Relationships Among Moral Distress, Level of Practice Independence, and Intent to Leave of Nurse Practitioners in Emergency Departments

Abstract

The aims of this research study were to investigate moral distress among emergency department (ED) nurse practitioners (NPs) and examine relationships between moral distress and level of practice independence as well as intent to leave a position. Moral distress has been studied regarding registered nurses and physicians (MDs) but less so in NPs. It is important to explore moral distress in NPs because they tread a unique path between nursing and physician roles. Moral distress may play a significant role in staff nurses' intention to leave practice, and level of practice independence is found to have a relationship with NPs' intention to leave. A convenience sample of ED NPs was obtained from a mailing list of a national nursing specialty organization, the Emergency Nurses Association. Using a correlational design, survey methods assessed moral distress with the Moral Distress Scale-Revised (MDS-R), level of practice independence with the Dempster Practice Behavior Scale, and intent to leave with self-report. Correlational and regression analyses of data were conducted to characterize moral distress among ED NPs and associations between moral distress, level of practice independence, and intent to leave. Results found ED NPs do experience moral distress with poor patient care results from inadequate staff communication and working with incompetent coworkers in their practice. The MDS-R was a significant predictor of intention to leave among respondents. This study is the first of its kind to explore moral distress in ED NPs. Results suggest moral distress influences ED NPs' intent to leave their position. Further studies are needed to explore the findings from this research and to formulate interventions to alleviate moral distress in ED NPs and improve retention in the clinical setting.

Cross-cultural adaptation and validation of the Moral Distress Scale-Revised for nurses

“…In agreement with this study, national and international studies found elevated levels of moral distress in nurses who participated in situations of pain and suffering for patients undergoing life prolonging procedures, with no evidence of success (7)(8)(15)(16)(17)(18)(19) . The professionals had feelings of incapacity when carrying out their procedures and of violation of their ethical principles, which shows situations of great emotional vulnerability (17)(18) .…”

“…Studies with nurses practicing at hospital context in various countries found that working with health professionals seen as insecure strongly influences experiences of moral distress, decreasing decision-making capacity (6,(16)(17)(18)(19)(20) . The main negative characteristic perceived in the work context was lack of ability of technical and scientific competence, which are crucial for conducting specific health activities (16) .…”

“…The main negative characteristic perceived in the work context was lack of ability of technical and scientific competence, which are crucial for conducting specific health activities (16) . Thus, the possibility of a negative impact on care quality can upset the essence of care, making it an alert ethical challenge (19) .…”

“…Although there were variations in frequency and intensity at different health units, it is evident that moral distress can occur in multiple clinical environments (19) . It is crucial to recognize and improve autonomy in nurses for their health attributions, especially when ethical values are compromised.…”

Psychic and moral exhaustion in primary care workers

“…Of these, despite their desire to leave, only a small portion effectively leaves their working position and most remain in their jobs for various contextual factors, such as shortage of other jobs (37) . This reality requires that researchers, managers and nursing leaders work together to identify and implement strategies to deal with the psychic and moral exhaustion of health workers in order to improve retention and job satisfaction (38) . Nurses in leading positions, such as managers, would be more likely to experience psychic and moral exhaustion mainly because of the inherent complexity in the decisionmaking process that involves expectations of the organization, patients, and workers (39) .…”