Document Type


Publication Date

Spring 2023

Date of Final Presentation


Committee Chair

Sara Ahten, DNP, RN, NC-BC

Committee Member

Rosanna Moreno DNP, MBA, RN, FACHE

Coordinator/ Chair of DNP Program

Teresa Serratt, PhD, RN

Abstract/ Executive Summary

Problem Description: First defined in 1984, as a nurse knowing the correct course of action but perceiving barriers that constrain the action, moral distress has evolved to include challenging situations associated with moral uncertainty, moral conflict, and ethical or moral dilemmas (Campbell et al., 2016; Fourie, 2015, 2016; Jameton, 1984). While the bulk of the moral distress literature has highlighted the challenges of direct care nurses, nurse leaders also grapple with ethical dilemmas that often lead to moral distress (Edmonson, 2010; Ganz et al., 2015; Prestia et al., 2017). Additionally, research indicates that nurse leaders lack experience in navigating ethical dilemmas, and that managers often report feeling anxious and fearful in providing employee performance feedback as part of the performance evaluation process (Aguinis et al., 2012; Bell et al., 2020; Makaroff et al., 2014; Pavlish et al., 2016; Storch et al., 2013). The lack of confidence and competence in ethical-decision making in the context of performance management is problematic and has the potential to create a situation ripe for nurse leader moral distress. In a Northwest academic Magnet® designated medical center, nurse leaders report angst in navigating the evaluation of personnel who are not meeting performance expectations. With dual ethical obligations to oversee the delivery of safe patient care and create a just culture, ethical dilemmas frequently surface. The lack of a formalized pathway for nurse leader professional development in professional practice evaluation leads to continued nurse leader moral distress. Additionally, in evaluating personnel performance, leaders lack a standardized performance evaluation approach which potentially jeopardizes just culture.

Setting: This scholarly project was implemented in a Northwest academic Magnet© designated medical center with nurse leaders serving as participants for pilot program.

Rationale: Corley’s (2002) model of moral distress provided the theoretical framework for this scholarly project. Depicted in Appendix B, the theory is grounded in the basic assumption that nursing is a moral profession and nurses’ moral agents. The model depicts the internal and external contexts that impact various moral concepts to strengthen the development of moral intent to act which when combined with moral courage can lead to moral comfort or create an opportunity for moral distress. This scholarly project was guided by the development and implementation of a logic model (see Appendix C), that served as the blueprint for the project manager.

Implementation & Project Outcomes: Following a comprehensive literature review, evidence-based practices were selected for implementation. An educational module and a live application session were deployed that included the incorporation of the American Nurses Association Code of Ethics for Nurses (2015), the American Association of Critical-Care Nurses Association 4 A’s to Rise Above Moral Distress tool, use of a balanced experiential inquiry technique, application of the Reflexive Principlist decision-making framework, and a gratitude practice (Downs et al., 2022; Kisselburgh et al., 2014; Rushton, 2006; Sekerka & Godwin, 2010; Sekerka et al., 2011).

Evaluation Plan: There were several evaluation tools that were used to measure the impact of the pilot program. These included a pre/posttest developed in coordination with organizational stakeholders and modeled after evaluation questions from Kirkpatrick’s Four Levels of Training Evaluation (2016; Kirkpatrick Partners, 2021), the Professional Moral Courage Scale (PMCS) (Sekerka et al., 2009) and portions of the Perceived Confidence Scale (PCS) (Laabs, 2012). Additionally, a summative evaluation tool was created to gather qualitative and quantitative participant feedback.

Results: Participants knowledge of moral distress concepts increased, with 97% of participants reporting the ability to identify 2 signs and symptoms of moral distress, and 100% of participants correctly identifying the 4 steps in the 4 A’s to Rise Above Moral Distress tool, 2 strategies to mitigate moral distress, and 2 organizational resources to assist with ethical decision-making. Nurse leader moral courage did not meet the intended target of a 20% increase, and only increased 5.7%, while ethical decision-making confidence increased 20.2%.

Interpretation: Overall the pilot program was successful in meeting most of the project’s outcomes, and had value for the host organization’s participants as they led during the wake of the COVID-19 pandemic and subsequent recovery.

Conclusions: The findings of this pilot program reinforce the findings for individual level approaches to moderate moral distress. Specifically, ethics education and skill development incorporating reflective practice, small group discussion, and storytelling were positively received by the pilot program participants with most of the program outcomes successfully met.