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  1. Pavlish, Carol PhD, RN, FAAN
  2. Brown-Saltzman, Katherine MA, RN
  3. So, Loretta MSN, RN, CGRN
  4. Wong, Julia BS


OBJECTIVE: The aim of this study is to explore nurse leaders' experiences working in ethically difficult situations and helping nurses cope with moral distress.


BACKGROUND: Moral distress is associated with ethically complex situations where nurses feel voiceless and powerless. Moral distress can lead to disengagement, burnout, and decreased quality of care.


METHODS: The critical incident technique was used to collect descriptions of ethically complex situations from 100 nurse leaders in California. Responses were qualitatively coded, categorized, and subsequently counted.


RESULTS: Participants noted affective, behavioral, cognitive, physical, and relational signs of moral distress. System-level factors along with team conflict and different perspectives were perceived to increase the probability of ethical conflicts. Key actions to address moral distress included acknowledging its presence, creating a culture of care, and increasing nurses' resilience to difficult circumstances through education, support, and collaboration.


CONCLUSIONS: On the basis of study findings, we created the SUPPORT model as an action guide for addressing moral distress.