Nurse managers' moral distress in the context of the hospital ethical climate

Moral distress is a negative emotional and somatic response to external constraints on moral action. The constraints are typically identified as a component of the work environment, called the ethical climate. Moral distress is identified as a primary reason for job attrition by up to one-quarter of registered nurses who leave their jobs. One strategy suggested to staff nurses who experience moral distress is to consult their Nurse Manager (NM). However, the moral distress of NMs who are employed in acute care hospitals is poorly understood. The purpose of this qualitative study was to examine NMs' perceptions of the external constraints on moral agency, specifically the hospital ethical climate, which leads to their experience of moral distress and how attributes of the ethical climate facilitated or impeded resolution of their moral distress. Semi-structured, audio-recorded telephone interviews were conducted with 17 NMs from across United States. An interpretive description design using an iterative process between data collection and data analysis was used. Data were analyzed through descriptive coding and thematic analysis.

The participants in this study were 15 women and 2 men with a mean age of 46.4 years. The mean length of time in their current positions was slightly less than 5 years. Of the 17 hospitals represented, 6 were affiliated with a university and 4 had a religious affiliation. Fifteen of 17 NMs described situations in which the implicit and explicit values of the hospital were incongruent with their personal moral values and professional ethics. Common themes describing factors contributing to moral distress were administrative policies, negative communication patterns and relationships with physicians, issues related to staff nurses, issues related to patients and families, and multiple competing job obligations. Respondents described strategies to navigate through their moral distress. The strategies included taking a positive perspective, seeking the advice of NM colleagues, reliance on a positive relationship with a supervisor, and talking it through with family members. For 5 of the 15 NMs who experienced moral distress, their final strategy included plans to resign from their positions. Issues within the ethical climate of the hospital that were perceived to contribute to the development of moral distress among this cohort of NMs differed from those reported for staff nurses. Further examination of strategies used by NMs to improve the ethical climate may yield insights into effective ways to address moral distress for this population.