Relationship between moral distress, perceived organizational support and intent to turnover among oncology nurses
Table of Contents
List of Tables ix List of Figures xi CHAPTER 1. INTRODUCTION 1 Introduction to the Problem 1 Background of the Study 3 Statement of the Problem 6 Purpose of the Study 8 Rationale 9 Research Questions 10 Hypotheses 10 Significance of the Study 11 Definition of Terms 12 Assumptions 13 Limitations 13 Theoretical Framework 14 Organization of the Remainder of the Study 18 CHAPTER 2. LITERATURE REVIEW 20 Introduction 20 Moral Distress 22 Perceived Organizational Support 34 Intent to Turnover or Leave 41
Summary 44 CHAPTER 3. METHODOLOGY 47 Introduction 47 Research Design 48 Variables 48 Research Questions 50 Hypotheses 50 Population and Sample 51 Instrumentation 53 Data Collection Procedures 60 Protection of Human Subjects 63 Response Rate Measures 63 Ethical Issues 64 Informed Consent 64 Confidentiality 65 Risk and Benefits 66 CHAPTER 4. DATA COLLECTION AND ANALYSIS 68 Results 75 Summary 80 CHAPTER 5. DISCUSSION OF THE RESULTS OF THE STUDY 82 Introduction 82 Summary of Results 83
Implications for Practice 91 Limitations of the Study 92 Recommendations for Further Research 94 Conclusion 96 REFERENCES 97 APPENDIX A. SURVEY INSTRUMENTS 108 APPENDIX B. STUDY CHARACTERISTICS AND CONSTRUCTS FOR PERCEIVED ORGANIZATIONAL SUPPORT 121
APPENDIX C. LETTER OF INTRODUCTION AND CONSENT FORM, STUDY INFORMATION SHEET, COVER LETTER, AND REMINDER LETTER 125
APPENDIX D. PARTICIPANT DEMOGRAPHICS 131
List of Tables Table 1. Psychometric Testing of the Original Moral Distress Scale 54 Table 2. Mean Scores and Alphas for the Moral Distress Scale 55 Table 3. Correlation of Variables 59 Table 4. Stepwise Multiple Linear Regression Analysis of Moral Distress Versus Demographic Variables 69 Table 5. Stepwise Multiple Linear Regression Analysis of Perceived Organizational Versus Demographic Variables 69 Table 6. Stepwise Multiple Linear Regression Analysis of Intent to Turnover Versus Demographic Variables 70 Table 7. Descriptive Statistics 71 Table 8. Current Primary Position 72 Table 9. Current Employment Status 72 Table 10. Patient Population 73 Table 11. Racial/Ethnicity of Study Participants 73 Table 12. Highest Level of Education 74 Table 13. Types of Basic Health Care Ethics Education 74 Table 14. Knowledge of Ethics Committees Within Their Organizations 75 Table 15. Cronbach’s Alpha for Each Scale 75 Table 16. Correlation Between Anticipated Turnover and Moral Distress 77 Table 17. Correlation Between Anticipated Turnover and Perceived Organizational Support 79 Table 18. Analysis of Variance Results 79 Table 19. Coefficients for the Dependent Variable, Anticipated Turnover 80
Table 20. Extent of Moral Distress 83
List of Figures Figure 1. Relationship between moral distress and anticipated turnover 76 Figure 2. Relationship between perceived organizational support and anticipated turnover 78
1 CHAPTER 1. INTRODUCTION Introduction to the Problem The current nursing shortage experienced in health care institutions in the United States is about to enter its 12th year, and there is no evidence of a narrowing of the gap between the supply and the demand for nursing professionals (Auerbach, Buerhaus, & Staiger, 2007). The Health Resources Services Administration (HRSA, 2007) indicated in its recent report that by year 2020, U.S. hospital officials expect a 20% shortage of nurses and that every single city in the United States will be severely affected by the shortage by 2015. An inadequate supply of health care workers affects quality, safety, and access to health care. A study conducted by Auerbach et al. showed that 82% of the nurses and 81% of the physicians surveyed perceived nursing shortages in their areas of employment. Thus, there is an urgent need to develop strategies not only to recruit nurses but also, more importantly, to retain existing personnel. The HRSA (2007) predicted that in the next few years, a disproportionate number of nurses, especially oncology-trained nurses, will be available to meet the demands of an aging population. Cancer is the primary cause of death for one of every four people in the United States (American Cancer Society, 2007). The disease is most common among older adults; therefore, as the baby boomer cohort reaches generativity, the number of older adults with diagnoses of cancer is expected to double. The HRSA projected that the combination of an increased nursing demand and an aging nursing workforce will result
2 in an increased rate of vacant nurs ing positions. This phenomenon will negatively affect rural areas, specialty practice areas, and long-term care settings. The majority of the nurses (75%) who participated in a 2004 National Survey of Registered Nurses (n = 3,500), drawn from a random sample of compiled lists from individual state boards of nursing, believed that the existing nursing shortage affected their quality of work, the quality of the care they provided their patients, and the length of time they spent with their patients. Almost all of the survey participants viewed the nursing shortage as a primary trigger for increased nursing stress and decreased quality of patient care. It was also a cause for nurses leaving the profession (Buerhaus et al., 2007). Nurses believed that the shortage resulted in greater burnout, increased turnover, and poorer quality of patient care. Nurses were fatigued and experienced more stress in the workplace; their patient load and the acuity of their patients were also increasing (Ludwick & Silva, 2003). They felt powerless to make changes and, as a result, experienced moral distress. Nurses were frustrated with their inability to take what they believed were ethically appropriate actions. They were unable to act on their professional values and believed that these values were being compromised (Volbrecht, 2002). Nurses’ work satisfaction has had a negative relationship to turnover in both the practice of and the profession. Additionally, work satisfaction has been positively related to the quality of care delivered in nursing practice (Collins et al. , 2000; Lucas, Atwood, & Hagaman, 1993; Schader, Broome, Broome, West, & Nash, 2001; Stamps, 1997; Verran & Mark, 1992). In the context of the current nursing shortage, the importance of identifying factors to promote nursing recruitment and retention must not be undervalued by organizational leaders. The findings of this study should add to the current literature in
3 that its aim was to identify the relationship between moral distress, perceived organizational support, and intent to turnover in a population of oncology nurses. Background of the Study In the care of a patient who is diagnosed with cancer, highly technical skills must be integrated with psychosocial and spiritual support for patients and families. This care often results in challenging moral and ethical situations for the oncology nurse. The current and predicted shortage of nurses in the health care system has received wide coverage in the nursing literature and the general media (Armstrong, 2004; Berliner & Ginzberg, 2002; Buchan & Calman, 2005; Erlen, 2004; Lynn & Redman, 2005; Sochalski, 2002). A shortage of nurses has been linked to clinical errors and untoward clinical incidents of patient care (Ludwick & Silva, 2003). Cohen and Erickson (2006) suggested that the staff shortage in oncology units is related to high levels of burnout and job dissatisfaction, resulting in individual nurses strongly considering leaving positions, units, or the profession of nursing itself. This consideration of leaving has been termed "intent to turnover” in the human resource management and business literature (Gifford, Zammuto, & Goodman, 2002). Moral distress, the experience of being blocked from following a course of action that has been determined to be morally justified, could be closely related to the causes of burnout. Erlen (2001) and others (Cassells, Silva, & Chop, 1990; Corley, 2002; Corley, Minick, Elswick, & Jacobs, 2005; Joseph & Deshpande, 1997; Olson, 2002; Penticuff & Walden, 2000; Powell, 1997; Sundin-Huward & Fahy, 1999) suggested that development of supportive environments in organizations may result in nurses being better able to cope with moral distress and other issues that are causes of job dissatisfaction. Because currently little is
4 known about the interactions of these variables, examination of the relationship of moral distress, perceived organizational support, and intent to turnover should provide organizational leaders with greater understanding of the reasons nurses leave nursing positions or the profession of nursing during a time of severe shortage. The findings of this study should be an addition to the current literature on nurse moral distress, establishment of supportive organizational climates, and factors that result in decreasing turnover ratios. A leading researcher who studied the impact of moral distress in health care providers defined moral distress as a feeling that "arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action" (Jameton, 1984, p. 6). The consequences of moral distress could include frustration, interpersonal conflict, dissatisfaction, physical illness, and possibly abandonment of the profession. Understanding more about the contextual factors that affect moral distress should result in enhanced nursing knowledge and should be useful in the development of strategies to support those nurses experiencing moral distress in their practice (Fry, Harvey, Hurley, & Foley, 2002). The importance of creating a supportive, ethical climate has been described in nursing, business, and educational literature. Health care research has shown that organizations able to recruit and retain nursing staff in highly competitive environments and to provide quality care have processes for nurses to identify, discuss, and resolve moral and ethical issues that arise during their clinical practice (Schluter, Winch, Holzhauser, & Henderson, 2008). The organizational ethical climate of a hospital is the context in which ethical behavior and decision making occur (Olson, 1998). Ethical climate has been
5 described as the “ethical personality” of an organization, an organizational variable that can be modified to improve the work environment (Olson, 2002). Factors affecting moral distress and the consequences or results of moral distress must be studied further to comprehend fully the impact of moral distress upon the nursing profession (Corley, 2002). The nurse’s perception of organizational support could be one factor in buffering the impact of moral distress on the individual. Researchers, especially those using social exchange theory (Cropanzano & Mitchell, 2005), have linked supportive and caring organizations with a number of desirable outcomes. Eisenberger, Stinglhamber, Vandenberghe, Sucharski, and Rhoades (2002) posited that when an organization cares about the well-being of its members, the employees are likely to reciprocate with positive feelings, job attitudes, and behavioral intentions toward the organization. This perception of level of support for ethical practice and moral choices has been viewed as a vital element of the constraints upon nurses’ actions (Erlen, 2001). This perception must be examined in nurses working with critically ill patients to study adequately ethical climate and its relation to the experience of moral distress. Corley,
Elswick, Gorman, and Clor (2001) noted that a nurse's level of moral distress may result in resignation from a position. Therefore, the relationship between this variable and the work environment should be investigated. Intent to turnover has been defined as "a conscious and deliberate willfulness to leave the organization" (Teft & Meyer, 1993 p. 260). Intention to turnover is an important construct studied in relation to job satisfaction, organizational commitment, affiliation, and job involvement (Kacmar, Carlson, & Brymer, 1999). Thoughts of leaving a position, also known as withdrawal cognitions, have strong linkages to actual voluntary job turnover (Teft & Meyer, 1993). Corley (2002) theorized a profound effect of moral distress on job satisfaction and
6 retention but noted the need for deeper examination of the environment of care to understand these interactions fully. Statement of the Problem The U.S. Bureau of Labor Statistics ranked the nursing profession as having "the largest projected job growth in the years 2002 to 2012" (American Nurses Association, 2010, p. 1). Thus, the demand for new nurses should continue to increase because existing nurses are getting older, retiring, or leaving the profession. Nurses are also being enticed to relocate through advertisements displaying warmer climates, higher salaries, and bonuses and are resigning from their current positions and moving. Because of these changes, an increased emphasis on recruitment and retention efforts by health care organizations must occur. The organization is the environment in which patient care is provided. According to the literature, ethical issues that nurses face in their daily work result in increasing the stress they experience (O’Donnell et al., 2008). When nurses perceive that management is not listening or not supporting them, they begin to experience fatigue, stress, and burnout. They may leave one health care organization for another, thinking that the new situation may be better. Although initially that may be the case because they are the new nurses in the organization, given the widespread nature of the nursing shortage, that initial feeling of having found a better work environment may pass quickly. A focus group of nurses interviewed in Nevada cited management and staffing as the two primary reasons they left their previous positions (Cline, Reilly, & Moore, 2003). The nurses expressed feelings about the effects of the nursing shortage and increased
7 patient loads in terms of greater burnout, fatigue, and stress in the workplace. These, in turn, resulted in increased turnover and poorer quality of care (Ludwick & Silva, 2003; Volbrecht, 2002). The nurses were concerned that both they and their patients were at risk because of compromised patient care, short cuts, and errors that occurred and could occur. They were also concerned that management did not listen to them or take actions to address the shortage issues (Ludwick & Silva). Thus, because of the persistent nursing shortage, nurses have continued to experience moral distress. Although nurses can identify the appropriate ethical actions to take, they have been unable to intervene because of factors outside of their control or because of constraints within the organization (Erlen, 2001). The shortage could result in moral distress that affects the shortage, thus becoming a circular predicament. A search of the research literature revealed that the relationship between moral distress, perceived organizational support, and the turnover intent of oncology nurses was underdeveloped. The following databases were searched for relevant articles published between 1980 and August 2010: CINAHL, MEDLINE, PubMed, and ABI/INFORM Global. The following terms were used to conduct the searches: moral distress AND nurs*, retention, nursing shortage, turnover, burnout, ethical climate, moral distress, organizational climate, perceived organizational support, organizational commitment, and job satisfaction. The research available on moral distress was focused primarily on job satisfaction, burnout, role stress, and turnover intent. In the majority of the studies, nurses from intensive care units, emergency departments, and neonatal intensive care were sampled. No research studies involving oncology nurses in inpatient and outpatient settings were found in the exhaustive literature search. Therefore, the
8 variables of moral distress, perceived organizational support, and turnover intent of oncology nurses practicing in inpatient and outpatient settings were important concepts to study in light of the supply and demand imbalances and their resulting economic, quality, and access hardships on the stakeholders involved (e.g., patients, providers, and administrators). Purpose of the Study The Joint Commission on Accreditation of Healthcare Organizations published a report in 2002 warning that the nursing shortage in the United States was putting patients in jeopardy. The commission reviewed 1,609 hospital sentinel events from 1996 to 2002 and found that low nurse levels in patient care areas were a contributing factor in 24% of the cases. Nursing vacancies in the hospitals meant that nurses felt they had to sacrifice the quality of their care because of the shortage of staff. Moral distress occurred when the study participants experienced negative emotional feelings (e.g., anger) and/or symptoms (e.g., headaches) because the nursing shortage made it challenging for them to take the actions they felt were morally right. Therefore, identifying the factors related to moral distress, perceived organizational support, and turnover intent among inpatient and outpatient oncology nurses was important to provide additional information on the relationship of the three variables and to aid in improving the quality of patient care and increase nursing retention. The purpose of this study was to examine the relationship of moral distress, perceived organizational support, and turnover intent in a randomized sample of inpatient and outpatient practicing nurses in the United States to determine the relationship of these
9 variables. Better understanding of the contributing factors to high levels of moral distress might facilitate the development of educational programs, specific support methods, and organizational structures for the ethical practices of nurses and reduce the likelihood of nurses leaving positions, specialties, or the profession of nursing. Chambliss (1996) concluded from a series of studies of nurses, ethics, and health care organizations that nurses experience moral distress rather than moral dilemmas and that their "ethical problems . . . are inseparable from the organizational and social settings in which they arise" (p. 182). Therefore, understanding the interactions of these three variables should result in increasing the collective knowledge of the profession of nursing and its workforce issues. Rationale Nurses are an integral part in the delivery of quality care. With the current economic challenges associated with hospitals, as well as political issues, organization officials must understand what makes this group of professionals satisfied and committed to their jobs to decrease their intentions to leave. In the acute care environment, nurses must deal with difficult situations in which they may experience moral distress. Medical advances have resulted in practitioners having to make treatment decisions that did not exist previously. Chronic staffing shortages and inadequate resources have resulted in feelings of inadequacy in providing appropriate care to patients. Managed care directives, health care regulations, and institutional expectations have resulted in additional complications in the provision of care. Faced with these challenges, 15% of the nurses in one study reported resigning positions due to experiencing moral distress (Corley et al., 2001). In a study completed in
10 2007, researchers noted that nurses who perceive they do not have institutional support in handling ethical issues and stress are more likely to want to leave their jobs (Ulrich et al., 2007). In the same study, 25% of the sampled population reported they would like to leave their current positions, especially younger staff and full-time staff. Given the vast number of career options available, young nurses may leave the profession if they feel stress, disrespect, and dissatisfaction (Ulrich et al., 2007). With the American Association of Colleges of Nursing (2007a) predicting a continuing intensification of the current nursing shortage, understanding and addressing this issue with its potential to affect nursing retention has become crucial. Research Questions The purpose of this quantitative, nonexperimental study was to describe the relationships of moral distress, perceived organizational support, and intent to turnover in a randomized sample of oncology nurses. The following research questions were used to guide this study: 1. Among oncology staff nurses, is there a relationship between the degree to which they anticipate leaving the job and their level of moral distress?
2. Among oncology staff nurses, is there a relationship between the degree to which they anticipate leaving the job and their level of perceived organizational support?
3. Among oncology staff nurses, does perceived organizational support moderate the effect of moral distress on their anticipation of leaving the job?
Hypotheses Three statistical hypotheses were tested in this study. Both the null hypothesis (H o ) and the alternative hypothesis (H a ) have been given for each.
11 H1 0 : There is no correlation between anticipated turnover and moral distress.
H1 a : There is a correlation between anticipated turnover and moral distress.
H2 0 : There is no correlation between anticipated turnover and perceived organizational support.
H2 a : There is a correlation between anticipated turnover and perceived organizational support.
H3 0 : Perceived organizational support does not moderate the effect of moral distress on anticipated turnover.
H3 a : Perceived organizational support moderates the effect of moral distress on anticipated turnover.
Significance of the Study According to Hinshaw and Atwood (1982), the nature of the majority of actual staff turnover is voluntary, thus modifiable in a preventive and constructive manner. Intention to leave is very costly for organizations (Kosel & Olivio, 2002; Vandenberg & Nelson, 1999), particularly given the tight labor market that currently exists for registered nurses across the country. In general, employees who are unhappy are likely to perceive a number of more attractive alternatives outside the organization. The empty positions created by their departure have become difficult to fill with equally qualified replacements (Thoresen, Kaplan, Barskey, Warren, & de Chermont, 2003). The demand for new nurses should continue to increase because existing nurses are getting older, retiring, or leaving the profession. Therefore, an increased emphasis on recruitment and retention efforts should be undertaken in health care organizations. In the midst of the ongoing nursing shortage of bedside nurses, knowledge of factors that affect nurses’ intent to leave the profession have become important to organizational leaders for
12 several reasons. Nurse turnover has been negatively linked to increased organizational, delivery system, and consumer costs. More important, loss of experienced staff nurses could compromise the delivery of quality nursing care to consumers (Jones, 1992). Given this supply shortage and demand surplus for nurses, hospital administrators and human resource managers must identify moral distress and perceived organizational support ratings to assist in their development of strategies to retain nurses. Definition of Terms The following terms have been defined as used in this study: 1. Oncology nurse is a person who has achieved a diploma, associate degree in nursing (ADN), or bachelor of science degree in nursing (BSN) from an accredited program; is a licensed registered nurse; is currently working in an oncology unit; and specializes in the care of patients diagnosed with solid organ malignancies.
2. Ethical climate is the term applied to the organizational conditions and practices that affect the way difficult patient care problems with moral complications are managed and addressed. The ethical climate of an organization is articulated in its goals; mission; vision; treatment of patients and families; and support of staff, students, and the community (Shirey, 2005).
3. Turnover intent is the perception of an employee of leaving the organization on a voluntary basis as measured by the Anticipated Turnover Scale (ATS; Hinshaw & Atwood, 1984).
4. Moral distress is the experience of knowing the right thing to do but not being able to act on the right course of action (Jameton, 1984).
5. Perceived organizational support is the employees’ perceptions concerning the extent to which the organization values their contributions and cares about their well- being (Eisenberger, Huntington, Hutchinson, & Sowa, 1986).
13 Assumptions The following assumptions were made in designing and conducting this study: 1. The instruments used in the study were valid and reliable. 2. The participants completed the instruments openly and candidly. 3. The chosen sample was representative of the population of oncology nurses from across the United States.
Limitations The study was limited by the following: 1. The participants in the study were volunteers.
2. The study was limited to oncology nurses practicing in outpatient and inpatient settings in the United States only; thus, the findings could not be generalized beyond this population.
3. The study was limited by the subjectivity of the survey and the indicated measurement tools.
4. Affective response and satisfaction could be affected by daily events beyond the control of the researcher.
5. The conclusions drawn were limited to those responses elicited through the questionnaires, which were deemed valid and reliable by the developers of the instruments.
6. Using these instruments might result in an additional burden on respondents, thus potentially affecting the response rate.
7. The study instruments were not designed to control for socially desirable responses.
8. Other possibly related variables, such as mood disorders (including anxiety and depression) and socioeconomic status, were not considered in the data survey and data analysis.
9. Participant self-selection could have the potential to bias the sample. Those choosing not to answer the survey questionnaires because they were uncomfortable with the memories of moral distress situations might be under represented. Likewise, those who had very little experience with ethically charged situations or limited recognition of such situations might have chosen not to participate because they felt they had little to contribute.
Theoretical Framework This study was an investigation of the relationships between the concepts of moral distress, ethical climate, and intent to turnover. The conceptual framework for this research was derived from the concepts developed by the authors of two of the instruments used to measure these phenomena (Corley, 1995; Eisenberger et al., 1986). The framework for moral distress was derived from the concept development of those who researched this phenomenon: Corley (2002); Fry et al. (2002), and Wilkinson (1988). The concept of moral distress was first identified in 1984 by Jameton, who defined it as the feeling of “psychologic disequilibrium” (p. 6) that occurs when nurses are conscious of the morally appropriate action a situation requires but cannot carry out that action because of institutionalized obstacles. These challenges, which might result in feelings of moral distress, could include time constraints, lack of supervisor support, an intimidating medical power hierarchy, inhibiting organizational policy and guidelines, or legal barriers. In 1993, Jameton widened the moral distress framework and included definitions of initial and reactive moral distress. In the study, he noted that a person develops feelings of frustration, anger, and anxiety when faced with institutional obstacles and interpersonal conflict about values in initial distress. In contrast, reactive distress occurs when individuals do not act upon their feelings of initial distress. This