RESEARCH
MORAL DISTRESS IN EMERGENCY NURSES
Authors: Robin Fernandez-Parsons, MSN, RN, Lori Rodriguez, PhD, RN, and
Deepika Goyal, PhD, RN, FNP-C, San Jose and Milipitas, CA
Introduction: For nurses, moral distress leads to burnout,
attrition, compassion fatigue, and patient avoidance.
Methods: Using a quantitative, cross-sectional, and descrip-
tive design, we assessed the frequency, intensity, and type of
moral distress in 51 emergency nurses in 1 community hospital
using a 21-item, self-report, Likert-type questionnaire.
Results: Results showed a total mean moral distress level of
3.18, indicative of overall low moral distress.
Discussion: Situations with the highest levels of moral
distress were related to the competency of health care
oral distress is a significant problem for nurses,
M leading to physical and emotional problems, as
well as affecting job retention, job satisfaction,
and quality of care. 1 Increased levels of moral distress have
been found to lead to medical errors, nurse burnout,
attrition, compassion fatigue, feelings of powerlessness, and
patient avoidance. 2-4 Furthermore, high frustration and job
dissatisfaction may lead to lateral violence and an overall
unhealthy work environment. 5
Jameton 6 defined moral distress in nurses as follows:
“Moral distress arises when one knows the right thing to do,
but institutional constraints make it nearly impossible to
pursue the right course of action.” Jameton identified different
types of moral distress in nurses: initial distress and reactive
distress. Initial distress was identified as the frustration, anger,
and anxiety faced with institutional obstacles and interper-
sonal conflicts. Reactive stress was identified as occurring
when the nurse is unable to act on his or her initial distress.
Robin Fernandez-Parsons, Member, Loma Prieta Chapter ENA, is Director of
Emergency Services, Kaiser Permanente San Jose Medical Center, San Jose,
CA, and currently Assistant Medical Group administrator for Kaiser
Permanente Milpitas Medical Office, Milipitas, CA.
Lori Rodriguez is Associate Professor, The Valley Foundation School of
Nursing, San Jose State University, San Jose, CA.
Deepika Goyal is Associate Professor, The Valley Foundation School of
Nursing, San Jose State University, San Jose, CA.
For correspondence, write: Robin Fernandez-Parsons, MSN, RN, 13610 Llagas
Avenue, San Martin, CA 95046; E-mail: robin.f.parsons@kp.org.
J Emerg Nurs 2013;39:547-52.
Available online 12 February 2013.
0099-1767/$36.00
Copyright © 2013 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2012.12.009
November 2013 VOLUME 39 • ISSUE 6
providers and following family wishes to continue life
support, also known as futile care. Moral distress was the
reason given by 6.6% of registered nurses for leaving a
previous position, 20% said that they had considered
leaving a position but did not, and 13.3% stated that they
are currently considering leaving their position because of
moral distress.
Key words: Burnout; Emergency nurses; Ethical dilemmas;
Moral distress
Reactive distress has been shown to lead to physical symptoms
such as anxiety and sadness. Nurses often do not recognize
moral distress as the source of their symptoms, and unrelieved,
moral distress can lead to frustration and anger and can
negatively affect job retention. 1 The purpose of this article was
to explore the frequency of moral distress, intensity of moral
distress, and situations that increase moral distress in nurses
working in an emergency department.
Despite the documented intensity and frequency of
moral distress among critical care nurses, little is known
about moral distress in nurses working in the emergency
department. In a study of 28 nurses, Elpern et al 2
suggested that critical care nurses experience moral distress
frequently and intensely. Their highest source of moral
distress was “providing aggressive care to patients not
expected to benefit,” 2 which can be described as futile
care. Thus our study was undertaken to determine
whether previous studies conducted with other groups of
nurses could be generalized to emergency nurses. The
research questions addressed in this study were as follows:
(1) What are the intensity and frequency of moral distress
in emergency nurses? (2) What is the level of moral
distress of nurses who work in the emergency department?
(3) What are the situations associated with significant
moral distress in emergency nurses?
According to Corley et al, 1 15% of nurses (n = 23)
reported resigning a position because of experiencing moral
distress. In another study nearly 23% of nurses planned to
leave their current position within 1 year, and when nurses
aged under 30 years were studied, the number increased to
33% as a result of moral distress. 7 In addition, Corley et al
noted that 45% of nurses working in an intensive care unit
responded that they either left or considered leaving a
position because of moral distress.
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RESEARCH/Fernandez-Parsons et al
Literature Review
2 Before data collection, human subjects approval was
Elpern et al studied moral distress in a medical intensive
care unit using an earlier version of the Moral Distress
Scale (MDS). 1 Moderate levels of moral distress with
varying degrees of frequency were noted among the 28
participants in the sample. Study findings suggested high
levels of moral distress in situations involving providing
aggressive care to patients, futile care, and care related to
patients who would not benefit from these interventions.
These findings were consistent with other similar studies in
critical care nurses. 8
Zuzelo 4 presented a comprehensive review of moral
distress in her study of 100 registered nurses providing
direct care to patients in a large urban medical center with
both inpatient and outpatient settings. The sample included
but was not specific to emergency nurses. Using the MDS
and qualitative data generated from open-ended questions,
results suggested moderate levels of moral distress. The
event with the highest level of distress was “work with levels
of nurse staffing that I consider unsafe.”
In a phenomenological study of the lived experience of
emergency nurses in Australia, Kilcoyne and Dowling 9
identified themes consistent with the reported experiences
of moral distress. Themes uncovered in this study included
powerlessness, anxiety, stress, fear and frustration, and a
poor sense of safety and security. Although this study was
not focused on moral distress, the narratives showed a
central theme of a loss of power and inability to deliver
quality of care to patients.
More recently, a study examined moral distress in 96
neonatal intensive care unit nurses. 5 A revised version of the
MDS was used. With a 48% response rate (n = 46), findings
showed low to moderate moral distress within this nursing
specialty. Interestingly, this research had its highest frequency
with the item “follow the family's wishes” to continue life
support even though it was not in the best interest of the child.
Methods
DESIGN
This study used a quantitative, cross-sectional, descriptive
design.
STUDY SAMPLE AND SETTING
This study took place in the emergency department of a
242-bed community hospital in northern California. All
registered nurses, aged over 18 years, actively working in the
emergency department, regardless of the number of hours
worked, during the time frame of the study were invited to
participate in this study.
548 JOURNAL OF EMERGENCY NURSING
PROCEDURE
obtained from both the hospital and university institutional
review boards. The MDS questionnaire and an explanatory
cover letter were placed in nurses' individual mailboxes.
Participation in the study was strictly voluntary, and no
identifying information was collected. Return of the
completed study questionnaires implied consent. No
demographic data were collected given the small depart-
ment to ensure participant anonymity. Compensation in
the form of a raffle was provided to participants.
MEASURES
Moral distress was assessed by use of the registered nurse
version of the Moral Distress Scale–Revised (MDS-R) (A. B.
Hamric, written communication, 2010). The scale was
revised by Dr Ann Hamric from Corley's original 38-item
scale with responses ranging from 1 to 7; the revised version
has 21 items with responses ranging from 0 to 4 (see
Appendix). Some of the reasons for revision were to
eliminate redundant items, enhance clarity, broaden
applicability beyond critical care settings to all inpatient
settings, and allow construction of parallel versions to apply
to other health care fields, including physicians (A. B.
Hamric, written communication, 2010). The revised tool
also added open-ended questions to gain data on other
situations causing moral distress and added questions
regarding leaving or considering leaving a current position
because of moral distress. Moreover, the revision allows the
creation of a composite score that can be used in multivariate
analysis (A. B. Hamric, written communication, 2010).
The MDS-R has established reliability and validity (A. B.
Hamric, written communication, 2010). The tool was tested
in 8 intensive care units (6 adult and 2 pediatric) with
responses from 37 physicians and 163 registered nurses. The
Cronbach α, measuring internal consistency (reliability), of
the 21-item MDS-R was .88 overall and was .89 specific to
registered nurses (A. B. Hamric, written communication,
2010). Construct validity was tested by use of 4 hypotheses
from earlier literature findings. The findings were significant
in the expected directions: (1) moral distress was negatively
correlated with ethical climate (r = –0.415, P b .001), (2)
physicians had significantly lower moral distress than nurses
(t = –5.972, P N .001) (A. B. Hamric, written communica-
tion, 2010), (3) MDS-R scores were significantly higher for
clinicians leaving or thinking about leaving their positions (F =
48.557, P b .001 [analysis of variance]), and (4) nurses with
more experience had higher moral distress (r = 0.17, P = .037)
(A. B. Hamric, written communication, 2010).
The MDS-R, a 21-item Likert scale, assesses both the
frequency and intensity of moral distress. The 21 items
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describe clinical situations scored from 0 (none) to 4 (very
frequent) for frequency of moral distress symptoms
experienced by the participant. The 21 items also assess
the level of disturbance experienced by the participant from
0 (none) to 4 (great extent). In addition to the 21 items,
space is available for participants to answer the following
question: “If there are any situations, in which you have felt
moral distress, please write them and score them here.” Three
additional questions assess retention by asking participants if
they have ever left a nursing position, considered leaving a
nursing position, or were presently considering leaving their
current position because of moral distress.
To obtain an overall moral distress score, the frequency
score is multiplied by the intensity score, providing an
overall moral distress score between 0 and 16 (A. B.
Hamric, written communication, 2010), where a higher
score is indicative of increased frequency and increased
intensity of moral distress.
DATA ANALYSIS
SPSS software, version 18 (IBM, Armonk, NY), was used to
analyze data. Scores for each of the situations were totaled
and divided by 51 (total participants) to produce the mean
score for frequency, intensity, and level of moral distress.
The situations were then ranked from highest to lowest and
arranged by situation, with ranking of the top 10 situations.
Results
Of the surveys, 61 were returned, 10 with incomplete data,
leaving 51 complete surveys, for a response rate of 53%.
SAMPLE CHARACTERISTICS
Although demographic data were not assessed, the following
data provide a general demographic “snapshot” for the total
participant pool of nurses (N = 97) who were invited to take
part in this study: the age of the nurses ranged from 27 to 68
years; the length of experience in the emergency department
ranged from 3 months to 27 years; and 43% of participants
self-reported as white, 31% as Asian, 11% as Hispanic, 4%
as African American, and 4% as “other.” The setting for this
study is a 28-bed, comprehensive emergency department,
with a mean length of stay of 228 minutes (3.8 hours).
MORAL DISTRESS
The mean frequency score was 1.14, with a range from 0.37
to 2.16 (range of possible scores, 0-4). The situation with the
highest mean score was “follow the family's wishes to
continue life support even though I believe it is not in the
best interest of the patient.” Some of the other high-
frequency situations were related to carrying out unnecessary
orders, initiating lifesaving actions that will likely prolong
November 2013 VOLUME 39 • ISSUE 6
Fernandez-Parsons et al/RESEARCH
TABLE 1
Top 10 items for frequency of moral distress
Mean
Rank Item frequency
1 Follow the family's wishes to continue 2.16
life support even though I believe it is
not in best interest of patient
2 Carry out the physician's orders for 2.12
what I consider to be unnecessary tests
and treatments
3 Initiate extensive life-saving actions 1.94
when I think they only prolong death
4 Witness diminished patient care quality 1.73
due to poor team communication
5 Work with nurses or other health 1.69
care providers who are not
as competent as the patient care requires
6 Watch patient care suffer because 1.65
of a lack of provider continuity
7 Work with levels of nurse or other care 1.51
provider staffing that I consider unsafe
8 Continue to participate in care for a 1.33
hopelessly ill person who is being
sustained on a ventilator, when no one
will make a decision to withdraw
support
9 Assist a physician who, in my 1.22
opinion, is providing incompetent care
10 Provide care that does not relieve the 1.08
patient's suffering because the physician
fears that increasing the dose of pain
medication will cause death
death, and witnessing poor communication among the team.
Table 1 shows the top 10 detailed results for frequency.
The mean intensity score was 2.45, with a range from
1.98 to 2.96 (range of possible scores, 0-4). The situation
with the highest mean intensity was “work with levels of
nurses or other care provider staffing that I consider unsafe.”
Mean intensity scores for the top 10 situations ranged from
2.37 to 2.96. The lowest 11 situations ranged from 1.98 to
2.31, with situations such as continuing care for the
hopelessly ill, increasing doses of sedative to hasten death,
and witnessing health providers giving “false hope.” Table 2
shows detailed results for intensity.
The mean composite scores (frequency × intensity) for
moral distress for the situations ranged from 0.90 to 5.35,
with an overall scale mean of 3.18 (range of possible scores,
0-16). The situation with the highest level of moral distress
was “work with nurses or other health care providers who are
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RESEARCH/Fernandez-Parsons et al
TABLE 2
Top 10 items for intensity of moral distress
Mean
RankItem intensity
1 Work with levels of nurse or other care 2.96
provider staffing that I consider unsafe
2 Assist a physician who, in my opinion, 2.96
is providing incompetent care
3 Witness diminished patient care 2.86
quality due to poor team communication
4 Avoid taking action when I learn a 2.8
physician or nurse made a medical
error and does not report it
5 Work with nurses or other health care 2.78
providers who are not as competent as
the patient care requires
6 Take no action about observed ethical 2.74
issue because staff or someone in
authority requested I do nothing
7 Watch patient care suffer because of a 2.71
lack of provider continuity
8 Ignore situations in which patients 2.62
have not been given adequate information
to ensure informed consent
9 Continue to participate in care for a 2.58
hopelessly ill person who is being sustained
on a ventilator, when noone will make a
decision to withdraw support
10 Initiate extensive life-saving actions 2.37
when I think they only prolong death
not as competent as the patient requires.” The situation with
the second highest level of moral distress was “follow the
family's wishes to continue life support even though I believe
it is not in the best interest of the patient,” and the third
highest was “witness diminished patient care quality due to
poor team communication.” Mean levels for the top 10
items (Table 3) ranged from 2.96 to 5.35. Situations with
lower levels of moral distress were similar to those identified
by frequency and intensity.
With regard to the final 3 questions asking about leaving
or considering leaving one's position because of moral distress,
the responses were as follows: Moral distress was the reason
given by 6.6% of registered nurses for leaving a previous
position; 20% said that they had considered leaving a position
but did not; and 13.3% stated that they were currently
considering leaving their positions because of moral distress.
At the end of the survey, space was provided for
respondents to describe other situations causing them moral
distress; examples include the following:
550 JOURNAL OF EMERGENCY NURSING
1. “lack of family support during sudden death of a
loved one”
2. “MD not providing a high enough level of care that I
believe the patient needs”
3. “judging patients and providing minimal care”
Discussion
This research study provided insight into levels of moral
distress within 1 emergency department. The emergency
nurses who participated in this study self-reported low levels
of moral distress, which are incongruent with other studies
suggesting moderate and high levels of moral distress. 1-5
Possible explanations as to why the nurses in this sample had
lower moral distress compared with nurses in other settings
may be a reflection of the amount of time that they spend with
their patients. In general, nurses working in the emergency
department spend much less time with each patient compared
with other settings such as the intensive care unit, where
patients stay for days, not hours. ED stays have a national
average of 154 minutes, and the average length of stay in our
emergency department is 228 minutes. 10 Unlike intensive
care nurses, emergency nurses have less time with each patient
to build a relationship, to get to know the family, and to get to
know the needs and wishes of the patient. Futile care
situations including end of life and resuscitation often arise
suddenly when the patient arrives in the emergency
department. Although these situations can be distressing,
they may be less morally distressing for emergency nurses
given the limited knowledge that they have about the patient
and/or the patient's wishes before the event.
The results of this study also identified that those nurses
who were considering leaving their current position were
having high levels of moral distress. Of the nurses who took
part in this study, 7 (13.3%) were thinking about leaving
their current position. The cost of replacing 1 nurse working
in a specialty area is staggering, $64,000, with additional
costs of up to $145,000 for personnel costs. 7 Retaining
experienced, qualified nurses is a priority for nursing
managers. The results of this study highlight that moral
distress is a problem and cannot be ignored.
Findings in our study regarding the nurses' concern
about working with nurses and/or other health care
providers who are not competent have been echoed in
several other studies. 1,3,4 Providing futile care and carrying
out the family's wishes against nurses' own beliefs was rated
as the second most distressing issue for nurses in our study,
and again, findings are consistent with other studies. 2,5
Although the situations with high moral distress in our
study were similar to other studies, the overall mean score
for moral distress was 3.18, indicative of low moral distress.
VOLUME 39 • ISSUE 6 November 2013

TABLE 3
Top 10 items for level of moral distress (frequency ×
intensity)
Rank Item Mean
1 Work with nurses or other health 5.35
providers who are not as competent
as the patient care requires
2 Follow the family's wishes to 5.29
continue life support even though I
believe it is not in the best interest
of the patient
3 Witness diminished patient care quality 5.24
due to poor team communication
4 Initiate extensive life-saving actions 5.22
when I think they only prolong death
5 Carry out the physician's orders for 5.18
what I consider to be unnecessary
tests and treatments
6 Watch patient care suffer because of a 5.04
lack of provider continuity
7 Work with levels of nurse or other care 4.98
provider staffing that I consider unsafe
8 Assist a physician who, in my opinion, 3.8
is providing incompetent care
9 Continue to participate in care for a 3.33
hopelessly ill person who is being
sustained on a ventilator, when no one
will make a decision to withdraw support
10 Provide care that does not relieve the 2.96
patient's suffering because the physician
fears that increasing the dose of pain
medication will cause death
Limitations
This research study was limited by several factors including
the self-selected convenience sample, use of a relatively
newly developed instrument, and no assessment of
participant demographic data. This study involved a small
sample of nurses from an emergency department in a single
medical center, and the findings cannot be generalized to
other emergency departments. To date, only 2 other studies
have used the MDS-R to examine moral distress, providing
few comparative data. Moreover, no studies to date in the
United States have used the MDS-R to examine moral
distress in emergency nurses. Although demographic data
were not assessed to protect the anonymity of the nurses,
results are limited by the omission. Without racial/ethnic
November 2013 VOLUME 39 • ISSUE 6
Fernandez-Parsons et al/RESEARCH
information, it is difficult to assess differences in moral
distress among racial/ethnic groups.
Implications for Emergency Nurses
Moral distress has a negative impact on nurses, patients,
health care providers, and the health care system. Although
moral distress will never completely be eliminated from
health care, it can be mitigated. Moral comfort is achievable
with attention and diligence. According to the American
Association of Critical-Care Nurses, it is the responsibility
of both the employer and the nurse to alleviate the
detrimental effects of moral distress and to create a healthy
work environment. 11 Findings of our study and others
provide rich data to develop education and support
programs. It is imperative to address moral distress and to
limit the number of nurses leaving the profession. Future
research should focus on developing and evaluating
interventions and programs aimed at reducing moral
distress in nurses. Moreover, replication studies including
nurses in larger institutions and racial/ethnic diversity may
be helpful in furthering the knowledge of moral distress
specific to emergency nurses.
REFERENCES
1. Corley MC, Elswick RK, Gorman M, Clor T. Development and
evaluation of a moral distress scale. J Adv Nurs. 2001;33(2):250-6.
2. Elpern EC, Covert B, Kleinpell R. Moral distress of staff nurses in a
medical intensive care unit. Am J Crit Care. 2005;14(6):523-30.
3. Pauly BV, Varcoe C, Storch J, Newton L. Registered nurses' perceptions of
moral distress and ethical climate. Nurs Ethics. 2009;16(5):561-73.
4. Zuzelo P. Exploring the moral distress of registered nurses. Nurs Ethics.
2007;14(3):344-59.
5. Cavaliere TA, Daly B, Dowling D, Montgomery K. Moral distress in
neonatal intensive care unit RNs. Adv Neonatal Care. 2010;10(3):145-56.
6. Jameton A. Nursing Practice: The Ethical Decisions. Englewood Cliffs,
NJ: Prentice Hall; 1984.
7. Pendry PS. Moral distress: Recognizing it to retain nurses. Nurs Econ.
2007;25(4):217-21.
8. Meltzer LH. Critical care nurses' perceptions of futile care and its effect
on burnout. Am J Crit Care. 2004;13(3):202-8.
9. Kilcoyne M, Dowling M. Working in an overcrowded accident and emer-
gency department: nurses' narratives. Aust J Adv Nurs. 2007;25(2):21-7.
10. Centers for Disease Control and Prevention. Available at: http://www.cdc.
gov/nchs/data/ahcd/nhamcs_emergency/nhamcsed2008.pdf. Accessed
October 11, 2011.
11. American Association of Colleges of Nursing. Hallmarks of the
Professional Nursing Practice Environment. Washington, DC: American
Association of Colleges of Nursing; 2002.
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Appendix. The Moral Distress Scale – Revised (MDS-R)

MDS-R
Nurse Questionnaire (ADULT)
Moral distress occurs when professionals cannot carry out what they believe to be ethically appropriate actions because
of internal or external constraints. The following situations occur in clinical practice. If you have experienced these
situations they may or may not have been morally distressing to you. Please indicate how frequently you experience each
item described and how disturbing the experience is for you. If you have never experienced a particular situation, select “0”
(never) for frequency. Even if you have not experienced a situation, please indicate how disturbed you would be if it
occurred in your practice. Note that you will respond to each item by checking the appropriate column for two
dimensions: Frequency and Level of Disturbance.

Frequency Level of Disturbance

Never Very frequently None Great extent
0 1 2 3 4 0 1 2 3 4
1. Provide less than optimal care due to pressures from
administrators or insurers to reduce costs.
2. Witness healthcare providers giving "false hope"
to a patient or family.
3. Follow the family's wishes to continue life support
even though I believe it is not in the best interest of
the patient.
4. Initiate extensive life-saving actions when I think
they only prolong death.
5. Follow the family's request not to discuss death with
a dying patient who asks about dying.
6. Carry out the physician's orders for what I consider
to be unnecessary tests and treatments.
7. Continue to participate in care for a hopelessly ill
person who is being sustained on a ventilator, when
no one will make a decision to withdraw support.
8. Avoid taking action when I learn that a physician or
nurse colleague has made a medical error and does
not report it.
9. Assist a physician who, in my opinion, is providing
incompetent care.
10. Be required to care for patients I don't feel
qualified to care for.
11. Witness medical students perform painful proce-
dures on patients solely to increase their skill.
12. Provide care that does not relieve the patient's
suffering because the physician fears that increasing
the dose of pain medication will cause death.
13. Follow the physician's request not to discuss the
patient's prognosis with the patient or family.
14. Increase the dose of sedatives/opiates for an
unconscious patient that I believe could hasten the
patient's death.
15. Take no action about an observed ethical issue
because the involved staff member or someone in a
position of authority requested that I do nothing.
16. Follow the family's wishes for the patient's care
when I do not agree with them, but do so because of
fears of a lawsuit.
17. Work with nurses or other healthcare providers
who are not as competent as the patient care requires.
18. Witness diminished patient care quality due to
poor team communication.
19. Ignore situations in which patients have not been
given adequate information to insure informed
consent.
20. Watch patient care suffer because of a lack of
provider continuity.
21. Work with levels of nurse or other care provider
staffing that I consider unsafe.
If there are other situations in which you have felt
moral distress, please write them and score them here:
Have you ever left or considered quitting a clinical position because of your moral distress with the way patient care
was handled at your institution?
No, I've never considered quitting or left a position ______
Yes, I considered quitting but did not leave ______
Yes, I left a position ______
Are you considering leaving your position now? Yes No
© 2010, Ann Baile Hamric
All Rights Reserved

552 JOURNAL OF EMERGENCY NURSING VOLUME 39 • ISSUE 6 November 2013

Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.