NURSE MORAL DISTRESS AND

ETHICAL WORK ENVIRONMENT

Mary C Corley, Ptlene Minick, RK Elswick and Mary Jacobs
Key words: ethical environment; moral distress; nurse expertise; staffing adequacy

This study examined the relationship between moral distress intensity, moral distress
frequency and the ethical work environment, and explored the relationship of demo-
graphic characteristics to moral distress intensity and frequency. A group of 106 nurses
from two large medical centers reported moderate levels of moral distress intensity, low
levels of moral distress frequency, and a moderately positive ethical work environment.
Moral distress intensity and ethical work environment were correlated with moral distress
frequency. Age was negatively correlated with moral distress intensity, whereas being
African American was related to higher levels of moral distress intensity. The ethical work
environment predicted moral distress intensity. These results reveal a difference between
moral distress intensity and frequency and the importance of the environment to moral
distress intensity.

Introduction
Rapidly changing technology, conflicting societal and cultural values, the pressure to
control health care costs, and reduced staff ratios of registered nurses1 all contribute to
moral quandaries for nurses providing care and may lead to moral distress.2 This
moral distress may affect the nursing care that patients receive and the retention of
nurses.3 The purpose of this research was to determine if ethical work environment
was related to nurse moral distress intensity and frequency. A subpurpose was to
explore the relationship of demographic characteristics (age, race, education, years of
nursing experience) to moral distress intensity and frequency. The nurses were also
asked if they had ever left a position in the past because of moral distress.

Background and significance of the study

Although researchers have conducted numerous studies on nurse job satisfaction and
stress,4 and more recently on the work environment climate,5,6 few researchers have
focused on the moral component of these concepts. Developing a more specific under-
standing of the moral response to problems that arise in the work environment could aid
in the identification of more effective strategies to address these complex situations.

Address for correspondence: Mary C Corley, 1 North 29th Street, Richmond, VA 23223, USA.
E-mail: mccorley@mail2.vcu.edu

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382 MC Corley et al.

Moral distress
The concept of moral distress was first identified in 1984 by Jameton,7 who defined it
as painful feelings and/or the psychologic disequilibrium that occurs when nurses are
conscious of the morally appropriate action a situation requires but cannot carry out
that action because of institutionalized obstacles. These obstacles can include lack of
time, supervisory reluctance, an inhibiting medical power structure, institution policy,
or legal constraints. In 1993 Jameton8 elaborated further on the concept of moral
distress, distinguishing between initial and reactive moral distress. In initial distress,
the person feels frustration, anger and anxiety when faced with institutional obstacles
and interpersonal conflict about values. Reactive distress occurs when people do not
act upon their initial distress. The current research focuses on reactive moral distress
and factors that influence it.
One institutional constraint is inadequate nursing staff. Although inadequate staffing
has been a problem in the past, the current and growing shortage of nurses impedes
their ability to provide the care patients need.9 As a result, many nurses experience what
Jameton7 defined as moral distress. As a form of stress, this takes a toll on nurses.10
According to Selye,11 stress is a response to a disequilibrating stimulus in the social
environment. Although stress can be a motivating influence for change, moral distress
reflects a negative response to problems in the work environment. In a study of nurses
carried out in the early 1990s, 15% of them reported that they had left a previous position
owing to moral distress.3 Some even leave the profession because of moral distress.10,12
Guiding the development of this research were reports on moral distress and nurse
stress. Wros13 identified one type of job stress (e.g. a patient’s deteriorating condition
or death). Another type of stress may be related to ethical problems; in the current
study this is labeled ‘moral distress’. Knowing that moral distress is one type of job
stress is important because Lucas et al.14 found that job satisfaction buffers the effects
of job stress.
Wilkinson’s10qualitative research on moral distress verified the presence of this
important phenomenon among nurses. In that study the nurses reported that their
moral distress, characterized by frustration, anger and guilt, often led them to avoid
patients and even to leave nursing. They identified the major causes of moral distress
to be: the treatment of patients as objects in order to meet institutional require-
ments;10,15 harm to patients in the form of pain and suffering;16,17 withdrawal of
treatment without nurse participation in the decision;18
20 poor pain management;19
and disregard for patients’ choices about accepting or refusing treatment, or the failure
fully to inform them and their families about treatment options, leading to nurses’
feelings of powerlessness.20 Using an instrument that she had developed with a
sample of critical care nurses, Corley21 found levels of moral distress of moderate
intensity. A subsequent study of 214 nurses revealed moderate to moderately high
levels of moral distress.3 Although our hypothesis was that the demographic variables
of education, age and years of experience would predict the intensity of moral distress,
this did not prove to be the case.

Ethical work environment

The nursing practice environment has been defined ‘as the organizational charac-
teristics of a work setting that facilitate or constrain professional nursing practice’

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 Moral distress 383

(p. 178).6 More specifically, McDaniel22 described an ethical environment as one in

which ethical values guide behavior, including setting priorities that provide for the
ethical treatment of patients. An organization that supports professional nursing
practice provides an ethical work environment.
Health care organizations often do not support professional nursing practice. In a
recent survey of American nurses, more than 70% cited acute and chronic stress,
overwork and overtime as their top three health and safety concerns.1 Cross-national
comparisons have also revealed major problems with work design and workforce
management that jeopardize patient care.9,23 In today’s complex, rapidly paced health
care environment, nurses experience difficulties with thinking clearly, which prevents
the early recognition of patients’ problems.24 Not being able to fulfill this important
nursing responsibility can lead to moral distress. If nurses do not advocate for patients
because they fear reprisals from the institution’s administration, they will feel moral
distress.
Another source of moral distress for nurses is ethical conflict with hospital policy.
For example, conflict arises when the organization requires that costs be controlled;
however, the needs of patients require adequate nurse time despite the cost.25
Ineffective legal and policy structures of the organization for managing bioethical
problems can lead to moral distress. If the organization has not developed strategies
for managing conflict that arises between patients and family members, or among
patient care staff over treatment decisions, nurses who do not advocate effectively for
patients experience moral distress.
Although nurses have identified that some organizational cultures are more positive
than others,26,27 and that organizational culture affects the decision latitude of nurses
for patient care decisions,28 only recently have researchers focused on the ethical
nature of the organization. McDaniel29 proposed that the work environment must also
be an ethical environment, which she defined as one in which ethical values are
reflected in an organization’s strategies, structures and processes. Values in health care
become evident in the priorities given to the rights of patients,22 particularly in how
those nurses with difficult care problems that have ethical implications are managed.30
Reiser31 argues that not only does an ethical environment address ethical problems
involving patients but it also is reflected in how the organization treats the staff, sets
institutional goals and manages conflict.
Both McDaniel29 and Olson30 developed instruments to measure the ethical work
environment. In McDaniel’s22 research, nurses identified three major problems
including the inability to engage in deliberations regarding practice as it pertains to
ethics, to receive support for their practice from administrators, and to work with
policies and procedures that are consistent with their care practices. Olson30 identified
five factors in her Hospital Ethical Climate Survey: relationships of nurses with peers,
patients, managers, the hospital and physicians.
Several researchers have evaluated the relationship between nurses and organiza-
tions in ethical dilemmas. On studying perinatal nurses’ responses to ethical
dilemmas, Penticuff and Walden32 found that those who were more likely to
be involved in ethical dilemma resolution perceived that they had more influence
in their practice environment and had higher levels of concern about ethical aspects
of patient care. The negative impact of the environment was also identified
by Raines,33 who showed that nurses were willing to compromise their values
in favor of hospital rules. This negative impact of hospital rules is evident in

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Redman and Fry’s34 research, where nurses reported that the organization was not
receptive to supporting nurses in conflicts involving physicians, a frequent source of
moral distress. These research findings reflect the importance of the ethical environ-
ment in addressing the problems that arise for nurses in meeting their professional
responsibilities.
How often nurses experience moral distress differs from how intense the moral
distress is experienced. Both aspects of moral distress were measured in the current
research. Although previous study had not shown a relationship of moral distress
with age, education, years of experience, and previous resignations because of
moral distress,3 the potential for these variables to be related to nurse expertise
justified their inclusion in the current research, in which the following questions were
addressed:
. Is moral distress intensity related to moral distress frequency?
. Does the nature of the ethical environment of the hospital affect nurse moral distress
intensity and frequency?
. Do age, race, education and years of nursing experience affect moral distress
intensity and frequency?

Method
Design/setting
This was a descriptive-correlational study using two relatively new instruments with a
convenience sample of registered nurses working in two large medical centers, one a
federal health care facility and the other a university medical center. All respondents
were located in a mid-Atlantic city. The research was approved by the university
institutional review board.

Sample
The sample for this research consisted of 106 registered nurses (62% response rate)
working on medical and surgical units in two large medical centers. The majority of
the nurses were Caucasian (67%), 21% were African American, 3% Asian, 2% Hispanic,
and 3% other; 4% did not identify race. Their mean age was 41 years (standard
deviation (SD) /14.15). They had an average of 13.4 (SD /12.2) total years of nursing
experience; their average time in their current position was 6.1 years (SD /7.5). Over a
quarter (25.5%) reported that they had left a position in the past owing to moral
distress.

Instruments
Moral Distress Scale
The first author developed the original 32-item Moral Distress Scale (MDS) to measure
two aspects of moral distress: frequency and intensity.3,21 The MDS had three factors
based on factor analysis measuring the intensity of moral distress:

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 Moral distress 385

. Individual responsibility: 20 items (mean /4.98; SD /1.53; Cronbach’s alpha /

0.98; scale 1
/7);
. Not in patient’s best interest: 7 items (mean /4.93; SD /1.12; Cronbach’s
alpha/0.82);
. Deception: 3 items (mean /4.34; SD /1.61; Cronbach’s alpha /0.84).
The total variance explained by the three factors was 19.38. The theta test was 0.96 for
the entire instrument. Because the original MDS did not include items about pain
management, managed care or incompetent health care personnel (problems identified
in previous surveys of ethical concerns),35,36 items on these topics were added to
the scale for the current research. Scale revisions also included a zero response option
for one of seven options for moral distress intensity (scale 0
/6; anchors labeled ‘none’
and ‘great extent’) and for the frequency of each item measuring moral distress
using seven options (scale 0
/6; anchors labeled ‘none’ and ‘very frequently’). Three
experts, who were doctorally prepared with research experience in nursing ethics,
reviewed the revised MDS (38 items) to assess the extent to which each item could
measure moral distress intensity and frequency. The content validity index was
100% after three items were revised, based on the experts’ evaluations. In the
current research, Cronbach’s alpha for the revised MDS intensity scale was 0.98
(mean /3.71; SD /1.57; range 0
/6) and 0.90 for the MDS frequency scale (mean /1.54;
SD /0.68).

Ethical work environment

The Ethical Environment Questionnaire (EEQ) was developed by McDaniel29 to
estimate the degree to which a health care practice setting exhibits an ethical
environment. The EEQ is a 20-item questionnaire with a 5-point Likert-type format.
Responses range from ‘strongly agree’ to ‘strongly disagree’. Cronbach’s alpha
coefficient was 0.93 for the total scale, and test
/retest reliability was 0.88. Factor
analysis supported the unidimensionality of the scale, with most items loading at 0.50
or greater. According to McDaniel, a score of 3.5 (score range 1/low to 5/high)
reflects a positive ethical environment. In the current research the Cronbach’s alpha
was 0.93 (mean /3.23; SD /0.73).

Procedure
All registered nurses working on medical and surgical units in two large medical
centers were given self-report instruments to complete by one of the investigators; if
the nurses were absent, the forms were put in their mailboxes. Two weeks after the
initial contact, a postcard reminder was send to all the nurses. Four weeks after the
initial data collection, a second copy of the form was sent to the nurses who had not
responded.

Data analysis
The data were analyzed using SPSS for descriptive and inferential statistics, both
parametric and nonparametric, focusing on the impact of the demographic and EEQ
variables on the frequency and intensity of moral distress.

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Results
The mean moral distress intensity item scores ranged from 2.61 to 4.79 (SD /2.28 and
1.65 respectively). The mean MDS score was 3.64 (SD /1.57). Eight items had a mean
of 4.0 or higher. The mean moral distress frequency item scores ranged from 0.08 to
3.05 (SD /0.33 and 1.88 respectively); the mean scale score was 1.45 (SD /0.67). The
item with the highest frequency score also had the highest intensity score. This was:
‘Work with levels of staff that I consider ‘‘unsafe’’.’ The moral distress intensity item
with the lowest score was: ‘Give medication intravenously during a code [cardiac and
respiratory resuscitation] with no compressions or intubation.’ For moral distress
frequency, the item with the lowest score was: ‘Respond to patient’s request for suicide
assistance when the patient has a poor prognosis.’ Forty-five percent of the nurses
rated the moral distress intensity at the highest level for this item. However, the
frequency of the events measured by these items was low, with only eight items
scoring 2 or higher. The EEQ mean score was 3.23 (SD /0.73); item mean scores
ranged from 2.51 to 3.97. These items were respectively: ‘I am involved in deliberations
addressing ethics concerns about my work’ and, ‘There is an ethics committee in this
organization available to me if I need it’.
The correlations of all variables were calculated. The correlation between moral
distress frequency and intensity was significant (r /0.42, P/0.01). Age was nega-
tively correlated with moral distress intensity (r / /0.215; P /0.05). Race (African
American) was correlated with moral distress intensity (Kendall’s tau /0.27; P /0.01).
The EEQ was negatively correlated with moral distress frequency (r / /0.42;
P /0.01). The EEQ significantly predicted moral distress intensity (F /1.65;
P /0.038) but not frequency. A moral distress intensity/frequency score created
by multiplying the intensity score by the frequency score was used in the analysis
without yielding any significant findings related to demographics or the EEQ.

Discussion
The mean moral distress intensity score of 3.64 out of a possible 6 reflects a moderate
amount of moral distress; however, the mean frequency score of 1.45 illustrates that
most of the items causing moral distress do not occur often. The moderate correlation
between intensity and frequency illustrates that these two concepts are different. The
nurses were asked to respond to the items on the MDS as they related to their current
position. One explanation is that the nurses continue to experience moral distress
when the situation is no longer occurring. The cumulative effects of unresolved
moral distress result in what Webster and Baylis37 have labeled ‘moral residue’. They
define this as what we have carried with us, powerfully concentrated in our thoughts,
when we knew how we should act but were unwilling and/or unable to do so. The
negative correlation between moral distress intensity and age may be explained
partially by the role of experience in learning to address the ethical problems that arise.
However, this correlation, although significant, is low and may mean that experience
can be of limited help. The correlation of race and moral distress intensity, although
significant, is low. The nurses in this study seemed to lack power, as reflected in the
EEQ score, a problem made more acute by the potential effect of being African
American.

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 Moral distress 387

Although the study findings on moral distress are not comparable with those in
previous studies because the MDS was modified, they may provide some insights for
further research. In a study of critical care nurses using the initial version of the
MDS with three factors, the means ranged from 2.4 to 2.721 and, in another sample, the
means ranged from 4.34 to 4.98,3 suggesting that nurses in today’s hospitals are
experiencing more moral distress (mean /3.7) than the critical care nurses were and
less than other nurses in a variety of clinical settings. However, the number of nurses
taking part in the current research who had left a position in the past because of moral
distress was considerably higher (25.5%) than reported by Corley et al.3
The mean EEQ score (3.23) for this research was moderately high, but not high
enough to reflect a positive ethical environment (3.5).22 However, it was slightly higher
than McDaniel found (3.1), and considerably higher than reported in a Finnish
sample38 (mean /2.84) or in a sample of nurse practitioners (mean /2.6).39 The item
with the lowest EEQ score related to the nurses’ involvement in deliberations
addressing ethical concerns. Improving this aspect of the work environment could
have a major impact on the level of moral distress that nurses experience and is an area
that should be addressed as health care organizations seek to retain nurses. Despite the
Joint Commission on Accreditation of Health Care Organizations’40 requirement that
organizations have ethics committees, nurses may not know that they exist or that they
are available to them. Many of the nurses’ ethical concerns are related to the daily
problems that arise, not the dramatic ones that tend to receive publicity. Thus health
care organizations need to broaden their ethics committee availability to discussing the
impact of inadequate staffing or incompetent health care workers.
Given the current and growing shortage of nurses, it is important to note that the
item with the highest moral distress frequency and intensity focused on the nurse’s
perception of unsafe staffing. These findings concerning staffing levels should be
considered in relation to research reporting a higher incidence of adverse events41 and
even death among patients undergoing elective surgery.42 Nurses may be apprehen-
sive that these adverse events such as urinary tract infections and pneumonia will
develop after major surgery,43 and are probably aware of increased rates of medication
errors, bed sores, and patient complaints.44 Blegen and Vaughn45 reported that
increasing the registered nurse staffing ratio correlated with a decline in errors. In a
study on chemotherapy administration mistakes, Schulmeister46 reported that 25% of
the errors were related to inadequate staffing, 20% were attributed to lack of
experience, and 15% were due to stress. The role of unsafe staffing as a source
of moral distress is explicated by Hamric,47 who suggests that inadequate staffing
leads to a complex interplay of factors of decreased frequency and quality of
communication and collaboration, decreased ability of nurses to know patients,
increased turnover resulting in less experienced staff, and difficulty with prioritizing
problems about immediate need. A related cause of moral distress is reflected in the
number of items rated as 4 or higher for the competency of personnel, physicians,
registered nurses and non-licensed personnel. Not explored in this research was the
relationship between unsafe staffing levels and the competency of other workers. In a
recent research report, Mark48 identified a number of organizational characteristics
(case mix index, growth in number of hospital admissions, number of beds on unit,
patient acuity, and past perceptions of staffing adequacy) that influence nurse
perception of staffing adequacy. Although an argument could be made that staffing
adequacy differs from safe staffing, her findings that adequacy depended on more

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than just the number and mix of personnel would be helpful in addressing staffing
problems and the related moral distress that often occurs. Ludwick and Silva49
reported that nurse staffing inadequacy increased the number of medication errors and
other untoward clinical errors and resulted in moral distress.
Research is needed on interventions that health care organizations can use to
enhance the ethical environment and provide a possible approach to reducing nurse
moral distress. One potentially useful strategy is to study the role of nurse expertise in
mitigating moral distress intensity.50,51 Inexperienced nurses lack the knowledge and
skill to push the boundaries, whereas those nurses with more experience probably
identify more situations that require them to push boundaries, but they cannot always
act on what they think should be done.18 The findings demonstrate the importance of
nurse empowerment and an environment that supports ethical practice in decreasing
the frequency of moral distress. In Penticuff and Walden’s32 research, nurses who had
higher nurse activism scores, a measure of their autonomy and organizational
influence, were more likely to be involved in ethical dilemma resolution. Nurses
who placed less emphasis on adherence to abstract standards were also more likely to
be involved in dilemma resolution. ‘Organizational practices that support raising and
discussing difficult patient care issues and problems with ethical implications
contribute to perceptions of ethical climate’ (p. 348).30 Being able to push the
boundaries reflects empowerment for nurses and is more likely to occur with
increased knowledge and experience. In order to push the boundaries effectively,
nurses must also have expertise reflected in knowing patients.50 A special focus for
empowerment should be those African American nurses who experience greater
moral distress intensity. Administrators must be especially committed to providing a
supportive environment for nurses and others who experience a high level of moral
distress intensity.
A measurement concern in the current research is important because we modified
the MDS by adding six items. In addition, the MDS could not be submitted to factor
analysis because of the sample size. The complexity of the factors involved with
moral distress contributes to the difficulty of its mitigation. The importance of the
problem is reflected in the percentage of nurses taking part in this study who had left a
position in the past because of moral distress. The findings provide support for
further research in this area, including qualitative studies of nurses with little
experience and low skill levels compared with nurses with a high level of expertise.
In addition, administrators in health care organizations must evaluate strategies that
create an ethical work environment for nurses so that they can provide quality patient
care.

Acknowledgement
This research was funded in part by the American Organization of Nurse Executives as
a research award to the first author.

Mary C Corley (Professor Emeritus) and RK Elswick, Virginia Commonwealth University,

Richmond, VA, USA.
Ptlene Minick, Georgia State University, Atlanta, GA, USA.
Mary Jacobs, HH Holmes McGuire VA Medical Center, Richmond, VA, USA.

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 Moral distress 389

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