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ICNE YALE # 25
Moral Distress, Ethical Climate, and Intent to Turnover
Among Critical Care Nurses
Karla M. Fogel, PhD, RN
North Park University
School of Nursing
Acknowledgements are given to members of my doctoral dissertation committee: Beverly
Kopala, PhD, RN (Chair); Karen Egenes, EdD, RN; Linda L. Olson, PhD, RN; David Ozar, PhD;
and to Mary C. Corley, PhD, RN and Ann Hamric, PhD, RN for significant support and advice
Funding recognition goes to Alpha Beta Chapter, Sigma Theta Tau, International Nursing Honor
Society, Loyola University Chicago.
Address for correspondence: Karla M. Fogel, Associate Professor, School of Nursing, North
Park University, 3225 West Foster Avenue, Chicago, IL, 60625. Tel: 773-244-5758; FAX: 773-
244-5280; E-mail: kfogel @northpark.edu.
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The purpose of this study was to explore relationships between moral distress, likelihood
of leaving a position, and the ethical climate of the unit and hospital. A descriptive, correlational
study of these three variables using three Likert-type tools and a demographic data form revealed
significant levels of moral distress that correlated positively with intent to turnover. N=100
critical care staff nurses from 2 tertiary level health care institutions in a major metropolitan area.
The highest levels of distress were related to aggressive treatments for terminally ill patients. A
positive perception of the ethical climate was strongly, negatively correlated with intent to
turnover. Subjects’ age and length of tenure in the hospital indicated a lower likelihood of
turnover. Relationships with peers and managers and feelings of competence moderated the
effect of moral distress levels on intent to turnover. Implications are noted for administrators to
decrease staff turnover.
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As the concept of moral distress was defined and examined in nursing literature in the
past 20 years, the experiences described have resonated strongly with critical care nurses
struggling to understand their emotional discomfort as it related to the ethical issues they
encountered in practice.1-7
An increasingly complex and bureaucratic healthcare system with
economic pressures to control costs has increased this moral distress.8
In addition, the staff
shortages in critical care units have been attributed to high levels of “burnout” and job
Safe and supportive environments in health care institutions for nurses have
been discussed as a way to help nurses cope with moral distress and other issues causing job
The purpose of this study was to examine the relationships of moral distress, ethical
climate, and intent to turnover among critical care nurses. The research questions looked at
the level of moral distress, perception of ethical climate, and level of intent to turnover, as well
as the relationship between frequency and intensity of moral distress and intent to turnover,
and the moderating effect of ethical climate on this relationship in critical care nurses.
Moral Distress was first defined by Jameton15
as an experience that “… arises when one
knows the right thing to do, but institutional constraints make it nearly impossible to pursue the
right course of action.” Later it was described by Kelly16
as the result of one’s efforts to preserve
moral integrity while not acting on moral convictions.
Ethical Climate has been described by Olson17
as the perceived environment within an
organization that promotes ethical reflection, and allows for inquiry, debate, and expression of
differing viewpoints, while promoting each individual’s values and mutual trust.
Intent to Turnover was defined by Kacmar et.al 18
as employee withdrawal from the
workplace, whether actually leaving a position or thinking and talking about quitting.
The experience of moral distress leads to frustration, discouragement, and eventual
flight from an intolerable situation. Therefore, leaving a particular position in a certain area of
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practice or even leaving the profession is perceived to be the result of the distress. Perception
of the ethical climate of one’s workplace is a based upon the relationships one has with peers,
patients, managers, hospital administration, and physicians when encountering ethical
problems. These relationships are influenced by the conditions of varying levels of power, trust,
inclusion, role flexibility, and inquiry that are necessary for ethical reflection, dialogue, and
ethical problem-solving to occur.17
Conditions of ethical climate may allow for the elimination of
a barrier to moral action prior to the employee experiencing initial moral distress. The conditions
of perceived ethical climate may also assist with moral distress by overcoming barriers after the
initial experience so that the moral action may be completed eventually. A source of support for
the nurses may be found within an organization in which they perceive an ethical climate that
allows for inquiry and discussion with all stakeholders.14
A descriptive, correlational study design was used with three self-administered Likert-
type scale surveys, the Moral Distress Scale (MDS)19
, Hospital Ethical Climate Scale (HECS) 17
and a portion of the Quality of Work Life Measurement tool (QWL)20
and a demographic data
tool (DDS). Responses to the surveys were converted into scores that were then statistically
analyzed for descriptive, correlational, regressive, and path analysis information. Intensity and
frequency scores of Moral Distress were the independent variables. The dependent variable
was the Intent to Turnover score. The Perception of Ethical Climate score was the moderating
A convenience sample meeting the following selection criteria was used: a registered
nurse, currently working at least 16 hours per week, caring for patients as a staff nurse in a
critical care unit, experienced in critical care nursing for a minimum of one year and working in
the current institution for at least 6 months. Subjects were recruited from 11 units at two
university affiliated tertiary care medical centers in a Midwest metropolitan area. One institution
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was affiliated with a faith-based organization and the other was a non-profit community multi-
hospital system. Examining the mission statements of each organization yielded comparable
goals of commitment to excellence in patient care with a focus on the education of health
professionals. Power analysis determined that a sample size of 84 was necessary to find
statistical significance in correlational and regression analyses. In the final sample (n = 100,
return rate=40%), the subjects’ mean age was 38.8 years with a range of 25-53 years, 10%
were male, and education as well as race/ethnicity of the sample was comparable to the
national average of the nursing population with a slightly higher representation of entry
bachelor’s degrees and Asian nurses. Permissions for the study were obtained from
Institutional Review Boards of all participating institutions. Data were collected in the early
spring of 2005.
Significant findings were noted when examining the correlational data from the four tools
(MDS α=.938, HECS α=.922, QWL α =.904, and DDS). In general, issues concerning nurses’
own competence, the competence of other staff, the views of one's manager, and the hospital
support/respect for nurses all showed a significant relationship (R= .3463,.2082,-.535,-.371;
p<.05 or .01) to intent to turnover. The findings of the regression and path analyses further
supported the findings in the correlational relationships. Three variables demonstrated
statistically significant direct effects (beta weights > ±.10) on likelihood of turnover. “Years in
Hospital” showed that the longer a subject had worked in the same hospital, the less likely it
would be for them to quit. From the HECS, the more positive the perception of one’s manager
and/or the more positive one’s perception of the hospital administration policies were, the less
likely it would be for the nurse to be quit. The impact of Moral Distress on Turnover Likelihood
was seen as being moderated by the effects of the Ethical Climate factors, particularly related to
concerns about poor care (by others or oneself) and justice issues (or financial influence) on
patient care. Ten percent of the subjects stated that they had previously left a position in nursing
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because of moral distress. No statistically significant differences between the two healthcare
systems were found in Intent to Turnover scores, however a wide range of scores was found
between individual units that were statistically significant (p=.002), possibly reflecting the fact of
different managers for each unit.
Many interesting items of note were found in the data from this study, especially when
compared to previous studies using the same instruments. For example, the types of issues that
were causing the most distressful feelings (based on highest mean MDS Intensity Subscale
scores of items) in this current study related to working with unsafe levels of nurse staffing. Two
other studies using the MDS reported this item also with the highest mean score.12,24
appears to reflect the concern of nurses that a high work load would increase the potential for
mistakes, but not that they might have too much work to do. The resulting likelihood of injury to
their vulnerable patients is the cause of the distress supported by the strong relationship
between patient-to-nurse ratio and patient deaths from medical error already widely reported.9
The highest scoring items from the MDS Frequency Subscale related to aggressive
treatment in patients life-limiting illnesses, which are consistent with other studies reporting
MDS frequency scores.12,24,25
Healthcare professionals become concerned when they are
obligated to give aggressive treatments and/or inadequate pain medication. This conflicts with
the caregivers’ priority to maintain comfort for all patients.
Items in the HECS related to positive relationships among health care team members
demonstrated high scores. These findings are consistent with studies of practice environments
using other instruments.26
Items about dealing effectively with conflict scored the lowest, which
was consistent with previous studies.27
The high and low scoring findings echo the themes
found in a phenomenological study of nurses leaving the profession.28
The HECS strongly
correlated with Intent to Turnover in 65% of the individual items and in four of five factors. All
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findings are comparable with Hart’s regression analysis which used the HECS with a similar
Generalizability of the findings is limited due to the use of a nonrandomized convenience
sample and self selection may have eliminated those with particularly painful or traumatic
experiences or those with limited recognition of ethical issues. Pressure to give socially
desirable answers was also possible even with confidentiality and anonymity assured.17
The major findings of this study have implications for nurse executives and hospital
administrators. Currently, the highest nurse vacancy rates, 14.6%, are found in critical care
, and it has been estimated that it costs a hospital from $62,100 to $67,100 to replace a
The levels of moral distress have been shown to be related to increased intent to
turnover, and the identified elements of the ethical climate, specifically the relationships of the
staff nurses to their unit managers, appear to moderate the negative effects of moral distress.
Therefore, investment in the development of leadership skills among the nurse managers could
well be a significant cost effective measure.
This study described the relationships of moral distress in the context of the perceived
ethical climate while searching for a moderating effect on potential turnover in critical care
nurses. When examining individual variables, the most disturbing issues causing moral distress
were shown to be related to aggressive treatments for patients at the end of life as well as the
lack of ability or lack of staff to adequately care for patients. The aggressive treatments were
also the most frequently seen. While perceptions of ethical climate varied between settings as
expected, overall the most positive items related consistently to the relationships of subjects
with their peers. Turnover intent did not vary significantly between healthcare systems, but did
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vary widely by individual critical care unit within the settings.
Analysis of the relationships between the major variables demonstrated correlations
between the morally distressing state of feeling incompetent to care for patients and the strong
desire to leave. Even stronger indications of quitting were correlated with a negative relationship
with the unit manager. Demographic variables of age and years of experience indicated that the
older and more experienced nurses were least likely to leave. Causal relationship analysis
revealed a moderating effect of perception of ethical climate on the impact of moral distress on
Concern regarding moral distress continues to grow and calls for recognition of the
potential loss of valuable nurses to critical care units and the profession itself.29
review of the nursing literature to date called for the empirical data to support the
predominant views that “poor ethical climate and resulting moral distress cause nurses to leave
the profession”(p. 319). This study has endeavored to do exactly that task. The next call should
be for evidence based solutions to the problem defined. Even though there may be little control
over the difficult situations in critical care units, such as families dealing with the imminent death
of a loved one, these findings indicate that the impact of these challenges can be decreased
with supportive relationships among the health care team members. Methods to foster these
relationships warrant continued study.
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