Moral Distress Among Healthcare Professionals at ...

JONA’S Healthcare Law, Ethics, and Regulation / Volume 15, Number 3 / Copyright B 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Moral Distress Among Healthcare Professionals at a Health System Rose Allen, MSM/HM, RN, CHPN & Tanya Judkins-Cohn, MSN, MEd, RN & Raul deVelasco, MD & Edwina Forges, MSN/Ed, RN & Rosemary Lee, DNP, ARNP & Laurel Clark, BSN, RN & Maggie Procunier, MSN, MHA/Ed

A B S T R A C T

Moral distress is increasingly recognized as a problem affecting healthcare professionals. If not addressed, it may create job dissatisfaction, withdrawal from the moral dimensions of patient care, or even leaving the profession. Using the 21-Moral Distress ScaleYRevised to assess moral distress, 323 surveys were received from 5 healthcare disciplines. The overall results showed that all disciplines experienced moderate to high actual moral distress, related to similar and/or different patient care situations. ................................................................................................................................................................

I

n the 28 years since Jameton’s

Those professionals who are re-

because of various constraints.

description of moral distress

peatedly exposed to situations

Since then, studies such as those

in nursing, it is now known

where they feel they cannot carry

of Hamric et al11 and Ulrich et al12

that other healthcare professionals

out what they consider to be the

have identified moral distress in

are affected by this phenomenon.

ethically appropriate actions are

both nurses and physicians. The

In today’s challenging healthcare

potentially subject to moral dis-

study of Schwenzer et al3 of respi-

world, where advanced technol-

tress, which leads to job dissatis-

ratory therapists (RTs) noted moral

ogy has improved medical care

faction, burnout, and leaving a job

distress related to dissatisfaction

or even the profession.

with chronic illnesses, healthcare

Moral distress was first defined

professionals are increasingly ex-

in 1984 by Jameton10 as a phenom-

posed to conflicting societal and

enon that occurs when nurses can-

cultural values while facing pres-

not carry out what they believe

sure to control healthcare costs.

to be ethically appropriate actions

.......................................

and people are living longer, often

1Y9

Author Affiliations: Bioethics & Palliative Care, Baptist Health South Florida, Miami. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Rose Allen, MSM/HM, RN, CHPN, Bioethics & Palliative Care, Baptist Health South Florida, 8900 N Kendall Drive, Miami, FL 33176 ([email protected]). DOI: 10.1097/NHL.0b013e3182a1bf33

JONA’S Healthcare Law, Ethics, and Regulation / Volume 15, Number 3 / July–September 2013

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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

from perceived practice of unsafe staffing. A social worker (SW) study by Openshaw7 noted frequent ethical dilemmas such as abuse and mental illness, which have limited solutions and cause moral distress. What has been realized is that moral distress that is not addressed is likely to lead to what Epstein and Hamric5 called moral residue, described as the lingering feelings after a morally problematic situation has passed, resulting in a loss of moral identity that is lasting and powerful. Repeated experiences of moral distress with moral residue and loss of moral integrity are manifested personally (anxiety, depression) and professionally (avoidance of patients, burnout). A third phenomenonVcrescendo effectVis experienced as increases in moral distress and increases in moral residue. Not addressing any of these related phenomena can result in any 1 of these 3 patterns: (a) some clinicians may experience a numbing of their moral sensitivity and withdraw from involvement in ethically challenging patient situations; (b) some clinicians may demonstrate conscientious objections by voicing opinions, such as refusing to care for a patient on artificial life-support that the nurse perceives as having no chance for meaningful recovery; and (c) other clinicians may demonstrate the effects of burnout and leave the job or even the profession.5,13Y15

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Assessing Moral Distress Among Healthcare Professionals The Bioethics Department’s interest in assessing moral distress at this 7-hospital organization stemmed from observing distress among the interdisciplinary care teams when responding to ethics consults. The distress was related primarily to challenges with complex patient care issues. The research study purposes were to measure moral distress among healthcare professionals (nurses, physicians, nurse practitioners, SWs/case managers [CMs], RTs) working in the adult and pediatric areas of community and rural hospital settings of a health system using the Moral Distress ScaleYRevised (MDS-R), determine differences in moral distress among those professionals (common sources, intention to leave the job or profession), and explore relationships of demographic characteristics to moral distress. It was proposed that the findings of this study would identify moral distress among healthcare professionals. From those findings, improvement strategies would be explored to decrease identified moral distress.

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Design A cross-sectional, descriptive, comparative study using survey methodology with the 21 MDS-R was performed for 3 months. After institutional review board approval was granted, data collection commenced and included mailed surveys to 523 of the following adult and pediatric physician groups: hospitalists, cardiologists, neurologists, nephrologists, pulmonologists, oncologists, intensivists, and neonatologists. E-mails were sent with a survey link to

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1794 adult and pediatric nurses, SWs/CMs, and RTs. Each participant was provided a cover letter explaining the purpose of the study, voluntary participation, and measures taken for anonymity. Healthcare profession and settingYspecific 21 MDS-Rs were provided to participants based on job title or e-mail distribution group, and those interested in participating completed and submitted their surveys.

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Setting The study was conducted at 6 adult acute care hospitals and a children’s hospital of a health system with 1843 beds in the southeast of the United States. Four adult hospitals and 1 children’s hospital were classified as community hospitals. The other 2 remaining adult acute care hospitals were classified as rural hospitals.

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Moral Distress ScaleYRevised The MDS-R measures an individual’s perceptions to a situation based on (1) intensity of moral distress and (2) frequency of the encountered situation.16 It includes 6 parallel versions, of which 3 focus on the adult setting (nurses, physicians, and other healthcare professionals) and 3 focus on the pediatric setting (nurses, physicians, and other healthcare professionals). Moral distress Likert scale includes frequency range from 0 (never) to 4 (very frequently) and intensity range from 0 (none) to 4 (great extent).16 The Likert scale data can then be computed into a composite score or actual moral distress using a 2-part procedure. First, the frequency multiplied by intensity (fxi) score is obtained, which can range from 0 to 16, where items that are less distressing have low fxi scores versus more distressing items, which will have higher fxi scores.16 Reporting fxi scores allows you to identify individual items or situations that are distressing. Second, the composite or actual moral distress score is obtained by summing each item’s fxi score, resulting in a range of 0 to 336, where less actual distress is low composite scores and more actual moral distress is higher composite scores.16 Content validity of the MDS-R resulted in 88% interrater agreement and full agreement on 19 of 21 items, resulting in the rewording of 1 item, elimination of another item, and creation of a new item. Internal consistency was established via Cronbach ! for nurses (.89), physicians (.67Y.88), and all participants combined (.88).16 In addition, construct validity was determined through the use of Olson’s Hospital Ethical Climate Survey, where moral distress and ethical climate are negatively correlated. For this study, internal consistency using Cronbach ! ranged from .88 to .95.

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Data Analysis All physician data were inputted and all online survey data were exported into Excel. After review and coding of



all data, it was exported on SPSS 19.0 for data analysis. Descriptive statistics were calculated for demographics, ranking of common situations of moral distress by healthcare professionals, and intentions to leave the profession. To measure actual moral distress among healthcare professionals, composite scores were calculated by discipline and reported in mean (SD), range. Pearson correlation, independent t tests, and analysis of variance were performed to analyze relationships and differences among disciplines along with demographics and hospital type.

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Results The study sample of 323 included (1) 62 physicians (51 adult and 11 pediatric), with a response rate of 12%; (2) 207 registered nurses (194 adult and 13 pediatric) along with 7 adult-setting advanced registered nurse practitioners (ARNPs), resulting in a 15% response rate; (3) 27 adult-setting SWs/CMs (SW/CM), with a 16% response rate; and (4) 20 RTs (15 adult and 5 pediatric),

with a 12% response rate. Table 1 depicts demographic data of the sample by healthcare profession. Table 2 lists the 21 items from the MDS-R survey questions with the mean and standard deviation scores by healthcare professionals. A further breakdown is shown in Table 3, listing 9 items from the MDS-R survey questions. Among those 9 items are the top 5 most common situations of moral distress identified by each healthcare professional group. Both nurses and RTs were the only ones to have the same item ‘‘carry out physician’s orders for what I consider unnecessary tests and treatments’’ as number 1. However, 4 of the 5 healthcare professional groups ranked ‘‘following the family’s wishes to continue life support even though I believe it is not in the patient’s best interest’’ second (Table 3). Composite scores of actual moral distress illustrated an overall range of 0 to 214 for all disciplines, with ARNPs having the highest mean actual moral distress (Table 4). Nurses with more years of experience in their profession did not demonstrate higher moral distress (r = j0.190, P = .010), and this was the same for physicians (r = j0.415, P = .004). This relationship did not occur for

T A B L E

1

Demographics of the Study Sample Characteristic RN (n = 207) MD (n = 62) SW/CM (n = 27) ARNP (n = 7) RT (n = 20) ........................................................................................................................................................................... Age, mean (SD), y

44.16 (12.79)

54.63 (12.29)

41.93 (10.56)

42.50 (12.80)

46.37 (7.55)

Gender, % (n) Male

10.2 (21)

81.0 (47)

11.1 (3)

14.3 (1)

30 (6)

Female

89.8 (184)

19.0 (11)

88.9 (24)

85.7 (6)

70.0 (14)

Hispanic or Latino

35.2 (70)

47.5 (28)

72.0 (18)

28.6 (2)

55.6 (10)

Non-Hispanic or Latino

64.8 (129)

52.5 (31)

28.0 (7)

71.4 (5)

44.4 (8)

71.4 (140)

84.2 (48)

92.3 (24)

57.1 (4)

83.3 (15)

Black or African American

8.7 (17)

3.5 (2)

28.6 (2)

Asian

8.2 (16)

8.8 (5)

14.3 (1)

Native Hawaiian/Pacific Islande

0.5 (1)

1.8 (1)

11.2 (22)

1.8 (1)

Ethnicity, % (n)

Race, % (n) White

91 race Years of experience, mean (SD)

17.17 (11.88)

23.65 (12.48)

7.7 (2)

16.7 (3)

13.04 (9.41)

12.29 (10.23)

100.0 (27)

100.0 (7)

21.21 (10.15)

Hospital type, % (n) Adult

93.7 (194)

82.3 (51)

6.3 (13)

17.7 (11)

Community

78.6 (158)

93.5 (58)

85.2 (23)

85.7 (6)

75.0 (15)

Rural

21.4 (43)

6.5 (4)

14.8 (4)

14.3 (1)

25.0 (5)

Pediatric

75 (15) 25 (5)

Hospital setting, % (n)

Abbreviations: ARNP, advanced registered nurse practitioner; MD, medical doctor; RN, registered nurse; RT, respiratory therapist; SW/CM, social worker/case manager.


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T A B L E

2

The 21 MDS-R Survey Items and Mean Scores of Healthcare Professionals RN MD (n = 205) (n = 62)

Situation

SW/CM (n = 27)

ARNP (n = 7)

RT (n = 20)

........................................................................................................................................................................... 1. Provide less than optimum care due to pressure from administrators or insurers to reduce costs.

4.13 (5.54)

3.87 (4.32)

5.22 (6.03)

2.43 (4.39)

1.40 (3.03)

2. Witness healthcare providers giving ‘‘false hope’’ to a patient or family.

3.24 (4.17)

2.72 (3.25)

3.15 (3.31)

3.57 (3.16)

3.80 (6.01)

3. Follow the family’s wishes to continue life support even though it is not in the best interest of the patient.

4.67 (4.88)

4.54 (4.41)

4.33 (5.75) 11.14 (7.98)

6.70 (5.52)

4. Initiate extensive life-saving actions when I think they only prolong death.

4.0 (4.33)

4.15 (3.89)

2.30 (3.15) 11.71 (7.52)

5.95 (4.95)

5. Follow the family’s request not to discuss death with a dying patient who asks about dying.

2.81 (3.52)

1.77 (2.85)

1.52 (1.89)

5.71 (5.09)

1.10 (1.52)

6. Carry out the physician’s orders for what I consider to be unnecessary tests and treatments.

4.85 (5.19)

4.02 (4.61)

1.44 (2.50)

6.43 (6.13)

7.20 (6.10)

7. Continue to participate in care for a hopelessly injured person who is being sustained on a ventilator, when no one will make a decision to withdraw support.

1.97 (3.63)

2.86 (3.14)

1.48 (2.50)

4.00 (3.83)

4.47 (4.67)

8. Avoid taking action when I learn that a physician or nurse colleague has made a medical error and does not report it.

0.93 (2.18)

1.05 (1.57)

0.19 (0.681)

.43 (1.13)

0.60 (1.60)

9. Assist a physician, who in my opinion, is providing incompetent care.

2.34 (3.57)

1.97 (3.34)

0.85 (1.88)

2.14 (3.07)

1.35 (2.94)

10. Be required to care for patients I don’t feel qualified to care for.

1.18 (2.34)

0.75 (1.38)

0.89 (2.23)

0 (0)

0.40 (0.99)

11. Let medical students perform painful procedures on patients solely to increase their skills.

0.20 (1.12)

0.23 (0.83)

0.07 (0.385)

0 (0)

0.50 (1.46)

12. Provide care that does not relieve the patient’s suffering because the physician fears that increasing the dose of pain medication will cause death.

2.30 (3.40)

0.42 (1.13)

1.11 (2.19)

2.86 (3.64)

1.55 (2.01)

13. Follow the physician’s request not to discuss the patient’s prognosis with the patient or family.

1.42 (3.22)

0.48 (1.31)

0.96 (2.03)

2.14 (4.49)

0.05 (0.22)

14. Increase the dose of sedatives/narcotics for an unconscious patient that I believe will hasten the patient’s death.

0.62 (1.73)

0.51 (1.17)

0.48 (1.37)

2.00 (4.47)

0.35 (0.99)

15. Not take action about an observed ethical issue because the staff member who was involved requested that I do nothing.

0.36 (1.72)

0.75 (2.33)

0.04 (0.196)

0.57 (1.51)

0.90 (2.22)

16. Follow the family’s wishes for patient care when I do not agree with them, but do so because of fear of a professional complaint.

2.23 (4.01)

3.08 (3.36)

1.56 (2.49)

1.71 (2.36)

1.90 (2.57)

17. Work with nurses or other healthcare providers (other than physicians) who are not as competent as patient care requires.

3.49 (4.86)

3.22 (4.00)

2.04 (2.55)

5.29 (4.30)

3.70 (4.99)

18. Ignore situations of suspected patient abuse by caregivers.

0.64 (2.33)

3.78 (4.60)

0 (0)

1.29 (3.40)

1.80 (4.06)

19. Ignore situations in which patients have not been given adequate information to insure informed consent.

1.81 (3.67)

1.36 (2.92)

0.89 (2.38)

0 (0)

0.15 (0.67)

20. Watch patient care suffer because of lack of provider continuity.

4.53 (5.56)

4.77 (4.64)

4.74 (4.73)

3.00 (2.23)

2.60 (4.69)

21. Work with levels of nurse or other care provider staffing that I consider unsafe.

3.28 (5.24)

1.95 (3.32)

0.96 (2.03)

2.14 (2.47)

2.05 (3.84)

Data are presented as mean (SD). Abbreviations: ARNP, advanced registered nurse practitioner; MD, medical doctor; MDS-R, Moral Distress ScaleYRevised; RN, registered nurse; RT, respiratory therapist; SW/CM, social worker/case manager.

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T A B L E

3

Most Common Situations of Moral Distress Identified by Healthcare Professionals RN (n = 205) Situation

MD (n = 62)

SW/CM (n = 27)

ARNP (n = 7)

RT (n = 20)

Mean Mean Mean Mean Mean (SD) Rank (SD) Rank (SD) Rank (SD) Rank (SD) Rank

........................................................................................................................................................................... Carry out physician’s orders for what I consider unnecessary tests and treatments.

4.85 (5.19)

1

4.02 (4.61)

4

1.44 (2.50)

10

6.43 (6.13)

3

7.20 (6.10)

1

Follow the family’s wishes to continue life support even though I believe it is not in the patient’s best interest.

4.67 (4.88)

2

4.54 (4.41)

2

4.33 (5.75)

3

11.14 (7.98)

2

6.70 (5.52)

2

Watch patient care suffer because of a lack of provider continuity.

4.53 (5.56)

3

4.77 (4.63)

1

4.74 (4.73)

2

3.0 (2.23)

8

2.60 (4.69)

7

Provide less than optimum care due to pressure from administration or insurers to reduce cost.

4.13 (5.53)

4

3.87 (4.32)

5

5.22 (6.03)

1

2.43 (4.39) 10

1.4 (3.03)

11

4.0 (4.33)

5

4.15 (3.89)

3

2.30 (3.14)

5

11.71 (7.52)

1

5.95 (4.95)

3

Witness healthcare providers giving ‘‘false hope’’ to the patient and family.

3.27 (4.17)

8

2.72 (3.25)

10

3.15 (3.31)

4

3.57 (3.15)

7

3.80 (6.01)

5

Follow the family’s request not to discuss death with a dying patient who asks about dying.

2.81 (3.52)

9

1.77 (2.85)

12

1.52 (1.88)

8

5.71 (5.09)

4

1.10 (1.51)

13

Continue to participate in care for a hopelessly ill patient who is being sustained on ventilator.

1.97 (3.63)

11

2.86 (3.13)

9

1.48 (2.50)

9

4.00 (3.83)

6

4.47 (4.67)

4

Work with nurses and other healthcare 3.49 (4.86) providers that are not as competent as patient care requires.

6

3.22 (3.99)

8

2.04 (2.54)

6

5.29 (4.30)

5

3.70 (4.99)

6

Initiate extensive life-saving actions when I think they only prolong death.

Abbreviations: ARNP, advanced registered nurse practitioner; MD, medical doctor; RN, registered nurse; RT, respiratory therapist; SW/CM, social worker/case manager.

ARNPs, SW/CM, and RTs. No differences in actual moral distress for ethnicity (t287 = 0.302, P = .763), race (F3, 280 = 1.065, P = .364), and hospital setting (t296 = 1.86, P = .066) were found. However, actual moral distress was statistically higher for healthcare professionals working in an adult hospital compared with those working in a pediatric hospital (t306 = 2.86, P = .007). Actual moral distress was also statistically significantly higher for healthcare professionals who had previously considered and actually left a position compared with those who had not considered quitting or leaving a position (F2, 303 = 24.326, P G .001). Furthermore, actual moral distress was statistically significantly higher for healthcare professionals who were currently considering leaving a position compared with those who were not (t303 = 4.410, P G .001). Our findings indicate that all disciplines experienced moderate to high levels of actual moral distress. Nurses and physicians with more years of experience in their profession did not demonstrate higher moral distress. These finding did not support those of earlier studies, which

indicated that those with more years of experience in their profession demonstrated higher moral distress.5,17,18 Our results found that particularly among physicians and nurses, internal perceptions are central to moral distress

T A B L E

4

Actual Moral Distress by Discipline Discipline Mean (SD), Range .................................................................................. ARNPs

68.6 (31), 1Y99

Nurses

51 (42), 0Y214

Physicians

48 (37), 0Y154

RTs

47 (37.5), 10Y134

SW/CM

34 (24.5), 0Y116

Abbreviations: ARNP, advanced registered nurse practitioner; RT, respiratory therapist; SW/CM, social worker/case manager.


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in the clinical setting. Another reason could be the demographics of the current sample, which warrants further research. Most of nurses’ responses concerned workplace situations as a source of moral distress, such as ‘‘carry out physicians orders for what I consider unnecessary tests and treatments,’’ ‘‘follow the family’s wishes to continue life support even though I believe it is not in the patient’s best interest,’’ ‘‘watch patient suffer because of lack of provider continuity,’’ ‘‘provide less than optimum care due to pressure from administration or insurers to reduce costs,’’ and ‘‘initiate expensive life-saving actions when I think they only prolong death.’’ The physicians in our sample appeared to view ‘‘watch patient care suffer because of a lack of provider continuity’’ as the number 1 source of moral distress. The second ranked response by physicians was ‘‘follow the family’s wishes to continue life support even though I believe it is not in the patients’ best interest’’ and third ranked was ‘‘initiate expensive life-saving actions when I think they only prolong death.’’ The impact of outside influences was reflected in the responses provided by our sample. The RTs in our sample responded by ranking ‘‘carry out physician’s orders for what I consider unnecessary tests and treatments’’ as the number 1 source of moral distress and ‘‘follow the family’s wishes to continue life support even though I believe it is not in the patient’s best interest’’ as the number 2 source of moral distress. The third ranked response for the RTs was ‘‘initiate extensive life-saving actions when I think they only prolong death.’’ The advanced practice nurses (ARNPs) in our sample responded by ranking ‘‘initiate extensive life saving actions when I think they only prolong death’’ as the number 1 source of moral distress and ‘‘follow the family’s wishes to continue life support even though I believe it is not in the patient’s best interest’’ as the number 2 source of moral distress. The third source of moral distress was ‘‘feel pressure from others to order what I consider unnecessary tests and treatments.’’ The SWs/CMs in our sample responded by ranking ‘‘provide less than optimum care due to pressure from administration or insurers to reduce costs’’ as number 1 and ‘‘watch patient care suffer because of a lack of provider continuity’’ as number 2. The third ranked response was ‘‘follow the family’s wishes to continue life support even though I believe it is not in the patient’s best interest.’’ Because responses to the survey questions as to the sources of moral distress per disciplines were different, it does not indicate that those mentioned less frequently are unimportant. Rather, it is likely that each mentioned ranked source of moral distress was highly salient to nurses, physicians, RTs, advance practitioners, and social/case managers. It is also possible that the differences reflect dissimilarities in the work dynamics and responsibilities of each discipline that participated in the study. Another possibility is that the sources of distress in clinical situations may be due to the culture of our organization that promotes patient- and family-centered care and respect for

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patient autonomy. Our findings are generally consistent with those of previous studies that have investigated moral distress. The decision or intention to leave a profession is of significant importance. This study demonstrated a correlation with actual moral distress and either past experiences of leaving a job and/or intentions to leave a current job. This suggests that interventions and preventative tactics are necessary and important to maintain a quality and morally healthy healthcare workforce. Since the discussion of moral distress in nursing by Jameton19 and associated ethical dilemmas by Davis,20 it was noticed that among other factors, some physicians’ treatment of patients at the end of life caused unnecessary suffering in patients and moral distress in nurses. It is of interest that in our study, physicians are now reporting moral distress due to these same issues and at a rate and intensity similar to those of the nurses. We hope in a follow-up study to identify reasons for moral distress and whether these reasons differ among disciplines such as nurses and physicians. Strategies to correct the causes of moral distress would be developed and implemented.

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Implications We have presented evidence that moderate to high moral distress is experienced by interdisciplinary healthcare professionals working in the clinical setting. Studies have shown that failure to address moral distress can adversely affect healthcare professionals’ physical, emotional, and behavioral well-being and may impact care delivery.5,13Y15 Further exploration of interdisciplinary team education on ethics and moral distress, improved collaboration, communication, and team support is warranted. The impact of job satisfaction and retention is of concern. The cost of hiring well-qualified healthcare professionals is far greater than the cost of retaining them. The current workforce demand is to meet the growing needs of an aging population with complex, chronic, and life-threatening conditions and to provide optimum quality care using a patientand family-centered collaborative approach. Therefore, working with administrators to address moral distress and improve job satisfaction and retention of well-qualified healthcare professionals is necessary to meet the workforce demand. Changes in organizational policies and practices may be necessary to facilitate empowering healthcare professionals to address identified moral distress.

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Strategies to Reduce Moral Distress Various strategies have been recommended in recent literature to reduce moral distress and improve job satisfaction and retention. In the study of Winland-Brown and Dobrin,4 professionals with formal education on improving one’s own moral reasoning ability, along with years of



experience, had the ability to reason critically and better supported patient autonomy. The American Association of Critical Care Nurses developed the 4As to Rise Above Moral Distress framework as standards for organizations to use in addressing moral distress and promoting a healthy work environment.21 Nevertheless, more studies are needed to identify best practices in improving moral distress.

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Limitations This study had several potential limitations. First, it involved only disciplines working within the 7-hospital organization; results may not be generalized to other disciplines working in other healthcare organizations and facilities. Second, the analyzed responses reflect only the views of those disciplines that completed the surveys. Nonrespondents may have views that differ from those who responded. Third, the amount of variations in sample size may have influenced statistical tests used to assess relationships and differences. Although there was a large sample size, there was a low response rate, resulting in smaller subgroups and reduced generalizability. The smaller subgroups of healthcare professionals resulted in a lack of normal distribution; however, data analysis remained consistent to the intention of Hamric et al16 for the MDS-R. Various factors may have contributed to the low response rate, such as (a) other hospital surveys were distributed around the same time (Press Ganey, other study projects); (b) with increased patient acuity, busy healthcare professionals may have limited time away from patient care to complete the electronic e-mailed survey and ultimately dismissed or deleted it; and (c) healthcare professionals may not have felt comfortable answering questions about moral distress. Finally, qualitative data were not gathered from participants regarding the effects of moral distress on them personally and professionally.

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Conclusion This study demonstrated that healthcare professionals frequently encounter morally distressing situations in the clinical settings. Actual moral distress was statistically significantly higher for healthcare professionals who were considering leaving the profession, which is consistent with earlier studies. In this study, we did not assess the personal and professional impact of moral distress on the healthcare professionals. We recognize the need to identify root causes at the clinical and systems level to facilitate appropriate implementation of improvement strategies. Such strategies may include education on moral reasoning and other initiatives. Therefore, we plan to further explore the personal and professional impact of moral distress among our healthcare professionals and identify the causes. Subsequently, improvement strategies would be developed,

implemented, and evaluated for their effects on reducing moral distress and improving job satisfaction.

Acknowledgments The authors gratefully acknowledge the following key personnel: Karol Harrelson, RN, Susan Howard, RN, and Patricia Russell, RN, for their assistance in mailing out the physicians’ surveys and distributing the research flyers on the hospital units and at staff meetings. In addition, the authors appreciate the help from Traci Virelli, Raquel Gossett-Mateu, and Beth Krause, who assisted with providing the physician specialty mailing listing. REFERENCES 1. Corley MC, Elswick RK, Gorman M, Clor T. Development and evaluation of a moral distress scale. J Adv Nurs. 2001;33(2):250Y256. 2. Edward KL, Hercelinskyj G. Burnout in the caring nurse: learning resilient behaviors. Br J Nurs. 2007;16: 240Y242. 3. Schwenzer KJ, Wang L. Assessing moral distress in respiratory care practitioners. Crit Care Med. 2006; 34(12):2967Y2973. 4. Winland-Brown JE, Dobrin AL. A comparison of physicians’ and nurses’ responses to selected ethical dilemmas. Forum Public Policy. 2009:1Y19. 5. Epstein EG, Hamric AB. Moral distress, moral residue and the crescendo effect. J Clin Ethics. 2009;20(4):330Y334. 6. Epstein EG, Delgado S. Understanding and addressing moral distress. Online J Issues Nurs. 2010;15(3):1. 7. Openshaw L. Moral distress and the need for moral courage in social work practice. Presented at: North American Association of Christians in Social Work Convention 2011; October, 2011; Pittsburgh, PA. 8. Maslach C. Engagement research: some thoughts from a burnout perspective. Eur J Work Organ Psychol. 2011; 20:47Y52. 9. Epp K. Burnout in critical care nurses: a literature review. Dynamics. 2012;23(4):25Y31. 10. Jameton A. Nursing Practice: The Ethical Issues. Englewood Cliffs, NJ: Prentice Hall; 1984. 11. Hamric AB, Davis WS, Childress MD. Moral distress in healthcare professionals: what is it and what can we do about it? Pharos Alpha Omega Alpha Honor Soc. 2006;69:16Y23. 12. Ulrich C, Hamric AB, Grady C. Moral distress: a growing problem in the health professions? Hastings Cent Rep. 2010;40(1):20Y22. 13. Catlin A, Armigo C, Volat D, et al. Conscientious objections: a potential neonatal nursing response to care orders that cause suffering at the end-of-life? Neonatal Netw. 2008;27(2):101Y108. 14. Shepard A. Moral distress: consequence of caring. Clin J Oncol Nurs. 2010;14(1):25Y27.


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For more than 14 additional continuing education articles related to legal issues, go to NursingCenter.com\CE.

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