Critical care nurse leaders’ moral distress: A qualitative descriptive study

Abstract

Background

Unit-based critical care nurse leaders (UBCCNL) play a role in exemplifying ethical leadership, addressing moral distress, and mitigating contributing factors to moral distress on their units. Despite several studies examining the experience of moral distress by bedside nurses, knowledge is limited regarding the UBCCNL’s experience.

Research aim

The aim of this study was to gain a deeper understanding of the lived experiences of Alabama UBCCNLs regarding how they experience, cope with, and address moral distress.

Research design

A qualitative descriptive design and inductive thematic analysis guided the investigation. A screening and demographics questionnaire and a semi-structured interview protocol were the tools of data collection.

Participant and research context

Data were collected from 10 UBCCNLs from seven hospitals across the state of Alabama from February to July 2023.

Ethical considerations

This study was approved by the Institutional Review Board at the University of Alabama in Huntsville. Informed consent was obtained from participants prior to data collection.

Findings

UBCCNLs experience moral distress frequently due to a variety of systemic and organizational barriers. Feelings of powerlessness tended to precipitate moral distress among UBCCNLs. Despite moral distress resulting in increased advocacy and empathy, UBCCNLs may experience a variety of negative responses resulting from moral distress. UBCCNLs may utilize internal and external mechanisms to cope with and address moral distress.

Conclusions

The UBCCNL’s experience of moral distress is not dissimilar from bedside staff; albeit, moral distress does occur as a result of the responsibilities of leadership and the associated systemic barriers that UBCCNLs are privier to. When organizations allocate resources for addressing moral distress, they should be convenient to leaders and staff. The UBCCNL perspective should be considered in the development of future moral distress measurement tools and interventions. Future research exploring the relationship between empathy and moral distress among nurse leaders is needed.

Keywords

Moral distress nurse leader nursing leadership nursing ethics critical care

Introduction

Moral distress (moral distress) was originally defined by Andrew Jameton¹ as occurring when a nurse “knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (p. 6). The concept of moral distress has further evolved since the term’s inception and can be characterized today as occurring when nurses or other clinicians are constrained from taking what they believe to be ethically appropriate actions or are forced to enact in an ethically inappropriate manner based on their professional obligations, resulting in a sense of complicity and wrongdoing.^2–5 Nursing workforce studies continue to indicate an increasing trend in the intensity and frequency of moral distress experienced by nurses and overall decreased well-being, especially those working in the critical care setting.⁶

Moral distress is known to occur at higher frequencies and intensities among emergency and critical care nurses.⁷ Ethical challenges and situations associated with the high-intensity work environment coupled with frequent exposure to death predisposes critical care nurses to the experience of moral distress.⁸ While the COVID-19 pandemic highlighted various ethical challenges, including moral distress, studies have indicated moral distress has been a frequent factor associated with burnout, compassion fatigue, and turnover among critical care nurses well before the pandemic.^6,9–13 Recently, nurse well-being has been identified as a top issue for nurse leaders.¹⁴

Nurse leaders are challenged to model ethical leadership for their staff as a means to generate psychologically safe ethical work environment.^15,16 Evidence suggests nurse leaders are challenged in modeling ethical leadership as a result of systemic constraints.^17–22 These constraints stem from challenges associated with being the leader, upholding policies that conflict with values, and a lack of organizational accountability.^17,19–22 Studies of moral distress among nurse leaders indicate organizational distrust can develop when there is a lack of leadership support and transparency related to leadership roles.^17,19–22 The International Council of Nurses’²³ Code of Ethics coupled with country-specific Codes of Ethics provide a guide for ethically appropriate nursing practice. Unit-based nurse leaders, or those leaders positioned at the unit-level, such as charge nurses, unit educators, unit managers, and unit directors, are imperative in modeling ethical practice and behaviors for nursing staff and other healthcare professionals. When ethical leadership is well-established, ethical challenges, such as moral distress and the contributing factors of moral distress, may be more effectively addressed and alleviated.²⁴

The evidence surrounding moral distress among nurse leaders is limited, highlighting a need to further explore moral distress among this population. Existing literature examining moral distress among nurse leaders have been conducted in specific geographic areas;^17–22 therefore, a need existed to explore nurse leaders’ experiences of moral distress in a new geographic context (Alabama) to investigate convergence or divergence of findings and interpretations. Additionally, previous studies have explored moral distress among nurse managers^{18–20,22,25} and Chief Nursing Officers (CNO);^17,21 thus, a gap exists in which the perspectives of other unit-based, frontline nursing leadership, such as charge nurses and unit educators, should be explored. In this study, the authors aimed to highlight the unit-based critical care nurse leader’s (UBCCNL) perspective of the experience of moral distress in Alabama through individual interview sessions.

Research aim

The aim of this study was to gain a deeper understanding of the lived experiences of Alabama UBCCNLs regarding how they experience, cope with, and address moral distress.

Research design

The authors chose a qualitative descriptive design. This design takes a subjective approach to exploring lived experiences using the language and descriptions that closely align with the study participant perspectives.^26–28 An inductive thematic analysis was used to explore UBCCNL’s perceptions of moral distress and to allow the authors flexibility during the exploration of moral distress and not be constrained by existing theory.²⁹ Figure 1 provides an overview of research design.

Figure 1.

Overview of study procedures.

Participants

The authors sought to recruit participants who were (i) Registered Nurses in the state of Alabama, (ii) currently practicing as a UBCCNL, and (iii) English-speaking. Recruitment initiatives involved convenience and snowball sampling and materials were shared by the research team with professional nursing contacts. Some nursing schools, professional nursing organizations, and relevant social media sites were agreeable to sharing recruitment materials. Thirty-six individuals were interested and accessed the study screener. Eligible respondents were contacted for interview (n = 13). Ten UBCCNLs, from seven urban hospitals, agreed to participate in an interview (see Figure 2 for Consort Diagram). Participants (N = 10; M_{age (years)} = 44; Range = 26–65) worked within neonatal (n = 1), pediatric (n = 1), surgical (n = 1), medical (n = 2), and general (n = 3) intensive care units and the emergency department (n = 2). Table 1 depicts further characteristics of this sample. The sample demonstrates homogeneity as all participants were UBCCNLs. Individual participant age and other individual and facility-specific information deemed threatening to anonymity are not reported as a measure to protect the identity of study participants; however, the authors ensure these omissions do not threaten the integrity of the results reported herein.

Figure 2.

Study consort diagram.

Table 1.

Participant characteristics and self-reported levels of moral distress.

Participant	Role	Unit	Sex/Gender	Race/Ethnicity	Education level	Nursing experience (years)	Critical care nursing experience (years)	Leadership experience (years)	Years in current role	Length of interview (minutes)	Moral distress^a at time of survey	Moral distress at time of interview	Time between survey completion and interview (days)
P1	Charge nurse	ED	Female	White/Caucasian	BSN	40	30+	35+	35	38	5	4	88
P2	Relief charge nurse	ICU	Female	White/Caucasian	MSN	10	3	5	1	41	3	6	1
P3	Charge nurse	ICU	Female	White/Caucasian	MSN	12.5	12	4	4	24	2	1	23
P4	Unit educator	ICU	Female	-	BSN	4	4	1	1	43	6	6	101
P5	Clinical resource coordinator	ICU	Female	White/Caucasian	BSN	5	4	1	1	25	2	2	2
P6	Unit director	Pediatric ICU	Female	White/Caucasian	MSN	43	20	20+	6.5	46	4	6	122
P7	Unit educator	ED	Male	-	ADN	10	10	3	3	34	9	6	104
P8	Charge nurse	ICU	Female	White/Caucasian	BSN	15	12	7	2	36	2	1	1
P9	Relief charge nurse	ICU	Female	White/Caucasian	BSN	15	15	10	2	63	6	8	3
P10	Unit manager	ICU	Female	White/Caucasian	BSN	21	19	14	11	18	8	5	7
Range						4–40	3–30+	1–35+	1–35	18–63	4–9	1–8	1–122
Mean (rounded to nearest whole number)						∼23	∼13	∼10	∼8	∼37	4.7	4.5	45.2
Median						13.6	12	4.5	2.5	37	4.5	5.5	15
Standard deviation						13.6	6.4	4.5	10.4	12.9	2.5	2.4	51.4

- = “prefer not to say.”

^a = Measured using the Moral Distress Thermometer (MDT) (0 = absent; 1–3 = mild; 4–5 = uncomfortable; 6–7 = distressing; 8–9 = intense; 10 = worst possible).

Data collection

Data collection occurred in April through July of 2023. An investigator-developed screening and demographics questionnaire was created utilizing Qualtrics (Qualtrics.com). The demographics questions explored general participant characteristics, nursing experience, facility characteristics, and perceived moral distress. Perceived moral distress was measured using the Moral Distress Thermometer (MDT).³⁰ The MDT measures acute, real-time moral distress as perceived by the reporting individual at the time of the assessment and within the prior 2 weeks.³⁰ The scale consists of a single-item, visual analog in which respondents can rate their moral distress from 0 (absent) to 10 (worst possible).³⁰ The MDT is a valid and reliable tool for measuring moral distress and has been tested for use among nurses and other healthcare providers.^2,30

Eligible individuals who completed the questionnaire were contacted to participate in an audio-recorded phone interview (n = 10). Interviews were guided by the interview protocol (see Table 2) and conducted by a single interviewer (PHM) in a private space. The interview protocol development was informed by Corley’s³¹ Moral Distress Theory and the results of a qualitative systematic review exploring moral distress among nurse leaders.³² The protocol consisted of 10 open-ended questions: two questions served as ice-breakers; four questions queried nurse leaders’ experience of moral distress; one question queried how nurse leaders cope with moral distress; two questions queried how nurse leaders address moral distress; and one question served as a closure to give the participants an opportunity to add anything additional. Interview duration averaged 37 min. Audio recordings were transcribed verbatim.

Table 2.

Interview protocol.

Research aim	#	Interview question
Ice breaker	1	Please tell me about yourself and your responsibilities as a leader on your unit
Ice breaker	2	How would you describe the state of nursing?
Moral distress experience	3	What are some moral or ethical situations you routinely encounter as a nurse leader on your unit that results in moral distress for you?
	4	Are there any moral challenges or situations you feel are unique to your role as a unit-based critical care nurse leader that contribute to the moral distress you experience?
	5	Thinking back on experiences you may have had prior to becoming a nurse leader, how would you compare the ethical and moral challenges faced as a staff nurse versus a nurse leader?
	6	Can you identify and describe any positive impacts your experience(s) of moral distress have had on you as a person and nurse leader?
Coping with moral distress	7	You mentioned ________, how did you cope with that/those experience/experiences?
Addressing moral distress	8	Describe the resources available to you to address moral distress within yourself and among your staff
Addressing moral distress	9	In your ideal world, how would you want to see moral distress, or factors contributing to moral distress, addressed?
Closer	10	Is there anything else you would like to add in terms of how moral distress impacts you as a nurse leader that we have not addressed?

Data analysis

Interview data were analyzed using Nvivo via inductive thematic analysis.^29,33 Interview summaries were sent via secure email to participants as a means of member checking to ensure accuracy of the investigator’s summary and understanding of the interview session. Transcripts were coded sentence-by-sentence and constant comparison and open-coding were incorporated throughout the analysis process to identify similarities and differences among the data.³³ Codes were then grouped and analyzed to identify themes. Themes were then reanalyzed in relation to the research aims. Finally, themes were named and defined and sub-themes were identified. Supporting quotes from the data were then extracted as meaning units for each theme and sub-theme. Research team meetings occurred frequently throughout the data collection and analysis phase as a means to check biases, review data, and affirm interpretations. Data saturation was met at eight interviews. To confirm data saturation, two additional interviews were conducted; no new information emerged, confirming data saturation. Hence, participant recruitment stopped. Codes, themes, sub-themes, and meaning units were reviewed and affirmed by the research team and consensus among the team regarding data saturation was achieved.

Ethical considerations

Institutional Review Board approval preceded recruitment (Ref. No. EE202313). Participants consented to the demographic questionnaire within the Qualtrics survey and those who participated in interviews re-acknowledged the consent on the day of the interview. Hamric and Epstein³⁴ have noted potential re-traumatization when exploring moral distress; therefore, participants were provided a copy of the American Association of Critical Care Nurses (AACN) Recognize and Address Moral Distress tool.³⁵ Participant data were anonymized by the use of a participant ID (P1-P10), redacting any names of people or institutions in the transcript, and deleting audio files after transcription accuracy verification. All research data were password-protected.

Findings

Alabama UBCCNLs reported experiencing moral distress frequently and at varying intensities (Table 1). Three main themes, related to how nurse leaders experience, cope with, and address moral distress. Emerged from the data: (i) feelings of powerlessness precipitate moral distress among nurse leaders; (ii) nurse leaders experience emotional and physical responses to moral distress; and (iii) nurse leaders cope with and address moral distress. Table 3 depicts the main themes, associated sub-themes, and exemplary meaning units.

Table 3.

Research aims, themes, sub-themes, and meaning units.

Research aim	Theme	Sub-theme	Meaning units
Experience	A lack of control precipitates moral distress	Difficult end-of-life situations	Usually, I would say, patient-wise, the most common times that I think of is end of life, when either a patient has expressed their wishes in the form of an advanced directive or living will, and the family does not abide by them for one reason or another. (P9)
		Difficult end-of-life situations	I’ve seen really sad things, like, sometimes, it’s [keeping a patient alive when it appears futile] because they’re getting the patient’s social security check, which I think is very morally wrong […] (P9)
		Systemic barriers	There’s not enough beds, there’s not enough people. (P1)
			I would love to be able to give them [staff nurses] a break. But I’m trying to get staffing back up. So the people that are having to precept are having to precept over and over again. We had a big, not big, but a few new grads, they were, they were in nursing school during COVID, they were getting very little hands-on clinical experience, they were doing a lot more online learning, so I’ve been faced too with people requiring more and more orientation time. And more, we give them more orientation time. And it still just doesn’t work out. They don’t have what it takes to be an ICU nurse. And I think with COVID, that kind of setting that they weren’t getting the hands-on experience or education was not what it was when I went through nursing school. So not only are my people having to precept over and over again, but they’re having to have precepting time added on to try to make these nurses successful. And then heaven forbid, it doesn’t work out. And then you’re back to square one, you haven’t increased staff, you’ve got to tell the nurse, hey, I’m so sorry. It’s just not working out. And then you’ve spent all this time and effort and this preceptor has worked with this person for weeks and weeks and weeks. And it doesn’t help the staffing because they’re no longer there. And they’re back to square one having to precept somebody else. (P4)
			I feel like they have new nurses have a lot of book knowledge but they are not getting the bedside clinicals that they need before coming to the bedside. (P10)
	Responses to moral distress	Negative responses	But when you feel that emotional toll, it gets me down physically and emotionally way more than just a physical, physically busy, or physically taxing day. (P4)
	Responses to moral distress	Positive responses	Maybe more empathetic, to families, to their situations, to fellow nurses. And to especially our newer, our newer nurses coming in, it helps me see through their eyes. (P5)
Cope and address	Coping with and addressing moral distress	Internal organizational resources and support	[…] E.A.P. is a formal, formal pathway. And I think some people see the E.A.P. as a pathway for other avenues related to work related stress. (P7)
		A need for organizational support	[… ] but I think if we had somebody on staff in the house, that would be a good, a good thing for the staff. (P10)
		Seeking external support	[…] So, I seek out opportunities that are provided through professional affiliations, I seek out opportunities to perform better and take continuing education […] (P7)
		Seeking external support	I have learned that sometimes just the support of my friends […] it helps. (P8)

E.A.P. = Employee Assistance Program.

Feelings of powerlessness precipitate moral distress among nurse leaders

Feelings of being powerless was expressed among UBCCNLs. UBCCNLs voiced experiencing moral distress at least once a week, sometimes daily. Some participants further acknowledged moral distress is an unavoidable phenomenon they encounter as nurse leaders.

But yes, I find this job [unit-based educator versus staff nursing] much more morally distressing because I have much more responsibility and much less power to make change. (P4)

[…] one to two times a week at least. (P6)

[…] everybody keeps a spectrum of it [moral distress]. There’s not just the you are in distress […] it flows from day to day based on our, what the day is, what the work environment looks like [...]. (P7)

Some of these experiences of moral distress were attributed to a feeling powerless as a nurse leader in decision-making.

[…] I've done what all I can do to the best of my ability and know that, for lack of a better term, my hands are tied. (P5)

I think just a lot of the times the, the staff nurse would, will come to me as a charge nurse and express their concerns. And so, I take that normally to the nurse practitioners and it's just, it's frustrating, because I, I usually can't control it. (P3)

Feeling powerless tended to arise from various nurse leadership situations, the most frequent of which were difficult end-of-life situations and systemic barriers.

Difficult End-of-Life Situations. Most UBCCNLs expressed feeling powerless in difficult end-of-life situations, which tended to precipitate moral distress. Some end-of life situations are difficult for nurse leaders because they must manage and address their staffs’ moral distress while also managing their own. The experience of moral distress related to end-of-life situations typically arose from family and/or provider decisions that are perceived to either be futile and/or conflict with the patient’s wishes, leaving the UBCCNL feeling powerless to advocate for the patient(s) and nursing staff.

[…] And they’re, they're coding these patients and you just don't feel […] the patients, their wishes aren't executed like they want it to be executed. (P1)

[…] I will go to the physicians and say, ‘Can you please explain what your reasoning is behind this? Why are we continuing to do CRRT [continuous renal replacement therapy] on someone that's brain dead,’ or whatever. So, those kinds of things really caused me a lot of moral distress. (P6)

Systemic Barriers. UBCCNLs attributed experiencing moral distress as a result feeling powerless to systemic barriers, to which appropriate actions could not be enacted by the nurse leader. Systemic barriers included upholding policies and procedures that did not align with participant beliefs or were perceived as not feasible, lack of safe staffing, lack of resources, and issues with developing and maintaining new nurses. These various systemic barriers led to participants feeling powerless and unsupported as nurse leaders within their organization.

[…] sometimes upper management, just don't really think about it, before they just make a policy. […] Well, how, how is that policy gonna be carried out? Is there enough staffing to carry it out? Is it what's best for all patients? (P8)

Yes, I believe that, that higher ups have very high and unrealistic expectations of bedside nurses, and the enforcement of some of the policies that are in place. (P10)

We see a lot of younger nurses allowed into positions that they might not be fully qualified, or they might not completely comprehend all of the components of it due to recruiters trying to push it, you know, an acceptance of a position because they are greatly needed. (P2)

Nurse leaders experience emotional and physical responses to moral distress

Participants reported an array of responses to moral distress. Some form of physiologically, psychologically, and/or emotionally negative responses were referenced by all of the participants. While negative responses were more abundant, participants also reported positive responses to moral distress.

Negative Responses. The frequent emotional responses to moral distress, reported by nurse leaders included anger (P2; P5; P10), worrying (P2; P5; P7; P9), and frustration (P1). Compartmentalization (P6) and “putting up a wall” (P3) were avoidance behaviors referenced as a response to moral distress. Some UBCCNLs (P1; P2; P4; P5; P7; P10) discussed how their leadership role contributed to them taking moral distress home. An additional emotional response attributable to moral distress in conjunction with being a leader was feeling responsible (P2; P3; P4) when moral distress occurred and could not be adequately addressed. Long term psychological symptoms attributed to moral distress included depression (P4; P6), anxiety (P6), and burnout (P8).

As a staff nurse you worry about, and you stress about, your own decisions, your own moral distress and you worry about your own patients. With a nurse leader, you take work home with you, you take everybody's moral distress home with you. (P5)

[…] depression, just like I don't want to talk to anybody or be with anybody. I want to come home, and just, you know, not do anything. (P6)

While less common, physical responses to moral distress were reported by nurse leaders. Three UBCCNLs described physiological responses such as “loss of appetite” (P2), “headaches” (P6), and “fatigue” (P2; P7). Three of the participants (P6, P9, P10) attributed moral distress as a factor associated with thoughts of leaving their current or past roles. However, no UBCCNLs directly attributed moral distress to leaving a past role.

Positive Responses. Contrary to the negative impacts of moral distress, participants did report some positive responses attributable to the experience of moral distress. ‘Being a better advocate’ and ‘increased empathy’ were the two most frequent sub-themes identified among participants when queried on the positive impacts of moral distress. Feeling empowered to be a better advocate and increased empathy was attributed to experiences within the nurse leadership role encountered over time. Advocacy, or being a supportive voice, was frequently referenced or alluded to among seven of the 10 participants. Advocacy for patients, families, and staff was described as part of the nurse leadership role. The experience of moral distress among four of the participants was directly linked to making them a better advocate.

I think I'm definitely utilizing these situations of moral distress as a way to be a better advocate for my patient. (P2)

[…] But I always feel like, if you're a good leader, and you have good insight, and you can rely on what you've learned, you can also help others get the resources they need, the support they need, and help them grow to be the people they need. (P6)

Six participants directly referenced increased empathy as a positive impact they associated with moral distress. This increased empathy was directed towards patients, patient families, and staff.

It [moral distress] just, it makes me, you know, empathetic towards them. (P3)

[…] And that's why it's for the patients, for the families, for the nurses, and I've even started to have empathy for doctors […] (P9)

Nurse leaders cope with and address moral distress

Nurse leaders reported a variety of mechanisms to cope with and address moral distress. These mechanisms ranged from accessing “internal organizational resources and support” to “seeking external resources.”

Internal Organizational Resources and Support. Resources and support systems within the UBCCNL’s organizations are characterized as “internal” resources and support. Eight nurse leaders described having access to Employee Assistance Programs. These programs were described as offering therapy and counseling services free to employees.

[…] Employee Assistance counselor […] [redacted organization name] does offer that free of charge. (P4)

[…] we have the Employee Assistance Program […] They can go and talk with a therapist or with a counselor. (P5)

UBCCNLs described that formal debriefs within organizations following critical events were helpful for coping with and addressing morally distressing situations.

Everybody comes that was involved and can come. You know, sometimes I'm not involved, but I'll go out and watch a patient while they go do their debrief just so they can have this opportunity to say, “Well, why didn't we do this?” Or, “Do you think we did something wrong that caused this?” Or just so that they can do it and have that conversation and not go home thinking about it. That's been very helpful. (P6)

Informal debriefs were those described by participants as occurring outside of the clinical setting. These informal gatherings were described as both “pulse checks” (P2) and “off-hour debriefing” (P7).

[…] whether it be a meal, or whatever it may be to kind of wind down, it's a good time to debrief, get the whole picture, maybe see how other people are doing. (P7)

A Need for Organizational Support . Despite most nurse leaders reporting organizational resources to address moral distress, nearly all UBCCNLs expressed that resources should be promoted more frequently, more convenient, and more effective.

But, to me, if I was in the employee assistance program, I think I would like to do a lot of rounds. Because you do have that experience. And go with the staff because I think those people can see if somebody is distressed, or let them to be aware that things are available to them. (P1)

[…] I've worked at places where there's been ethics committees about dealing with people's death and dying and stuff like that. Most places don't have that. (P6)

I felt like I was taking a BIG step, and I was calling the Ethics Committee. […] And I guess that I, I don't know what I imagined, but I thought there would be, like, this group of people that, you know, goes through a patient's case and says, you know, “oh, wow, this really isn't right.” (P9)

Additionally, all UBCCNLs expressed a minimal amount of leadership and ethics training, leaving them ill-equipped to address moral distress as a nurse leader. Participants reported seeking outside resources such as continuing education courses. No UBCCNLs had received training specific to moral distress as a nurse leader.

I will tell you, I never got trained on how to deal with moral distress or how to help others deal with it. (P6)

No. I remember saying, “Fake it till you make it.” That’s what I told myself every day. (P8)

Seeking External Resources . Nurse leaders described coping with moral distress by focusing on their mental health. UBCCNLs referenced spending time in nature, being active, and participating in counseling and therapy.

[…] during COVID I began doing therapy through EmotionalPPE.org. That's a really good free service for healthcare workers. […] I actively want to do things to help my mental health, too. Which to me is like therapy, exercise, talking to people, that type of thing. (P9)

Seven participants expressed relying on family and friends for support.

[…] I have certain people that I talk to […] (P1)

[…] my husband is amazing. Sometimes he gets more of my stress and emotions than he probably wishes. (P5)

Seven participants described a reliance on faith or religion as a means to cope with moral distress. Additionally, faith and religion served as a moral framework for some of the participants.

Prayer and just moral beliefs based on my religion. (P10)

Discussion and implications

Findings indicate Alabama UBCCNLs experience moral distress with an array of responses resulting from feelings of powerlessness associated with systemic barriers and difficult end-of-life situations preventing them from acting in a manner they perceive as morally correct. The resulting positive and negative responses to the experience of moral distress may be facilitated by availability or lack of internal organizational resources and/or external forms of support. To our knowledge, this study is the first to explore the experience of moral distress solely among the UBCCNL population. Despite differing population contexts, findings from this study converge with findings of similar studies among nurse leaders.^17–22,36

Difficult end-of-life situations are known factors associated with moral distress among the nurse leader population³² and well-explored among other nursing populations.^37,38 Ethics consultation services have been identified as effective means for navigating challenging end-of-life issues which may perpetuate moral distress. In addition to these end-of-life barriers, systemic barriers such as disagreement with policy and protocol, staffing shortages, and a lack of resources have been factors associated with moral distress identified among the nurse leader population due to value conflict.³² A systemic barrier discussed by participants in this study is the concern regarding the preparation of new nurses. A significant barrier referenced among participants was the perceived lack of training among new graduate nurses which hinder their transition to the critical care setting, especially when staffing issues constrain UBCCNLs from placing new nurses with experienced staff. Organizations may consider instituting more robust orientation programs while UBCCNLS may increase their focus on the emotional needs of new graduate nurses³⁹; however, implementing these strategies may be challenging given the effects of the staffing shortage referenced among participants and within the literature.⁴⁰

The negative responses reported by UBCCNLs are consistent with those described among nurse managers and CNOs³² and other nursing populations.^41,42 Some participants of this study highlighted one key difference between being a staff nurse versus being in a leadership role is that as a leader you often take everyone’s moral distress home on top of the individual moral distress experienced by the leader. While most of the participants did not describe moral distress as a factor associated with them leaving their role or profession, other studies among nurse leaders have found that moral distress may result in nurse leaders stepping away from their role.^17,20,21 Increased empathy and the perception of being a better advocate were the primary positive responses of moral distress reported by participants. Participants of this study highly regarded their roles as advocates for patients, patient families, and their staff. While empathy has been shown to not correlate with moral distress, empathy does increase job satisfaction.⁴³ Conversely, Rushton and colleagues’⁴⁴ Framework for Addressing Moral Distress identified empathy as a potential response to a triggering event and may play a role in either positive or negative responses to moral distress depending on an individual’s moral sensitivity. The findings of this study may indicate a need to further explore the relationship between moral distress and empathy among the UBCCNL population.

UBCCNLs were able to cope with and address moral distress through a variety of strategies, some of which were internal to their organization while others were external. The reliance upon external sources of support is congruent with findings among other nurse leader populations.³² Given the geographical location of the study (Alabama), the reliance upon faith and religion as a mechanism to cope with and address moral distress may be attributed to the Bible Belt, which is a region of the Southern and Midwestern United States with a high density of Protestant Christians. A recent scoping review reveals that spirituality may place individuals at risk for experiencing moral distress to a higher degree than non-spiritual staff and may benefit from organizations which provide support for those who need to access spiritual resources to cope with moral distress.⁴⁵

UBCCNLs indicated a need for organizational support in terms of basic leadership development, ethics training, moral distress awareness, and adequate resources to cope with and address moral distress. These findings converge with those of previous studies and highlight that, despite years of research regarding moral distress and the development of interventions,^46–48 organizations have been hesitant to adopt strategies for addressing moral distress. While most participants did report having access to an Employee Assistance Program or some equivalent, they were adamant that the program was not convenient or practical for their needs. Additionally, ethics consultation services were referenced; however, the perception of the service was poor or the lack thereof was noted. Findings supported participants’ appreciation for formal and informal debriefing following critical events and correspond with findings within the extant literature supporting unit huddles and formal debriefs as a means to mitigate the negative responses of moral distress; however, more research is needed to validate the effectiveness of these strategies in mitigating moral distress.^48,49

The National Academies’⁵⁰ The Future of Nursing 2020–2030 calls for organizations to focus on three strategies: (1) prioritize, budget for, and monitor outcomes related to well-being initiatives; (2) refine policies and processes and shape the work environment and culture to promote access to adequate resources; and (3) provide support for individual nurses in navigating work-system stressors. To achieve these strategies, organizations may consider the implementation of a system-wide moral distress consultation service,³⁴ unit-based ethics conversations,⁵¹ or other interventions such as training in moral distress mapping⁵² as a means to support nurse leaders and other healthcare professionals within their organization. In Alabama, UAB Medicine has instituted a grant-funded program, Workforce Engagement Compassionate Advocacy, Resiliency and Empowerment (WE CARE),⁵³ as a means to address nurse well-being by conducting meaningful nursing staff rounding, identifying distressing situations, and implementing targeted interventions based upon internal findings. As part of the WE CARE program, a Nurse Wellness Manager collaborates with nursing professional development specialists for initiatives specific to nurses at UAB Medicine. Interventions and programs targeting the well-being of nurses may benefit nurse leaders by equipping them with the strategies and skills necessary to identify, address, and mitigate future moral distress among themselves and their staff. Pending data regarding outcomes, organizations may benefit from modeling well-being initiatives after the WE CARE program at UAB Medicine; however, limitations exist in that not all organizations are able to receive external funding for these programs. While this article is presented within the context of nurse leaders, organizations may consider implementing institution-specific well-being programs that are multi-disciplinary in nature.⁵⁴

Trustworthiness

To ensure trustworthiness, the approach detailed by Guba and Lincoln.⁵⁵ was employed. Trustworthiness was achieved by accounting for dependability, credibility, transferability, and confirmability.^33,55 Direct participant quotes have been presented to support the authors’ interpretations. A semi-structured interview protocol (Table 2) allowed for a clear focus and consistent data collection across all interview sessions. Interviews were conducted by a single interviewer (PHM) and member checking was conducted. The research team met frequently to discuss data analysis, check biases, and affirm interpretation. Additionally, an audit trail, containing session notes, interview summaries, and interviewer bias checking, was maintained with the data.

Limitations

This study was limited by several factors. The primary limitation was a lack of a diverse sample. A broader sample of more racially and/or ethnically diverse UBCCNLs may have provided additional nuances or perspectives regarding the UBCCNL’s experience of moral distress. While attempts were made to recruit from across the state of Alabama, none of the participants worked at rural hospitals despite the majority of counties in Alabama having a rural designation.⁵⁶ UBCCNLs working within rural hospitals may have provided additional perspectives not described by those interviewed. Findings may not be transferable to other geographic locations; however, the findings do converge with findings reported within similar studies.^17–22 Finally, the sample size (N = 10) limits transferability; however, given the homogeneity of the sample, the sample size aligns with recommended qualitative sample sizes suggested within the literature.⁵⁷

Conclusion

The results of this study suggest systemic barriers and difficult end-of-life situations can leave nurse leaders feeling powerless and unsupported within their institution, which may precipitate moral distress. While nurse leaders experience negative emotional and physical responses to moral distress, moral distress may enhance feelings of empathy and actions of advocacy among nurse leaders towards their staff, patients, and patient families. While UBCCNLs report some organizational resources to cope with and address moral distress, these resources should be more convenient for UBCCNLs to access and utilize for themselves and their staff. More research regarding moral distress within the nurse leader population is needed to support the development of targeted interventions to address moral distress among nurse leaders.

Footnotes

Acknowledgements

The authors would like to thank the participants for sharing their experiences which made this study feasible and Dr Lucia Wocial for granting permission for us to use the Moral Distress Thermometer (MDT).

Declaration of conflicting interests

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Preston H. Miller

Jennifer R. Bail

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