The Relationships of Conscience, Ethical Climate and Moral Distress in Registered Nurses Working in the Acute Care Setting

Monday, 9 November 2015

Theresa Kyzar, MSN, MBA, RN
College of Nursing & School of Allied Health, Northwestern State University, Shreveport, LA, USA


Health care providers, including nurses, are often faced with ethical dilemmas on a daily basis and experience conflicts between their professional oath, a desire to care for the suffering, and a fiduciary duty to serve when weighed against the ever expanding body of legal and regulatory requirements. This is compounded further when resulting moral dilemmas ensue because of factors involving: quality of life issues, deciding when, or if, life should be terminated and determining how best to honor a patient’s  or family member’s health care decisions—which may inevitably conflict with the moral or religious beliefs of the care provider. Nurses often struggle with how to balance their own personal beliefs with patient care decisions in various work environments. They are responsible for multiple aspects of the healthcare delivery process. Oak (1996) discusses that nurses are accountable to the facility that employs them, to the physician with whom they work, to the patient whom they provide care, to the family to whom they must respond, to the nursing profession which they belong, and to the familial, cultural, and religious communities that shape their sense of identity. In each of these areas, it is possible for moral conflicts to arise causing the nurse to encounter multiple ethical challenges and a stress of conscience (Corley & Selig, 1994; Cronqvist, Theorell, Burns, & Lutzen, 2004; Corley, 1995; Kelly, 1995; Glasberg, Eriksson, & Norberg, 2007; Peter, Macfarlane, & O’Brien-Pallas, 2004).

In general, the rights of nurses consist of human and civil rights, rights based on health care legislation, rights based on professional ethics, and earned rights (Kangasniemi, Viitalahde, & Porkka, 2010, p. 630). Currently, they, along with their physician counterparts, possess their right to conscientious objection to procedures or services which they may deem as morally objectionable. Such protections exist due to the Church Amendment, also known as the “Conscience Clause”, which was passed in 1973 by the U.S. Congress (Wicclair, 2011). While the right to conscientious objection was initially aimed at protecting physicians and nurses who morally objected to participation in abortion services, it has expanded over the years to include other factors of reproductive rights such as late term abortion, stem cell research, and end of life care issues associated with withdrawal of hydration and nutrition, euthanasia, assisted suicide and the discontinuance of other technological life-saving medical treatments (Curlin, 2007; Lindsay, 2007; Ersek, 2005; Epstein, 2010 ).

The national implication regarding the use of conscientious objection remains an unsettled area of bioethics (Pope, 2010, p. 11) and an intense national debate is occurring. Recently the issue regarding a health care provider’s right to conscientious objection has come under greater scrutiny (Roberts, 2014; Pate, 2009; Rienzi, 2012; Kane, 2009; Dresser, 2005; & Lindsay, 2007) and some have called for its discontinuance based on views regarding: 1) the need for fair and equitable care (Savelescu, 2006; Card, 2007; Brock, 2008; Savelescu, 2007; & Meyers & Wood, 1996), 2) addressing the needs of the medically indigent, and 3) to remove the potential access barriers to care.  Another concern is that changes in professional roles, referred to as “task shifting” or “task sharing” (such as what transpires when a nurse transfers the care of a patient to another nurse due to his/her moral objections) have frequently not succeeded in the past, sometimes compromising health care quality and safety (Crisp & Chen, 2014, p. 955). 

Registered nurses are experiencing ethical dilemmas with greater regularity in the health care setting and the potential for being placed in situations where the nurse’s conscience may be compromised or placed at risk due to a patient fidelity requirement is increasing. A few research studies have examined the general role of stress of conscience in nurses primarily in the critical care settings (Caitlin, Volat, Hadley, Bassir, Armigo, et al, 2008; Glasberg, Erikkson, & Norberg, 2007; van Zuuren & van Manen, 2006; Ferrell, 2006; DeVillers & DeVon, 2012; Wiegand & Funk, 2012 ) and its effect on burnout and moral distress. However, research to date has not provided a clear picture regarding how nurses view the importance of their options to claim a conscientious objection to certain care procedures that they may deem as morally objectionable. Moreover, the possible implications of what nurses might choose regarding their career status or specializations if such rights were modified or even possibly eliminated in the future are not well understood.  


The purpose of this research design was to gather quantitative data to determine what, if any statistical relationship exists between the use of conscientious objection, moral distress and intent to turnover among acute care nurses working in obstetrical and critical care departments. Thus, a quantitative non-experimental correlational study design using a random sample of 500 staff nurses working full time was chosen. Corley’s Moral Distress Theory and the Stress of Conscience Model were used as the framework design. Using a Pearson’s correlation coefficient, four primary research questions were used to guide this study. Preliminary results reveal a higher correlation on the importance of using conscientious objection by nurses working in the obstetrical setting than in the critical care setting. A significant relationship exists among nurses who describe a high importance to religious or spiritual practices and the use of conscientious objection. Moral distress was found to be high in both clinical settings. Data showed that nurses (>70%) in this sample did not tell their employers about their views on conscientious objection during moral dilemmas as prior to their hiring for employment.

Conclusions and Implications for Practice  

Nurses want to know how to maintain fidelity to patients and their families, follow orders from their physician colleagues, work in a family-centered interdisciplinary team, yet be able to follow their consciences when the care ordered appears to be harmful (Caitlin et al, 2008, p. 106) or involves the ending of life. However, the study findings could greatly influence how the professional nursing community views the challenges which may be associated with conscientious objection and moral distress. It is hoped that the results will offer insight into the registered nurses’ attitudes about the importance of conscientious objection and whether there may be a causal link to staff retention and turnover for healthcare organizations. Nursing turnover has a profound fiscal impact on healthcare organizations in terms of associated costs, perceptions of quality of care, and places a heightened pressure on nurses to work in an increasingly fractured and unsatisfactory environment (Lee, Dai, Park & McCreary, 2013; Hairr, Salisbury, Johannsson & Redfern-Vance, 2014). With increased technological demands, increased patient acuity, and the complex phenomena of the ongoing nursing shortage, retaining experienced nursing staff at the bedside is of the utmost importance (Aiken, Clark, Sloane, Sochalski & Silber, 2002). The findings provide empirical data on when nurses may opt to change certain clinical specializations where ethical dilemmas are becoming more common instead of choosing to leave their employer or the nursing profession.