As professionals, nurses are engaged in a moral endeavour, and thus confront many challenges in making the right decision and taking the right action. When nurses cannot do what they think is right, they experience moral distress that leaves a moral residue. This article proposes a theory of moral distress and a research agenda to develop a better understanding of moral distress, how to prevent it, and, when it cannot be prevented, how to manage it.

This study examined the relationship between moral distress intensity, moral distress frequency and the ethical work environment, and explored the relationship of demographic 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.

The results support the reliability and validity of the MDS.

Development and evaluation of a moral distress scale Aim of the study: This methodological research developed and evaluated the moral distress scale from 1994 to 1997. Background/Rationale: Although nurses confront moral questions in their practice daily, few instruments are available to measure moral concepts. The methodological design used a convenience sample consisted of 214 nurses from several Unites States hospitals. The framework guiding the development of the moral distress scale (MDS) included Jameton’s conceptualization of moral distress, House and Rizzo’s role conflict theory, and Rokeach’s value theory. Items for the MDS were developed from research on the moral problems that nurses confront in hospital practice. The MDS consists of 32 items in a 7‐point Likert format; a higher score reflects a higher level of normal distress. Results: Mean scores on each item ranged from 3·9 to 5·5, indicating moderately high levels of moral distress. The item with the highest mean score (M=5·47) was working where the number of staff is so low that care is inadequate. Factor analysis yielded three factors: individual responsibility, not in the patient’s best interest, and deception. No demographic or professional variables were related to moral distress. Fifteen percent of the nurses had resigned a position in the past because of moral distress. Conclusions: The results support the reliability and validity of the MDS.

BACKGROUND: Constraint of nurses by healthcare organizations, from actions the nurses believe are appropriate, may lead to moral distress. OBJECTIVE: To present findings on moral distress of critical care nurses, using an investigator-developed instrument. METHODS: An instrument development design using consensus by three expert judges, test-retest reliability, and factor analysis was used. Study participants (N = 111) were members of a chapter of the American Association of Critical-Care Nurses, critical care nurses employed in a large medical center, and critical care nurses from a private hospital. A 32-item instrument included items on prolonging life, performing unnecessary tests and treatments, lying to patients, and incompetent or inadequate treatment by physicians. RESULTS: Three factors were identified using factor analysis after expert consensus on the items: aggressive care, honesty, and action response. Nurses in the private hospital reported significantly greater moral distress on the aggressive care factor than did nurses in the medical center. Nurses not working in intensive care experienced higher levels of moral distress on the aggressive care factor than did nurses working in intensive care. Of the 111 nurses, 12% had left a nursing position primarily because of moral distress. CONCLUSIONS: Although the mean scores showed somewhat low levels of moral distress, the range of responses revealed that some nurses experienced high levels of moral distress with the issues. Research is needed on conditions organizations must provide to support the moral integrity of critical care nurses.