title: Assessing and addressing moral distress and ethical climate, part 1.
abstract: BACKGROUND
  There is minimal research exploring moral distress and its relationship to ethical climate among nurses working in acute care settings.
  
  
  OBJECTIVE
  Objectives of the study were to explore moral distress, moral residue, and perception of ethical climate among registered nurses working in an academic medical center and develop interventions to address study findings.
  
  
  METHODS
  A mixed-methods design was used. Two versions of Corley and colleagues' Moral Distress Scale, adult and pediatric/neonatal, were used in addition to Olson's Hospital Ethical Climate Survey. Participants were invited to respond to 2 open-ended questions. This article reports the results for those nurses working in adult acute and critical care units.
  
  
  RESULTS
  The sample (N = 225) was predominantly female (80%); half held a bachelor of science in nursing or higher, were aged 30 to 49 years, and staff nurses (77.3%). The mean item score for moral distress intensity ranged from 3.79 (SD, 2.21) to 2.14 (SD, 2.42) with mean item score frequency ranging from 2.86 (SD, 1.88) to 0.23 (SD, 0.93). The mean score for total Hospital Ethical Climate Survey was 94.39 (SD, 18.3) ranging from 23 to 130. Qualitative comments described bullying, lateral violence, and retribution.
  
  
  CONCLUSIONS
  Inadequate staffing and perceived incompetent coworkers were the most distressing items. Almost 22% left a previous position because of moral distress and perceived the current climate to be less ethical compared with other participants. Findings may potentially impact nurse retention and recruitment and negatively affect the quality and safety of patient care. Interventions developed focus on the individual nurse, including ethics education and coping skills, intraprofessional/interprofessional approaches, and administrative/policy strategies.
authors.affiliation: Jeanie Sauerland, BS, BSN, RN, is nurse manager Outpatient Surgery at University Hospital in San Antonio, Texas. She has a Bachelor's degree in Health Education from Texas A&M University and a BSN from the University of Texas Health Science Center in San Antonio, Texas. She is currently a student at M.D. Anderson working toward a certification in clinical ethics. Her research interest is nurse participation in ethical issues. Kathleen Marotta, BSN, RN, received a Bachelor of Science in Nursing at University of Texas Health Science Center, San Antonio, Texas; Bachelor of Science in Education, Our Lady of the Elms, Chicopee, Massachusetts; and community educator - Shaken Baby Syndrome. Her research interest is moral distress and ethical climate. Mary Anne Peinemann, MSN, RN, received her Diploma of Nursing at St. Paul's School of Nursing in Dallas Texas, and her BSN and MSN from Incarnate Word University. She has worked as a CNS nurse educator in pediatrics at University Health SystemWorked at UHS for 25 years. Her research interests include ethics, how children react to different nurses, and how/why nurses change or not change practices when change is recommended by research evidence. Andrea Berndt, PhD, is an assistant professor and statistician at the University of Texas Health Science Center at San Antonio, School of Nursing. Dr Berndt teaches research and statistics courses in the doctoral program, and provides research and statistics consultation for students, faculty, and community stakeholders. Her research interests primarily focus on assessment, evaluation, and instrumentation in nursing education and healthcare institutions. She received her BS in psychology, MS in Experimental Psychology, and PhD in Industrial-Organizational Psychology from Old Dominion University. Catherine Robichaux, PhD, RN, received her BSN from Cornell University, MSN from Incarnate Word College and PhD from the University of Texas at Austin. She is an assistant professor, adjunct, at
authors.forename: Jeanie
authors.initials: J
authors.lastname: Sauerland
authors.forename: Kathleen
authors.initials: K
authors.lastname: Marotta
authors.forename: Mary Anne
authors.initials: MA
authors.lastname: Peinemann
authors.forename: Andrea
authors.initials: A
authors.lastname: Berndt
authors.forename: Catherine
authors.initials: C
authors.lastname: Robichaux
mesh_terms: D000046:Academic Medical Centers; D000223:Adaptation, Psychological; D000328:Adult; D002055:Burnout, Professional; D064648:Critical Care Nursing; D004993:Ethics, Nursing; D005260:Female; D006801:Humans; D007400:Interprofessional Relations; D007588:Job Satisfaction; D008297:Male; D008875:Middle Aged; D009014:Morals; D009741:Nursing Staff, Hospital / Q000523:psychology*; D015279:Organizational Culture; D013315:Stress, Psychological