“They leave crying”: An exploration of moral distress in nurses facing workplace violence

Abstract

Background

Workplace violence (WV) is unfortunately common in healthcare environments and leads to difficult ethical choices for nurses who must decide how to provide for patients’ care needs while also navigating a risk of being harmed. When safety takes priority over care, nursing values such as non-abandonment and duty to care cannot be fulfilled, and moral distress results.

Research question

This study examined how moral distress is experienced when nurses encounter WV, to better understand the implications of these ethically fraught situations.

Design, Participants & Context

We conducted a secondary qualitative analysis using conventional inductive content analysis of interview transcripts related to nurses’ experiences of WV from 36 nurses working in a range of settings across Canada.

Ethical considerations

The study was approved by the University of Manitoba Fort Garry Campus Research Ethics Board (HE2023-0102).

Findings

Violence from patients is a significant moral event, creating moral distress for nurses. We identified three themes: Moral Compromise: angst related to the inability to meet patient needs, the impact of causing trauma to the patient, and being part of dignity-compromising care; Disengagement: decreased tolerance, restrictive boundaries, and leaving the situation; and Structural Influences: watching colleagues suffer, lack of options for violence prevention, and the impact of supervisor support.

Conclusion

This study provides critical insights into the ways that nurses experience WV-related moral distress, including the contextuality of the duty to care, opportunities to reframe the concept of abandonment to allow for withdrawal when needed to mitigate risk and moral distress, and the key role of institutions in the production of moral distress. The impact of moral distress experienced by nurses when facing WV and the profound ethical and professional consequences of violent interactions for nurses are a clear call for measures to address both the antecedent behaviors and the resulting distress.

Introduction

Moral distress, described as the anguish that arises from a moral event, ¹ frequently results from situations where one is prevented from doing something that they believe is right. ² It is a pervasive and predominantly negative experience among nurses. ¹ While moral distress is known to arise from various aspects of nursing practice, such as lack of autonomy and insufficient resources,^3,4 one particularly challenging and underexamined source is workplace violence (WV). WV is any incident in which staff are abused, threatened, or assaulted in circumstances related to their work, including verbal, physical, psychological/emotional, and sexual forms of aggression.^5–7 These situations place nurses in the position of having to determine how to provide for patients’ care needs while also navigating a significant risk of being harmed.

While WV can come from patients, visitors, colleagues, and superiors, this study focuses on WV against nurses from patients and/or their visitors. In these types of situations, safety must often take priority over care. The decision either to stay in a dangerous situation to provide for a patient’s needs or leave them without some elements of care to de-escalate risk is inherently ethical. Nurses are socialized to consider the biopsychosocial needs of a patient as paramount, reflecting the nursing values that prioritize caring. ⁸ The reality, however, is that there are times when that obligation cannot be fulfilled safely. When nursing values such as non-abandonment and duty to care cannot be fulfilled, it creates moral distress.^9,10

The inability to provide effective care due to incipient violence places the interests of the patient and nurse in tension and raises questions about the primacy of nursing obligations to the patient as compared with the value of their own personal safety. While there have been previous studies on the prevalence and outcomes of both workplace violence and moral distress, we know little about how moral distress manifests for nurses who have experienced workplace violence. This qualitative study aims to address that gap, by exploring nurses’ lived experience of workplace violence and moral distress.

Background

The concept of moral distress has evolved since it was proposed in the nursing literature in the 1980s. ² The term has come to encompass the angst that occurs at the point of challenging moral dilemmas, as well as in contexts where one was unable to act appropriately, ¹ or to live up to caring commitments. ⁸

Impediments to acting on judgments about the morally correct action are exemplified by the dilemma of WV. While attention to the needs of a patient is crucial, nursing values are what creates a caring and therapeutic relationship. When a nurse leaves a patient care encounter because it is unsafe to remain in the environment, it reduces their own risk, but it also prevents the nurse from upholding basic nursing values like trust, care, and non-abandonment. Missed care, and the resulting gap in the therapeutic relationship, while necessary for the nurse’s personal safety, leaves the patient without potentially essential interventions temporarily or even longer-term.^11,12 Such compromises, whether or not a result of WV, are reported to create a residual anguish for nurses that lasts long past the resolution of the event. ⁴ This is the painful impact of moral distress, and the sense of uncertainty and shame that results from acting, or failing to act in such a way that the nurse’s values have become compromised. ¹³

The frequency and severity of moral distress in nurses is high, ¹⁴ as are experiences of WV. ⁷ Worse, both have been shown to lead to profoundly negative outcomes.^15–18 While research on the consequences of WV that demonstrate its links to missed care and burnout hint at moral distress,^19,20 no previous studies have specifically examined nurses’ lived experiences of moral distress as a result of the choices they need to make in light of WV. Given that these problems are so pervasive and primarily experienced as undesirable, a deeper understanding is a priority.

Objective

This report provides findings from a secondary analysis of data gathered for a qualitative study on nurses’ decision-making when faced with aggression, abuse or violence during their practice. The objective of the primary project was to gain a deeper understanding of nurses’ lived experiences of when faced with a choice between fulfilling a duty of care and maintaining their personal safety in the face of violence. This report focuses on a sub-question about participants’ emotional experiences in relation to WV. This supported further understanding of how moral distress is experienced when nurses encounter WV.

Theoretical framework

Moral distress serves as the theoretical framework in this study, offering an analytical lens through which to examine nurses’ experiences of workplace violence. Moral distress sensitized the analysis to moments where nurses recognize ethically appropriate actions but are constrained from acting due to systemic, relational, or safety-related barriers.^1,2 This framing enabled a nuanced exploration of how violence in care settings generates ethically untenable situations that shape nurses’ emotional, professional, and moral experiences.

Methods

Design

We sought to build a picture of the implications of these ethically fraught situations via conventional inductive content analysis of interview transcripts. A qualitative approach was deemed appropriate as interviews provide a level of depth and insight into the perspectives, contextual factors, and processes involved in decision-making that are otherwise unavailable through observation or survey-based data. The semi-structured interview guide included questions about participants’ emotional responses to WV and whether/how it changed their practice. The concept of moral distress was not explicitly mentioned to participants to avoid steering or leading their responses.

Participants and data collection

Eligibility criteria included current and former nurses of any designation practicing in Canada who had experiences of WV about which they were willing to speak. The study was advertised on Instagram, LinkedIn, and Facebook and through QR codes on postcards distributed at a large nursing conference in 2023. Purposive recruitment aimed to permit themes to develop from the data rather than attempting to achieve a representative sample or data saturation. Interest was strong, and 20–60-min open-ended semi-structured interviews took place with 45 self-selected individuals virtually (n = 43) or in person (n = 2). Consent was received prior to each interview, and the conversation was audio recorded with the participant’s permission to facilitate transcription. After the interview, per the consent process, each participant reviewed their transcript and any requested additions or corrections were made. Ultimately, 36 participants completed this checking process, and their data were included in the dataset. Field notes comprising impressions, contextual details, and demographic details were included in the data analysis. The interview guide explored nurses’ professional backgrounds, experiences with workplace violence and its consequences, perceptions of safety and support, and recommendations for violence prevention and coping, but did not deliberately seek demographic information, to establish trust and respect privacy.

The sample included registered nurses, practical nurses, psychiatric nurses, nurse-midwives, and nurse practitioners from across western and northern Canada. They worked in acute care, specialty areas such as emergency or intensive care, home care, long-term care, psychiatry, and rural or northern settings (see Table 1). Participants’ nursing experience ranged from two to 41 years, although seven did not specify how long they had been practicing.

Table 1.

Profile of interviewed participants.

Characteristic	Number of participants
Nursing designation
LPN	5
RN	18
RPN	4
NP	1
Nurse-Midwife	2
Unspecified	6
Location
Alberta	4
BC	4
Manitoba	10
Northern territories	3
Ontario	14
Unspecified	1
Area of work
Acute care	9
Specialty areas	8
Home care	2
Long-term care	2
Psychiatry	11
Rural/Northern	3

Data analysis

Interview transcripts from the primary study were re-coded in their entirety to identify passages relevant to the question of how nurses experience WV-related moral distress. Data analysis followed an inductive content analysis approach. The first author read each transcript several times, first to gain a general understanding, and subsequently using an open coding process to develop initial codes. ²¹ Next, codes were further developed and refined through repeated reading of the dataset and interviewer field notes and sorted into categories and subcategories, which were defined and mapped to concepts identified in the literature on moral distress. These themes became the basis of our analysis and were continually checked against the data to ensure they accurately represented participants’ experiences. Analysis was facilitated by nVivo 14 software. Although participants were not specifically asked about moral distress, all described residual emotional impacts, and most employed language consistent with the literature on moral distress, indicating there was sufficient data to support analysis.

Rigor

Credibility was established by having the participant check and approve their transcript for textual accuracy. The interview guide was developed through discussions with research team. The PI (first author) conducted all interviews and the primary analysis, ensuring consistency. The second author provided methodological guidance, reviewed the coding framework, contributed to the interpretation and validation of findings, and reviewed the final thematic structure. Field notes and reflexive journals as well as progress meetings supported this process.

Ethical considerations

The study was approved by the University of Manitoba Fort Garry Campus Research Ethics Board (HE2023-0102). Participation was voluntary and participants could withdraw without consequences. Written consent was obtained prior to each interview, including for recording. A small honorarium was provided to cover any costs, which the participant kept even if they withdrew. Data was deidentified to maintain confidentiality throughout the process. Recordings were deleted once the participant approved their transcript and the data were deidentified. Participants were provided with a list of crisis resources in the event that the subject matter became distressing. None asked to stop the interview due to distress.

Findings

While WV for the purposes of this study was defined broadly, most participants focused on aggression from patients and visitors, thus the results and remainder of the paper reflect the primacy of the patient-nurse relationship and the impacts of WV in this context. Violence from patients is a significant moral event, requiring difficult choices and evoking strong emotions. During the analysis of participant interviews, moral distress arose as a significant issue when managing a patient or visitor who is violent. The data on this question coalesced around three themes: Moral Compromise, Disengagement, and Structural Influences (see Table 2).

Table 2.

Experiences of moral distress for nurses facing violence in the nursing workplace.

Moral compromise	Disengagement	Structural influences
• Inability to meet patient needs • The impact of causing trauma to the patient in the process of managing violence • Being part of care that compromised the patient’s dignity	• Decreased tolerance and resilience • Setting more restrictive boundaries • Minimizing interactions with the patient • Leaving the situation	• Watching colleagues suffer • Having a lack of options for violence prevention • Impact of supervisor support

Moral compromise

A sense of moral compromise is the first way in which participants experienced moral distress. For many participants of this study, the experience of moral distress manifested as lasting angst related to having been part of negative impacts for the patient as a result of their violence or aggression. This included distress related to (i) the inability to meet patient needs, (ii) causing trauma, and (iii) being part of care that compromised the patient’s dignity.

One of the most morally challenging compromises for participants was the inability to maintain a high standard of care because the patient’s behavior made it impossible to safely intervene. P3 described the torment of having to leave someone without addressing basic needs because their behavior was too volatile. They said, “We usually end up just leaving them until the bed is totally soaked. The pad is on the floor and it’s a real mess.” The sense of having failed to meet a standard of care was incredibly problematic for participants.

Participants also described feeling conflicted about playing a role in causing trauma to patients during the care decisions that had to be made when someone was abusive or violent. Often, aggressive measures are required to keep someone from harming self or others, leading participants to feel they had compromised important values. P56 described such distress, when working with a psychiatric population that occasionally required police intervention to enable the health care team to provide the care the person needed. They said, “I have had patients who, in being restrained and things like that, they have broken an arm, or they’ve been tased, so then those patients that have more of a trauma history, you know how traumatic this is for them too.” So, while the intervention is traumatizing to the patient, the nurse also leaves the situation feeling distressed about their part in it, even when the intervention was the only option available to protect the patient or others in the vicinity.

The ways in which patient dignity was compromised through the necessary choices made when dealing with violence also created moral distress for participants. As noted above, P3’s story of being unable to attend to a patient’s basic need for toileting was profound for them. Similarly, the measures required for managing the care of people with a history of violence could be infantilizing. P58, working in an isolated community where there was only one place to access health care, described requiring certain people to ensure they had someone with them if they needed to attend.

I wouldn't say that we ever had someone told that they could not come back, but what we did on more than one occasion (was to say) you cannot come back unaccompanied by a responsible adult… who can help you moderate your behaviour.

While this serves to support the provision of care and safety for everyone, it effectively treats the person as if they were a child and feels in important ways to be disrespectful.

The moral compromises required by these participants were varied and impactful, resulting in feelings of guilt and fractured integrity that stemmed from the inability to live up to value commitments and maintain nursing standards. These morally distressing experiences were significant and the impacts were long-lasting.

Disengagement

The second theme of participants’ moral distress experiences was disengagement, which was often necessary for self-protection, and identified as (i) decreased tolerance and resilience, (ii) the resetting of boundaries, (iii) minimizing interactions with the person, or transferring care, and, (iv) withdrawal from the situation.

Decreased tolerance and resilience for managing aggressive patients was a first step towards disengagement. Several participants talked about having a lower threshold for dealing with the emotional fallout of continually navigating unsafe patient behaviors. For example, P46 experienced anger and frustration after being grabbed by a patient. They felt that their response to the incident was exacerbated by the moral residue of accumulated stresses, including caring for multiple patients with aggression issues at the same time. They said, “It’s cumulative, you know, death by a thousand cuts […] that feeling of helplessness like you’re just barely getting through the shifts helping these people, […] wishing you could do better for them […].” They recognized the moral impact of this particular incident was more intense than it might have been, had they not felt worn-down by circumstances and unable to provide care to what they felt was an acceptable standard. Withdrawal was described as necessary for self-protection, to create a protective emotional distance from the patient in order to complete care tasks.

At times, participants felt the need to reset nurse/patient boundaries, often through an ultimatum, as a tool to disengage from a dangerous care encounter. This enabled the nurse to continue care or justify withdrawing from the situation. For example, P8 stated, “Umm, when there were more threatening situations? I just flat out told the patients. You know what? If you continue with your behaviour, then you’re not going to have a nurse.” This helped the nurse manage a morally troubling withdrawal from care, and feel less guilty when they decided to step away from a patient. However, an ultimatum could be morally distressing in more than one way: for some participants, it felt coercive or manipulative, and like it compromised the dignity of the patient. For others, distress came in the form of negative consequences for the patient when the ultimatum needed to be enforced, for example, when a disruptive family member was restricted from visiting due their continued aggression.

Disengagement also often took the form of avoidance of, or minimal interaction with the patient, also raising conflicting emotions for participants. While they recognized it might be important in terms of keeping people safe from violence, it also compromised their ability to meet the patient’s needs in a compassionate and respectful way, especially when withdrawing meant the person would not receive care. P10 said, “Sometimes people become more callous, too, right? […] It’s just like, well, if I have to do it, I’m just going to do it. But kind of go through the motions.” This emotional disengagement offered protection from physical injury as well as emotional harm. These nurses felt conflicted by the need for avoidance, as it was necessary to get through the situation safely, but acknowledged the resulting angst.

Much of the moral distress that resulted from withdrawal and avoidance came from a concern that while decisions to flee volatile situations contribute to the nurse’s safety, ultimately, they compromise the patient’s care, at least temporarily. To manage this, participants often used a transfer of responsibility for the person to mitigate some of the resulting moral distress. P23 described finding other providers to manage a patient’s care when the nurse-patient relationship was no longer tenable due to the patient’s aggression in the clinic, “I did set him up with other follow ups, they were keen to have him and he kind of fit exactly into what they had to offer.” This action mitigated some of the moral distress described by this participant when severing the relationship was felt to be the only safe option for everyone involved.

Ultimately, most participants found institutional resources inadequate, and were forced to physically leave a situation to protect their own safety. Sometimes this meant stepping away from a care encounter even when care was still required either because they had been harmed, or because the situation was intensifying, and they could no longer be confident about their safety. P8 said, “Whenever I even got the hint of feeling threatened, I would kind of back off. I probably wasn’t giving the greatest attention to the patient that I could because I was afraid that they were going to hurt me.” This nurse’s sense of regret in having to leave a care encounter due to their own vulnerability was clear.

The act of disengaging may protect the nurse from some of the impacts of managing an aggressive person, but it also compromises their ability to provide care. This perpetual catch-22 is a barrier to fulfilling the nursing role, and both causes and results in moral distress.

Structural Influences

Finally, the moral distress of participants was influenced by the structures around them that sometimes became barriers to doing the right thing. Under this theme, participants described (i) watching colleagues suffer, (ii) having a lack of options for violence prevention, and (iii) the impact of supervisor support. The impacts of these structural aspects were persistent and powerful.

Witnessing the suffering of colleagues was cited as a source of moral distress that participants often attributed to structural issues such as lack of training and education for managing WV. P1, a nurse manager, described feeling regret for their inability to mitigate the impact of an abusive family member for the staff that had to be involved with her.

I think some of the things that make me really […] sad for my own team is that they just don't really know how to respond. And so, they either [take] the verbal abuse. They leave crying, right? Like it affects how they do their job. They don't want to come to work. They're calling in sick if they know that that's the assignment they're going to have.

This was a common refrain among participants, and one that participants felt could be mitigated, were appropriate structures in place to provide support for decisions that enabled nurses to take what they felt was the morally correct action.

A perceived lack of legal and policy solutions for preventing or addressing violence also contributed significantly to participants’ moral distress. Some participants described concerns about being sued for their involvement in a care encounter that turned violent, and others spoke of the absence of effective legal remedies when they had been a victim of WV. For example, P2 described wanting to press criminal charges against a patient who had assaulted them, saying, “I want[ed] charges against this lady. And that’s when [the employer] said, well, she has dementia, and she doesn’t really know what she’s doing. And yeah, so that went nowhere.” Similarly, organizational anti-violence policies, while in place to prevent incidents, do little to manage volatile patients. As P1 noted, “I’ve pulled out our policy. We have respectful workplace [posters] all over the place… the respectful workplace thing is more around staff-to-staff [violence].” Not only is there seen to be little structural support for preventing violence, but there are also few remedies available once an incident does occur.

Finally, the impact of supervisor support was significant for participants. When an employer or manager disregarded a nurse’s concerns about WV, it functioned as a barrier to pursuing the preferred course of action. Participants described being made to feel guilty and disempowered for refusing to provide care in a dangerous situation. Knowing they would not be supported led some to remain in an unsafe care situation, increasing exposure to violence. Often, participants chose not to report an incident to an unsympathetic supervisor. One participant spoke of reporting an assault from a patient to their manager, who downplayed the event. “Yeah, they [were] like this is part of your job. This is your job. This is what you do, like violence is part of the job, which it’s not supposed to be…” (P39). The lack of support undermined the nurse’s experience and caused anger, frustration, and moral distress.

On the other hand, when supervisors responded to incidents with empathy and concern for the nurse, participants felt validated in whatever decision they made with respect to care of a violent patient. P23, for example, described a situation where a client had been sexually aggressive with them in an outpatient clinic setting. The nurse said, “If I’d said, I’m never working with this person again, I think I would have been supported.” They therefore felt comfortable with their decisions around continued care of the client, and moral distress was less evident as a result.

In summary, the WV-related moral distress experiences of participants in this study fell under three themes: moral compromise, disengagement, and structural influences. Together, the experiences described by these participants paint a vivid picture of the lasting impact of WV and moral distress. These findings offer insights into the consequences of moral distress for nurses’ sense of professional integrity, and the implications for retention of the nursing workforce.

Discussion and implications

This study offers important new insights into experiences of moral distress that arise from violent encounters in the workplace. A significant outcome of nursing work, moral distress has physical and emotional consequences for nurses’ wellbeing and intent to remain in the job.^14,15 Understanding these impacts is critical to mitigating their negative sequelae, providing opportunities for recognizing and addressing structural impediments and supports for managing these challenging situations.

One of the main residual impacts of WV was that the violent incident often left a sense of moral compromise that caused participants to question their moral and professional identity, creating fissures in participants’ self-concept and challenging principles such as humanizing care and honoring dignity ²² on which their nursing identity was based. The inability to meet standards of care, even when due to a need for self-protection, and the sense of having been complicit in causing trauma or indignity frequently caused participants to express feelings of inadequacy and despair and even consider leaving their position. This study advances our understanding of these complex and impactful experiences, which can build to a crescendo over time, ²³ and pose very real threats not only to the wellbeing of individual nurses, but to the entirety of the nursing workforce, as the compromises described by participants are consistent with the literature describing links between moral distress and decreased work satisfaction, ²⁴ burnout,^3,15,18,25 poor wellbeing,^18,25 poor patient care, ¹⁵ and turnover intention.^26,27 These are especially concerning, given the nursing shortage that threatens the health of people worldwide. ²⁸

The decisions required in the face of WV also raise important questions about the duty to provide care. For these nurses, disengagement was borne of the need for self-protection, both from the physical risks of injury due to violence, and the emotional consequences of having to make choices which could leave patients without needed interventions. This, however, left them feeling like they had violated central nursing values such as trust, care, and non-abandonment, even when it was ethically or practically justified.^11,12,22,29 While non-abandonment has long been a central nursing value, our findings position disengagement as a strategic or partial withdrawal that permits nurses to ethically reframe their duty to provide care to encompass interventions that meet the patient’s most essential needs, while remaining safe. This reconceptualization of abandonment recognizes the duty to care as contextual rather than absolute, and offers an ethical means of responding to dilemmas and distress arising from WV.

Added to the individual impacts of WV-related moral distress, the structural influences on its development described by participants were undeniably relevant. The situations that nurses face are intimately shaped by the working environment, and are particularly demoralizing when issues are predictable and effective solutions are out of reach.^18,30 WV is a system-level issue, ³¹ positioning organizations and institutional leadership as key actors in the production of moral distress. Much of the anger, frustration, and fear described by participants as resulting from incidents of WV arose from a sense of powerlessness due to the near certainty that it would happen again, and the compromises, such as being forced to withdraw from providing care, required in response to inadequate organizational support. Our findings expose a feedback loop, where insufficient organizational responses to WV cause compromise and disengagement, leading to further ethical strain. In addition to evidence that supportive team and supervisor relationships may mitigate some of the negative impacts of WV by alleviating the consequences of moral compromise^4,18,32 and moderating the desire to disengage, ³³ this study advances the discourse on the necessity of measures to mitigate the institutional moral breakdown demonstrated by unsupportive work environments. Nursing work, such as caring for aggressive people in need of intervention, frequently results in ethical dilemmas that are impossible to satisfactorily resolve. The critical role of institutions and supportive leadership to address both WV and the moral distress that results for individual nurses cannot be understated.

In summary, we found that WV-related moral distress poses a threat to individual nurses and the workforce as a whole. This study further demonstrates the contextuality of the duty to care, and the act of disengagement that permits the nurse to reframe the concept of abandonment allows for strategic and ethical withdrawal when needed to protect safety, mitigating the resulting moral distress. Finally, we found that institutions are key actors in the production of moral distress when they provide inadequate support to nurses, demonstrating the critical importance of effective organizational solutions to the issue of WV. Further study to explore the extent to which supportive workplaces can mitigate the impacts of moral distress is recommended.

Limitations

As this study was a secondary analysis and experiences of moral distress were not explicitly elicited, additional research is required to more deeply explore these concepts. Other limitations of this study include its convenience and self-selected sampling via social media and a nursing conference, as well as the exclusion of participants who did not complete the transcript-checking process, resulting in potential selection bias. This precludes assumptions about the experiences of moral distress across the full scope of the nursing profession and among different types and degrees of WV. The limited scope of the study also restricts the ability to compare experiences of moral distress across different clinical settings. Finally, the limited participant demographic information impacts the ability to draw conclusions about nurse demographic characteristics on the experience of moral distress.

Conclusion

Participants in this study described the profound impact of moral distress experienced by nurses when facing WV, which fell into three themes. The first was moral compromise from the inability to meet the needs of a violent patient and being part of care that caused trauma or compromised the patient’s dignity. Disengagement, in the forms of withdrawal, avoidance, boundaries, and transfer of responsibility, was both a cause of and a response to the physical and moral risks of providing care to someone who is violent and often reached the point of considering a change of position. Finally, structural constraints including witnessing colleagues suffer and having a lack of options for violence prevention led to the experience of moral distress, while the impact of supervisor support either exacerbated or mitigated the distress resulting from WV. These highly emotional outcomes resulted in damage to participants’ sense of moral integrity, affecting their wellbeing, and often raising questions about their professional identity and intention to remain in their position. The morally significant consequences of violent interactions for nurses are a clear call for measures to address both the antecedent behaviors and the resulting distress. In the end, moral distress is not simply a reflection of the individual moral compromises required of nurses facing these ethically impossible situations, but a call to health care institutions to ensure the necessary resources and supports are available to those who bear the burdens of caring work, so they are no longer left to carry the weight of their work in tears.