Title: Contributing factors to moral distress among nurses providing care to high acuity patients
Abstract:
Significance: Nurses experience moral distress when they are restricted from making sound decisions emanating from their ethical beliefs and values. Nurses at some point are constrained from providing care congruent with their ethical beliefs in scenarios relevant to End-Of-Life (EOL) care and futile treatment. Moral distress may negatively influence the quality of patient care and nurse's well-being.
Purpose/Aim: This study aims to identify factors contributing to moral distress among nurses providing care to patients in high-acuity units. This study focuses on nurses’ perceptions of futile care and factors that may impact moral distress such as: preparation for EOL care, communication skills, staffing issues, and demographic factors. The study results may provide guidance and strategies to support ethically-congruent nursing practice.
Design and Methods: This study utilized a mixed-methodology (triangulation) design and participation in this study was voluntary. The study sample invited nurses providing care to high acuity clients and are employed in the northeast region of the US. The study has been approved by the Montclair State University (MSU) IRB committee for human subject protection during the spring of 2025. Data was collected as participants completed the online survey; which included the Moral Distress Scale-Revised (MDS-R), and answered some open-ended questions. The quantitative data was analyzed using the most recent version of the SPSS program, while qualitative data was analyzed using Colaizzi's thematic analysis approach.
Results/Interpretation: This study explored the phenomenon of moral distress while focusing on the contributing factors to this phenomenon among nurses providing care to high-acuity clients. This mixed-methods study combined qualitative insights from participants’ narratives with quantitative data analysis. Although the results were not statistically significant , the moral distress was at a moderate level overall. Important trends revealed across moral distress scores and were supported by themes gleaned from qualitative data analysis. These results validate and converge with the review of literature conducted on moral distress, especially in relevance to: ineffective treatment, institutional restrictions, communication failures, and emotional toll.
Quantitative data revealed a mean total MDS-R score of 91.79, indicating a moderate level of moral distress among participants. In the context of futile care, the highest scores included the following subscales: staffing and system constraints, teamwork and communication, and ethical misconduct. Participant’s experience correlated positively with emotional disturbance (r =.452, p =.020), implying that longer professional exposure may intensify the emotional impact of morally upsetting events. However, demographic characteristics did not significantly correlate with total moral distress scores. Additionally, a strong correlation was evident between frequency and disturbance of moral distress (r = .642, p = .001) supports the idea that repeated exposure to distressing events is compounded by their emotional toll. Subscale intercorrelations further highlighted the interconnectedness of these pressures in clinical settings by showing that staffing issues and teamwork frequently coincided with suffering, and subsequently linked to unethical behavior and futile care.
Qualitative findings provided a deeper understanding of the statistical patterns. Nurses described scenarios in which they were unable to act in accordance with their ethical beliefs due to: absence of advance directives, family pressure, and administrative policies. Futile care was a recurring source of distress and often tied to aggressive interventions performed without expected outcomes. Participants reported emotional strain from these experiences, including feelings of helplessness, anger, and burnout. Communication failures; particularly between nurses and physicians or between nurses and families, further exacerbated the nurses’ experiences of moral distress. Nurses expressed frustration when their professional judgment was ignored or overridden, and some reported moral conflict in navigating family dynamics that delayed or complicated care decisions. Staffing issues and institutional policies also emerged as significant contributors to moral distress. Study participants identified specific scenarios in which client care was delayed due to overwhelming workloads or leadership inaction. Coping strategies varied, with some participants turning to peer support or professional counseling, while others reported emotional exhaustion and disengagement.
This study included implications for education, research, and practice to: 1) develop programs to eliminate factors that may contribute to moral distress, 2) suggest coping strategies to mitigate the impact of moral distress, and 3) support scholarly activities to better understand the moral distress phenomenon among nurses providing care to high-acuity clients.
