Healthy work environments could reduce moral distress among critical care nurses

Jan 3 2018

Critical care nurses who practice in healthy work environments (HWEs) report less moral distress and higher job satisfaction, according to new research published in American Journal of Critical Care (AJCC). The findings amplify the call for hospitals and healthcare organizations to improve the work environment and address barriers to practice.

"Predictors of Moral Distress in a U.S. Sample of Critical Care Nurses" identifies specific organizational factors that hospitals and healthcare organizations can change, improving the work environment and possibly reducing the prevalence of moral distress among clinicians. The recommendations are based on results of a national survey of 328 critical care nurses.

Co-author Catherine Hiler, RN, DNP, CCRN-CMC, led the research project while she was a doctorate of nursing practice student at Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland. She is now an assistant professor at Jefferson College of Health Sciences, Roanoke, Virginia.

She and faculty mentors at Case Western Reserve conducted the survey to explore the relationships among moral distress, the practice environment and perceptions of the quality of patient care. They recruited participants from subscribers to the e-newsletter or participants on social media channels of the American Association of Critical-Care Nurses (AACN).

Participants completed an online survey that included the Moral Distress Scale-Revised and the Practice Environment Scale of the Nursing Work Index, which are two valid and reliable survey instruments to capture moral distress, the health of the practice environment and quality of care as perceived by critical care nurses. A demographic questionnaire provided additional data.

"The negative impact of moral distress extends far beyond the individual nurse, and our findings offer evidence for preventive strategies on the organizational level," Hiler said. "The development of healthy work environments that promote collegial relationships could reduce moral distress among critical care nurses."

Overall, the study found that as the practice environment deteriorates, the level of moral distress rises. Specific findings include the following:

• As nurses participated in more hospital programs and activities, their moral distress decreased.
• Nurses who perceived positive quality of care indicated decreased moral distress.
• As nurse leadership support of staff increased, moral distress decreased.
• Nurses who reported adequate staffing and resources reported less moral distress.
• As nurses perceived collegial relationships between themselves and physicians, they reported less moral distress.
• The severity of moral distress was significantly associated with a nurse's intention to leave his or her current position.

The researchers found high levels of moral distress frequency when nurses deemed that the care being provided was futile. The highest level of moral distress frequency occurred when the wishes of the patient's family to continue life support were followed, even though the nurse believed that doing so was not in the best interest of the patient.

Further analysis established that higher states of job dissatisfaction, the practice environment and age were statistically significant predictors of the frequency of moral distress.

Respondents also indicated whether they worked in a unit that had received the AACN Beacon Award for Excellence or at a Magnet-designated hospital, both of which were considered ways to demonstrate commitment to a healthy work environment. In this sample, less than 19 percent of respondents worked in Beacon-recognized units, and those who did reported less moral distress.

The findings provide additional evidence on the benefits of HWEs, and the researchers recommend hospitals adopt "AACN Standards for Establishing and Sustaining Healthy Work Environments" as a guiding principle.

The AACN Healthy Work Environment Team Assessment is available to help organizations around the world align quality and safety improvement efforts with the HWE standards. Healthcare professionals can use the free online tool to survey staff, compare their results with industry standards and develop step-by-step strategies to improve performance, patient safety, staff recruitment and retention, and their workplace environment, as needed.