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  1. 1. Fogel ICNE 1 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 Chicago, IL 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
  2. 2. Fogel ICNE 2 Abstract 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.
  3. 3. Fogel ICNE 3 Introduction 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 dissatisfaction.9-11 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 dissatisfaction.12-14 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 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
  4. 4. Fogel ICNE 4 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 Methods 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 variable.21 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
  5. 5. Fogel ICNE 5 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. Results 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
  6. 6. Fogel ICNE 6 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. Discussion 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 This 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
  7. 7. Fogel ICNE 7 findings are comparable with Hart’s regression analysis which used the HECS with a similar turnover scale.29 Limitations 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 Recommendations 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 units22 , and it has been estimated that it costs a hospital from $62,100 to $67,100 to replace a single nurse.23 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. Conclusion 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
  8. 8. Fogel ICNE 8 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 turnover likelihood. 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 Schluter’s14 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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