I cannot see myself staying at the bedside any longer due to the high level of stress, increasing acuity of the patients, and feeling undervalued as a senior nurse. (T1.P22)
	Lack of management support (n = 24)	- Upper management has no involvement in daily bedside activities and therefore should not be making decisions for bedside nurses. (T1.P4) - I have worked in this unit for many years... the environment is getting worse... the upper management speaks about taking care of the caregivers... It is talk not action.. (T1.P26) - I do not feel supported by some management when trying to follow policy and procedures. I also feel there is bias and unfair treatment towards other nurses. I feel increased stress based on other nurses not following policy and not having any implications for this. (T1.P33)
	Lack of respect (n = 23)	- Nurses are severely undervalued. We spend the most amount of time with the patient and deserve respect for noticing subtle changes in assessments. (T1.P4) - Being a nurse especially in this system has been an awful experience especially as a new nurse. Our opinions are not valued, our care provided to our patients is not appreciated. Our work is not valued. (T1.P47) - It is extremely difficult to take care of demanding patients and their family members without the support of upper management and the physicians. We do a lot for our patients, often times going above and beyond. Instead of recognition, we get reprimanded and told to do better. (T2.P2) - The current attitude toward nursing by physicians is like nothing that I have encountered in 30 years of practice. There have always been a physician or two who tend to demean nursing; but this attitude has permeated our entire unit. I’ve seen new nurses in tears; senior nurses angry; many nurses (new and senior) looking for new jobs. It makes it difficult to care for patients thinking that your every move will be criticized. (T2.P4)
	Career advancement (n = 35)	- Further career by going back to school (T2. P31) - Furthering education (T1. P78) - Career progression (T2. P41)

^*T: Timepoint; P: Participant number.

Discussion

The primary focus of this research was to understand the frequency and intensity of sub-categories of moral distress that were previously identified in qualitative research.⁸ Nearly one-half of nurse participants reported experiencing moral-conflict distress at baseline and this sub-category also ranked as the most frequent type of moral distress among nurses who completed three or more surveys. The second most frequent sub-category of moral distress at baseline was moral-constraint distress and this sub-category ranked as the second most frequent among nurses who completed three or more surveys. These results were important since moral-constraint distress represents the traditional narrow description of moral distress. Our findings substantiated that some sub-categories of moral distress had a high prevalence and were more prominent than is represented by the narrow definition. Importantly, in our survey, participants did not need to know the right thing to do when experiencing a constraint, rather, they responded if they felt unable to do what they believed, thought, or felt to be right. We intentionally utilized this wording because it was previously suggested that knowledge of the right thing is too high of an epistemic threshold for moral-constraint distress to occur.¹⁹

At baseline and among participants who completed three or more surveys, moral-tension distress was the sub-category that was the most intensely felt, even though it occurred less frequently. This is an interesting finding since this sub-category of moral distress was first identified by Morley et al.⁸ Moral-tension distress occurs when an individual feels unable to share their beliefs with others. It is therefore likely to be important to nurture an environment in which nurses feel more able to articulate their moral perspective in order to mitigate this sub-category of moral distress.

There were wide standard deviations among mean moral distress sub-category scores indicating variability of occurrence. This finding was not surprising given that moral distress is a subjective phenomenon that impacts individuals differently. The subjectivity of moral distress makes it a challenging phenomenon to capture and a clear limitation of this survey is that participants could have different scenarios in mind when responding to the moral distress questions. Free text responses provided insight into the morally distressing scenarios that participants did not think were captured in the sub-categories of moral distress proposed. Some of the free text responses mapped onto items already listed in existing moral distress measures. For example, feeling unable to provide high quality care due to insufficient staffing could reflect the item “Working with unsafe staffing levels” on the Moral Distress Scale-Revised,²⁰ or “Experience compromised patient care due to lack of resources/equipment/bed capacity” on the Measure of Moral Distress for Healthcare Professionals (MMD-HP).²² Some scholars may question, therefore, whether a new moral distress measure is needed when the Moral Distress Scale-Revised is valid, reliable and has been used internationally,^20,23,24 and the newer MMD-HP shows promising validity and reliability.²² There are three significant critiques of current moral distress scales: that they fail to generate participant responses representative of the clinical and ethical situation^25,26; perpetuate the assumption morally distressed individuals have correctly assessed the ethically supportable pathway¹²; and scale items do not prompt the ethical reflection required to address moral distress.^25,26 In addition, these scales focus on constraint-based moral distress only. The approach used in this study to capture five sub-categories of moral distress may enhance diagnostic capability and lead to more specific testing of interventions. In our findings, some free-text responses could have been re-categorized as moral-constraint distress, but others were representative of moral-conflict distress, such as conflicts about the plan or care, and improvements in inter-professional communication. Kolbe and Melo-Martin²⁵ argued that moral distress measures and tools would have more utility if they took a diagnostic approach that provoked participants to critically consider the current constraints in place. One future direction for the MD-SCS is to repurpose it as a database repository of real-time, longitudinal morally distressing situations that can be assessed. Alternatively, the questions could provide real-time capture with prompts for reflection or identification of next steps.

Other scholars developed surveys designed to capture moral distress in real-time that have utility for pre-post intervention testing, such as Wocial and Weaver’s Moral Distress Thermometer.²⁷ However, use of real-time surveys that measure the intensity of sub-categories of moral distress can raise questions about the possibility of a threshold point that requires response or intervention. In our study, the “other” sub-category of moral distress tended to have a high intensity when it occurred; thus, a real-time approach may create recognition of situations that require immediate attention, such as a high workload and feeling unable to provide sufficient quality of care to patients.

With regard to specific resources, participants indicated utilizing peer supports (colleagues/senior colleagues) most frequently, which were moderately helpful. If peer support were optimized, it could be a more effective resource. Though peer support is gaining popularity as a support mechanism for healthcare professionals experiencing second victim phenomenon and other stressful experiences,²⁸ it has not been well studied in relation to moral distress. Recently, ethics education programs emerged that combined elements of peer support into their curriculum,^29–32 but the peer support element needs to be directly explored in future research.

About a third of participants described using daily, multidisciplinary “plan of care rounds” as a resource. During rounding, the plan of care should be discussed and formulated in partnership with the patient, family and nurse. Patient and healthcare team-focused rounds have the potential to increase inter-professional communication and decrease epistemic injustices between team members that occur when nurses are not involved in formulating the plan of care, or informed of the reasoning behind specific plans.³³ Epistemic injustice has been recognized as a cause of moral distress that occurs when nurses are not recognized as credible sources of knowledge (testimonial injustice) or when nurses are prevented from understanding their own social experiences (hermeneutical injustice).^33,34 Optimization of daily rounds, via collaboration of all parties involved, may mitigate occurrences of sub-categories of moral distress.

Since about 50% of participants reported that professional clinical ethicists rounded on their ICU during the data collection period, it was surprising that so few nurses stated that they contacted the ECS when they experienced moral distress, and also, that the ECS ranked low in helpfulness. In a quality survey, over 90% of ECS users (n = 84; physicians, nurses, social workers, case managers) found the guidance they received to be helpful in addressing ethical issues in patient care.³⁵ Our research findings raise questions about nurses’ perceptions of the utility of ECS to address moral distress. Future research might provide new insights and interventions surrounding ECS structures, systems or processes. In a national survey of ethics practitioners, Fox et al.³⁶ reported that ethics consultation was effective to reduce moral distress expressed by staff, patients, and family members involved in ethics consultation. Fox et al.³⁶ acknowledged substantive limitations of recall bias and perceived impact on another person’s experience. Based on nurses’ perspectives of the ECS from our research, it will be important to learn if some practitioners have an over-inflated sense of their ability to mitigate moral distress or if there are common practices that all ECS should adopt to more effectively address the sub-categories of moral distress.

Once sub-categories of moral distress have been identified, interventions can be assessed for their value. In one report, authors built a Moral Distress Consultation Services (MDCS), separate to their ECS, based on the work of Hamric and Epstein.³⁷ The American Society for Bioethics and Humanities³⁸ recommends an ethics facilitation approach to ECS in which an ethics consultant (usually an individual consultant) follows a number of process steps to clarify the ethical issue, identify a range of ethically appropriate options and provide supporting rationale, which is often provided in the electronic medical record. In contrast, MDCS is a form of ethics support offered to a group of individuals who are provided with a safe space to share their experiences of moral distress. Two individuals, a facilitator and scribe lead the consult session. The facilitator promotes discussion of the patient or system issue with the group, and the scribe makes notes and produces a report that is shared internally, not in the medical record. Advantages of MDCS is that nurses and other stakeholders who may not have an opportunity to engage in ethics consultation can share their experience of moral distress, and systems issues that contribute to moral distress can be addressed. However, the creation of two distinct consult services may create confusion for stakeholders. Morally distressed individuals may believe that there is no mechanism to address their moral distress outside of a group process and discussion of moral distress that is not constraint-based³⁹ may not be recognized since some sub-categories of moral distress identified in this study are not typically included. Based on resources, an ECS that is well-integrated into the clinical setting, responsive to stakeholders, and that integrates additional mechanisms and approaches into consultation to address moral distress may be better positioned than a separate consult service. The approach selected will most likely depend upon current institutional structures. Regardless of the approach selected, the impact on sub-categories of moral distress will require more research.

Of resources used by clinical nurses in this study, the Employee Assistance Program was seldom used but it was the most helpful resource. Conceptualizing moral distress as the psychological distress that is causally related to a moral event may enable individuals to more clearly disentangle their emotional response from the underlying cause of distress. Mitigating moral distress may require focused support that addresses the psychological distress (such as mental health support) and the moral event (such as ethics support). To better understand if this is a promising approach, more research is needed.

Actual turnover of clinical nurses was not reported in other papers that assessed moral-constraint distress; however, our findings on intention to leave were similar to that of Whitehead et al.²⁰ and Epstein et al.²² who reported that 20% or fewer nurses considered leaving their workplace and under 17% reported leaving a previous position. It is unknown if our low actual turnover was due to nurses being personally committed to their hospital and unit, the large number of potential work opportunities available across the health system, employee benefits, work-related friendships, or other reasons, despite the prevalence and intensity of moral distress. Further research is needed to understand the relationship between the different sub-categories of moral distress and actual nurse turnover.

Study limitations

This research was conducted in a single healthcare system so more research utilizing this survey in other contexts is needed to better understand the generalizability of the results. Nursing units included in the study had a significant likelihood of nurse moral distress since the sample included high acuity areas such as critical care and emergency departments, which have previously been units in which moral distress occurs.⁴⁰ Therefore, findings related to the frequency and intensity of moral distress may be higher than would be found if other, potentially less acute units were included. Participants could indicate that they had experienced more than one sub-category of moral distress and had used more than one resource to address their distress during each occurrence. The survey was designed in this way since the sub-categories and resources are not mutually exclusive but this prevented us from conducting analysis to understand if specific resources were more or less helpful in relation to specific sub-categories of moral distress. Furthermore, the ability to check multiple moral distress sub-categories and resources led to wide standard deviations around the mean scores. We did meet our minimal sample size expectations but a larger sample size would allow for more responses in each category and provide more detail about characteristics of nurses and their work sites in relation to moral distress sub-categories. Finally, because we sent out the survey and electronic information sheet via email there is no way to know how many potential participants actually opened the email and saw the opportunity to participate making it impossible to know the response rate.

Conclusion

Among nurses who participated in this study, they indicated experiencing distress due to morally relevant causes beyond constraint. In free-text comments, nurses described a number of issues that might be considered to cause moral-conflict distress such as feeling disrespected by various stakeholders. Nurse participants indicated the need for more support to improve inter-professional communication. There is a need to put interventions in place that reduce moral-conflict distress experienced by nurses; especially programs that enhance communication between healthcare professionals and assure that all providers of patient care have the same understanding related to patients’ plans of care. Further research is needed to understand whether findings of this study are replicated outside of one healthcare system and also, by healthcare professionals in different healthcare settings, especially related to the frequency of moral distress by sub-category. Future research is also needed to understand whether nurses experiencing the different sub-categories of moral distress regard specific interventions to be more, or less, useful.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was Internally funded.

ORCID iDs

Georgina Morley

James F Bena

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