Nurse Leaders Face Moral Distress Alone

Researchers hope to bring the discussion about moral distress among chief nursing officers into the open.

Ethical challenges are not left at the bedside when nurses move into leadership positions.

Chief nursing officers still experience moral distress—the disequilibrium resulting from the recognition of and inability to react ethically to a situation—it's just taboo to talk about it, finds a qualitative study published in the Journal of Nursing Administration in February 2017.

"There's shame and isolation when you do have the experience, so it can make it very difficult for people to feel like they can openly discuss it," says Rose O. Sherman, EdD, RN, NEA-BC, FAAN, professor and director of the Nursing Leadership Institute at Florida Atlantic University.

Sherman is one of the study's authors. "I think that the other piece of it is, CNOs might not always label it as moral distress. But these are uncomfortable situations where they're making decisions against their values systems."

The Causes of Moral Distress

Through oral interviews, Sherman and her co-author, Angela S. Prestia, PhD, RN, NE-BC, discussed chief nursing officers' experiences of moral distress, including its short and long-term effects. Prestia is corporate chief nurse at The GEO Group.

The study's 20 participants described their experiences of moral distress, and several said they experienced it on more than one occasion. It was often related to issues like:

• Staff salaries and compensation
• Financial constraints
• Hiring limits
• Increased nurse-to-patient ratios to drive productivity
• Counterproductive relationships
• Authoritative improprieties.

"For example, a physician went to someone over a CNO's head and said, 'I think you should pay a scrub tech more. She is very valuable to me," Prestia says. "And of course he was a high-admitter, high-profile physician."

The CEO approved the special compensation, creating a salary inequity among the other scrub techs.

In another scenario, six participants reported their CEOs had improper sexual relationships with staff members. Prestia points out that the CNOs did not object to these relationships because of religious or moral beliefs, but because they were harming productivity at the organization.

"In their [the CNOs'] mind' of right and wrong, these people had access to things that they should not have had access to and [those relationships] create barriers to getting the work of the organization accomplished."

Lasting Effects

The study uncovered six significant themes related to CNO moral distress:

• Lacking psychological safety
• Feeling a sense of powerlessness
• Seeking to maintain moral compass
• Drawing strength from networking
• Moral residue
• Living with the consequences

CNOs reported they often felt very isolated during the experience of moral distress.

"If they pushed back on a decision because they felt it was in conflict with their values they were isolated within the organization and they no longer felt safe. They weren't invited to meetings. They weren't included in decision making," Sherman says.

Even though they took steps to do what they felt was right—documenting meeting minutes, reviewing policies and procedures, and referring to The Joint Commission standards—to maintain their moral compass, those efforts were often unsuccessful.

"What happened was when they were in this situation… they were beat down at every turn," Prestia says. "Then the 'flight' started to set in. 'Maybe I need to leave? Maybe I should resign? Maybe I need to start planning my exit strategy?' Or before they could do that, they were terminated."

Moral Residue

Even once they were out of the situation, many CNOs reported the experience left them with a 'moral residue.'

"It is a lingering effect of the moral distress. I liken it to a fine talc that lingers on your skin and it manifests itself either physically or emotionally," Prestia says. "We actually had several participants say, 'When I get a call about staffing now in my new job, all of a sudden I get this feeling of impending doom.'"

Both Sherman and Prestia hope this research will open up a larger conversation about CNOs and moral distress.

"What we found in the work that we did was, clearly, collegial support from a strong network is very important in building one's resiliency and being able to deal with these situations," Sherman says.

"I think that having others who've been through it is very important, which is why forums that allow people to talk about this candidly, when a CNO finds him or herself in this situation, become critical."