Background: Moral distress can negatively impact nurses, patients, and the healthcare system and has been well-documented in high-acuity care environments. Levels of moral distress and experiences of moral distress have been reported as high and severe among nurses in high-acuity care environments; however, the levels and experience of moral distress are unknown in rural clinic nurses. Research Question/Aim/Objectives: This study sought to gain a broader understanding of moral distress in nurses working in rural clinic settings. The aims were (1) Determine the level of moral distress among rural clinic nurses; (2) Examine the relationships of moral distress levels, demographic characteristics, and work experience variables of rural clinic nurses; (3) Identify themes regarding the perceived experiences of moral distress of nurses working in rural clinics; (4) Explore how aspects of rural practice impact moral distress for rural clinic nurses. Research Design: Convergent mixed methodology gathered quantitative and qualitative data in parallel, employed correlation and thematic analysis, respectively, then data were merged. Participants and Research Context: Informed by Rural Nursing Theory, a consecutive sample of 52 nurses across four states were surveyed using the Measure of Moral Distress for Healthcare Professionals and narrative questions. Ethical Considerations: The healthcare system and University IRBs granted exempt status. Findings/Results: The mean moral distress was 74.7 (SD = 76.8), range was 0 to 246, and no significant relationships were found between moral distress, demographics, or work experience variables. Four main themes were identified: (1) Lack [of something] Leads to Moral Distress (2) Barriers to Patient Care and Adherence (3) Inappropriate Healthcare Utilization (4) Care and Practice Factors that Lead to Moral Distress. Conclusions: Rural clinic nurses experience moral distress for reasons unique to rural practice, while other triggers are shared with urban nurses. Further research is warranted on sources of moral distress for rural clinic nurses.
GiannettaNVillaGPennestrìF, et al.Ethical problems and moral distress in primary care: a scoping review. Int J Environ Res Publ Health2021; 18(14): 7565.
2.
SalariNShohaimiSKhaledi-PavehB, et al.The severity of moral distress in nurses: a systematic review and meta-analysis. Philos Ethics Humanit Med2022; 17(1): 13.
3.
WattsTSydorAWhybrowD, et al.Registered nurses’ and nursing students’ perspectives on moral distress and its effects: a mixed-methods systematic review and thematic synthesis. Nurs Open2023; 10(9): 6014–6032.
4.
Christodoulou-FellaMMiddletonNPapathanassoglouEDE, et al.Exploration of the association between nurses’ moral distress and secondary traumatic stress syndrome: implications for patient safety in mental health services. BioMed Res Int2017; 2017: 1–19.
5.
EpsteinEGHamricAB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics2009; 20(4): 330–342.
6.
LamianiGBorghiLArgenteroP. When healthcare professionals cannot do the right thing: a systematic review of moral distress and its correlates. J Health Psychol2017; 22(1): 51–67.
7.
LynchJJ. Patient safety protocols and moral distress. J Hosp Ethics2019; 5(3): 119–121.
8.
MorleyGIvesJBradbury-JonesC, et al.What is “moral distress”? A narrative synthesis of the literature. Nurs Ethics2019; 26(3): 646–662.
JametonA. Nursing practice: the ethical issues. Prentice Hall, 1984.
11.
AuerbachDIBuerhausPIDonelanK, et al.A worrisome drop in the number of young nurses. Health Affairs Forefront2022 (accessed 15 June, 2023).
12.
OhYGastmansC. Moral distress experienced by nurses: a quantitative literature review. Nurs Ethics2015; 22(1): 15–31.
13.
Orlandi BarthPSouza RamosFRDevosBEL, et al.Generating situations of moral distress in primary care nurses. Rev Bras Enferm2019; 72(1): 35–42.
14.
GágyorIHeßlingAHeimS, et al.Ethical challenges in primary care: a focus group study with general practitioners, nurses and informal caregivers. Fam Pract2018; 36(2): 225–230.
15.
WhiteingNBarrJRossiDM. The practice of rural and remote nurses in Australia: a case study. J Clin Nurs2022; 31(11-12): 1502–1518.
16.
MacKaySCSmithAKyleRG, et al.What influences nurses’ decisions to work in rural and remote settings? A systematic review and meta-synthesis of qualitative research. Rural Remote Health2021; 21(1): 1–26.
17.
ScharffJE. The distinctive nature and scope of rural nursing practice; philosophical bases. In: WintersCA (ed). Rural nursing concepts, theory, and practice. 6th ed.Springer, 2022, pp. 145–162.
18.
SwanMAHobbesBB. Lack of anonymity: changes for the 21st century. In: WintersCA (ed). Rural nursing concepts, theory, and practice. 6th ed.Springer, 2022, pp. 145–162.
EpsteinEGWhiteheadPBPrompahakulC, et al.Enhancing understanding of moral distress: the measure of moral distress for health care professionals. AJOB Empir Bioeth2019; 10(2): 113–124.
FaulFErdfelderELangAG, et al.G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods2007; 39(2): 175–191.
25.
BraunVClarkeV. Using thematic analysis in psychology. Qual Res Psychol2006; 3(2): 77–101.
26.
BoothATDobsonBFChristianBJ, et al.Institution-wide moral distress among nurses. J Nurs Adm2024; 54(11): 597–604.
27.
PrompahakulCKeim-MalpassJLeBaronV, et al.Moral distress among nurses: a mixed-methods study. Nurs Ethics2021; 28(7–8): 1165–1182.
28.
ShowalterBLMalechaACesarioS, et al.Moral distress in clinical research nurses. Nurs Ethics2022; 29(7/8): 1697–1708.
29.
Rodriguez-RuizECampelo-IzquierdoMVeirasPB, et al.Moral distress among healthcare professionals working in intensive care units in Spain. Med Intensiva2022; 46(7): 383–391.
30.
EmmamallyWChiyangwaO. Exploring moral distress among critical care nurses at a private hospital in Kwa-Zulu Natal, South Africa. S Afr J Crit Care2020; 36(2): 105–108.
31.
BruggmannMSSchneiderDGRamosFRS, et al.Intensity and frequency of moral distress in mental health nurses in Brazil. Rev Esc Enferm USP2023; 57: e20230122.
32.
OldenmengerWHBergerEStoppelenburgA. The inner struggle of nurses, exploring moral distress among hospital nurses: a cross-sectional study. Int J Nurs Stud2024; 158: 104864.
33.
JamesJ. Dealing with drug-seeking behaviour. Aust Prescr2016; 39(3): 96–100.
34.
MalmqvistJHellbergKMӧllåsG, et al.Conducting the pilot study: a neglected part of the research process? Methodological findings supporting the importance of piloting in qualitative research studies. Int J Qual Methods2019; 18: 160940691987834.
