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ethical dilemmas, moral distress, NICU nurses, registered nurses



  1. Cavaliere, Terri A. DNP, RN, NNP-BC
  2. Daly, Barbara PhD, RN, FAAN
  3. Dowling, Donna PhD, RN, NNP-BC
  4. Montgomery, Kathleen MS, RN


BACKGROUND: Moral distress is a significant problem for nurses (RNs). It has physical, emotional, and psychological sequelae and a negative impact on the quality, quantity, and cost of patient care. Moral distress leads to loss of moral integrity and job dissatisfaction and is a major cause of burnout and RNs leaving the profession. The majority of research has been carried out with RNs working in acute care, adult inpatient settings, especially critical care areas. Neonatal intensive care unit (NICU) RNs confront ethically and morally challenging situations on a regular basis. There are limited data clarifying their moral distress.


AIMS: The purpose of this study was to describe the moral distress of RNs working in NICUs and to identify the situations that are associated with their moral distress.


RESEARCH QUESTIONS: What are the intensity and frequency of moral distress in NICU RNs, what situations are associated with moral distress in NICU RNs, and what personal characteristics are correlated with moral distress in NICU RNs?


DESIGN AND METHODS: This descriptive, correlational study was conducted with RNs in the level III NICUs of a healthcare system in the northeastern United States. Participation was voluntary and anonymous. A convenience sample of RNs completed a demographic data sheet and the Moral Distress Scale Neonatal-Pediatric Version. Data were collected during October 2008. Ninety-four of 196 eligible RNs (48%) participated in the study.


FINDINGS: As a whole, the subjects did not perceive that the situations described in the instrument occurred frequently and did not cause great distress. Subjects' individual scores displayed wide variations for all dimensions of moral distress ranging from low to high, indicating that individual RNs may be experiencing moral distress.


The situations receiving the highest scores are comparable with the areas that are problematic for other critical care nurses as described in the literature. In this study, 4 RN characteristics were significantly related to moral distress: the desire to leave their current position, lack of spirituality, altered approach to patient care, and considering but not leaving a previous job because of moral distress.


CONCLUSIONS: The results of this study add to the understanding of the moral distress in NICU RNs. The data will provide evidence for eventual psychometric testing and factor analysis of the Moral Distress Scale Neonatal-Pediatric Version.