Tuesday, August 14, 2012
Nurses struggle with moral distress - survey
Almost 50 per cent of nurses surveyed in a New Zealand-first study have considered quitting after struggling with moral
issues beyond their control.
More than 400 hospital-based nurses took part in the moral distress survey by Massey University School of Health and
Social Services researchers.
Dr Martin Woods, a nursing ethics and education expert, says preliminary results show 48 per cent had considered leaving
their current position after experiencing moral distress. Sixteen per cent were currently considering leaving their
“It’s very disturbing; half the nursing workforce at some stage have had such moral disquiet that they wanted to leave.”
The national survey reveals the causes and impact of moral distress. “This survey uncovers the ethical issues and
constraints affecting nurses,” Dr Woods says.
“It shows moral distress is a reality nurses are struggling with – and they are really struggling. Stories of burnout
and leaving not just a given position but nursing itself must be taken seriously.”
He explains it can lead to feelings of depression, burnout and stress and researchers plan to use the results to develop
guidelines for nurses and health care agencies to address and minimise its effects.
Dr Woods, who led the study, explains moral distress occurs when professionals cannot carry out what they believe to be
ethically appropriate actions because of internal or external constraints.
Factors include being unprepared for the complexities of an ethical dilemma, lack of peer and/or managerial support and
difficult working conditions, among others. “However, the research findings showed that in nearly all cases it is the
institutional constraints, and not personal factors, that cause distress for nurses when they confront moral issues in
the workplace,” Dr Woods says.
The survey revealed five major issues of moral difficulty challenging nurses. The main concerns, in order of frequency,
• Moral concerns over the delivery of less than optimal care due to pressures from management to reduce costs
• Watching patient care suffer because of a lack of provider continuity
• Working with nurses or other health care workers who are not as competent as the patient’s care requires
• Carrying out physician’s orders for what was considered by the nurse to be unnecessary tests and treatments
• Initiating extensive life-saving actions when the nurse thought she/he was only (unnecessarily) prolonging the
Thirty to forty per cent of surveyed nurses had experienced moral distress related to the five factors. “These occur
more frequently – and often with more devastating effects – than perhaps may have otherwise been anticipated,” Dr Woods
Many nurses also outlined the moral dilemmas they faced and how they responded, and one participant summed up the mood,
and consequences, when they stated: “I am considering leaving the job that I generally enjoy due to the lack of
leadership and pressures from management to accept more numbers of patients or patients with high acuity of care with no
increase in resources.”
Dr Woods says the level of intensity of the moral difficulties was even more indicative of the effects on nurses. “For
instance, nearly 90 per cent of those nurses experienced a moderate or high degree of moral distress when having to work
with nurses and other health care workers they perceived to be unsafe.”
Younger nurses aged 25-34, experienced higher moral distress (63 per cent) than other age groups – a concern when the
average age of the nursing workforce is 45.6 years.
Dr Woods says Massey University student nurses are exposed to ethical issues in nursing in their three-year degree, and
an entire second-year paper is dedicated to ethics and law. A post-graduate level paper on ethics has also been popular
with nurses as it gives them an opportunity to share their moral concerns and explore ways to respond to ethical
The research also suggests nurses are increasingly likely to challenge and seek solutions to some of the causes. As one
nurse put it: “These situations have had a significant impact on my nursing practice. I feel I have a very strong
ethical duty to prevent these types of situations arising and strive to work through ethical dilemmas as a team.”
Following a detailed analysis of the data researchers will provide nurses and agencies with information on ethical
issues and constraints affecting nurses, and offer guidelines to reduce future incidents.
The research conducted earlier this year surveyed 412 nurses from around New Zealand, and results were similar to
overseas studies. It backs up findings from a pilot study last year led by Dr Woods of 15 nurses, which found that six
out of 10 respondents had quit previous positions due to moral issues, and 4/5 of all respondents had experienced
moderate to high levels of moral distress sometime in their careers.