A recent study from the University of Pennsylvania confirms that the ethical issues that nurses face cause stress and affect job satisfaction and overall retention rates. The study, which surveyed 1,215 practicing nurses and social workers in four states and differing census regions, found that 25 percent of respondents want to leave the profession because of moral distress and 41 percent failed to say they would choose the profession again if given the opportunity to start over.

Connie Ulrich, Ph.D., RN, assistant professor of Bioethics and Nursing for the University of Pennsylvania School of Nursing, said that the nursing community has been aware of the problems concerning ethical and moral distress, but there has not been much research or evidence concerning the effects of these issues and how the stress impacts a nurse’s professional life.

“We knew that providers were facing tremendous amounts of stress in providing care to patients but we really didn’t have empirical evidence to help us better understand the problems,” Ulrich explained. “We surveyed nurses and social workers in the U.S. and found that both groups of providers feel a sense of powerlessness within the system, both are tired, both feel overwhelmed and both feel frustrated.“

The nurses and social workers that were surveyed worked in a variety of settings including acute care facilities, ambulatory clinics and outpatient health centers. “We did find that about 40 percent are frustrated and 40 percent are fatigued. One out of three feels powerless and the same even said they were physically ill.”

According to Ulrich, two out of three respondents also reported that there were ethical issues that they felt they can do nothing about and 39 percent cited that there were no organizational resources to assist them with ethical problems.

This data points to an alarming trend in nursing that could gravely affect the nursing shortage in years to come. Limited ethics training and resources have contributed to the feelings of moral distress that nurses are confronted with on a daily bases.

“Additional data demonstrated that nurses have limited ethics education; this in turn influences ethical confidence and ability to act as a moral agent. Almost one quarter (23%) of nurses in the study reported no ethics training and those with less training experienced more ethical issues and were less likely to seek support,” Ulrich said.

According to the study, the most common situations that create ethical and moral distress in nurses in the workplace include: issues concerning patient rights and advocacy, end of life care, conflicts, balancing technology and care, and caring for the acute, chronic and emergently ill.

Many nurses also reported feeling conflicted in their decision making or felt they were unable to carry out certain decisions, contributing to the overall feelings of moral distress. Nurse leaders believe that an unhealthy ethical climate may have far more negative implications than anyone realizes.

“I do believe that that ethical and moral distress ultimately does affect patient care,” Ulrich said. “If one believes that they know the ethically correct course of action but are precluded from carrying that out, then patient care suffers in some way. If a nurse or social worker cannot meet their primary commitment to patient care, ultimately everyone suffers. The patient may not receive what is in their best interest, the nurse cannot provide what they perceive to be the best care and might decide to leave, and the administration suffers for losing individuals who might be their best and brightest.”

Ulrich believes that communication and broader dialogue on the subject will help to limit moral distress and the negative impact it has on health care providers. There is very limited information concerning this topic, which makes the impact of moral distress on patient care somewhat of an unknown.

“Improving the ethical climate begins with administration and managerial leaders. First, I believe they have to recognize that nurses and other health care workers are facing tremendous ethical challenges in providing care and encountering stress related to these concerns. To me, this only impacts the quality of care that is delivered.”

Creating a positive ethical climate where nurses feel engaged and comfortable takes time and participation from all parties involved. Every nurse who speaks up when feeling ethical or moral distress is one step closer to eliminating the issue entirely.

“Nurses must command respect and ask questions if they feel uncomfortable; they are intelligent, well educated individuals and deserve a voice at the table, especially as it pertains to patient care and other related issues,” Ulrich added. “They need to have a voice. If you are uncomfortable with the way care is delivered—speak up.”